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Surgery for chronic pancreatitis

Surgery for chronic pancreatitis
Literature review current through: Jan 2024.
This topic last updated: Feb 28, 2022.

INTRODUCTION — Chronic pancreatitis (CP) is a benign, inflammatory disorder of the pancreas resulting in fibrotic replacement of the pancreatic parenchyma. The clinical presentation of CP is marked by severe, refractory abdominal pain. CP often leads to progressive endocrine failure (type 3c diabetes mellitus [1]) and exocrine failure (malabsorption with attendant nutritional compromise) of the pancreas.

Clinical management of CP is challenging, given incomplete understanding of disease pathogenesis and the complexities of pain control. Initial management of CP entails risk factor modification with alcohol abstinence and tobacco cessation, treatment of pain (ideally) with supportive behavioral therapy, and nutritional optimization with pancreatic enzyme replacement. Patients who continue to have debilitating pain despite best medical management are candidates for therapeutic intervention.

We discuss the indications, techniques, and outcomes of surgery for chronic pancreatitis in this topic. Nonsurgical treatments of chronic pancreatitis and surgical treatments of other pancreatic diseases are discussed in other topics. (See "Chronic pancreatitis: Management" and "Surgical resection of lesions of the head of the pancreas" and "Surgical resection of lesions of the body and tail of the pancreas" and "Total pancreatectomy".)

ENDOSCOPY VERSUS SURGERY — For patients with chronic pancreatitis (CP) who require therapeutic intervention, endoscopic approaches are usually undertaken before surgery, owing to the perception that less invasive procedures should be attempted first. The optimal timing of surgery for patients who fail endoscopic interventions, however, is debated.

A 2015 Cochrane review suggested that for CP, surgery is superior to endoscopy in achieving lasting pain relief, and that early surgical intervention may help preserve pancreatic function [2]. Included in the Cochrane review are two randomized trials that compared endoscopic with surgical treatment of CP:

In one trial, 72 patients with painful obstructive CP were randomly assigned to endoscopic or surgical intervention. Endoscopic therapy consisted of endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stenting (52 percent of patients) and/or stone removal (23 percent), while surgery consisted of a resection (80 percent) or drainage (20 percent) procedure. At five years, more patients who underwent surgery were pain free than those who underwent endoscopy (34 versus 15 percent); the rates of partial pain relief were similar (52 percent after surgery versus 46 percent after endoscopy) [3].

In a second trial, 39 patients with painful obstructive CP underwent endoscopic intervention (ERCP with sphincterotomy and stenting) or surgery (drainage procedure). At five years, more patients reported sustained pain relief after surgery than after endoscopy (80 versus 38 percent). Patients who underwent surgery also had greater improvements in quality of life; underwent fewer procedures; and had similar morbidity, length of stay, and pancreatic function compared to patients treated endoscopically [4,5].

In another trial published in 2020 (ESCAPE), 88 patients with chronic pancreatitis evidenced by a dilated duct, who had been started on narcotic pain medications recently, were randomly assigned to early surgery (Puestow, Frey, or Beger procedure) versus the endoscopic-first approach [6]. At 18 months, early surgery resulted in a lower pain score (37 versus 49) and higher partial or complete pain relief (58 versus 39 percent) than the endoscopic-first approach. The total number of interventions was also lower in the early surgery group (median, 1 versus 3); all other outcomes were similar.

There are also data suggesting that a prolonged disease course, indicated by daily opioid use, and high number of endoscopic interventions are predictive of worse outcomes in CP [7]. In light of this evidence, surgeons and gastroenterologists should work collaboratively to offer patients the best possible care, rather than exhausting nonoperative therapies first before considering surgery.

Endoscopic management of chronic pancreatitis is discussed in detail in another topic. (See "Chronic pancreatitis: Management", section on 'Endoscopic therapy'.)

SURGERY FOR PAIN — Forty to 75 percent of patients with chronic pancreatitis (CP) fail medical and endoscopic therapies and are considered for surgery, most commonly for debilitating abdominal pain [8-10]. The goals of surgery are to effectively and durably relieve pain, minimize short- and long-term morbidity, and preserve pancreatic parenchyma and therefore long-term pancreatic function. Currently, pancreatic ductal anatomy and gland morphology are the primary determinants in surgical planning algorithms (algorithm 1).

