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

Surgery for pain in chronic pancreatitis

Timing and indications

Dr Sujoy Pal

Dept of GI Surgery, AIIMS

background
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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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