SURGERY FOR CHRONIC PANCREATITIS

Vikas Gupta, Pavan Kumar G, Soundara Rajan L

Chronic pancreatitis (CP) is a progressive, chronic inflammatory ar.d debilitating condition characterized
by disabling pain and :s associatt::d with development of exocrine and endocrine pancreatic
insufficiency. It usually affects yOl!nger popul&lion which leads to enormous socio-economic burden to
the patient and his family due to loss of working hours because of pain. These patients usually have a
poor quality of life and a shortened life expectancy due to the development of secondary complications.
Ongoing pancreatic inflammation can lead to formation of a mass in the head ot pancreas in about 30-
50% of the oatients. The disease can be.~mplicated with the development of biliary (about 30%) or
rarely duodenal (5-7%) obstruction, porto-mesenteric compression (8-10%) and splenic vein thrombosis
(3-5%).

Indication of Surgery .
Majority of the patients during the course of disease require surgical intervention. Pain is the most
common indication of surgery. Failure of medical and endoscopic management to pmvide adequate
pain relief is the classir3I indication of surgery.
Other indications of surgery:
.. Development of an inflammatory mass
• Multiple strictures in pancreatic duct unsuitable for endotherapy
• Development uf biliary or duodenal stenosis
• Suspicious of malignanacy

. Rationale of Surgery In Chronic pancreatltls

lntra-ductal and interstitial hypertension have been the proposed as the mechanisms of pain in chronic
pancreatitis. This situation is quite similar to the occurrence of compartment syndrome in pancreas.
Both the etiologies caii be very effectively addressed by the surgical decompression and adequate
drainage of the pancreas.
Pancreas head has been found to be enlarged in aboul half of the paffents with chronic pancreatitis due
to the ongoing inflammatory process. 'Pancreatic head has been considered as a 'pacemaker of pain'
Jn chronic pancreatitis. Head mass is often addressed with resectional procedures.
In a randomized controlled trial, surgery has been proved to be superior to endoscopic treatment of
chronic pancreatitis In-terms of long term complete pain relief and increase in body weight at 5 years.
However, development of de novo diabetes was similar in both the ar!TIS- Another randomized trial
comparing surgery and endotherapy was terminated earty after interim analysis on the basis of
significant improvement of pain score and better quality of life favoring surgjcal interventions.

Timing of Surgery
SUl'gical intervention should be performed early in the course of the disease. Not only does it achieve
a better pain relief but also it can delay the onset of insufficiency in these patients. It can slow down the
ongoing inflammatory process by providing surgical decompression. It is imperative to have intervention
before the changes become irreversible to cause permanent damage to the pancreas.

Surgical options
The main aim of the surgical intervention is to provide a lasting pain relief and at the same time preserve
endocrine and exocrine function. Surgical procedures can be divided as (table 1)
Table 1: Classification
. .
of Surgical
. .
Procedures
. for. Chronic. . Pancreatitis
. ·-
-·
Resectional procedures Drainage procedures Hybrid procedures

1.. P.ancreaticoduodenectomy
2.· PPPD
1. Duval's procedure
2. Puestow-Gillesby
1. Head Coring and drainage
(Frey's procedure)
I
3. Total pancreatectomy with or 2. DPHR(Beger's Procedure)
procedure
without duodenum preservation 3. lzbicki (Hamburg)
3. Partington-Rochelle
4. Total pancreatectomy with islet modification
variant of the Puestow
cen autotransplantation 4. Berne modification
procedure
5. left sided r~section

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 Preoperative assessment
Proper patient selection is essential for an excellent outcome. Components of assessment indudes:
a) Confirmation of the diagnosis of chronic pancreatitis and to establish the benign nature of the
head mass if present
b) Define the anatomy of pancreatic dl.ic!, head mass and parenchyma
c) Evaluation for biliary and duodenal obstruction
d) Ascertain the patency of spleno-porto-mesenteric axis
e} Assessment of exocrine- and endocrine function
f) Pain assessment in terms of severity and opioid dependence
g) Assessment of nutritional, medical anci psycho-sociai co-morbidities.

