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CHOICE OF SURGICAL PROCEDURES FOR CHRONIC PANCREATITIS
PM Udani, Vimla Purohit, Paresh Desai
Ravi D Bapat*; Ranka Satish R**, Chetan V Kantharia***
Pain of chronic pancreatitis pose a therapeutic challenge. A conservative approach with replacement enzyme therapy socio-economically burns out the patient. Drainage or resection with drainage procedures are most ideal, however their indications differ according to ductal morphology. This article reviews various surgical procedures proposed till date for relief of chronic pancreatic pain. It gives a brief description of the procedure, highlights its indications and major adverse affects. It is proposed to give insight to undergraduates, postgraduates as well as the practising surgeons about the evolution of pancreatic surgery and guide them to the proper choice of procedure to adopt. There is however always a gray zone wherein experience, patient’s condition and available expertise dictate the final procedure the patient undergoes.
INTRODUCTION
Chronic pancreatitis is defined as "a chronic inflammatory condition characterized by recurrent bouts of acute exacerbation which eventually results in a defective restitution after acute pancreatitis" [1] . Pain is the principle symptom although its exocrine / endocrine insufficiency are also equally important. A number of procedures have been developed in the 20th century to deal with it. Literature review indicates the maximum efficacy of any procedure upto date being 85-90%. There is no procedure evolved so far to provide a 100% cure to this condition. This is probably due to the fact that chronic pancreatitis is an ongoing process with multifactorial aetiology. The ideal procedure for treating pain in chronic pancreatitis should be the one which is simple, easy to perform, associated with a low morbidity / mortality rate and at the same time providing adequate drainage and not for augmenting its endo / exocrine insufficiency. Surgeries for chronic pancreatitis can be broadly classified as :
A. Drainage procedures :
1. Partial : Draining the duct partially e.g. Duval, Puestow.
2. Complete : Consists of draining the main duct completely e.g. Partington’s, Bapat’sB. Resectional procedure : Resecting a part of pancreas with adjoining organs : e.g. Whipples, Child’s.
C. Extended drainage procedure : Adding a pancreatic sphincterotomy to the drainage procedure e.g. Rumpf’s.
D. Resection with extended drainage : A combination e.g. Beger’s, Frey’s.
The rationale for various procedures are :
•Drainage procedures were developed on the basis that pain in chronic pancreatitis is due to ductal hypertension2 and proper drainage would decompress it.
•On the other hand, theory of perineural inflammation3 as the cause of pain led to development of resectional procedures.
A. Drainage Procedures
It has been more than 3/4th of a century since these procedures were proposed.4,5 Duval andZollinger6 first applied this principle. These procedures provide pain relief in upto 60-80% of cases.
I. Partial Drainage Procedures
1. Duval [7] : Developed on the basis of presumption that a single stricture of duct of Wirsung near the ampulla was responsible for the obstructive pathology and terminal drainage would treat the condition. It consists of a distal pancreatectomy with splenectomy and retrograde drainage of the main duct into a defunctioned jejunal loop (Fig. 1).
Fig 1 : Duval's procedure
2. Peustow - Gilesby Procedure [8] : These authors demonstrated that multiple strictures (chain - of - lake appearance) were the pathology involved in chronic pancreatitis. They recommended a longitudinal opening of pancreatic duct from site of transection of the pancreatic duct after resection of pancreatic tail and splenectomy, to a point just to the right of mesenteric vessels and invagination of the open duct with pancreas into a Roux-en-Y loop of jejunum (Fig. 2). This achieved wider drainage of the ductal system.
Fig 2 : Peustow - Gilesby Procedure
3. Leger’s Procedure [9] : Developed for distal stricture and consists of upto 40% distal pancreatectomy with splenectomy and opening of pancreatic duct into a loop of jejunum by a retrograde, lateral pancreatico jejunostomy (Fig. 3).