Dilated pancreatic duct — Patients with a dilated main pancreatic duct (≥6 to 7 mm) are assumed to have obstructive pancreatopathy and would benefit from a drainage procedure (eg, lateral pancreaticojejunostomy). A limited resection can be added to the drainage procedure (eg, Frey procedure) to address fibrotic parenchyma that drains poorly and peripancreatic neural damage in the pancreatic head.

Lateral pancreaticojejunostomy — Retrograde pancreatic drainage was presented by Puestow and Gillesby in a small series of patients with relapsing pancreatitis in 1957 [11]. In 1960, Partington and Rochelle described a modification of Puestow's procedure, which more closely resembles the modern-day technique of lateral pancreaticojejunostomy (LPJ) [12].

LPJ is the traditional operation for pancreatic drainage and entails opening the pancreatic duct anteriorly along its length, medially to the level of the gastroduodenal artery, and laterally into the tail beyond all appreciable pancreatic duct strictures. The opened pancreatic duct is cleared entirely of stones and then sewn to a Roux-en-Y jejunal limb for drainage (figure 1).

Minimally invasive LPJ has been more commonly undertaken over the past decade [13,14]. The success rate for the minimally invasive approach increases as the size of the pancreatic duct increases.

Multiple retrospective single-institution case series have reported pain relief rates ranging from 48 to 91 percent [12,15-21]. Complications are uncommon (20 percent), including intraoperative hemorrhage (due to splenic vein, splenic artery, or gastroduodenal artery injury), postoperative hemorrhage (typically from the gastroduodenal artery), and anastomotic leak (10 percent). Because pancreatic parenchyma is not removed, endocrine and exocrine functions are usually preserved or even enhanced after LPJ due to amelioration of obstructive pancreatopathy [22].

Although LPJ is a safe and effective procedure for CP with a dilated duct, patients with a nondilated main pancreatic duct are generally not candidates for LPJ [23]. Recurrent pain can occur after LPJ, typically due to unaddressed fibrosis or stones in the pancreatic head. Clearance of intraductal stones in the head of the pancreas during LPJ with the aid of intraoperative pancreatoscopy or electrohydraulic lithotripsy has been shown to improve outcomes [24]. Combining a localized pancreatic head resection with LPJ can also reduce the risk of recurrent pain. (See 'Lateral pancreaticojejunostomy with localized pancreatic head resection' below.)

Lateral pancreaticojejunostomy with localized pancreatic head resection — In 1987, Frey described a technique that opens the pancreatic duct along its length and into the head and uncinate process of the pancreas for drainage, "cores" out the overlying fibrotic pancreatic head tissue without transecting the pancreatic neck, and preserves the pancreatic parenchyma along the posterior and lateral margin of the pancreatic head and the duodenum to minimize long-term gastrointestinal dysfunction (figure 2) [25].

The initial report by Frey included 50 patients; 89 percent of patients had pain relief, 64 percent experienced significant weight gain, and only 11 percent had progression of diabetes [26]. Frey's results have been validated by other series both at his own institution and others, with reported pain relief rates of 62 to 91 percent and morbidity rates of 8 to 39 percent [27-31].

Nondilated pancreatic duct — In patients with a small-diameter main pancreatic duct (<6 to 7 mm), resection, rather than drainage of the fibrotic and poorly drained parenchyma, is required. Patients with head-dominant or tail-dominant disease can undergo a directed partial resection (pancreaticoduodenectomy or distal pancreatectomy). Patients with diffuse parenchymal involvement require a total pancreatectomy, ideally with islet autotransplantation.

Head-dominant disease — The techniques most commonly used to resect the head of the pancreas include classic pancreaticoduodenectomy (PD), pylorus-preserving PD (PPPD), and duodenum-preserving pancreatic head resection (DPPHR).

Multiple small trials, most of which are from Germany, failed to elucidate any consistent advantage of one technique over the others [31-36]. A 2016 Cochrane review of five such trials and 269 participants concluded, based on low- or very-low-quality evidence, that there was no difference in mortality, adverse events, or quality of life between PD and DPPHR. The length of stay was shorter after DPPHR by one to five days, depending on trials [37].

The ChroPac trial, a multicenter study published in 2017, randomly assigned 226 patients with CP for either PD/PPPD or DPPHR [38]. At 24 months, there was no difference in the quality-of-life score, mortality, or major morbidity rate. The operative time was shorter for DPPHR (4.7 versus 5.3 hours), but readmission due to chronic pancreatitis was less frequent after PD/PPPD (27 versus 11 percent).

