surgery in chronic pancreatitis
DESCRIPTION
sx in chr pancreatitisTRANSCRIPT
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SURGERY IN CHRONIC PANCREATITIS
Resident of surgeryDr SNMC,JODHPUR
---Dr sumer 2013
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definition
Continuous inflammatory disease of pancreas characterised by irreversible morphologic changes [[irregular fibrosis, acinar and islet cells loss,inflammatory infiltrates,stone formation]]of both the parenchyma and ducts;typically coupled with permanent loss of function +/-pain
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prevalence
1. 10-15/100000 population in western countries
2. 114-200/100000 in southern india3. Typical age 35-55
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CP Etiologies
Alcohol;60-70% of all cases in developed countries {6-12 yr history of 150-175 g/day}
Obstruction of pancratic duct;pancreas divisum,post traumatic stricture,tumours
Cystic fibrosis[CFTR mutation] Tropical pancreatitis Autoimmune Hypercalcemia Hyperlipidemia idiopathic
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Symptomatic features
Exocrine insufficienc
yMaldigestion,diarrhea Weight loss
Endocrine insufficienc
yDiabetes mellitus
pain Varies with etiology
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Diagnostic tests in CP
TESTS OF STRUCTURE
1.ERCP 2.EUS 3.MRI AND MRCP 4.CT scan 5.X ray abdomen 6.USG abdomen
TESTS OF FUNCTION 1.S. Glucose 2.S.Trypsinogen 3.Fecal elastase 4.Fecal chymotrypsin 5.Fecal fat[72 hr
collection] 6.Secretin pancreatic
stimulation test with duodenal intubation
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X ray abd -calcification
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EUS
Hyperechoic walls of duct Duct dilatation Stones in duct Parenchymal lobularity,strands and cysts
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CECT-Homogenous enhancement of pancreas
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MRCP-Dilated duct and intraductal debris
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Management of CP
Medical therapy Endoscopic therapy Surgical options Nerve blocks
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INDICATIONS FOR SURGERY
Pain –commonest indication[[[70-90%]]] Mass/suspicion of malignancy Biliary obstuction Duodenal stenosis Pseudocysts Internal pancreatic fistulae Vascular problems
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AIMS OF SURGICAL TREATMENT
Pain relief Control of complications Preservation of exocrine and endocrine
functions Social and occupational rehabilitation Improvement of quality of life
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Issues related to surgery
Problems;
Subjective Severity grading:often
arbitrary Pain scoring systems Natural history:alc cp
‘burn out theory’ Timing of surgery
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Pain Mechanisms
Pancreatic duct hypertension{outflow obstruction}
‘Compartment syndrome’ Neural involvement Genetic factors
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Pain scoring systems
Parameters assesed Intensity a.visual analog scale b.pain medication c.narcotic addiction Frequency Trials:>1 episode per month Duration most surgical series >1 yr Conseqences absence from work number of hospitalisations
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Literature based evidence for surgery
Large prospective surgical series;75-90% success in pain relief and improvement in QOL
Pain relief with surgery vs medical Rx :63vs43% at 10 yr
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The case for surgery………….
‘……..seems unreasonable to adopt a conservative approach in the hope that pain relief will be obtained sometime in the future,at which stage risk of narcotic addiction increses and results of surgery are invarably poor.’
Andrew
wershaw wershaw al
gastroenterology;1984
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Surgical decision making
Anatomy of the disease 1.small duct disease 2.large duct disease 3.location of inflammatory mass Associated complications 1.biliary obstruction 2.duodenal stenosis 3.pseudocysts 4.GI bleeding / PHT 5.Malignancy Etiology
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Timing of surgery
Patients presented with complications;early surgery
For pain relief .early surgery [<4 yrs ]may delay
progress of exocrine/endocrine insufficiency[alc CP]
Ann surg 1999 .early surgery in NACP/trop CP improves
nutitrional status,weight gain,decrased insulin requirement.
Controversies:how early what surgery:drainage or resection?
