sx in chr pancreatitis

1. Resident of surgery
Dr SNMC,JODHPUR
---Dr sumer 2013

2.  Continuous inflammatory disease of pancreas
characterised by irreversible morphologic
changes [[irregular fibrosis, acinar and islet
cells loss,inflammatory infiltrates,stone
formation]]of both the parenchyma and
ducts;typically coupled with permanent loss of
function +/-pain

3. 1. 10-15/100000 population in western countries
2. 114-200/100000 in southern india
3. Typical age 35-55

4.  Alcohol;60-70% of all cases in developed
countries {6-12 yr history of 150-175 g/day}
 Obstruction of pancratic duct;pancreas
divisum,post traumatic stricture,tumours
 Cystic fibrosis[CFTR mutation]
 Tropical pancreatitis
 Autoimmune
 Hypercalcemia
 Hyperlipidemia
 idiopathic

6. Exocrine
insufficiency
Maldigestion,diarrhea Weight loss
Endocrine
insufficiency
Diabetes mellitus
pain Varies with etiology

7.  TESTS OF
STRUCTURE
 1.ERCP
 2.EUS
 3.MRI AND MRCP
 4.CT scan
 5.X ray abdomen
 6.USG abdomen
 TESTS OF
FUNCTION
 1.S. Glucose
 2.S.Trypsinogen
 3.Fecal elastase
 4.Fecal chymotrypsin
 5.Fecal fat[72 hr
collection]
 6.Secretin pancreatic
stimulation test with
duodenal intubation

9.  Hyperechoic walls of duct
 Duct dilatation
 Stones in duct
 Parenchymal lobularity,strands and cysts

12.  Medical therapy
 Endoscopic therapy
 Surgical options
 Nerve blocks

13.  Pain –commonest indication[[[70-90%]]]
 Mass/suspicion of malignancy
 Biliary obstuction
 Duodenal stenosis
 Pseudocysts
 Internal pancreatic fistulae
 Vascular problems

14.  Pain relief
 Control of complications
 Preservation of exocrine and endocrine
functions
 Social and occupational rehabilitation
 Improvement of quality of life

18.  Large prospective surgical series;75-90%
success in pain relief and improvement in QOL
 Pain relief with surgery vs medical Rx
:63vs43% at 10 yr

19.  ‘……..seems unreasonable to adopt a
conservative approach in the hope that pain
relief will be obtained sometime in the future,at
which stage risk of narcotic addiction increses
and results of surgery are invarably poor.’

21.  Patients presented with complications;early
surgery
 For pain relief
.early surgery [<4 yrs ]may delay progress
of exocrine/endocrine insufficiency[alc CP]
Ann surg 1999
.early surgery in NACP/trop CP improves
nutitrional status,weight gain,decrased insulin
requirement.
 Controversies:how early what surgery:drainage or
resection?

22.  Indicated for failure of medical management
 Suspicion of malignancy
 Drainage procedure
indicated in large duct disease
 Resection-drainage procedure
indicated when there is inflammatory
mass
procedure of choice dictated by surgeon
experience and individualized to pt

23.  1954 Duval
distal pancreatectomy,spleenectomy,end to
end roux en Y pancreaticojejnostomy
 1958 Puestow and Gillesby
longitudinal incision and invagination into
jejunal roux
 1960 Partington and Rochelle
side to side longitudinal
anastomosis;preserve distal pancreas and
spleen;need dilated duct >6mm

24.  Inflamed and enlarged pancreatic head
 Requires resection
1.Whipple
2.Beger[duodenum preserving pancreatic
head resection]
3.Frey

25. Most commonly performed today

31.  Was developed for periampullary malignancy
 More popular in the past 2 decades for CP also
due to advances in op technique,anesthesia and
perioprative mx
 End to side PJ using 2 layer tech {vicryl/silk} duct-
to-full-thickness bowel
 5 Fr pediatric feeding tube is used as a pancretic
stent
 End to side choledochojejunostomy
 2 layer GJ/DJ
 Feeding jejunostomy

33.  Duodenum-sparing pancreatic head resection
 C/I in suspected pancretic cancer
 Portal vein freed,neck divided
 Longitudinal pancreaticojejunostomy
 Frozen section to rule out malignancy[5%]

35.  Coring of head of pancreas
 Duodenum-sparing pancreatic head resection
and lateral pancreaticojejunostomy
 Indicated for small duct disease
 Technically easier then beger.
 Local resection of pancreatic head relieves
CBD obustruction in 70% of cases

36. Beger vs Freys

38. Other
procedures

39.  1998,longitudinal V shaped excision of ventral
pancreas
 Indicated for small duct pancreatitis
 Author described 95% pain relief

40.  Pathology predominantly limited to distal
portion of gland
 Distal psedocyst,mass, SVT
 Cut edge of gland oversewn

42.  Psedocyst complicates CP in 30% to 40% of
pts
 Surgery indicated for pts with symtomatic
pseudocysts who are either not candidate or
have failed an initial attempt at
transampullary,transgastric,or transcutaneous
drainage
 septated cyst with elevated fluid CEA and CA
15-3 levels treated by resection.[? Neoplasm]


43.  Cyst-gastrostomy/duodenostomy
 Roux-en-Y cyst-jejunostomy [simpler]
 For small multiple cysts of pancreatic head-
Whipple proc
 For cyst of pancreatic tail – distal
pancreatectomy

44.  Surgical cyst-enterostomy is associated with
90-100% success
 Success rates from cyst-duodenostomy-
100%,cyst-gastrostomy-90% and cyst-
jejunostomy-92%
 Morbidity 9%-36%
 Mortality 0%-1%

47.  Last resort for pts with persistent or recurrent
pain following lesser proc
 Requires autologous islet cell
autotransplantation
 extended hospitalisation due to Poor diabetes
control

49.  Indicated in intractable pain abdomen due to
pancreatic and gastric carcinoma
 Celiac ganglion block have transient effects,but
this neural ablation offers higher success rates
 Thoracotomy is more invasive,VATS is less
invasive and offers more rapid recovery

50.  All pts with recurrent pain abdomen
reevaluated with CTscan MRCP/ERCP,UGI
endoscopy.
 For diffuse parenchymal disease-completion
pancreatectomy with or without islet cell
autotransplantation
 For dilated duct-decmpressive surgery
 For stricture-subtotal resection

51.  1995-2009 [[n=170]]
 Pain is the main indication 90%
pain duration 1-30 yrs
 Biliary obstruction alone 10%
 NACP: 95 ; Alc CP ;75
 DRAINAGE PROCEDURE …………….115
LPJ ………………………………….62
LPJ+BILIARY BYPASS …………….30
CYST-ENTEROSTOMIES …………23
 RESECTIONS…………………………….19
WHIPPLES ………………………….11
WHIPPLES+LPJ …………………….3
DISTAL PANCREATECTOMY …….5

52.  Pain relief and quality of life issues are the
main concern in pts of chronic pancreatitis
undergoing treatment
 Surgery is indicated for relief of intractable pain
and complications associated with CP
 Failure of nonsurgical treatment and presence
of complications influence timing and need for
surgical intervention[[jury is still out:early surgery for
mild to moderate pain]]

53.  Pain relief is sustained in NACP->85%
 Duration of pain does not necessarily correlate
with surgical outcome
 No consistent documentation of recovery of
pancreatic function following ductal drainage
 Need for biliary bypass: frequent
 Associted SVT/PHT makes surgery difficult
 Late deaths occurs due to malignancy or
continued alcoholism

54. THANKS