|Year : 2013 | Volume
| Issue : 2 | Page : 85-88
Chronic pancreatitis: A surgeon's perspective
Nadiminti Subbarao, Rajesh Muppana, Vidya Konduru
Department of Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
|Date of Web Publication||21-May-2013|
Department of Surgery, Andhra Medical College, Visakhapatnam, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
The incidence of pancreatic diseases is increasing in view of changing lifestyle. Better understanding of the pathophysiology of chronic pancreatitis and improved postoperative care has led to the increasing role of surgery in those cases where all conservative measures fail. Drainage procedures, particularly for idiopathic variety, which is commoner in these parts, give gratifying results. Resection procedures such as Whipple's operation are reserved for small duct disease as in alcoholic pancreatitis. In the West, some centers even practice a total pancreatectomy followed by islet auto-transplantation, which not only relieves pain but also minimizes the otherwise inevitable diabetes.
Keywords: Chronic pancreatitis, pancreatic calculi, pancreatic surgery
|How to cite this article:|
Subbarao N, Muppana R, Konduru V. Chronic pancreatitis: A surgeon's perspective. J NTR Univ Health Sci 2013;2:85-8
| Introduction|| |
Very few surgeons used to operate on pancreas possibly due to dreaded complications such as fistula and even mortality. But with increased awareness of the intricate anatomy and pathophysiology, improved surgical skills and post-operative care, more and more surgeons are attempting pancreatic surgeries. Another reason for this trend is the fact that pancreatic disease itself is on the rise.
This is mainly due to the increased consumption of alcohol and fatty foods and smoking, especially among youth. Of the various diseases of pancreas, acute pancreatitis is most often treated conservatively and carcinoma pancreas (except periampullary) is rarely diagnosed in operable stage. Hence, the bulk of the surgery on pancreas is for chronic pancreatitis.
| Etiology|| |
Most of the etiological agents blamed for acute disease, especially alcohol, are the culprits even for chronic pancreatitis. But one characteristic entity unconnected with any of these is seen in Asia, and especially in South India. It is named variously as chronic calcific pancreatitis of the tropics,  tropical pancreatitis,  South Indian pancreatitis, and fibrocalculous pancreatitis,  etc. It used to be frequent in Kerala when cassava was the staple diet among the poor.  But it is found that with improved nutritional standards, the incidence of this particular variety is on the decline.  However, disease of similar pattern unrelated to alcohol, the idiopathic chronic pancreatitis is still fairly common in these regions. 
| Pathology|| |
The chief pathological feature of chronic pancreatitis is progressive and irreversible fibrosis, leading ultimately to both exocrine and endocrine insufficiency.  Idiopathic chronic pancreatitis differs from the alcoholic variety in many ways. It presents at a much younger age (10-30 years)  and there is early onset of diabetes.  Calcification, mainly intraluminal, and ductal dilatation are pronounced, making it more amenable for surgery. 
| Clinical Features and Diagnosis|| |
The clinical features of chronic pancreatitis are typical. Pain is the chief complaint and is associated with features of malabsorption (steatorrhea) and diabetes. Occasionally the patient may present with the complications such as pseudocyst, gastric outlet obstruction and obstructive jaundice. Although tests for exocrine functions can be done, the diagnosis of chronic pancreatitis depends mainly on imaging studies such as ultrasound and computed tomography scan, which show duct dilatation and calculi. The intraductal calculi in tropical pancreatitis are discrete, dense and up to 5 cm in size. They can also extend into the side branches. In contrast, the calculi in alcohol-related chronic pancreatitis are usually small and speckled.  Magnetic resonance cholangiopancreatography and computed tomography cholangiopancreatography are more frequently used of late. Endoscopic ultrasound is a recent addition, but it is costly and needs expertise. It is especially useful for detection of early-stage disease  and evaluation of mass lesions. 
| Management|| |
The main aim of treatment of chronic pancreatitis is pain relief. Patients should quit alcohol and smoking. Pancreatic enzymes are to be supplemented. Non-narcotic analgesics are tried first and as the disease progresses, even narcotic analgesics may be needed.
