SURGICAL MANAGEMENT OF

CHRONIC PANCREATITIS

INDICATIONS

• Upper abdominal pain refractory to medical management(daily pain)

• Inflammatory /malignant head mass• Complications– Intrapancreatic CBD stenosis– Multiple narrowing of PD– Compression of SMV/portal vein– Severe stenosis of peripapillary duodenum– Large persisting pancreatic/peripancreatic pseudocyst

after endo/interventional treatment

HISTORY

• Goethe Link – first PD drainage for CP in 1911• Duval (1954)

– Distal pancreatectomy– Splenectomy– Caudal PJ

• Puestow & Gillesby – LPJ– Splenectomy– Longitudinal incision of PD– Implantation of tail into Roux loop– Did not decompress the head

TWO STRATAGIES

• DRAINAGE PROCEDURES• RESECTIVE PROCEDURES

DRAINAGE PROCEDURES

• Pancreatic duct sphincterotomy• Puestow procedure• Partington & Rochelle’s modification

DRAINAGE PROCEDURES

• Preservation of tissue• Prevent further loss of pancreatic function• Symptomatic improvement• Avoid complicated surgeries• Reduce morbidity & mortality• Address the ductal hypertension• Duct dilatation is essential

RESECTIVE PROCEDURES

• DPPHR(Duodenum preserving pancreatic head resection)/Beger procedure

• Frey procedure• Berne modification of DPPHR• Pancreaticoduodenectomy (whipple’s operation)• PPPD(Pylorus preserving Whipple’s)• Pancreatic left resection• Central pancreatectomy

DRAINAGE PROCEDURE

PD sphincterotomy• One of the first surgical procedure• Suspected Stenosis at papilla of Vater• Lower success rate/dangerous• Abandoned procedure

DRAINAGE PROCEDURES

PUESTOW PROCEDURE• Resection of tail of pancreas• Longitudinal incision along the body of

pancreas• Anastamosis with Roux-loop of jejunum

DRAINAGE PROCEDURES

PARTINGTON & ROCHELLE’S MODIFICATION OF PUESTOW PROCEDURE

• No resection of the tail• Longitudinal opening of the duct• Anastamosis with Roux loop of jejunum

DRAINAGE PROCEDURES

• Goals– Preservation of tissue– Reduction of mortality to <1%– Reduction of morbidity to <10%

• Long term pain relief in 85-95% of patients

Evans et al,1997/Izbicki et al,1999/

RESECTIVE PROCEDURE

• DPPHR– Pancreatic head mass– Adjacent organ involvement– Dilated pancreatic duct– Duct occlusion– Pancreas divisum

DPPHR• Ventral dissection & dorsal mobilisation of pancreatic head• Pancreatic division above the portomesenteric vein• Pancreatic head resection towards the papilla of Vater• Subtotal resection leaving a margin of tissue

– between the duodenum & CBD– Towards the venacava

• Mostly it is possible to free the CBD from surrounding scar• In some cases CBD has to be opened to drain in to the cavity( 24 % by

Beger et al,1999)• Mesoduodenal vessels to be respected• Reconstructed using a Roux loop of jejunum• In 10% DPPHR is combined with lateral pancreaticojejunostomy(Beger et

al,1999)-due to multiple stenosis of MPD

BEGER PROCEDURE

DPPHR

• Mortality is <1%• Morbidity 15%– Beger et al

DPPHR

• Advantages– Greater weight gain– Better glucose tolerance– Higher insulin secreting capacity

• Buchler et al,1995/Muller et al,1997

– Endocrine function preserved in 39%(in the natural course of chronic pancreatitis 17% has normal glucose metabolism)

• Disadvantages– 20% developed new onset diabetes

DPPHR

• In 91% of patients it promotes clinically manifested chronic pancreatitis in to a silent one

• Delays the natural course of disease– Improves pain status– Lowers frequency of acute episodes– Rarer need for further hospitalisation– Low early & late mortality rates– Restoration of quality of life

FREY PROCEDURE

• Described by Frey & Smith– Local pancreatic head excision/coring– Longitudinal pancreaticojejunostomy

FREY PROCEDURE

BERNE MODIFICATION OF

DPPHR

CENTRAL PANCREATIC HEAD RESECTION(CPHR)

• Described by Gloor & colleagues(2001)• Combines the advantage of Beger & Frey• Central pancreatic head resection without

transection• Longitudinal PJ in Frey operation is omitted• Advantages – Reduces bleeding in PHT

BERNE TECHNIQUE• Perioperative and follow-up results after central pancreatic head resection (Berne technique) in a consecutive series

of patients with chronic pancreatitis• Top of Form• Michael W. Müller, M.D.Helmut Friess, M.D.Sarah Leitzbach Christoph W. Michalski, M.D.Pascal Berberat, M.D.