Based on available data, PD/PPPD and DPPHR are equally effective and morbid in treating chronic pancreatitis. Although DPPHR was associated with a shorter operative time and length of stay, PD/PPPD was more definitive with fewer readmissions for CP. Thus, surgeons should choose a procedure based on their experience and the patient's anatomical and clinical conditions. DPPHR may be preferred in patients with compression or occlusion of the portal vein to avoid bleeding complications. As an oncologic operation, PD/PPPD may be a better operation when pancreatic cancer cannot be excluded with certainty.

Pancreaticoduodenectomy — Classic PD was described for CP as early as 1946 by Whipple [39]. In the modern era, classic PD is typically performed for head-dominant CP in patients who present with duodenal or biliary obstruction and/or an inflammatory mass in the head of the pancreas (figure 3). In high-volume centers, classic PD results in pain relief in 70 to 89 percent, morbidity in 16 to 53 percent, and mortality in <2 percent of patients with CP [40-43].

PPPD was promulgated by Traverso and Longmire in 1978 with the intent of maintaining an intact gastric emptying mechanism (figure 4) [44]. PPPD has become a standard technique in modern pancreas surgery, although the purported nutritional advantages remain unrealized [45-49]. Some retrospective series have demonstrated earlier return to work [46] and better quality of life after PPPD [48] than after classic PD.

Laparoscopic PD is performed at many academic centers more commonly for malignant diseases than for CP. In experienced hands, laparoscopic PD offers reasonable operative time (357 to 368 minutes), blood loss (75 to 240 cc), morbidity (26.7 to 42 percent), and pancreatic fistula rates (6.7 to 18 percent) [50-52]. Robot-assisted laparoscopic PD has also been reported to have comparable or favorable short-term outcomes to those of open PD [53,54]. Wider application of minimally invasive PD, however, is limited by technical difficulties due to distorted anatomy and loss of tissue planes associated with CP.

Pancreaticoduodenectomy is discussed in detail in another topic. (See "Surgical resection of lesions of the head of the pancreas".)

Duodenal-preserving pancreatic head resection — A duodenal-preserving pancreatic head resection (DPPHR) technique was described by Beger in 1980 for CP in an effort to decrease the morbidity of pancreatic head resection. In DPPHR, the pancreas neck is transected, followed by a subtotal resection of the head. A rim of pancreatic parenchyma along the duodenal wall, which contains the arcade of duodenal arterial blood supply, is preserved. A Roux-en-Y limb of jejunum is then used to create a pancreaticojejunostomy (figure 5).

In the large series of 504 patients reported by Beger, pain relief was achieved in 92 percent of the most recent 388 patients [55]. In several other series, pain relief was reported in 77 to 88 percent of patients, professional rehabilitation in 63 to 69 percent, and morbidity and mortality in 28.5 and 1 percent, respectively [32,49,55-57].

Tail-dominant disease — In 1948, Eliason and Welty described distal pancreatectomy (DP) for pain relief in three patients with CP [58]. In the 1960s and 1970s, DP was the most commonly performed operation for painful CP, but DP for CP fell out of favor in the 1980s given high rates of postoperative diabetes and the emergence of localized pancreatic head resection procedures. (See 'Duodenal-preserving pancreatic head resection' above.)

In patients with CP and disease localized to the left side of the pancreas, or in patients with a main pancreatic duct stricture in the neck or body, DP can be an effective means of achieving pain relief. Patients with this pattern of CP often have associated severe inflammatory changes involving the splenic vessels or splenic vein thrombosis with large collateral vessels, making DP with concomitant splenectomy, rather than spleen-preserving DP, the most pragmatic approach (figure 6).

In large series, DP was applicable in approximately 9 to 25 percent of patients undergoing surgery for CP [21,59]. Pain relief rates of 57 to 84 percent and occupational rehabilitation rates of 29 to 73 percent were reported. Morbidity and mortality rates were 15 to 32 percent and 2 percent, respectively [60-62]. Postoperative pancreatic fistula is the primary short-term complication of DP. It occurs in approximately 30 percent of patients and appears to be related more to patient-specific factors than to operative techniques [63,64]. Postoperative endocrine failure was reported in 8 to 45 percent of patients undergoing DP for CP.

