Download - Chronic pancreatitis surgery class
Chronic Pancreatitis
Issues
• Diagnosis
• Natural course of the disease
• Treatment – Medical or Surgery or Endotherapy
• Surgery – Timing of Surgery Type of Surgery
• Recurrence of pain
Chronic Pancreatitis
Pathology : Progressive loss of exocrine & endocrine function. In late stage pancreas is enlarged & hard Ductal change – areas of stricture & dilatation Calcification – Intraductal & parenchymal
Pathogenic Mechanisms
Toxic and
metabolic
Idiopathic
GeneticHPCFTRSPINK -1
Autoimmune
RecurrentSAP
Obstructive
Oxidativestress
ToxicMetabolic
NecrosisFibrosis
SAPEHypothesis
Stone &DuctObstruction
Large Duct
ChronicPancreatitis
Cl. Featute – Pain, wt. Loss, diabetes, steatorrhoea
Clinical Presentation
Early onset _ Age < 35Late onset - Age > 35
Pain Characteristics of Chronic Pancreatitis
Type of Pain
Type A - Intermittent ,short duration, several episodes in a year
Type B - Continuous chronic pain Pseudocyst Obstructive pathology
Assessment: Pain severity
The needSelection of patients for surgery‘Objective’ documentation of pain reliefAssessment of treatment efficacyComparison of data
The “Tools”Pain scoring systems‘Quality of life’ assessment
Function scalesSymptom scales
Bloechle C et al, Pancreas 1995, Izbicki JR et al, Ann Surg 1998
Pain scoring systemsParameters assessed• Intensity
• Visual analog scale• Pain medication• Narcotic addiction
• Frequency• Trials: > 1 episode per month
• Duration• Most surgical series: > 1 year
• Consequences• absence from work• number of hospitalizations
Rai RR et al, Gastroenterol Jap 1988; Bloechle C et al, Pancreas 1995
The Izbicki pain score
A validated pain score specifically designed forchronic pancreatitis . It consists of four questions regarding • Frequency of pain• Intensity of pain (VAS score)• Use of analgesics• Disease-related inability to work
Based on these question a pain score can be calculated ranging from 0 (no pain) to 100 (severe, debilitating pain).
• Ductal Dilatation• Parenchymal Hypertension• Parenchymal Ischaemia• Neurohumoral inflammation• Obstruction of luminal structures
Aetiology of Pain in CP
Investigation - Exocrine function test
Direct Test InvasiveSecretin – Cerulein Test
Lundh Test
Fecal Test• Fecal Chymotrypsin test• Fecal Elastase 1 Test
Indirect Test• 24 hours Stool weight and Fecal fat
estimation• Pancreolauryl Test and PABA test• Breath Test – 13 C labeled substrate
Imaging Studies USG / MRCP/ ERCP/ CT/ EUS
CP with pancreas Divisum
MRCP in Chronic Pancreatitis
CP with CBD obstruction
CP with CBD Stone
MDCT Pancreatogram
MDCT
Ch Pancreatitis with Pseudocyst
Ch Pancreatitis and Carcinoma of Pancreas
Ch Pancreatitis with Pseudoaneurysm
Pancreatic Ascites
TreatmentMedical management – Nutrition Enzyme replacement Insulin Analgesics
Indication of surgery 1. Intractable pain 2. Complication – Obstruction – CBD, D2 Vascular involvement Panc. Cyst Presence of mass Pancreatic Ascites
Surgery for Chronic Pancreatitisa timeline
Date Author Procedure1946 Clagget Total Pancreatectomy
Whipple Pancreaticoduodenectomy1950 Richman and Colp Gastrectomy1954 Duval Caudal pancreaticojejunostomy1955 Bowers Choledochojejunostomy1956 Doubilet and
MulhollandSphincterotomy
1958 Puestow and Gillesby Lateral pancreaticojejunostomy1965 Fry and Child 95% Distal Pancreatectomy1978 Traverso and Longmire Pylorus-preserving “Whipple”1987 Frey and Smith Head resection and drainage1989 Beger et al Duodenum-preserving resection
Timing of Surgery
Early Vs Late
What is the appropriate type of Surgery ?
Surgery for Chronic pancreatitisA. Drainage procedure Longitudinal side to side Roux-en-Y pancreatojejunostomy (Modified Peustow or Partington Rochelle) B. Resection Procedure 1.Begers operation 2.Whipple’s Pancreatoduodenectomy 3.Distal pancreatectomy C. Combined procedure Frey’s operation Izbicki’s operation
Non operative Methods Endoscopic Therapy Caeliac ganglion block
LPJ – Partinhton- Rochelle
Frey’s Procedure
Berne Procedure – Modified DPPHR
Duval’s Procedure
Peustow-Gilesby Procedure
Beger’s Procedure - DPPHR
Izbicki’s procedure – Small duct Disease
Salvage or Redo Surgery after failure of Primary Surgery for pain relief
Drainage Surgery Resection Surgery
Resection Surgery Total Pancreatectomy
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