Stenotic Complications of Chronic Pancreatitis

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Magnitude of the problem. Initially thought to be uncommon Current figures ~ 50% of patients of CP undergoing surgery. Stenotic complications Pathophysiology. Extension of inflammation into peripancreatic tissues Involve CBD, duodenum, colon, Portal vein, Splenic vein OedemaFibrosisTransient or

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Stenotic Complications of Chronic Pancreatitis

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1. Stenotic Complications of Chronic Pancreatitis V Baskaran Department of Surgery Armed Forces Medical College Pune

2. Magnitude of the problem Initially thought to be uncommon Current figures ~ 50% of patients of CP undergoing surgery

3. Stenotic complications Pathophysiology Extension of inflammation into peripancreatic tissues Involve CBD, duodenum, colon, Portal vein, Splenic vein Oedema Fibrosis Transient or Permanent To be distinguished from compression caused by pseudocysts

4. Stenotic complications CBD Duodenum Colon

5. Bile duct stricture Incidence 3.2% to 62% !! Clinical jaundice 7.8% to 9% Anicteric cholestasis > 8.5%

6. Bile duct stricture

7. Bile duct stricture Equal incidence in alcoholic & non-alcoholic CP Higher incidence in CP with inflammatory head mass

8. Bile duct stricture Natural history Difficult to predict! Many resolve Some persist Some progress Complications

9. Bile duct stricture Complications Cholangitis 6%-15% of stricture patients Biliary cirrhosis- 3% to 10% Liver fibrosis Common -up to 73% Not evaluated often Reduction after decompression

10. Bile duct stricture Morphological types Long regular stenosis Short stenosis at upper margin of head of pancreas ?Stenosis at distal CBD

11. Bile duct stricture CBD obstruction does not cause pain in patients with CP Prior PJ does not prevent development of CBD stricture later

12. Bile duct stricture When to intervene? Absolute indications Complications Persistent jaundice Relative indications Being considered for intervention for some other reason Previous history of cholangitis Dilated system with cholestasis Observation

13. Bile duct stricture Management options Observation Endoscopic biliary stenting Surgery

14. Bile duct stricture Endoscopic stenting Technically possible nearly in all Risk of stent block & cholangitis Regular change mandatory with plastic stents Better results with metallic stents

15. Bile duct stricture Results - plastic stents-Best Protocol- dilatation & stenting Change 3-4 months 80% of strictures respond and dilate after a course of stenting for 12-18 months Stricture free –mean follow-up 32 m

16. Bile duct stricture Results - plastic stents Respond better to the increasing numbers of endoscopic stents, and remain stent free for medium term periods

17. Bile duct stricture Results - plastic stents-Usual Improved 18% Improved but stricture persists 41% Failure 31% Death 10%

18. Bile duct stricture Results - plastic stents Excellent short term results Moderate medium term results –median ~40 months 17-fold risk of failure of a 12 month course of endoscopic stenting more with calcifications of the pancreatic head

19. Bile duct stricture Results - plastic stents The high incidence of late complications due to non-compliance is a limitation of stenting in alcoholic CP Potentially harmful.

20. Bile duct stricture Results with metallic stents Excellent short-term results Moderate to excellent medium term results In long-term treatment for purely palliative purposes, metal stents remain patent far longer than plastic stents

21. Bile duct stricture Results with metallic stents Most patients with metallic stents will develop recurrent cholangitis or stent obstruction Chronic inflammation and obstruction may predispose the patient to cholangiocarcinoma

22. Bile duct stricture Surgical options Choledochoduodenostomy Choledochojejunostomy Cholecystoduodenostomy Cholecystojejunostomy T-tube drainage Resectional procedures

23. Bile duct stricture Surgical procedures Higher initial post procedure risk Acceptable morbidity in the majority Near zero mortality Excellent long term results

24. Bile duct stricture Surgical drainage CDD and CDJ are safe and reliable CCE is associated with failure in 50% & 31% require conversion to CDD or CDJ Cholecystojejunostomy only for the terminal patients requiring a short-term biliary bypass

25. Bile duct stricture Stenting vs surgery >30% do not benefit of biliary stenting, who are candidates for surgery Surgical treatment provides better long-term results than endoscopic therapy Along with another surgical procedure

26. Bile duct stricture Stenting vs surgery Initial therapy before surgery Can be the definitive approach for older and morbid patients Should not be considered as a routine procedure for symptomatic cases

27. Bile duct stricture What to offer? Absolute indications Good risk pt- surgery Plan to delay surgery- Stenting Poor risk pt- Stenting Failure of endoscopic drainage – Surgery Relative indications Being considered for intervention for some other reason -Surgery Previous history of cholangitis – Surgery Dilated system with cholestasis

28. Duodenal stricture Incidence 1% to 36% !! Wide spectrum Majority –transient Diagnose on history Confirm with Ba meal & UGIE Exclude common causes of GOO

29. Duodenal stricture Pathophysiology Second part, at times 3rd part Duodenal wall oedema Intramural haematoma Fibrous stricture Cause- ?Ischaemic

31. Duodenal stricture Natural history Majority transient Most – partial obstruction Few- complete obstruction

32. Duodenal stricture When to intervene Most need no intervention TPN Intervention when obstruction persists for > 2 weeks

33. Duodenal stricture Surgical options GJ+Vagotomy Pyloroplasty Stricturoplasty Duodenal widening with pedicled jejunal transplant

34. Duodenal stricture Pancreaticoduodenectomy Coexisting strictures of PD and CBD Severe pain associated with GOO

35. Colonic stricture Very rare Involvement of tr colon & splenic flexure Usually short segment stricture Adynamic ileus of tr colon Resection

36. Stenotic complications of CP Summary Frequent Higher detection with higher index of suspicion & higher level of investigations Majority need no therapy Intervention to be tailor made Stents- Low initial risk with high cumulative risk Surgery- High initial risk with low cumulative risk

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