Surgical management of chronic

pancreatitis

Gajanan Wagholikar
MS,DNB; MCh,DNB(Gastro); Fellow HPB surg; FACS
Deenanath Mangeshkar Hospital
Aditya Birla Hospital
“The pancreas is the most untrustworthy organ.”
Robert Zollinger

“God put pancreas in the back because he did not want

surgeons messing with it. “
Harold Ellis
Marathon des Sable
 Chronic Pancreatitis - The Indian scenario

Prevalence

• Western countries 10-15/100000

• Japan 45/100000
• India 125/100000
Garg PK, Curr Gastroenterol Rep 2012
 Chronic Pancreatitis - The Indian scenario
Changing Profile

• Idiopathic pancreatitis 60.2%

• Alcohol related 38.7%
• Rare 1.1%

• Classical Tropical chronic pancreatitis 3.8%

JOP 2008
 Chronic pancreatitis - The waters are murky

Contentious issues
• Definition
• Aetio-pathogenesis
• Diagnosis
• Natural history
• Optimal management approach
An inflammatory disease characterised by fibrosis and
irreversible destruction of pancreatic parenchyma
with progressive loss of exocrine and endocrine
function
 Clinical presentation

Asymptomatic/ Incidental 5-20%

Symptoms 85-90%
• Pain 80-95%
• Exocrine insufficiency – malabsorption - diarrhea,
steatorrhoea, wt loss
• Endocrine insufficiency – Diabetes mellitus
 Complications

visceral artery
pseudoaneurysms
Splenic vein
Duodenal stenosis
pseudocyst
thrombosis
Duodenal stenosis
lower CBD stricture

risk of malignancy
Management of Chronic pancreatitis is
essentially the management of the pain
 Chronic Pancreatitis – Basic principles in
Management
• Treatment should be conservative and symptom
related

• In that sense treatment is palliative (and not curative)

Exception – if suspicion of malignancy resection with
an intent of curing Mg

• Mgt only when disease is symptomatic and for the

symptoms that are present
 Mechanisms of pain
Perineural inflammation Intraductal hypertension

ductal obstruction
↓
iraductal hypertension
& pancreatic capsular fibrosis
↓
compartment syndrome
Pain patterns
 Pancreatic burnout - How common is it?

• 80% late onset CP by around 5 years

Progression and Burnout is delayed in Non alcoholic
CP Ammann et al

• 48% at persistent pain even after 5 yrs Miyake et al

• 50% had intermittent pain even beyond 10 yrs

No difference in behaviour of alcohol related and non
alcohol CP Creutzfeld et al
 “It is unreasonable to continue with conservative
approach in the hope that pain relief will be achieved
sometime in the future, at which stage the risk of
narcotic addiction increases and the results of surgery
are invariably poor”
Andrew Warshaw
 Can Natural history be predicted ? - No, it can't

No particular pattern between course of pain, and

• pancreatic calcification
• severity of ductal abnormalities
• duration of disease
• exocrine and endocrine insufficiency

• Non alcoholic CP progress is delayed; spont relief is

delayed
 Management of Chronic pancreatitis

• Medical Management
– PPIs (Acid suppression)
– Pancreatic Enzyme replacement therapy
– Analgesics
• Endotherapy – stone extraction, dilatation of
strictures and drainage of duct (stenting/
sphincterotomy)
• Surgery
 Management Approach

• Less invasive to more invasive

• Conservative -symptom related

• Medical →→Endoscopic →→ Surgical (??)

• Tailored approach should be better than Step-up

 Indications for surgery

• Intractable pain not responsive to medical

management and/or endoscopic interventions
• Complications of chronic pancreatitis
– Biliary stricture
– Duodenal stenosis
– Suspicion of malignancy
– Pseudocysts
– Visceral pseudoaneurysms not controlled by
interventional radiology
 Timing of surgery

• Timing of surgery – No convincing data to suggest

that early surgery can alter the natural history of
disease; conflicting reports

Improvement in function No Improvement in function

Nealon and Thompson, Ann Surg Warshaw et al Gastroenterology

1993 1999
Sidhu et al Am J Gastroenterol 2001 Sikora et all World J Surg 2002
 Timing of surgery

• Intervention when pain unresponsive to medical mgt,

needs opioids , repeated admissions, results in impaired
QOL – loss of work

• Patient should ‘earn his surgery’ (but before it is too late)

• Patients of endoscopic failure who needed surgery did not

do well Cahen et al. Gastroenterology 2011

• Pancreatic ‘ burn-out’ – unpredictable; May take more than

10 years
• Treat symptoms and not every visible abnormality
(Cf. CBD stones)
The ongoing ESCAPE (Early surgery versus optimal
current step-up practice for chronic pancreatitis)
should be giving us this answer
BMC Gastroenterol 2013
 Chronic Pancreatitis - Scope or operate?

• Two RCTs
n = 72 pts
More pts in Sx arm had complete pain relief at 5 yrs
(34% vs 15%)
Partial pain relief similar (52% vs 46%)
Surgical pts had almost 25% more wt gain
Dite et al. Endoscopy 2003
• Mean FU - 79 months

Pain relief
• Surgery 80% vs Enodscopy
38%
 Tailored Approach
Endoscopy first Surgery first
• Pain < 3yrs • Inflamm head mass
• Non narcotic dependent • Dilated MPD > 5mm
• Single cephalic stricture • with multiple strictures
• Limited stone load in • Significant stone load,
head/neck and /or in body/tail
• MPD < 5mm
Patients in between zones need to be studied in the
setting of trials for endoscopy vs surgery
 Referral for surgical management -
It better be early
• Patients not settling even after one year of
endotherapy
• Patients not improving even after 5 sessions of
endoscopic interventions
• Less than 3 yrs of symptoms and not needing
opioids
– Ahmed AU et al (Dutch Pancreatitis Study Group),
Arch Surg 2012
 Investigations

• Abdominal Xray
• USG
• CT-scan abdomen
• MRCP
• EUS
• ERCP
 What information do you need from imaging?

