Surgical and Medical management of Chronic Pancreatitis https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/

1. Chronic Pancreatitis
Dr Dhaval Mangukiya

3. Mechanism of pain in
chronic pancreatitis. The
neuropathic pain syndrome
involves molecular and
morphological alterations at
intrapancreatic (peripheral) and
extrapancreatic (dorsal root
ganglia, spinal cord, brainstem,
and cerebrum) sites. Reproduced
with permission from Demir et al.
Langenbeck’s Archives of
Surgery, 2011. 396(2): p. 151–
160 [33]

4. Complications

5. Aims of therapy
• pain control
• management of exocrine and endocrine
insufficiency
• management of complications
Complete abstinence from alcohol and smoking is essential for all patients to
slow progression of disease and improve pain
D'Haese JG, Ceyhan GO, Demir IE, et al. Treatment options in painful chronic pancreatitis: a systematic review. HPB
2014;16:512–21
Coté GA, Yadav D, Slivka A, et al. Alcohol and smoking as risk factors in an epidemiology study of patients with chronic
pancreatitis. Clin Gastroenterol Hepatol 2011;9:266–73.

6. Management of CP
Medical
• Opioid
• Adjuncts such as gabapentin tricyclic antidepressants
• pancreatic enzyme replacement therapy (PERT)
Nutritional
• The majority of patients can be managed with normal
diet (30% fat content) and PERT, however if calorie
intake is low, protein supplementation can be
considered.

7. Endoscopic management
• dilate strictures, remove stones or drain pseudocysts
• EUS-guided coeliac plexus blocks with steroid and local
anaesthetic
• Covered self-expanding metalstents (SEMS) have been
shown to be a safe and effective therapy in benign biliary
stricture
• Stones in the main pancreatic duct can be removed with
ERCP but if ≥5 mm they are likely to require extracorporeal
shock wave lithotripsy
• Pancreatic divisum - endotherapy (including minor
papillotomy, stent placement and balloon dilatation of
minor papilla)
Management of CP

8. Surgical management
• Beneficial for patients with obstructive CP from a
dilated pancreatic duct
• (Frey’s procedure) with initial benefit is reported
in up to 80% of patients, with 60% reporting
benefit for >2 years
• Gastroenterosotmy (gastric bypass surgery) is
also indicated for gastric outlet obstruction from
chronic fibrotic compression of the duodenum
once pancreatic cancer
Management of CP

9. Indications of Pancreatic Resection

10. Puestow Procedure or Longitudinal
Side-to-Side Pancreaticojejunostomy

13. • Total Pancreatectomy with Islet Autologous
Transplantation (TP–IAT)

14. Indian J Surg (September–October 2015)
77(5):453–469

15. Endoscopic or surgical intervention for painful obstructive chronic pancreatitis (Review)
Ahmed Ali U, Pahlplatz JM, Nealon WH, van Goor H, Gooszen HG, Boermeester MA
The Cochrane Library
2012, Issue 1

16. • In the long term, symptomatic patients with
advanced chronic pancreatitis who underwent
surgery as the initial treatment for pancreatic
duct obstruction had more relief from pain,
with fewer procedures, than patients who
were treated endoscopically. Importantly,
almost half of the patients who were treated
with endoscopy eventually underwent surgery.
GASTROENTEROLOGY 2011;141:1690–1695

17. splenic preservation was found to be independently associated with higher mortality rates

18. JOP. J Pancreas (Online) 2015 Sep 08;
16(5):438-443

19. Early Surgery
• Patients who received early surgery had an
increased likelihood of complete post-
operative pain relief and a reduced risk of
pancreatic insufficiency when compared with
those undergoing late surgery
Yang CJ, Bliss LA, Schapira EF, Freedman SD, Ng SC, Windsor JAet al. (2014)
Systematic review of early surgery for chronic pancreatitis: impact on pain,
pancreatic function, and re-intervention. J Gastrointest Surg 18:1863–1869

21. • LPG is a simpler and safer procedure than LPJ for
ductal decompression in chronic pancreatitis with
dilated MPD.
• Duration of operation and hospital stay for LPG is
shorter than LPJ.
• It is associated with lower morbidity and
mortality.
• Pain relief achieved after LPG is comparable to
LPJ.
• Return to normal activities occurs earlier in LPG
than LPJ.

22. SIDS DATA
Demographic Detail
Gender
Male 19
Female 5
Etiology
Alcoholic 11
GB - stone 4
Ideopathic 9
Pancreatic stone 5
Clinical
presentation
Hemetemesis 2
Melena 4
Weight loss 5
Insufficiancy
Endocrine 5
Exocrine 6
Acute exacerbation
Pre-operative
complications
Pseudocust 9
Splenic vein
thrmobosis
1
Portal vein
thrmobosis
1
CBD stenosis
Pseudo aneurysm 8
Diabetes mellitus
Insuline dependent 1
Oral Antidiabetics 5
PD stenting 6
Failure of endovascular embolization 3
Surgical procedure
Pancreatic surgery
Lateral
pancreaticojejunost
omy
9
Frey's procedure 3
Distal
pancreatectomy
3
Pseudoaneurysm
ligation
6
Spleenectomy 2
Transgastric
cytogastrotomy
1
Post operative Result
Oprative time;
mean (min)
162.5
Intraoperrative
blood loss (mL)
205.8
Blood
transfusion
6
Pancreatic
fistula
10
Post operative
Hospital stay;
mean (days)
8.5
Hospital
readmission
3
Sustain
abdominal pain
3
CBD stricture;
Cholengitis
1
Pseudocyst 1