Management of Chronic Pancreatitis

4. Endocrine DysfunctionExocrine DysfunctionIntra-ductal
Hypertension
Oral Hypoglycemics
Insulin
Enzyme
Supplement
Analgesics / Surgery *
*
*

6. Should contain sufficient Lipase Units
Treats both Exocrine Insufficiency and Malnutrition

7. Uncoated
Preparations
Enteric coated
preparations
Enteric coated
microsphere
preparations
Combi-therapy
Poor results
Inactivated by Gastric Acid
Large doses needed
Strongly discouraged
Ineffective in decreasing fat excretion due
to erratic enzyme release
Superior
Decreased stool fat excretion has been
established (Layer and Holtman et al)
Combination of acid reducing agents (PPI
or H2 Blocker) with Enzyme Supplements
Expensive
Reduces faecal nutrient loss
Long term role is doubtful (Lebenthal et al)

9. Alcohol Abstinence
Enzyme Therapy
Anti-oxidant Therapy
Analgesia
Total abstinence can decrease 50%
pain in Mild to Moderate Cases
(Gullo et al)
Effect is Uncertain
(Brown et al , Winstead & Wilcox et al)
Doubtful
Ahmed et al – anti-oxidants reduce pain slightly
ANTICIPATE Study – fails to prove the reduction
of pain
Initial Managements with NSAIDS
Opiates may be necessary
Patients are advised to maintain a pain
diary

10. • Selective destruction / Temporary
Blockade
• Visceral afferent Nociceptors are
blocked
• Agents commonly used – Alcohol,
Phenol for Neurolysis and Bupivacaine
and Triamcinolone for Temporary
Block.
• Percutaneous , USG guided , CT
guided , Endoscopic Ultrasound
Guided .
• EUS is superior but response is low
(Gress et al.)

15. Resection HybridDrainage
• Pancreatoduodenectomy
• PPPD
• Total Pancreatectomy +/-
Duodenum Preservation
• Total pancreatectomy +
Islet Cell Transplantation
• Left Sided Resection
• Duval
• Puestow – Gillesby
• Partington – Rochelle
variant of Puestow
• Head Coring and
Drainage (Frey’s)
• DPPHR (Beger)
• Izbicki (Hamburg)
modification
• Bern Modification

16. • Pancreatic head , duodenum and
lower one third of stomach, distal
biliary tract and bile duct is resected
• Poor post operative digestive
function -> dumping , diarrhoea,
peptic ulcer , dyspepsia
• 20% reported cases have subsequent
diabetes mellitus -> increased
morbidity
• Pylorus is preserved
• Drawbacks of Classical PD are
ameliorated -> gastric dumping,
marginal ulceration, bile reflux
are reduced
• Post operative weight gain in
90% patients
Kausch-Whipple (PD)
Traverso- Longmire (ppPD)

17. Total pancreatectomy and Islet cell transplantation has been
proposed in the recent years for the management of Chronic
Pancreatitis
Rationale of Islet Cell Transplant is to :
1. Removal of the inciting organ and inflammation
2. Preventing Type 3c Diabetes

19. • Duval and Zollinger in separate studies reported Distal
Pancreato-splenectomy and Caudal Pancreato-jejunostomy
• Designed originally for Chronic Pancreatitis
• Drained only a small segment of the distal duct without
addressing the strictures
• Failed to provide long lasting pain relief

20. Distal
Pancreato-
Splenectomy
with
Caudal Drainage
Longitudinal PJ
from the caudal
end with
implantation of
the divided tail
into the Roux en
Y limb
Longitudinal
incision over
Pancreas with
side to side
Anastomosis of
the Jejunum and
MPD
DUVAL
PUESTOW LPJ
Doesn’t decompress the head
and the pain isn’t cured

21. Indications:
•Substantially dilated duct (> 7mm) ~ 25 %
•Without a dominant inflammatory mass in
the head
(Buchler and Warshaw et al)
Hence, pure drainage procedures have a
short coming. It’s better to combine
Resection and Drainage procedures.

24. Bern ModificationIzbicki Modification

25. • Increased Cost
• Increased Operative cost
• Better R0 Resection
• Decreased Hospital stay
• 5 year survival rates of MIPD
and OPD are comparable