Endoscopic retrograde cholangiopancreatography is useful for the removal of stones of less than 5 mm and placement of stents across strictures and sphincterotomy may be done.  Extracorporeal shock wave lithotripsy is also being attempted. Other nonsurgical methods such as celiac ganglion blocks (with endoscopic and radiological guidance) rarely give permanent relief.
| Role of Surgery|| |
The chief indication for surgery in chronic pancreatitis is persistent pain in spite of all conservative measures. Idiopathic pancreatitis, which is characterized by stone formation and duct dilatation, is managed by drainage procedures after removal of calculi. In most other varieties, where there is small duct disease, resection such as Whipple's operation is the procedure of choice.  Surgeries for chronic pancreatitis can be classified as follows: 
- Duval's procedure
- Puestow-Gillesby procedure
- Partington-Rochelle longitudinal pancreaticojejunostomy
- Distal pancreatectomy
- Kausch-Whipple pancreaticoduodenectomy
- Pylorus-preserving pancreaticoduodenectomy (PPPD)
- Beger operation (duodenum-preserving resection of the head of pancreas)
Resection and drainage
- Frey procedure
- Izbicki procedure
Subtotal or total pancreatectomy with pancreatic islet autotransplantation.
Though many modifications for the original Duval  and Puestow's  procedures are in vogue, Partington's longitudinal (lateral) pancreaticojejunostomy  [Figure 1] is widely used. A dilated main pancreatic duct (minimum diameter of 8 mm) is a prerequisite for good duct to mucosa anastomosis. The duct is identified by prior aspiration with a 10-cc syringe [Figure 2]. It is laid open either with knife or diathermy in its entirety from head to tail. All the calculi, some of which may be firmly adherent and quite big [Figure 3] and [Figure 4], are to be removed for complete pain relief. A long side-to-side, lateral pancreaticojejunostomy (Roux-en-Y) is done in two layers [Figure 5] and [Figure 6]. Vicryl 3-0 suture is preferred for the inner layer.
|Figure 2: Intra-operative photograph showing identifi cation of the pancreatic duct by aspiration|
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|Figure 3: Intra-operative photograph showing a large calculus being extracted from the pancreatic duct|
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|Figure 5: Intra-operative photograph showing the dilated pancreatic duct|
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|Figure 6: Intra-operative photograph showing the completed lateral pancreaticojejunostomy|
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Resection procedures are not routinely practiced in these parts of the country in view of the facts that (a) they involve removal of normal organs against the principles of surgery for benign diseases, (b) they are technically challenging with high rates of morbidity and (c) there is paucity of referral (of alcoholic chronic pancreatitis cases). Either distal pancreatectomy or pancreaticoduodenectomy is done depending on the site and extent of disease.
Resection in distal pancreatectomy varies from 50 to 90% of the gland, depending on how it is defined.  It is less commonly done as it is useful mainly for disease confined to distal body or tail, which is rare. Whipple's operation or its modification, the PPPD reported by Traverso and Longmire in 1978  [Figure 7] is gaining popularity due to decreasing morbidity rates. The rationale of removing the pancreatic head in chronic pancreatitis is (a) the concept of Longmire that the pain pacemaker is located there (b) chronic pancreatitis mainly affects that region and (c) both carcinoma and chronic pancreatitis can present as a space-occupying lesion in the head of pancreas.
|Figure 7: Traverso-Longmire's pylorus preserving pancreatic oduodenectomy|
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Combined drainage and resection procedures were advocated by some, both to achieve cytoreduction and reduction of intraductal pressure. Beger's duodenum preserving resection of the head of the pancreas,  Frey's procedure  where in addition, extended drainage is done and Izbicki's V-shaped ventral pancreatic excision  [Figure 8] are few such procedures.
At the other end of the spectrum is total pancreatectomy and islet autotransplantation for chronic pancreatitis practiced since 1977 in North America.  Pancreatic surgeries are now being performed through the laparoscopic approach.
Surgery is also necessary to tackle complications such as pseudocysts, where cystogastrostomy or cystojejunostomy is required. Occasionally, mass formation results in obstruction of the common bile duct or duodenum, necessitating suitable drainage operations.
| Summary|| |
There is an increasing trend towards pancreatic surgery, particularly for chronic pancreatitis. The idiopathic variety, which differs from alcoholic pancreatitis, is more common in these parts of the world. In view of its pathology, it is more amenable for surgical treatment, particularly drainage procedures, which give gratifying results. In alcoholic chronic pancreatitis, if conservative measures fail, pancreatic resection such as PPPD can be safely performed now due to improved surgical skills and postoperative management.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]