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Surgical procedures in CP Indicated for failure of medical
management Suspicion of malignancy Drainage procedure indicated in large duct disease Resection-drainage procedure indicated when there is
inflammatory mass procedure of choice dictated by
surgeon experience and individualized to pt
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Drainage procedures
1954 Duval distal
pancreatectomy,spleenectomy,end to end roux en Y pancreaticojejnostomy
1958 Puestow and Gillesby longitudinal incision and invagination
into jejunal roux 1960 Partington and Rochelle side to side longitudinal
anastomosis;preserve distal pancreas and spleen;need dilated duct >6mm
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Combined resection-drainage procedure
Inflamed and enlarged pancreatic head Requires resection 1.Whipple 2.Beger[duodenum preserving
pancreatic head resection] 3.Frey
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Lateral PJ [[Puestow]]
Click icon to add picture
Most commonly performed today
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Two layered suturing
Click icon to add picture
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PancreaticoduodenectomyWhipple procedure
Was developed for periampullary malignancy More popular in the past 2 decades for CP also
due to advances in op technique,anesthesia and perioprative mx
End to side PJ using 2 layer tech {vicryl/silk} duct-to-full-thickness bowel
5 Fr pediatric feeding tube is used as a pancretic stent
End to side choledochojejunostomy 2 layer GJ/DJ Feeding jejunostomy
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Retroperitoneum after whipple specimen removed
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Beger procedure
Duodenum-sparing pancreatic head resection
C/I in suspected pancretic cancer Portal vein freed,neck divided Longitudinal pancreaticojejunostomy Frozen section to rule out
malignancy[5%]
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Freys procedure
Coring of head of pancreas Duodenum-sparing pancreatic head
resection and lateral pancreaticojejunostomy
Indicated for small duct disease Technically easier then beger. Local resection of pancreatic head
relieves CBD obustruction in 70% of cases
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Beger vs Freys
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Other procedures
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Modifications of beger and freys proc
1998,longitudinal V shaped excision of ventral pancreas
Indicated for small duct pancreatitis Author described 95% pain relief
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Distal pancreatectomy
Pathology predominantly limited to distal portion of gland
Distal psedocyst,mass, SVT Cut edge of gland oversewn
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Laparascopic assisted distal pancreatectomy
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Operations for pancreatic pseudocyst
Psedocyst complicates CP in 30% to 40% of pts
Surgery indicated for pts with symtomatic pseudocysts who are either not candidate or have failed an initial attempt at transampullary,transgastric,or transcutaneous drainage
septated cyst with elevated fluid CEA and CA 15-3 levels treated by resection.[? Neoplasm]
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CONTd
Cyst-gastrostomy/duodenostomy Roux-en-Y cyst-jejunostomy [simpler] For small multiple cysts of pancreatic
head-Whipple proc For cyst of pancreatic tail – distal
pancreatectomy
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CONTd
Surgical cyst-enterostomy is associated with 90-100% success
Success rates from cyst-duodenostomy-100%,cyst-gastrostomy-90% and cyst-jejunostomy-92%
Morbidity 9%-36% Mortality 0%-1%
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Confirm location of psedocyst by aspiration
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Cyst-jejunostomy
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Total pancreatectomy
Last resort for pts with persistent or recurrent pain following lesser proc
Requires autologous islet cell autotransplantation
extended hospitalisation due to Poor diabetes control
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Infusion of islets into the portal vein using 18 g angiocatheter
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Video-assisted thoracoscopic splanchnicectomy
Indicated in intractable pain abdomen due to pancreatic and gastric carcinoma
Celiac ganglion block have transient effects,but this neural ablation offers higher success rates
Thoracotomy is more invasive,VATS is less invasive and offers more rapid recovery
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Reoperative pancreatic surgery
All pts with recurrent pain abdomen reevaluated with CTscan MRCP/ERCP,UGI endoscopy.
For diffuse parenchymal disease-completion pancreatectomy with or without islet cell autotransplantation
For dilated duct-decmpressive surgery For stricture-subtotal resection
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GI SURGERY AIIMS DATA
1995-2009 [[n=170]] Pain is the main indication 90% pain duration 1-30 yrs Biliary obstruction alone 10% NACP: 95 ; Alc CP ;75 DRAINAGE PROCEDURE …………….115 LPJ ………………………………….62 LPJ+BILIARY BYPASS …………….30 CYST-ENTEROSTOMIES …………23 RESECTIONS…………………………….19 WHIPPLES ………………………….11 WHIPPLES+LPJ …………………….3 DISTAL PANCREATECTOMY …….5
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Summary and conclusion
Pain relief and quality of life issues are the main concern in pts of chronic pancreatitis undergoing treatment
Surgery is indicated for relief of intractable pain and complications associated with CP
Failure of nonsurgical treatment and presence of complications influence timing and need for surgical intervention[[jury is still out:early surgery for mild to moderate pain]]
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CONTd
Pain relief is sustained in NACP->85% Duration of pain does not necessarily
correlate with surgical outcome No consistent documentation of recovery
of pancreatic function following ductal drainage
Need for biliary bypass: frequent Associted SVT/PHT makes surgery difficult Late deaths occurs due to malignancy or
continued alcoholism
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THANKS