Chronic Pancreatitis and the role of early Surgery

Chronic Pancreatitis is an inflammatory disorder of the pancreas leading to fibrosis and irreversible morphologic changes, with permanent loss of exocrine (Digestive) function and endocrine function. The most common and debilitating symptom is pain with the pattern varying from mild complaints to recurrent attacks or continuous uncontrollable pain. Other symptoms and complications develop due to extension of fibrosis to surrounding organs and may include recurrent vomiting due to duodenal stenosis, Jaundice due to bile duct stenosis, loss of endocrine function (diabetes), and exocrine function (Steatorrhea)

Role of Surgery:-

1. Timing of Surgery: – Recent studies have shown that early surgery is superior in providing pain relief and improving the quality of life as compared to the STEP UP approach in which medical therapy is followed by endoscopy and finally surgery. Delaying surgery leads to ongoing opioid use, repeated episodes of intense pain which leads to difficult to control pain syndromes, and poor pain outcome. Recent ESCAPE TRIAL BY the DUTCH Pancreatitis group showed that early surgery compared with an Endoscopy first approach resulted in lower pain scores at 18 months.
2. Types of Surgery: – Depends upon the pattern of disease.

• Chronic Pancreatitis with Large duct disease. A dilated pancreatic duct (>7 mm) with no pancreatic head mass is an indication of lateral Pancreatico-Jejunostomy/Partington Rochelle/ Modified Puestow Procedure. The Pancreatic duct is opened longitudinally along the full length, the duct is cleared of stones and anastomosed with a Roux-en-y limb of the Jejunum.
• Chronic Pancreatitis with Enlarged Pancreatic head/ pancreatic head mass (4 cm). Pain outcomes are equivalent with a resection procedure (Pancreaticoduodenectomy) or a combination of Resection and drainage (duodenum Preserving Pancreatic head resection)
• Chronic Pancreatitis with Small duct disease or Diffuse Sclerosis: – V-Shaped excision of the gland (Izbicki Procedure) and total pancreatectomy with Islet Auto transplant are the options when there are diffuse fibrosis and atrophy of the pancreas.

3. Surgery for complications of chronic pancreatitis:-
4. Pseudocyst of Pancreas: Drainage (Endoscopic/ Surgical) is indicated: F symptomatic or persistency enlarged in size.
5. Bile duct obstruction and duodenal stenosis. Can be managed by endoscopic stenting temporarily but surgery is the definitive cure.