Chronic pancreatitis surgery class
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chronic pancreatitis
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Chronic pancreatitis surgery class
- 2. Issues • Diagnosis • Natural course of the disease • Treatment – Medical or Surgery or Endotherapy • Surgery – Timing of Surgery Type of Surgery • Recurrence of pain
- 3. Chronic Pancreatitis Pathology : Progressive loss of exocrine & endocrine function. In late stage pancreas is enlarged & hard Ductal change – areas of stricture & dilatation Calcification – Intraductal & parenchymal
- 5. Pathogenic Mechanisms Toxic and metab olic Idio pathic Genetic HP CFTR SPINK -1 Auto immune Recurrent SAP Obstru ctive Oxidative stress Toxic Metabolic Necrosis Fibrosis SAPE Hypothesis Stone & Duct Obstruction Large Duct Chronic Pancreatitis
- 6. Cl. Featute – Pain, wt. Loss, diabetes, steatorrhoea
- 7. Clinical Presentation Early onset _ Age < 35 Late onset - Age > 35
- 8. Pain Characteristics of Chronic Pancreatitis Type of Pain Type A - Intermittent ,short duration, several episodes in a year Type B - Continuous chronic pain Pseudocyst Obstructive pathology
- 9. 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
- 10. 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
- 11. The Izbicki pain score A validated pain score specifically designed for chronic pancreatitis . It consists of four questions regarding • Frequency of pain • Intensity of pain (VAS score) • Use of analgesics • Disease-related inability to work Based on these question a pain score can be calculated ranging from 0 (no pain) to 100 (severe, debilitating pain).
- 12. • Ductal Dilatation • Parenchymal Hypertension • Parenchymal Ischaemia • Neurohumoral inflammation • Obstruction of luminal structures Aetiology of Pain in CP
- 13. Investigation - Exocrine function test Direct Test Invasive Secretin – Cerulein Test Lundh Test Fecal Test • Fecal Chymotrypsin test • Fecal Elastase 1 Test Indirect Test • 24 hours Stool weight and Fecal fat estimation • Pancreolauryl Test and PABA test • Breath Test – 13 C labeled substrate
- 14. Imaging Studies USG / MRCP/ ERCP/ CT/ EUS
- 15. CP with pancreas Divisum MRCP in Chronic Pancreatitis CP with CBD obstruction CP with CBD Stone
- 17. Ch Pancreatitis with Pseudocyst
- 18. Ch Pancreatitis and Carcinoma of Pancreas
- 19. Ch Pancreatitis with Pseudoaneurysm
- 21. Treatment Medical management – Nutrition Enzyme replacement Insulin Analgesics Indication of surgery 1. Intractable pain 2. Complication – Obstruction – CBD, D2 Vascular involvement Panc. Cyst Presence of mass Pancreatic Ascites
- 22. Surgery for Chronic Pancreatitis a timeline Date Author Procedure 1946 Clagget Total Pancreatectomy Whipple Pancreaticoduodenectomy 1950 Richman and Colp Gastrectomy 1954 Duval Caudal pancreaticojejunostomy 1955 Bowers Choledochojejunostomy 1956 Doubilet and Mulholland Sphincterotomy 1958 Puestow and Gillesby Lateral pancreaticojejunostomy 1965 Fry and Child 95% Distal Pancreatectomy 1978 Traverso and Longmire Pylorus-preserving “Whipple” 1987 Frey and Smith Head resection and drainage 1989 Beger et al Duodenum-preserving resection
- 23. Timing of Surgery Early Vs Late
- 25. What is the appropriate type of Surgery ?
- 26. Surgery for Chronic pancreatitis A. Drainage procedure Longitudinal side to side Roux-en-Y pancreatojejunostomy (Modified Peustow or Partington Rochelle) B. Resection Procedure 1.Begers operation 2.Whipple’s Pancreatoduodenectomy 3.Distal pancreatectomy C. Combined procedure Frey’s operation Izbicki’s operation Non operative Methods Endoscopic Therapy Caeliac ganglion block
- 27. LPJ – Partinhton- Rochelle Frey’s Procedure Berne Procedure – Modified DPPHR
- 28. Duval’s Procedure Peustow-Gilesby Procedure Beger’s Procedure - DPPHR Izbicki’s procedure – Small duct Disease
- 29. Salvage or Redo Surgery after failure of Primary Surgery for pain relief Drainage Surgery Resection Surgery Resection Surgery Total Pancreatectomy