Surgery for pain in chronic pancreatitis
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Surgery for pain in chronic pancreatitis Timing and indications Dr Sujoy Pal Dept of GI Surgery, AIIMS Background Pain is the commonest indication 70-90% Other established indications: Complications Mass/ suspicion of malignancy Biliary obstruction Duodenal stenosis

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Surgery for pain in chronic pancreatitis l.jpg

Surgery for pain in chronic pancreatitis

Timing and indications

Dr Sujoy Pal

Dept of GI Surgery, AIIMS


Background l.jpg
Background

  • Pain is the commonest indication 70-90%

  • Other established indications:

    • Complications

      • Mass/ suspicion of malignancy

      • Biliary obstruction

      • Duodenal stenosis

      • Pseudocysts

      • Internal pancreatic fistulae

      • Vascular problems

  • Controversial:

    • prevention of exocrine/endocrine deficiency


  • Aims of surgical treatment l.jpg
    Aims of surgical treatment

    • Pain relief

    • Control of complications

    • Preservation of endocrine and exocrine function

    • Social and occupational rehabilitation

    • Improvement of quality of life


    Indication pain l.jpg
    Indication: Pain

    • Prime indication in NACP/ACP

    • Issues related to surgery

    • Problems: Subjective

      • Severity grading: often arbitrary

      • Pains scoring systems

      • Natural history:

      • Alc CP : ‘burn-out’ theory

      • Lack of stringent level I evidence

  • Timing of surgery

  • Lankisch PG et al, Digestion 1993; Ammann RW et al, Gastroentrology 1984


    Assessment pain severity l.jpg
    Assessment: Pain severity

    The need

    Selection of patients for surgery

    ‘Objective’ documentation of pain relief

    Assessment of treatment efficacy

    Comparison of data

    The ‘tools’

    Pain scoring systems

    ‘Quality of life’ assessment

    Function scales

    Symptom scales

    Bloechle C et al, Pancreas 1995, Izbicki JR et al, Ann Surg 1998


    Pain scoring systems l.jpg
    Pain scoring systems

    • Parameters 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


    Evidence in the literature l.jpg
    Evidence in the literature

    • Pancreatic ‘burn-out’ syndrome

    • Study n Follow up Exo-/endocrine Pain relief

    • (years) insufficiency (%) (%)

    • Ammann 145 10.4 100/100 83

    • Layer 192 14.6 77

    • Lankisch 152 > 10 46/78 65

    • Drawbacks

    • Selection bias

    • Evaluation of patients at a given period during

    • their natural course

    • Continued alcoholism: higher incidence of panc insufficiency


    Literature based evidence for surgery l.jpg
    Literature based evidence for surgery

    • Large prospective surgical series: 75-90% success in

    • pain relief and improved QOL

    • Pain relief with surgery vs medical Rx: 63% vs 43% at 10 y

    • Pain relief is unpredictable (both ALCP & NACP)

    • Pancreatic insufficiency & pain relief:

      • imperfect correlation

  • Patients with severe pain at onset:

  • less chance of pain relief

  • Young patients with NACP: more severe pain

  • NACP: slower deterioration of pancreatic function

  • Scuoro LA et al, AJG 1983;Bornmann PC et al, World J Surg , 2003


    The case for surgery l.jpg
    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

    the risk of narcotic addiction increases and

    the results of surgery are invariably poor.”