RESECTIONAL PROCEDURES
Partial or total resection of pancreas is an attractive and permanent solution for pain associated with
CP. however, it is associated with the risk of developing permanent pancreatic insufficiency,

Pancreatlcoduodenectomy
Kausch-Whipple pancreaticoduodenectomy (PD) entails the resection of pancreatic head along with
the entire duodenum, distal third of the stomach, bile duct, and proximal jejunum. With increasing safety
of the procedure, it is being clone for the benign disea~e as well.
Classical PD is associated with nutritional ~uelae associated with distal gastrectomy, so it is not the .
) preferred for chronic pancreatitis: Pylorus-preserving procedure (PPPD) on the other hand does not
entail the removal of stomach and has evolved as the preferred procedure for chronic pancreatitis..
, The major advantage of PD is the resection of an unrecognized adenocarcnoma in a patient with head
mass. The procedure in itself is sufficient to address the patients with duodenal and distal bile duct
J stricture.
Pancreatico-duodenectomy, provides long term pain relief has been reported in 85% of the patients.
However, it is associated with more than 50% incidence of new onset of diabetes and almost half of the
patients devel~ping exocrine i~ufficiency at a f~llow up of ten yeats:
·" .• •. •
Distal Pancreatectomy
This is suitable only small percentage patients (5-15%} have focal disease confined to the body and tail
of pancreas. This happens in patients with isolated dur.t stricture, pseudocyst, or b()th at the neck of the
pancreas. Since head is the pacemaker of pain in CP, this procedure leaves major portion of the gland
untreated. Therefore it is associated with a significant incidence of recurrence and is not widely
t advocated in the management of CP.

95o/o Distal Pancreatectomy

The procedure entails removal of almost entire pa, ,creas leaving a very thin rim of tissue over the
duodenum. This tissu3 accounts for only 5% of the pancreatic parenchymal tissue. This in tum helps in
preserving the pancreaticoduodenal arcade and intrapancreatic portion of the bile duct. This helps in
the preservation of the entero-duodenal axis.
The procedure was able to achieve a pa:n relief of more than 80% at long term follow up. However,
majority of the patients will develop brittle diabetes and -endocrine ·insufffciency. So the procedure of
95% -distal pancreatectomy didn.'t become popular.

DRAINAGE PROCEDURES
Duval and Zollinger et al in separate studies reported distal pancreato-splenectomy with caudal
pancreaticojejunostomy as a drainage procedure for chronic pancreatitis. The procedure provided
drainage of only a small distal segment of the duct without addressing the strictures. So it failed to
provide a lasting pain relief in the presence of classical 'Chain of lakes' appearance.
. ..

0
The procedure was later modified by Puestow and Gillesby by th6 addition of longitudinal
pancreaticojejunostomy from the caudal end with implantation of the divided tail into the Roux en Y limb
I
of the jejunum. This was done to have a larger drainage of the duct particularly in the body and tail of
pancreas. This procedure to decompress the head region as the jejunum limb was not brought beyond
the superior mesenteric vessels. So the failure rate in terms of recurrence of pain was high.

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In 1960, Partington and Rochelle tater modified the procedure by fashioning a side to side anastomosis
with jejunum after longitudinally incising the anterior surface of pancreas to expose the duct. This
procedure did not require posterior mobilization of the pancreas and had an advantage of avoiding distal
pancreatectomy and splenectomy. In addition it had an advantage of decompressing the pancreatic
-duct in the head region as well. So, this procedure has been widely popularized over the years and i
sa!so known as u:teral Pancreatico Jejunostomy (LPJ).

'Technique of Lateral Pancreatico Jejunostomy (LPJ):

