Pain from chronic pancreatitis can be caused by:
Pain from chronic pancreatitis has been ascribed to three possible etiologies. Ductal hypertension, due to strictures or stones, may predispose to pain that is initiated or exacerbated by eating. Chronic pain without exacerbation may be related to parenchymal disease or retroperitoneal inflammation with persistent neural involvement. Acute exacerbations of pain in the setting of chronic pain may be due to acute increases in duct pressure or recurrent episodes of acute inflammation in the setting of chronic parenchymal disease. Nealon and Matin have described these various pain syndromes as being predictive of the response to various surgical procedures. Pain that is found in association with ductal hypertension is most readily relieved by pancreatic duct decompression, through endoscopic stenting or surgical decompression.
A patient undergoing the Frey procedure to relieve pain from obstructive pancreatopathy is found to have 85% parenchymal fibrosis. The percentage of pain relief the patient is likely to experience is:
The surgical relief of pain due to obstructive pancreatopathy may be dependent on the degree of underlying fibrosis rather than the presence of ductal obstruction, per se, according to a recent study from Johns Hopkins by Cooper et al. Thirty-five patients with chronic pain associated with evidence of duct obstruction were treated with local resection of the pancreatic head and longitudinal pancreatico-jejunostomy (LR-LPJ), or Frey procedure, and the degree of pain resolution after surgery was compared to the degree of underlying parenchymal fibrosis. After a follow-up that averaged 22 months, patients with more than 80% fibrosis had 100% pain relief, whereas only 60% patients with less than 10% fibrosis experienced substantial or complete pain relief (Fig. below). These findings suggest that minimal fibrosis, or "minimal change chronic pancreatitis;' may produce chronic pain due to extra-pancreatic or "peri-pancreatic" inflammatory events which are not ameliorated by decompression.
Pain relief from chronic pancreatitis treated with the Frey procedure correlates with the degree of underlying fibrosis. Percent of patients with pain relief for those with mild or minimal fibrosis (M I F, n=1 3), intermediate fibrosis (I N F, n=7), and severe or extensive fibrosis (SEF, n=1 4). P
The only therapy shown to prevent the progression of chronic pancreatitis is:
The traditional approach to surgical treatment of chronic pancreatitis and its complications has maintained that surgery should be considered only when the medical therapy of symptoms has failed. Nealon and Thompson published a landmark study in 1993, however, that showed that the progression of chronic obstructive pancreatitis could be delayed or prevented by pancreatic duct decompression. No other therapy has been shown to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-3). Small-duct disease or "minimal change chronic pancreatitis" are causes for uncertainty over the choice of operation, however. Major resections have a high complication rate, both early and late, in chronic alcoholic pancreatitis, and lesser procedures often result in symptomatic recurrence. So the choice of operation and the timing of surgery are based on each patient's pancreatic anatomy, the likelihood (or lack thereof) that further medical and endoscopic therapy will halt the symptoms of the disease, and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeostasis, abstinence from alcohol and tobacco, and a detailed review of the risks and likely outcomes to establish a bond of trust and commitment between the patient and the surgeon.
Effect of surgical drainage on progression of chronic pancreatitis:
Eighty-three patients with chronic pancreatitis were evaluated by exocrine, endocrine, nutritional, and endoscopic retrograde cholangiopancreatography studies, and all had mild to moderate disease and dilated pancreatic ducts. A Puestow-type duct decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.
The part of the pancreas resected in order to ensure successful resolution of pain long-term for patients with chronic pancreatitis is:
The common element of these variations on the theme of LR-LPJ remains the excavation or "coring out" of the central portion of the pancreatic head. It remains uncertain, however, whether and to what degree the dichotomy needs to be extended into the body and tail. The logical conclusion of all of these efforts is that the head of the pancreas is the nidus of the chronic inflammatory process in chronic pancreatitis, and that removal of the central portion of the head of the gland is the key to the successful resolution of pain long-term.
In pylorus-preserving resections of the pancreas, the technique with the lowest rate of pancreatic leakage is:
The preservation of the pylorus has several theoretical ad vantages, including prevention of reflux of pancreaticobiliary secretions into the stomach, decreased incidence of marginal ulceration, normal gastric acid secretion and hormone release, and improved gastric function. Patients with pyloruspreserving resections have appeared to regain weight better than historic controls in some studies. Return of gastric emptying in the immediate postoperative period may take longer after the pylorus-preserving operation, and it is controversial whether there is any significant improvement in long-term quality oflife with pyloric preservation. Techniques for the pancreaticojejunostomy include endto-side or end-to-end and duct-to-mucosa sutures or invagination (Fig. below). Pancreaticogastrostomy has also been investigated. Some surgeons use stents, glue to seal the anastomosis, or octreotide to decrease pancreatic secretions. No matter what combination of these techniques is used, the pancreatic leakage rate is always about 10%. Therefore, the choice of techniques depends more on the surgeon's personal experience.
Techniques for pancreaticojejunostomy. A to D. Duct-to-mucosa, end-to-side. E. Intraoperative photographs of end-to-side pancreaticojejunostomy. F to J. End-to-end invagination. K to O. End-to-side invagination:
Techniques for pancreaticojejunostomy. A to D. Duct-to-mucosa, end-to-side. E. Intraoperative photographs of end-to-side pancreaticojejunostomy. F to J. End-to-end invagination. K to O. End-to-side invagination.
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