Essentials in Surgery for Chronic Pancreatitis

Abstract

Accessible online at: www.karger.com/journals/dsu Exocrine and endocrine pancreatic insufficiency and recurrent episodes of abdominal pain comprise the characteristic clinical features of chronic pancreatitis. Severe pain is the leading cause for hospitalization, inability to work, early retirement, and addiction to analgesics in devastating conditions of chronic pancreatitis [1]. Like other therapeutic modalities, surgery addresses pain as the incapacitating symptom, while causative treatment options are still lacking. The indications for surgical intervention are intractable pain, complications related to adjacent organs, endoscopically not permanently controlled pancreatic pseudocysts in conjunction with ductal pathology, and conservatively intractable internal pancreatic fistulas [1–3]. Occasionally the inability to exclude pancreatic cancer despite broad diagnostic workup also requires surgery [4]. The ideal surgical approach should address all these problems. Pain is the crucial symptom in severe chronic pancreatitis. Reflecting experimental evidence and clinical experience, ductal and parenchymatous hypertension and neural alterations in combination with extensive fibrosis have been developed as basic hypotheses on the pathogenesis of pain in chronic pancreatitis [5–10]. Referring to these different ideas of pain origin, drainage and resection have emerged as the main principles of surgery in chronic pancreatitis. Exclusively draining and resective operations [2, 3, 11–14] have failed to meet all the aims of an ideal surgical treatment for chronic pancreatitis (table 1). More recently, a variety of different procedures has been either been proposed [15, 16] or recalled [17, 18], relying on both drainage and resection with emphasis of one or the other. Classical partial pancreatoduodenectomy (PD) according to Whipple, pylorus-preserving pancreatoduodenectomy (PPPD) according to Traverso-Longmire, duodenum-preserving resection of the head of the pancreas (DPRHP) according to Beger, and longitudinal pancreatojejunostomy combined with local pancreatic head excision (LPHE-LPJ) according to Frey were performed to provide pain relief, to control complications arising from adjacent organs, and to identify intraoperatively pancreatic cancer which had been missed despite broad diagnostic workup [4, 9, 10, 19]. But from that kind of experience, superiority of any of these procedures cannot be concluded. In order to provide information on which procedure should be favored, prospective randomized trials are necessary which incorporate the criteria, i.e., pain intensity, analgesic regimen, exocrine and endocrine Table 1. Aims of surgical treatment for chronic pancreatitis