This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.

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