Surgery in chronic pancreatitis

sx in chr pancreatitis

1. Surgery in chronic pancreatitis Resident of surgery Dr SNMC,JODHPUR ---Dr sumer 2013

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

4. CP Etiologies 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

5. Symptomatic features

6. Diagnostic tests in CP 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

7. X ray abd -calcification

8. EUS Hyperechoic walls of duct Duct dilatation Stones in duct Parenchymal lobularity,strands and cysts

9. CECT-Homogenous enhancement of pancreas

10. MRCP-Dilated duct and intraductal debris

11. Management of CP Medical therapy Endoscopic therapy Surgical options Nerve blocks

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

13. AIMS OF SURGICAL TREATMENT Pain relief Control of complications Preservation of exocrine and endocrine functions Social and occupational rehabilitation Improvement of quality of life

14. Issues related to surgery Problems; Subjective Severity grading:often arbitrary Pain scoring systems Natural history:alc cp ‘burn out theory’ Timing of surgery

15. Pain Mechanisms Pancreatic duct hypertension{outflow obstruction} ‘Compartment syndrome’ Neural involvement Genetic factors

16. Pain scoring systems Parameters assesed Intensity a.visual analog scale b.pain medication c.narcotic addiction Frequency Trials:>1 episode per month Duration most surgical series >1 yr Conseqences absence from work number of hospitalisations

17. Literature based evidence for surgery 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

18. The case for surgery…………. ‘……..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.’ Andrew wershaw wershaw al gastroenterology;1984

19. Surgical decision making Anatomy of the disease 1.small duct disease 2.large duct disease 3.location of inflammatory mass Associated complications 1.biliary obstruction 2.duodenal stenosis 3.pseudocysts 4.GI bleeding / PHT 5.Malignancy Etiology

20. Timing of surgery 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?

21. Surgical procedures in CP 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

22. Drainage procedures 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

23. Combined resection-drainage procedure Inflamed and enlarged pancreatic head Requires resection 1.Whipple 2.Beger[duodenum preserving pancreatic head resection] 3.Frey

24. Lateral PJ [[ Puestow ]] Most commonly performed today

25. Two layered suturing

26. Pancreaticoduodenectomy Whipple procedure 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

27. Retroperitoneum after whipple specimen removed

28. Beger procedure 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%]

29. Freys procedure 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

30. Beger vs Freys

31. Other procedures

32. Modifications of beger and freys proc 1998,longitudinal V shaped excision of ventral pancreas Indicated for small duct pancreatitis Author described 95% pain relief

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

34. Laparascopic assisted distal pancreatectomy

35. Operations for pancreatic pseudocyst 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]

36. CONTd 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

37. CONTd 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%

38. Confirm location of psedocyst by aspiration

39. Cyst- jejunostomy

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

41. Infusion of islets into the portal vein using 18 g angiocatheter

42. Video-assisted thoracoscopic splanchnicectomy 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

43. Reoperative pancreatic surgery 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

44. GI SURGERY AIIMS DATA 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

45. Summary and conclusion 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]]

46. CONTd 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

47. THANKS