Laparoscopic DP was first reported by Gagner in 1996 [65]. It is currently the most commonly performed laparoscopic pancreatic resection. In a series of 667 distal pancreatectomies, 159 (24 percent) were attempted laparoscopically, including 14 (9 percent) for CP. Compared with open DP, laparoscopic DP was associated with less blood loss, shorter length of stay, and fewer complications but similar operative time and pancreatic fistula rates [66]. A meta-analysis of over 1800 DPs reached similar conclusions [67]. Wider application of laparoscopic DP, however, is limited by technical difficulties due to distorted anatomy and loss of tissue planes associated with CP.

Distal pancreatectomy is discussed in detail in another topic. (See "Surgical resection of lesions of the body and tail of the pancreas".)

Diffuse parenchymal disease — Total pancreatectomy (TP) for CP was performed as early as 1944 by Clagett at the Mayo Clinic. It involves resecting the entire pancreatic parenchyma and duodenum and anastomosing the stomach and bile duct to a jejunal loop (figure 7). TP can achieve pain relief in patients with diffuse small duct pancreatitis, in patients with genetic pancreatitis, and in patients who have failed previous pancreatic surgeries of a lesser extent (salvage pancreatectomy). Pain relief rates of 72 to 100 percent have been described with TP, with perioperative outcomes similar to those of other major pancreatic resections (morbidity 22 to 54 percent, mortality 0 to 14 percent).

Almost all patients develop brittle type 3c pancreatogenic diabetes after TP; 15 to 75 percent will experience severe problems with diabetic control [68,69]. After TP, there is loss of not only insulin-producing beta cells but also other composite cells of the islet that would otherwise produce hormones to maintain glucose homeostasis. As a result, patients may demonstrate an unpredictable response to exogenous insulin and, importantly, may develop morbid hypoglycemic unawareness [70]. (See "Total pancreatectomy", section on 'Postoperative management'.)

Total pancreatectomy with islet autotransplantation (TPIAT) was described by Sutherland and colleagues at the University of Minnesota in 1978 to ameliorate the high morbidity of TP [71]. The use of TPIAT for CP has increased over the past decade, and the understanding of its long-term outcomes is evolving. Pain relief rates of 72 to 86 percent have been reported, with morbidity rates of 47 to 55 percent and mortality rates of 1.4 to 6 percent.

With islet autotransplantation, patients reported a significantly improved quality of life [72], with 10 to 40 percent achieving insulin independence [73-76]. Insulin independence after TPIAT correlates with the number of islet equivalents transplanted per kilogram of recipient body weight [74,76]. Autotransplanted islet function appears to be durable, with outcomes reported for >13 years [77]. TPIAT has been safely and effectively performed in children with hereditary pancreatitis, achieving insulin independence in 55 percent of patients [78].

While TPIAT is a promising therapy for CP, data on long-term outcomes are currently limited.

A single-center observational study of 215 patients with at least 10 years of follow-up from the University of Minnesota reported 82 and 90 percent of pain relief at 10 and 15 years, respectively [79]. Narcotic use declined to 50 percent at 5 years and 37 percent at 10 years. Additionally, at 10 years, the rate of insulin independence was 20 percent, and the rate of partial graft function was 32 percent. Transplanting >4000 islet equivalents/kg was the strongest predictor of islet graft function at 10 years; pediatric patients performed better than adults. Despite these durable results, few adult patients with chronic pancreatitis have sufficient islet cell reserve that permits TPIAT.

In a report on 195 patients followed for five years after TPIAT, patients with genetic pancreatitis were more likely to be narcotic free and had better quality of life than patients with pancreatitis of other etiologies [80]. Nonsmokers with a shorter duration of pancreatitis and no prior pancreatic operation were more likely to be insulin free.

Total pancreatectomy is discussed in detail in another topic. (See "Total pancreatectomy".)

