Table of Contents
Page created on October 11, 2021. Last updated on October 19, 2021 at 21:15
Introduction
For introduction, etiology, and pathology, see the corresponding pathology 2 topic. For see clinical features, diagnosis, and non-surgical treatment, see internal medicine final topic 63.
Introduction to surgical treatment of chronic pancreatitis
Surgery is indicated for:
- Intractable abdominal pain (most common indication for surgery)
- Complications
- Pseudocyst > 5 cm
- Bile duct stenosis
- Duodenal stenosis
- Internal pancreatic fistula
- Suspicion of malignancy
The management differs based on whether the pancreatic duct is dilated or not, as this dilation indicates whether increased intraductal pressure is a contributing cause of the complaints or not. A dilated duct is an obstructed duct (due to stone or stricture), which requires drainage.
Surgical procedures involve resection of the pancreatic parenchyme, drainage of the pancreatic duct, or a combination of both.
Surgery for chronic pancreatitis with not-dilated pancreatic duct
Coeliac plexus block with bupivacaine gives pain relief for 3 – 6 months, after which it may be repeated.
Partial surgical pancreatectomy of fibrotic and poorly drained parenchyme may also be performed, although these are rarely necessary. These surgeries are the same as those performed for pancreatic malignancy (see topic B55), including Whipple operation or distal pancreatectomy. If the whole parenchyme is diffusely involved, a total pancreatectomy may be performed, which is followed by islet cell autotransplantation to reduce the risk for diabetes mellitus.
Surgery for chronic pancreatitis with dilated pancreatic duct
Endoscopic (ERCP) therapy is the first choice for treatment of dilated pancreatic ducts. If this is insufficient, surgery may be performed. Both modalities can treat any stones or strictures.
Surgical options include the Frey operation and the Beger operation. These are different forms of pancreatic head resections. If the chronic pancreatisis causes biliary tract obstruction and jaundice, pancreatic head resection can be combined with a biliodigestive anastomosis (topic B35).
The Frey procedure is a duodenum-preserving resection of the pancreatic head combined with longitudinal opening of the dilated pancreatic duct. A Roux-limb is anastomosed to the resected head and opened pancreatic duct as a longitudinal pancreatojejunostomy, which drains the pancreatic duct into the jejunum.
The Berne modification of the Beger procedure is another duodenum-preserving pancreatic head resection. A crater-shaped resection is made of the pancreatic head, after which a Roux-limb is anastomosed to it.