A dilated duct, with chain of lakes appearance in the absence of a head mass is suitable for this
procedure.
.'\ midHnc er.:: bilatom! m..:bco~t3! i~c:~:or. ls prefcrrbd. Gastr.o.colic .cmentum is divided so as to expose
the pancreas in its entire extent. Hepatic flexure is taken down to expose the pancreatic head. Anterior
pancreaticoduodenal and gastroduodenal veins are suture ligated and divided. Pylorus and the first part
of the duodenum should be lifted of the pancreas head. The head should be palpated for any suspicious
mass and frozen biopsy should be sent if required.: The superior and inferior borders of pancreas are
delineated anteriorly so as to facilitate the subsequent placement of sutures during anastomosis.
Pancreatic duct can be identified easily by palp,ation in the neck or body region where it is superficial,
as thin parenchyma overlies a dilated duct. h I patient with duct packed with stones, the needle can be
used to sound the stone for subsequent opening of the duct. Once the duct is located, it is r.onfirmed
by aspiration. Small ductotomy is made to gain sufficient access to place a fine instrument into the duct.
The ductotomy is extended towards the left till about 1 cm short d the tip of tail. The calculi n the
pancreatic duct can be removed as and when they are encountered while opening the duct. Towards,
the right, the ductotomy is 3Xtended just short of duodenum. Intra- parenchymal cyst if encountered is
incorporated into the ductotomy and drained into the jejunum. Bleeding from the pancreatic margin is
usually controlled with diathermy or a fine non absorbabf~ suture. •
About 15 cm from ligament of Trietz, jejunum is divided with a stapler cutter device. Jejunojunostomy
is fashioned 45-50 cm down-stream in a side to side. fashion. Roux limb is brought up through-retro-
colic route usualy to the left of midci(e colic· artery.
Jejunum is placed over the pancreatic su~ace and opened longitudinally serially to match the length qf
a·
dutotomy. Usually sing IE: ·1ayer continuous anastomosis with a long lasting fine ~nofilament suture
is performed. Full thickness jejuna! bites are sutured witfl p~ncreatic capsule taking partial thickness of
. parenchyma-. No attempt is made to sew directly the mucosa of pancreatic duct except the tail region
where the parenchyma is very thin. Deep bites into the parenchyma can occlude the side branches of
the gland and may limit the drainage. • ••
Results of LPJ:
Relief of pain is the primary end point of the operation. With LPJ it has been seen from 48% tC' 91 %.
Despite ear1y pain relief in more than 80% of the patients, about 30-35% of patients develop pain at a
follow up of 3-5 years. There is no evidence to suggest that this procedure worsens the pancreatic
insufficiency as it is associated with minimal loss of the functioning pancreatic parenchyma.

HYBRID PROCEDURES

Frey Procedure
With about one thirds of patients developing recurrence of pain, there was a need to develop new
procedure. As pancreatic head is a pacemaker for pain, so without excising the head, it is difficult to
achieve pain relief in patients with inflammatory head mass. Frey and Smith described a procedure
which combin~s partial excision of head as well as the drainage of duct.
In "patients with dilated duct, 30-50% pr1tients have· as associated inflammatory head mass. Partial.
excision of the head improves the ductal drainage and better clearance of calculi. Due to the more
posterior location of main pancreatic duct in the head region there is presence of thick pancreatic tissue
between the posteriorly placed duct and medial duodenal wall. It is important to excise this tissue for
adequate drainage of duct. .I
Surgical technique: The exposure of pancreas and opening of the pancreatic duct is performed as
described for lateral pancreatico-jejunostomy.

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 Head Coring:
The location of mesenteric vessels in relation to pancreas is identified as pancreas at this point wiK not
be divided and careful coring out is performed in this area. After the duct is opened till the neck of
panaeas, coring of pancreatic tissue in small bites is performed in the head region.
Panc:reaticoduodenal groove is preserved as it contains the vasculature of the duodenum. Marking
sutures are placed on the pancreas. 5mm parallel and medial to the inner aspect of duodenum to limit
the medial extent of resection. The pancreatic tissue is removed in small bits, and one should secure
hemostasis after removal of each and every bit. While coring out the pancreatic tissue, care should be
exP.f'Cised to avoid inj•Jring common bile duct Panccreatic duct is the posterior-most limit of the coring.
At the end of coring, a thin rim of pancreatic tissue should remain over the duodenum to preserve the
supetn- c:.1nd inferior arcade. Thb cored out head is in continuity with the main pancreatic duct and
drained in a Roux en Y limb of the jejunum as done in LPJ. In the head region, the jejunum is sutured
with lhe rim of pancreatic tissue left on the duodenal wall.
Complications: it can be performed with a mortality of less 1han 2%. Other complications like pancreatic .
fistula, intra-abdominal collection. haemorrhage, pulmonary complications, occur in 7 to 40%.. ••
Anaskmotic failure occurs in 2 - 3%. Outcome: Paih relief in 70% ·to roo¾ ofthe ·patients. New onset • ••
diabetes occurs in 8 to 34% while exocrine insufficiency occurs in 60 to 80%. Improved quality of life
and inproved nutritiona! status is reported in more than 90% of the patients.

