Surgical Management of Chronic Pancreatitis

Abstract

Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.

Keywords: Chronic pancreatitis; Frey; Neuropathic pain; Puestow; Surgery; Total pancreatectomy.

Fig. 1

Mechanism of pain in chronic pancreatitis. The neuropathic pain syndrome involves molecular and morphological alterations at intrapancreatic (peripheral) and extrapancreatic (dorsal root ganglia, spinal cord, brainstem, and cerebrum) sites. Reproduced with permission from Demir et al. Langenbeck’s Archives of Surgery, 2011. 396(2): p. 151–160 [33]

Fig. 2

Algorithm for the management of painful chronic pancreatitis

Fig. 3

Minimally invasive Frey procedure showing the resection of the anterior head of the pancreas (a) and reconstruction with robotic lateral pancreaticojejunostomy (b)

Fig. 4

Duodenum-preserving pancreatic head resection with complete resection of the head and uncinate process of the pancreas. A small remnant of pancreas left on the C-loop of the pancreas, B superior mesenteric vein, C transected pancreas