Güralp O. Ceyhan, M.D.Ulf Hinz, M.Sc.Choon-Kiat Ho, M.D.Jörg Köninger,Jörg Kleeff, M.D. Markus W. Büchler, M.D. published online 30 May 2008.

• A prospective evaluation of 100 consecutive patients who underwent CPHR for CP between January 2002 and December 2006 was performed. Long-term follow-up, including quality-of-life (QOL) assessment, was carried out.

• Results• The hospital mortality rate was 1%; the surgical morbidity rate was 16%; and the relaparotomy rate was 6%. Mean

surgery time was 295 ± 7 minutes; mean intraoperative blood loss was 763 ± 75 mL; and the mean postsurgical hospital stay was 11.4 ± .8 days. After a median follow-up of 41 months, pain was improved in 55% of patients; weight increase occurred in 67% of patients; and insulin-dependent diabetes mellitus developed in 22% of the patients. Comparison of QOL parameters with a German adult control population showed no statistically significant differences.

• Conclusions

• CPHR is a safe surgical option to resolve CP-associated problems. Long-term follow-up QOL after CPHR shows results comparable with date published data after the Beger and the Frey procedures.

•

BERNE TECHNIQUE• A modified technique of the Beger and Frey procedure in patients with chronic pancreatitis.• Gloor B, Friess H, Uhl W, Buchler MW.w• Dig Surg 2001; 18:21-5. [Full text] (PMID 11244255)• Resection of the pancreas requires control of tributaries of the superior mesenteric vein (SMV) inferior

to the head of the pancreas as well as separation of the posterior surface of the pancreas from the SMV and from eventually existing collateral veins. This usually is the most tedious part when performing a resection of the pancreatic head, in particular if there are signs of portal hypertension. Portal vein pathology contributes to intra- and postoperative morbidity in pancreatic surgery. OPERATIVE TECHNIQUE: Instead of dissecting the pancreas along the anterior surface of the SMV our proposed technique allows resection of the head of the pancreas without division of the gland. This approach combines elements of Beger's duodenum-preserving pancreatic head resection and of Frey's limited local pancreatic head excision combined with a longitudinal pancreaticojejunostomy. This modified technique avoids the risk of a bleeding complication which is increased in the presence of portal hypertension and dilation. SUMMARY: The advantages of this modified technique over standard Beger and Frey procedures are: (1) the minimized risk of a bleeding complication in case of portal hypertension because pancreatic transsection does not need to be done, and (2) the considerably more radical excision as compared to local excision. Also, it represents the most minimal surgical trauma for resecting the head of the pancreas as compared to other commonly used techniques.

WHIPPLE OPERATION

• Normal PD(6-7 mm in body)• Head mass with cysts & calcification• Ineffective previous drainage procedure• ?malignancy in the head(unresolved in 6-8%)

WHIPPLE PROCEDURE

• Advantages– Permanent pain relief in >80%– Results better than other procedures• Frey et al ,1993

– Low operative mortality(<5%) in major centres– Morbidity – acceptable range• Crist et al,1987/Trede et al,1990/Witzigmann et al,2003

WHIPPLE PROCEDURE

• Disadvantages– Unsatisfactory postoperative morbidity– Poor long term results in CP– Reduced quality of life– Digestive dysfunction• Dumping /diarrhoea/peptic ulcer/dyspepsia

– In 20% leads to DM & hence late morbidity & mortality

» Izbicki et al,1998

PYLORUS PRESERVING WHIPPLE(PPPD)

• Introduced by Traverso & Longmire in 1978• Advantages– It reduces

• Dumping• Marginal ulceration• Bile reflux gastritis

– Better QOL when compared to classical PD– Weight gain in 90% of operated patients– Long lasting pain relief in 85-95%(Martin et al,1997)