• Size of duct
– Large duct disease (≥5 mm) – surgically drainable
– Small duct disease (< 5 mm)
• Number and location of stricture
– Solitary / dominant and in Cephalic portion
– Multiple , tight all over or in body and tail
• Number of stones
– Solitary / few and in head region in main duct
– Multiple, scattered all over
– Calcifications in side branches
• Presence of head mass
Solitary dominant stricture
Few PD stones
Extensive stone disease
Head mass
 Operations in Chronic Pancreatitis

• Drainage
• Resection
• Combination of drainage and resection
• Denervation
Caudal - Duval
Puestow - Gillesby Partington Rochelle
 Resections
60% resection, 80% resection
95% Pancreatectomy - Child's resection
The head of the pancreas is the pacemaker of pain in
chronic pancreatitis
PPPD - Traverso- Longmire
Beger's operation
Frey's operation -Head-coring , LR-LPJ
Hamburg modification - Izbicki Berne modification - Buchler
Spleno-pancreatic denervation - Warren
 Total Pancreatectomy with Islet cell
Autotransplantation (TPIAT)
• Limited centres in North America
• Largest experience University of Minnesota - Around
700 pts
• At around 3 yrs roughly 1/3rd Insulin independent,
1/3rd partly depndent and 1/3rd fully dependent
• 97% 1 yr and 90% 5 yr survival
• Narcotic free 60% at 2 yrs
University of Minnesota criteria for TPIAT
 Aims of surgical management

• Alleviate Pain
• Palliate other complications
• with preservation of pancreatic function
LPJ
Pancreatico-
Partington Rochelle
duodenectomy
(modified Peustow-
Whipple’s operation
Gillesby)

The three blue chips

• LPJ
• LR - LPJ (Frey's)
Frey’s operation

• Whipple's
 Surgery for complications

• Biliary stricture - Hepatico-jejunostomy

• Duodenal stenosis - Gastro-jejunostomy

Surgical tit-bits
 Patient preparation

• Right timing – earn, yet not too late!

• Avoid alcohol/ narcotic dependant
• Counselling – incl possible malignancy
• Functional status – optimise Diabetes
• Comorbidity - cardioresp, CLD, malnutr
• Quality of life and psychosocial assmt
Best – working, non drinker, good family support, clear
expectation of outcome
 Surgery - safe extras!

• Antibiotic – 25% of PD fluid – GNB

• Bowel prep – esp in revision surgery
• DVT prophylaxis
• Availability of C – arm - cholangiogram or
pancreatography
• IOUS and effective operator!
 At surgery

• Exploration: thorough palpation, any suspicious area

- Frozen/ FNA
– Abnormal area of consistency
– Excess mucin
– Hard nodule
• Anterior gland exposed – adequate tissue margin
 Repeat surgery - exposure

• Gastrocolic omentum sparing GE vessels

• Gastropancreatic adhesions divided
• Gland identified between Splenic artery above and
sharp inferior border
• Full omentum down at the left - Splenic flexure
exposed esp for pancreatic tail retracted into splenic
hilum
 Exposure of pancreatic head

• Kocherise – sharp if retroperitoneal adhesions from

inflmn
• SMV traced down esp if retracted or mesocolic
adhesions
• Ligate and cut the gastro-colic trunk of Henle
 Duct identification

• Palpation – soft compressible in mid to distal body

• Needle aspiration of clear fluid
• Intraoperative Ultrasound
• Peroperative ductography/ cystogram
• Oblique incision into expected area
 Duct opening

• Identify course over a probe

• Head duct dives post and inf
• Deroof undilated areas
• V shaped excision of ant gland – in small ducts
 Head drainage

• All 3 major ducts (incl uncinate) opened and

deroofed until near duodenal wall
• Vessels ligated esp GDA br, vert brs of sup pancr-
duod, and gastroepiploic
• Maintain fibrous rim of at least 5 mm
• CBD protection by sound? If opened?
• Repeated palpation to identify undrained areas –
but keep post. rim
 Anast. technique

• 1 vs 2 layer
• Nonabsorb vs synth absorb
• Cont vs interrupted
• Duct vs capsule stitch
– Personal preferences
• Start with tail – staggered ant layer
 Portal Hypertension

• Carefully review risk vs benefit – esp degree of

symptoms to be palliated
• Splenic vein thrombosis – ? additional splenectomy
esp if varices bled/ present
• Portal vein thrombosis (not mere compression) –
rule out malignancy
 Ensure correct diagnosis
(History / Imaging)

Diet, Abstinence, Medical therapy

Small duct disease Big duct disease

EUS guided Blocks Dominant cephalic Bulky head /

Multiple strictures
Resection? stricture mass
And stones
Izbicki operation? Few stones Resection
TPIAT

Failure Surgery
Endotherapy Duct drainage
Thank You
MPD
Lateral Pancreaticojejunostomy
Stomach

Lateral pancreaticojejunostomy
Frey’s Procedure LPJ + Head coring