Fig 3 : Leger’s Procedure
4. Mercadier Procedure : For drainage of body of pancreas in Roux-en-Y Loop of jejunum by a side to side anastomosis. (Fig. 4)
Partial drainage procedures have been abandoned because of the small anastomosis which soon tends to occlude. Also the concept of preservation of spleen with pancreatic tail is important, as it prevents post-splenectomy sepsis10 and also delays the onset of Diabetes Mellitus. [11]
Fig 4 : Mercadier Procedure
II. Complete Drainage Procedures
1. Partington - Rochelle [12] (1960) : Suggested a refinement in Peustow’s procedure. A dilated mainpancreatic duct (minimum 8 mm) is a prerequisite for a good duct to mucosa anastomosis, however people have even reported a mucosa to capsule anastomosis when the duct size is 5 mm. It consists of a side to side, long, lateral pancreaticojejunostomy without resection of pancreatic tail or spleen. (Fig. 5)
Fig 5 : Partington - Rochelle
2. Bapat’s [13] modification of partingtons procedure :It consists of opening of the pancreatic duct from head to tail with wide drainage by a side to end pancreaticojejunostomy after fishmouthing the jejunal end to a required length. A duct to mucosa anastomosis is done. A dilated duct of minimum 7 mm is a prerequisite. Advantages of procedure : Straight, conical and dependent anastomosis, effective and complete drainage, more physiological and only two suture lines involved (Fig. 6).
Fig 6 : Bapat's - procedure
B. Resectional Procedures
These procedures were resorted to when lesser procedures failed especially when malignancy could not be ruled out.
1. Whipples [14] (1935) : Described by Allen O Whipple first in 1912, but published later for malignant lesions of head of pancreas, now used for benign, inflammatory mass in head of pancreas with a non dilated pancreatic duct. It consists of a pancreaticoduodenectomy with reconstruction by a pancreatico - jejunostomy / gastrostomy + Gastrojejunostomy + Choledochojejunostomy (Fig. 7). This is a complex, challenging technical exercise with higher mortality rates as compared to a drainage procedure however with good results. This procedure involves excising normal organs much against the principles of surgery for a benign disorder and has led to more conservative approaches.
Fig 7 : Whipples procedure
2. Traverso - Longmire Procedure [15] (1978) : It is a pylorus preserving pancreatico - duodenectomy (Fig. 8). To overcome the problems of postgastrectomy syndrome associated with classical Whipples, pylorus is preserved. Originally used for carcinoma of head of pancreas, now also used for the head related sequelae of chronic pancreatitis.
Fig 8 : Traverso - Longmire Procedure
3. Warren’s Denervated Pancreatic Flap [16] (1984) : Here the pancreas is divided over the portal - superior mesenteric vein after ligation ofsplenic artery and vein. The pancreatic head is excised with a thin rim of residual pancreatic head. Remaining pancreas is not drained. Ligation of spleenic artery and vein is presumed to denervate the gland. (Fig. 9)
Fig 9 : Traverso - Longmire Procedure
4. Subtotal Pancreatic Resection : Consists of resection less than 80% of pancreas. Spleen may be conserved. It is indicated when disease is confined to body and tail e.g. pseudocyst, failed pancreaticojejunostomy, non dilated duct, pseudoaneurysm and when it is not possible to rule out a malignant lesion in body and tail.
5. Child’s Resection [17] (1965) : It is a 95% distal pancreatectomy (Fig. 10). First described by Barret and Bowers18 in 1957, Child popularized it. The spleen, the tail, the body and the uncinate process of pancreas are completely removed. A small cuff of head is preserved along the lesser curvature of the duodenum, no more than 5% of the entire gland. This cuff protects the vascularity and common bile duct during surgery. Not frequently done and indicated when entire pancreas is uniformly and severely diseased and if previous or lesser procedures have failed. Following this procedure the incidence of insulin dependent diabetes mellitus rises upto 74% in non diabetics.
Fig 10 : Traverso - Longmire Procedure
6. Total Pancreatectomy : Rarely indicated primarily as less radical procedure suffice. Indicated secondarily after a pancreatico - duodenectomy or distal subtotal resection has failed to provide pain relief. Duodenum preserving total pancreatectomy is also reported to be effective. Since patients require insulin and also there are significant alteration in digestive and absorptive function, 95%. Distal pancreatectomy is preferred which preserves normal GI and biliary continuity.