PPPD

• Disadvantages– Transient delayed gastric emptying(30-50% of

patients)– Risk of cholangitis– Long term occurrence of exocrine & endocrine

pancreatic insufficiency(>45%)(Muller et al,1997)

PPPD

IZBICKI PROCEDURE

IZBICKI PROCEDURE

• V shaped excision of ventral pancreas– Secondary & tertiary ducts draining in to the Roux

loop of jejunum– Complete pain relief in 92%– 77% added 10% of their pre therapy weight

PANCREATIC LEFT RESECTION

• 40-60% of the gland is to be removed• 5-15 % of surgical candidates benefit • Indications– When associated with inflammatory complications

such as• Pseudocyst• Fistula• MPD stenoses• Recurrent acute pancreatitis• ?malignancy

PANCREATIC LEFT RESECTION

• Performed with or without splenectomy• Avoiding splenectomy is better– Prevents OPSI– Better for host defense mechanism

• Splenectomy indicated in– Splenic pseudocysts– Inflammatory & fibrotic encasement of splenic

vessels

PANCREATIC LEFT RESECTION

• Management of stump– Suture ligation– Roux-en-Y Pancreatico-jejunostomy

• Postoperative outcome is similar in both groups(shankar et al,1990)

• Hence drainage is indicated when there is– A dilated duct– Stricture in the pancreatic head

CENTRAL PANCREATECTOMY

• Done for neck & proximal body lesions• Indicated for – Focal chronic pancreatitis– Post-traumatic pancreatitis

• Reconstruction– Pancreatico-gastrostomy– Pancreatic jejunostomy

• Preserves– Endocrine &– Exocrine function

CENTRAL PANCREATECTOMY

CENTRAL PANCREATECTOMY

MINIMALLY INVASIVE PROCEDURES

• Indicated for– Distal chronic pancreatitis & – with pseudocysts

• Advantages– Pain relief achieved in 72%(schoenberg et al,1999) &80%

(Sakorafas et al,2000)– Adequate visualization– Avoid complications like bleeding & perforation– Shorter hospital stay(Heider et al)– Morbidity 20% – Mortality 1%

COMPLICATIONS IN PANCREATIC SURGERY

• Mortality <5%• Morbidity 20-40%• Morbidity are mainly– Delayed gastric emptying

• occurs in 40% cases• DGE is defined as need for nasogastric tube for >10 days• Benifitted by erythromycin(Yeo et al,1993)

– Pancreatic fistula • Incidence is 2-16%(Buchler et al,2000)• Fistula is defined as 30ml/day of amylase rich (>5000IU)fluid

for >10 days

COMPLICATIONS IN PANCREATIC SURGERY

• Prevented by– Routine peri-operative & post-operative octrotide-

100-200µg/day sc 3 times daily for 7 days(Bassi et al,1994/Buchler/Pederzoli))

– Standard surgical technique– Experienced surgeon– Duct to mucosa anastamosis– Temporary ductal stenting

REVIEW OF RCT’S

PPPD(20) vs DPPHR(20)

Buchler et al,1995• DPPHR had– Less pain– Greater weight gain– Better glucose tolerance– High insulin secreting capacity– Less morbidity

PPPD vs DPPHR

• Muller et al,1997– DPPHR(10)

• No DGE

– PPPD(10)• Early DGE

• Makowiec et al,2004– PPPD(44)– DPPHR(43)

• No difference in endocrine function & QOL

FREY(38) vs DPPHR(37)

IZBICKI ET AL,1997

• Decrease in pain score– DPPHR 95%– Frey 93%

• Morbidity – DPPHR 32%– Frey 22%

• Equal endocrine & exocrine function

FREY(30) vs PPPD(31)

IZBICKI ET AL,1998• Morbidity – PPPD 53%– Frey 19%

• QOL– Frey 71%– PPPD 43%

• Equal pain relief

Whipple(21) vs DPPHR(22)

KLEMPA ET AL,1995• DPPHR– Pain relief higher(100% vs 70%)– New onset of DM significantly lower(9% vs 28%)– Better weight gain– Equal morbidity & mortality

SUMMARY• Duct drainage

– Chronic pancreatitis– MPD dilated– No head mass

• DPPHR/FREY– Chronic pancreatitis– Head mass

• PPPD– Chronic pancreatitis– Head mass ?malignancy

• DPPHR– Pancreas divisum– Chronic pancreatitis

TREATMENT ALGORITHM