[Surgery of chronic pancreatitis. I. Late results after resection management]

Natural course of chronic pancreatitis

Although the three leading symptoms of chronic pancreatitis, pain, exocrine and endocrine pancreatic insufficiency, are well known, only a few long-term studies have correlated these symptoms with the natural course of the disease. Besides these symptoms, numerous pancreatic complications and/or pancreatitis-associated diseases may affect the course and determine the prognosis of chronic pancreatitis. Their influence, however, has not been studied in detail. This review has two major aims: The first one is to give an up-to-date survey of present knowledge on the natural course of the disease with a view to the leading symptoms under special consideration of how the duration of the disease, continual alcohol abuse as well as endoscopic procedures and surgical treatment affect pain. Included is also what is known about chronic pancreatitis as a precondition of pancreatic and extrapancreatic carcinoma. The effect of chronic pancreatitis on the socio-economic status of patients is discussed and the mortality rate of the disease. The second aim of this review is to stimulate pancreatologists from different centers to consolidate resources in order to perform larger controlled studies than any one single center can undertake and work out common criteria for the diagnosis of chronic pancreatitis and follow-up of its course.

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis

OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts.

PATIENT MATERIAL

The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification.

ASSESSMENT

Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily.

RESULTS

Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively.

CONCLUSIONS

The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis

OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts.

PATIENT MATERIAL

The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification.

ASSESSMENT

Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily.

RESULTS

Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively.

CONCLUSIONS

The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.

Pancreatic resection for chronic pancreatitis

Patients with chronic pancreatitis needing operative management include those with severe pain, those with complications of pancreatitis, or those in whom it is not possible to distinguish cancer of the pancreas from chronic pancreatitis. The use of endoscopic retrograde cholangiopancreatography, CT, and angiography to define the structural abnormalities has increased the surgeon's ability to select an operation matched to the patient's needs. A longitudinal pancreaticojejunostomy should be performed in patients whose ducts are dilated. When the head of the pancreas is enlarged and thickened, pancreaticoduodenectomy has been the traditional operation of choice. However, local resection with pyloric and duodenal preservation should now be considered an alternative that has a lower mortality rate and less likelihood of creating diabetes or exocrine insufficiency. Patients whose ducts are of insufficient caliber to permit longitudinal pancreaticojejunostomy are candidates for resection of the proximal or distal pancreas, depending on the site of disease or, alternatively, for the Beger or Warren procedure. Pain relief is achieved with surgery in about 80 per cent of patients with chronic pancreatitis. Many of the late deaths following operation for chronic pancreatitis are attributable, not to the operation, but to the effects of alcoholism. There is a need for surgeons to improve their observations and assessment of operative results.