    Andrew Warshaw

    Warshaw AL, Gastroenterology 1984


    Surgical decision making l.jpg
    Surgical decision making

    • Anatomy of the disease

      • ‘Large duct’ disease

      • ‘Small duct’ disease

      • Location of inflammatory mass

  • Associated complications

    • Biliary obstruction

    • Duodenal stenosis

    • Pseudocysts

    • GI bleeding/ Left sided portal hypertension

    • Malignancy

  • Etiology


  • Timing of surgery l.jpg
    Timing of surgery

    • Patients with associated complications: Early surgery

    • For pain relief:

      • Early surgery ( < 4years) may delay progress of

      • Exocrine/ endocrine insufficiency (Alc CP)

      • Patel AG et al, Ann Surg 1999; Nealon WH et al, Ann Surg 1993

      • Early surgery in NACP/ Tropical CP improves

      • nutritional status, weight gain, decreased insulin

      • requirement

      • Tripathy BB et al, 1987

  • Contrary evidence

    • Sikora SS et al, WJS 2002; Greenlee HB et al, WJS 1990

  • Controversies: How early & what surgery: drainage

  • or resection?


  • Timing and need for surgery l.jpg
    Timing and need for surgery

    • Contentious issues

      • Mild to moderate pain in patients with small

      • duct disease

      • Non abstinent alcoholics with continuing behavioral

      • problems/ addictions


    Indication complications of cp l.jpg
    Indication: Complications of CP

    • Biliary obstruction

    • Incidence:

    • Admitted patients 6% (3-23)

    • Radiological screening 33% (21-46)

    • Operated patients 35% (15-60)

    • Indication for intervention

    • Persistent jaundice and/or cholangitis

    • Biliary cirrhosis

    • mass lesion

    • ? Radiological/ biochemical derangement

    Prinz RA et al, WJS 2003


    Indication complications of cp14 l.jpg
    Indication: Complications of CP

    • Duodenal obstruction/stenosis

    • Incidence:

      • Admitted patients 2% (1-13)

      • Operated patients 12% (2-36)

  • Indication for treatment

    • Failure of conservative trial

    • Mass Lesion

    • Associated biliary obstruction

  • Vijungco JD, Prinz RA et al, WJS 2003


    Other complications l.jpg
    Other complications

    • Splenic vein thrombosis

      • Majority asymptomatic

      • Incidence is variable 4-45%

      • Prospective study (n=266) 13%

        • Gastric varices 17%

        • Variceal h’age 1 patient

        • Bernades P et al, Dig Dis Sci 1992

    • Management

      • Bleeders: Splenectomy

      • ? Prophylactic splenectomy

  • Only 4% of patients with gastric varices bleed

  • Pseudocysts and ductal disruptions

    • Retention cysts: require surgical drainage

  • Heider TR et al, Ann Surg 2004


    Pancreatic mass inflammatory or malignant l.jpg
    Pancreatic mass: Inflammatory or malignant ?

    • Clinical

    • Radiological

      • Helical CT/ MRI

      • ERCP/MRCP

      • EUS

  • Pancreatic duct/ fluid

    • CA19-9

    • p 53 immunohistochemistry

  • Preoperative /Intraoperative FNAC

  • Operative evaluation/biopsy

  • In case of doubt: resection is the best option


    Gi surgery aiims data 1985 2004 n 170 l.jpg
    GI Surgery AIIMS data1985-2004 (n=170)

    Pain as the main indication 90%

    Pain duration 1-30 years

    Biliary obstruction alone 10%

    NACP: 95; Alc CP: 75

    Drainage procedures 115

    LPJ 62

    LPJ + biliary bypass 30

    Cystoenterostomies 23

    Resections 19

    Whipple’s 11

    Whipple’s + LPJ 3

    Distal pancreatectomy 5


    Lessons learnt l.jpg
    Lessons learnt

    • 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 (~ 50%)

    • Associated SVT/ PHT makes surgery difficult

    • Late deaths occur due to malignancy, continued alcoholism


    Summary and conclusions l.jpg
    Summary and conclusions

    Pain relief and QOL issues are the main concerns in

    patients with chronic pancreatitis undergoing treatment

    Surgery is indicated for relief of intractable pain and

    associated complications of chronic pancreatitis

    Failure of non surgical treatment and presence of

    complications influence the timing and need for surgical

    intervention

    Jury is still out: early surgery for mild to moderate pain


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