SURGERY FOR OTHER COMPLICATIONS — Besides pain, patients with chronic pancreatitis (CP) can develop other complications due to the inflammation and parenchymal fibrosis. Operative intervention may be required, and planning entails taking into consideration the compilation of problems at hand as well as the underlying pancreatic ductal anatomy. Indications for surgery for CP besides pain include the following:

Terminal biliary stenosis can be managed with biliary bypass with choledochoduodenostomy or Roux-en-Y hepaticojejunostomy (figure 8) [81]. In patients whose biliary obstruction is associated with severe abdominal pain and a large amount of fibrotic tissue in the head of the pancreas, a pancreatic head resection may be indicated. In patients whose biliary obstruction is associated with a pseudocyst in the region of the pancreatic head, pseudocyst drainage alone may be sufficient to relieve the obstruction. The management of biliary obstruction is discussed in detail in another topic. (See "Bile duct resection and reconstruction".)

Duodenal stenosis is often associated with biliary obstruction and an inflammatory pancreatic head mass and may be best managed with resection of the head of the pancreas (classic Whipple procedure) [82]. When perivascular inflammation, mesenteric thrombosis, or patient comorbidities preclude a resection procedure, a "double bypass" procedure can be undertaken (ie, gastrojejunostomy (figure 9) and biliary bypass (figure 8)). The management of duodenal stenosis (ie, gastric outlet obstruction) is discussed in detail in another topic. (See "Gastric outlet obstruction in adults".)

Pancreatic pseudocysts associated with chronic pancreatitis are managed by addressing the primary underlying ductal disorder with either resection or drainage of the pseudocyst [83]. Pancreatic pseudocyst and its treatment are discussed in detail in another topic. (See "Approach to walled-off pancreatic fluid collections in adults".)

Gastric varices due to splenic vein occlusion, when bleeding, are best treated with splenectomy. Preoperative splenic artery embolization may mitigate intraoperative blood loss by decreasing flow through short gastric and lesser sac collaterals [84]. Gastric variceal bleeding due to splenic vein occlusion and its management are also discussed in other topics. (See "Overview of the complications of chronic pancreatitis", section on 'Splenic vein thrombosis and gastric varices' and "Chronic portal vein thrombosis in adults: Clinical manifestations, diagnosis, and management", section on 'Management of complications'.)

Fibrosing stenosis of the transverse colon, a rare complication of chronic pancreatitis, is managed with colonic resection and anastomosis or colostomy, depending on timing and the physiology of the patient [85].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic pancreatitis and pancreatic exocrine insufficiency".)

SUMMARY AND RECOMMENDATIONS

Chronic pancreatitis (CP) is a complex disease that is challenging to manage. Surgical intervention is required in 40 to 75 percent of patients, most commonly for debilitating pain refractory to medical or endoscopic therapies. (See 'Introduction' above and 'Endoscopy versus surgery' above.)

In patients who undergo surgery for painful CP, the operative approach is primarily selected based on ductal anatomy and gland morphology (algorithm 1) (see 'Surgery for pain' above):

Patients with a dilated main pancreatic duct (≥6 to 7 mm) should undergo a drainage procedure such as lateral pancreaticojejunostomy (LPJ) or Frey procedure (LPJ with added local head resection to address fibrotic parenchyma that drains poorly and peripancreatic neural damage in the pancreatic head). (See 'Dilated pancreatic duct' above.)

Patients with a nondilated main pancreatic duct (<6 to 7 mm) should undergo one of the resection procedures such as pancreaticoduodenectomy (PD), distal pancreatectomy (DP), or total pancreatectomy according to the center of disease. (See 'Nondilated pancreatic duct' above.)

Head-dominant CP can be treated with classic PD, pylorus-preserving PD, and duodenum-preserving pancreatic head resection. The choice is by surgeon preference. Multiple prospective randomized trials failed to elucidate any consistent advantage of one technique over the others. (See 'Head-dominant disease' above.)

Total pancreatectomy (TP) for CP is best performed with islet autotransplantation to minimize morbidity and maximize postoperative insulin independence. (See 'Diffuse parenchymal disease' above.)

Minimally invasive techniques (laparoscopic and robotic) have been described for PD, DP, and LPJ. Wide application of laparoscopic surgery for CP, however, is limited by distorted anatomy and loss of tissue planes intrinsic to the disease process. (See 'Lateral pancreaticojejunostomy' above and 'Pancreaticoduodenectomy' above and 'Tail-dominant disease' above.)

Surgery may also be required to treat symptoms or complications of CP that are not pain related, such as biliary, duodenal, or colonic stenosis; pancreatic pseudocyst; and gastric variceal bleeding due to splenic vein thrombosis. (See 'Surgery for other complications' above.)

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Topic 15109 Version 10.0

References

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