3004 Recurrent Painful Pancreatitis After Puestow Procedure

Abstract

INTRODUCTION: Chronic pancreatitis (CP) is a progressive, irreversible inflammation and fibrosis of the pancreas, leading to irreversible damage, chronic pain, and pancreatic insufficiency due to loss of endocrine and exocrine function. The most common etiologies are alcohol abuse, autoimmune pancreatitis, ductal obstruction, hypercalcemia, and hypertriglyceridemia.1 CASE DESCRIPTION/METHODS: A 23-year-old male with history pancreatitis, tobacco smoking with multiple admissions due to epigastric pain, nausea, and vomit after lateral pancreatojejunostomy. Prior workup for autoimmune pancreatitis and hypertriglyceridemia was negative. Evaluation was significant for an MRCP (Figure 1) that showed pancreatic duct stones with near complete atrophy of the remaining pancreatic gland and an abdominopelvic CT scan (Figure 2) that showed no gallstones or dilation of the common bile duct. Endoscopic ultrasound showed a duodenal ulcer negative for H. pylori., one major criteria A and three minor criteria. Findings consistent with chronic pancreatitis as per Rosemont classification. Repeated upper endoscopy showed no evidence of prior duodenal ulcer. Abdominal pain, nausea, and pain persisted without significant improvement for months after surgery, with more than four admissions in six months. DISCUSSION: CP is a debilitating painful condition. Pain from CP is associated with mechanical obstruction, damaged intrapancreatic nerves and increased intraductal pressure, leading to dilation of the pancreatic duct.2,3 Treatment is focused on pain control with non-steroidal anti-inflammatory drugs, opioids, and celiac plexus block. Medical therapy often fails, and patients tend to require invasive measures such as endoscopic therapy and surgical procedures.4 Invasive interventions are used to relieve obstruction caused by pancreaticolithiaisis or strictures. Whipple resection and Puestow procedure are surgical procedures used for pain control. Modified Puestow is associated with decreased morbidity and decreases length of hospital stay. This procedure is designed to preserve healthy pancreatic tissue retaining exocrine and endocrine function of the pancreas.5 Complete pain resolution occurs in 80% of patients after lateral pancreaticojejunostomy. Nonetheless, failure rates are prevalent in numerous, creating frustration and depression in patients with this debilitating condition. Newer options are available, but most of them are offered at specialized centers, leading to limited access of these novel therapies.6