Moclfications of Hybrid Procedures

' )
Beger's Procedure (Duodenum preserving head resection)
The procedure entails 95% resection of pancreatic head. The pancreas is transt.cted at the neck region
after 'ieparating it from porto-mesenteric axis and medially leaving a small rim of pancreatic tissue along ..
the medial duodenal wall. The pancreas remnant is drained in the Roux limb d the jejunum. This allows
the preservation of entero-duodenal axis which has the • major advantage over
J pancreaticoduodenectom1. However this is associateo with loss of pancreatic tissue leading on to the
development of brittle diabetes. . Complete or partial pain reflef
. is achieved in 70 - 100% of the pati~nts.
Bern Modification: This is a technical.simplification of the Beger-procedure with equivalent outcome.
J The excavation of the pancreatic ~ad is performed identical to that of Berger-procedure. However,
separation of. pancreas from-.the porto-mesentric·axis is no(required as it doesn't mandate transaction
) of the pancreatic neck. This makes the procedure technically easy and safer. The procedure is ideal for
patients with a dominaht inflammatory head mass with.out left side stenosis.
#" •

lzbicl,j"Modification: The procedure is most suitable for patients with small duct pancreatitis as defined
by duct diameter of less than 3 mm. The procedure entails removal of a longitudinal triangular cavity
) alonglhe ventral aspect of pancreas. This V-shaped excision provides ad~•Jate drainage of secondary
af'ld tertiary order pancreatic ducts. Subsequently, this V shaped cavity is anastomosed to a Roux-en-
y loop jejunum in a side-to- side manner. This achieves a complete pain relief in 75%, weight gain in
89%, improved quality of life and return to work.

Conclusions
) Pain is the dominant symptom for which surgical intervention is needed. The surgical should be selected
as per the stage of the disease and patho-morphology of the pancreas. Choice of surgical procedure is
determined by the main pancreatic duct diameter and the presence inflammatory. head mass as
described in the table 2. Pain relief is similar for hybrid procedures and pancreaticoduodenectomy.
Resectional procedures should be avoided as far as possible as it leads to the permanent loss of
functioning parenchyma. Development of endocrine or exocrine dysfunction occurs as a part of the
natural course of tho disease.

I
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/
Table 2: Choice of surgical procedure in Chronic pancreatitis
Procedure Patho-morphology
Dranage procedures
Caudal drainage {Duval) Puestow
Obsolete, replaced by newer procedures
Procedure
Dilated main pancreatic duct without presence of inflammatory
Lateral pancreaticojejunostomy
head mass
Resection Procedures
PO/ PPPn Suspected neoplasia
Presence of fixed duodenai stenosis
Distal Pancreatectomy Focal disease localized to the body and tail region of pancreas
Totat pancreatectomy Only as a salvage procedure; Caution of brittle diabetes
Preserves endocrine function Caution severe exocrine
Total pancreatectomy with AIT
insufficiency
Hybrid procedures Exclude malignancy by frozen section
Frey procedure Ductal obstruction with a small inflammatory head mass
Beger procedure Large Inflammatory head mass without a distal stricture
V shaped excision Small duct pancreatitis (< 3 mm )
AIT auiologous islet cell transplantation

Further reading
1. EA Choi, Mathews JB. Chronic Pancreatitis. In CJ Yeo, Mathews JB, McFadden OW,
Pemberton JH. Peters

~H. Editors, Surgery of the Almentary Trad, 1th edn, Elsevier Saunders, Publisher, 2016; pp
·~132-1·143 •

.... 2. Hartwig W, Strobel 0, Buchler MW, Werner J. Management of Chronic pancreatitis: . ··

conservative, endoscopic and surgical. In Jarnagin WR, Belghiti J, Buchler MW, Chapman
WC, D'Angelica Ml, DeMatteo RP, Hann LF, Blumt1art lH. Editors, St1rgery of the liver, biliary
tract an_d pa~creas, sth edition, Elsevier Saunders, publisher
2012; pt,871-881.
3. Beger HG, Rau BM, Poch B. Duodenum-preserving pancreatic head resection. In Beger HG,
Matsuno S,

Cameron JL, edit9rs, Diseases of the pancreas current surgical therapy; Springer, 1st edn. 399-
412.