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SSAT Patient Care Guidelines

Operative Treatment for Chronic Pancreatitis

Introduction
Chronic pancreatitis has an incidence in the United States of 5-10 per 100,000 population. It is most commonly associated with chronic alcohol use (75%). Patients usually present with chronic pain, either persistent continuous pain or postprandial pain. Patients with chronic pancreatitis may be at increased risk of developing pancreatic cancer.

Symptoms and Diagnosis
Pain is the major disabling symptom in patients with chronic pancreatitis, often leading to associated weight loss and/or narcotic dependency. Biliary obstruction (jaundice), endocrine insufficiency (diabetes), and exocrine insufficiency (malabsorption) may manifest with the progression of chronic pancreatitis and loss of functional pancreatic parenchyma.

CT scan, ultrasonography, MRCP, or ERCP usually makes the diagnosis of chronic pancreatitis and its complications. Typical findings can include a dilated pancreatic duct or strictures with dilatations of the duct ("chain of lakes"), pancreatic (parenchymal or intra-ductal) calcification, or pseudocyst. Biliary or duodenal obstruction and evidence of portal hypertension may also be present. It is difficult to distinguish between chronic pancreatitis and pancreatic cancer, especially in patients without pancreatic calcification.

By clearly defining pancreatic and biliary ductal anatomy, ERCP and MRCP can help to select patients who might benefit from surgery and to plan the most appropriate operation. In patients with atypical gastrointestinal bleeding and pancreatitis, angiography of the celiac and superior mesenteric arteries can detect and embolize a pseudoaneurysm.It is also important to establish a baseline of pancreatic exocrine and endocrine function, nutritional status, pain severity, use of pain medication or narcotics, employment status, and quality of life. Continued ingestion of alcohol or narcotics should be addressed in either a medical or surgical management plan.

Treatment
Patients with disabling abdominal pain, evidence of chronic pancreatitis, and pancreatic ductal dilatation are best managed by pseudocyst decompression or ductal decompression (Puestow panceraticojejunostomy procedure), while patients without ductal dilatation are best treated with resection. Biliary-enteric decompression may also be required in patients with chronic pancreatitis and bile duct obstruction. Although preservation of pancreatic tissue is desired to maintain both exocrine and endocrine function, partial pancreatic resection (such as distal pancreatectomy ,pancreaticoduodenectomy, or duodenal preserving pancreatic head resection/decompression [i.e. Beger or Frey procedures]) is at times the preferred treatment. While alternative procedures such as endoscopic sphincterotomy, short-term stent placement in the major pancreatic duct or pancreatic pseudocyst, may provide short-term relief of symptoms; long-term results are as yet unknown.

Risks
Risks and complications associated with operation for chronic pancreatitis include infection, bleeding, biliary and pancreatic anastomotic leaks, and aggravation of existing acute pancreatitis, with a frequency in the range of 0.5% to 5%. While it varies with the procedure, the mortality rate of pancreatic surgery is currently below 5% for major resections and even less for non-resective decompressive operations.

Expected Outcomes
Initial pain relief can be expected in 75-80% of patients and sustained in selected patients for 3-5 years. The incidence of postoperative diabetes and steatorrhea (fatty stool) depends upon the amount of pancreatic tissue resected and the disease status of the remaining gland. Among non-diabetic patients, 10-15% will develop diabetes within 10 years due to the natural progression of associated exocrine and endocrine insufficiency, which can be slowed in some patients by abstinence from alcohol or by decompression of an obstructed main ductal system. Successful relief of pain after operation is associated with weight gain in most patients. Overall, the best outcomes occur in patients who are compliant with pancreatic enzyme replacement and abstain from alcohol and narcotics use. The average length of hospital stay after major pancreatic surgical procedures is 7-14 days. Hospital stay tends to be longer after pancreaticoduodenectomy than after distal pancreatectomy or ductal decompression operations.

Qualifications for Performing Day Surgery
At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for pancreatitis . These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the pancreas. Pancreatic surgery should preferably be performed by surgeons with special knowledge, training and experience in the management of pancreatic disease. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery of the pancreas is important to assess. The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes.

References
Buchler MW, Friess H, Bittner R, Roscher R, Krautzberger W, Muller MW, Malfertheiner P, Beger HG. Duodenum-Preserving Pancreatic Head Resection: Long-Term Results. J Gastrointest Surg 1997;1:13-19.

Traverso LW, Kozarek RA. Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis. Ann Surg 1997;226:429-438.

Lucas CE, McIntosh B, Paley D, Ledgerwood AM, Vlahos A.Surgical decompression of ductal obstruction in patients with chronic pancreatitis. Surgery 1999;126:790-797.

Duffy JP, Reber HA. Surgical treatment of chronic pancreatitis. J Hepatobiliary Pancreat Surg 2002; 9: 659-668.

Frey CF, Mayer KL. Comparison of local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (frey procedure) and duodenum-preserving resection of the pancreatic head (beger procedure). World J Surg 2003;27:1217-1230

Written 3/11/96
Revised 5/5/96
Revised 9-26-96
Revised 10-05-96
Revised 2-5-97
Revised 5-6-97
Revised 5-11-97
Revised 9/26/99
Revised 10/25/99
Proofed 1/8/00
Revised 5/15/04
Revised 11/22/13
Board Approved 11/22/13

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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