Hypoglycaemic attacks after a Child’s procedure or a total pancreatectomy can lead to death or irreversible brain damage. However, there is a renewed interest for use of Whipples and its variant the pylorus preserving procedures especially in cases of inflammatory pancreatic mass with pain relief in upto 90% of cases with an acceptable morbidity (3.2%) and mortality (3%) after an average follow up of 6.6 years. [19]
C. Extended Drainage Procedures
1. Rumpf’s Extended Drainage [20] : It is a combination of Partingtons with a transduodenal pancreaticoplasty (Fig. 11). It is indicated when there is a prepapillary obstruction to the drainage of pancreatic duct due to stones or stricture. With the advent of endoscopy, the second half of theprocedure has become unpopular.
Fig 11 : Rumpf’s Extended Drainage
D. Resection with extended drainage
As incidence of inflammatory mass in head of pancreas is about 30% of which only 10% are malignant,21 resection with extended drainage provide cure in upto 94-95% of cases. [22]
1. Hans Beger’s [23] (1980) : It is a duodenum preserving resection of pancreatic head. Two major steps are involved viz sub total resection of pancreatic head conserving the duodenum and restitution of the exocrine pancreatic secretory flow. Resection : The pancreas is transected at the border between the head and body above the superior mesenteric vein, leaving a small disk of the head between the common bile duct and duodenal wall. Drainage : Body is drained by an end to end pancreaticojejunostomy and by a side to side anastomosis to the rim of the resection cavity of pancreatic head, the resection cavity is drained (Fig. 12). This procedure is indicated in chronic pancreatitis with inflammatory mass in head with medically intractable pain, obstruction of the common bile duct or duodenal stenosis. Duodenum is preserved to maintain gastrointestinal hormones at physiologic levels and also maintain intestinal continuity. Lately, the procedure has been extended to encompass low grade pancreatic malignancies by Japanese .[24] , [25]
Fig 11 : Hans Begers Drainage 2. Extended Beger’s : Performed in cases when there are multiple strictures in the left pancreas with an inflammatory mass at pancreatic head. Here in addition to head resection, a side to side anastomosis between the long incised main pancreatic duct and interposed jejunal loop is performed (Fig. 13).
Fig 13 : Extended Hans Beger’s Procedure
3. Frey’s Procedure [26] (1987) : It is also a duodenum preserving procedure and comparatively less technically demanding than Hans Beger. It involves coring out of pancreatic head overlying the duct of Wirsung, Sartorini and uncinate process using a cautery, keeping at least 5 mm pancreatic tissue posteriorly and medially along with opening the main duct in body and tail. Drainage of the cored head with the opened main duct is by a lateral pancreaticojejunostomy (Fig. 14). If duct is less than 8 mm in size : duct to capsule anastomosis is performed. This procedure is indicated for pain in chronic pancreatitis with its complications like a pseudocysts, common bile duct obstruction, pancreatic ascites, fistulas and recurrent pain after a lateral pancreaticojejunostomy. It is contra indicated in whom cancer cannot be ruled out, as it does not completely excise the head.27 Recently Frey has even advocated his procedure for small duct upto 3.5 mm. [28]
Fig 14 : Frey’s Procedure
4. Izbicki’s "V" Shaped Ventral Pancreatic Excision [29] (1998) : Indicated for sclerosing ductal pancreatitis (small duct disease) with maximum diameter of Wirsung duct less than 3 mm. In this procedure, a long "V" shaped excision of ventral aspect of pancreas is done with a lateral pancreaticojejunostomy by a mucosa to capsule anastomosis. (Fig. 15) This procedure drains the main as well as second and third order ducts.
Fig 15 : Izbicki’s "V" Shaped Ventral Pancreatic Excision
Duodenum preserving pancreatic head resection procedures are associated with less morbidity, less incidence of pain, a greater weight gain with better glucose tolerance and a higher insulin secreting capacity. Above all it leads to an early professional rehabilitation as compared to a pylorus preserving pancreatico-duodenectomy. Also recurrence of pain after a resectional with extended procedure is technical. This is due to insufficient decompression of pancreatic gland in the "Achilles Heel Triangle" which is bounded by common bile duct, hepatoduodenal ligament and wall of duodenum.
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