Management of Chronic Pancreatitis

1. Management of
Chronic Pancreatitis
DR. Q. MEHRANUDDIN AHMED
ASSISTANT REGISTRAR SURGERY
KMCH

2. Chronic Pancreatitis
 Chronic pancreatitis (CP) is a progressive and often irreversible
inflammatory and fibrotic disease of the pancreas.
In moderate to severe forms, CP can have a debilitating clinical course due to
 Chronic abdominal pain
 Attacks of acute pancreatitis
 Malnutrition and related complications including pancreatic malignancies

3. Chronic Pancreatitis

4. Chronic Pancreatitis
Pain in CP is multifactorial in origin and can result
from
 Increased pressure in the main pancreatic duct (MPD)
leading to intraparenchymal hypertension
 Peripancreatic/celiac neural inflammation.
Management aims at relieving pain and preventing further damage

5. Etiology
1. Alcohol
2. Autoimmune
3. Pancreas divisum
4. Genetic predisposition:
a. mutation in the trypsinogen gene
b. mutation in the serine protease inhibitor Kazal type 1 gene
c. mutations in the cystic fibrosis transmembrane conductance regulator

6. Diagnosis
 History of abdominal pain + Radiologic confirmation of fibrosis and calcification of the
gland
 Goals:
1. Anatomic evidence for presence of chronic pancreatitis
2. Assessment of the diameter of the duct
3. Determination of presence of associated disease (e.g. cysts, bile duct obstruction)
4. Look for unsuspected pancreatic malignancy.

7. Investigations
 ERCP: Gold standard for morphological diagnosis of chronic pancreatitis
(Multifocal dilations, strictures, irregular contours of the main pancreatic
duct, calcifications and stones)
 MRCP: Information about duct anatomy. Non invasive investigation
 CECT Scan: Sensitivity high as 95% in advanced disease. Useful to evaluate
the complications of chronic pancreatitis
 Pancreatic function tests: Limited value in diagnosis of chronic
pancreatitis.

8. Treatment
 Aims:
 Relieve intractable pain
 Preserve pancreatic endocrine and exocrine functions as much as possible
 Indications:
1. Intractable pain
2. Suspicion of malignancy
3. Biliary/ duodenal/ colonic stenosis
4. Pancreatic cysts/ pseudo cysts
5. Pancreatic ascites/ pleural effusion
6. Portal venous obstruction

9. Treatment
 Medical
 Oral analgesics
 Narcotics
 Tricyclic anti-depressants
 Endocrine dysfunction: Required insulin and dietary restrictions
 Exocrine dysfunction and malabsorption: Pancreatic enzyme replacement of at least 30,000
units of lipase with each meal.

10. Treatment
 Endoscopic:
 Pancreatic sphincterotomy
 Pancreatic ductal stenting
 ESWL of pancreatic stones
 Endoscopic drainage of pancreatic pseudo cysts
 Endoscopic celiac nerve block

11. Treatment
 Surgical
Principles and rationale
1. Relieve pancreatic duct pressure and interstitial pressure
2. Relief of ductal stenosis &/ or obstruction
3. Preserve as much parenchyma as possible
4. Preferably have dilated ducts 6-7mm in diameter

12. Treatment
 Surgical Procedures:
1. Decompression procedures
2. Resection procedures of the proximal, distal or total pancreas
3. Denervation procedures of pancreas
4. Hybrid procedures

13. Treatment
 Decompression Procedures:
 Duval’s procedure: resection of distal pancreas with dunking
of remaining pancreas
 Puestow and Gillesby- 1958
Longitudinal decompression of the body and tail
Lateral pancreatico-jejunostomy (PartingtoneRochelle operation)-1960
Unroofing of major and minor pancreatic ducts
Side to side Pancreatico-jejunostomy with Roux loop of jejunum

14. Treatment
 Resection Procedures:
1. Whipple’s procedure: distal segment (antrum) of the stomach, the first and
second part of the duodenum, the head of the pancreas, the common bile
duct, and the gallbladder are removed.
2. Distal Pancreatectomy
3. Total pancreatoduodenectomy
4. Total pancreatectomy with islet cell transplantation

15. Treatment
 Hybrid Procedures:
 Beger’s procedure- duodenum preserving pancreatic head
resection -1980
Indications:
Inflammatory mass in HOP especially associated with CBD/ duodenal
stenosis
Portal HTN due to portal vein compression
Advantages:
Avoids major surgical resection of CBD, duodenum, PV and need to
restore bile flow, food passage, portal blood flow.
Preservation of endocrine function of the gland

16. Treatment
 Hybrid procedures:
 Frey’s procedure-1987:
It is a surgical technique in which the diseased portions of the pancreas head are
cored out. A lateral pancreaticojejunostomy is then performed in which a loop of
the jejunum is then mobilized and attached over the exposed pancreatic duct to
allow better drainage of the pancreas, including its head. It is an organ preserving
surgery and the main pancreatic duct has to be more than 3.5mm in diameter.
 Hamburg modification:
Longitudinal V shaped excision of ventral aspect of pancreas. It is done in small
duct disease in which duct diameter is less than or equal to 3mm.

17. Conclusion
 Hybrid procedures such as DPPHR, Frey’s procedure and their
variants have been proved to be safe and effective than decompression or resection
alone.
 Surgical treatment provides effective long term pain relief and improves quality of life
but it can’t always preserve the endocrine or exocrine function of the pancreas.
Therefore, strategies to improve or maintain pancreatic endocrine and exocrine function
remain an important field of research.