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General Surgery
Chronic Pancreatitis
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 173 slides
Overview
- Scope of this presentation
What chronic pancreatitis is
An irreversible, fibrosing disease of the gland that makes digestive juice
- Definition of chronic pancreatitis
- Exocrine and endocrine function of the pancreas
- Natural history
- Principles of decision making
- Autodigestion and zymogen activation
- Acute versus chronic pancreatitis
- Limits of the acute-chronic distinction
- Morphological subtypes of chronic pancreatitis
- Coexistence of subtypes
Risk factors and the TIGAR-O framework
Why the disease is better described by risk modifiers than by causes
- Limits of the alcohol hypothesis
- Risk modifiers rather than causes
- The TIGAR-O framework
- Categories of risk in chronic pancreatitis
- TIGAR-O risk categories: toxic, idiopathic, genetic, autoimmune
- TIGAR-O risk categories: recurrent acute and obstructive
- Alcohol as a risk factor
- Proposed mechanisms of alcohol-related injury
- Tobacco and other toxic risk factors
- Idiopathic chronic pancreatitis
Genetic and autoimmune disease
Gene faults that leave trypsin switched on, and the IgG4 form of the disease
- Hereditary pancreatitis
- Normal trypsin activation and control
- How PRSS1 mutations cause disease
- Other genes in hereditary pancreatitis
- Cystic fibrosis and the CFTR gene
- CFTR mutations in otherwise idiopathic disease
- Mechanism of CFTR-associated pancreatitis
- SPINK1 as a trypsin brake
- Safeguards against early trypsin activation
- Autoimmune pancreatitis: pathology
- Autoimmune pancreatitis: immunology
- Autoimmune pancreatitis: clinical picture
- Autoimmune conditions associated with pancreatitis
- Recurrent and severe acute pancreatitis
- Obstructive risk factors
- Pancreas divisum
Pathophysiology and the origins of pain
How a single severe attack can prime the gland for permanent scarring
- Obstacles to understanding pathogenesis
- Traditional theories of acute pancreatitis
- The sentinel acute pancreatitis event hypothesis
- How fibrosis becomes permanent
- From sentinel attack to fibrosed gland
- Ductal hypertension as a source of pain
- Neuropathic mechanism of pain
- Two proposed sources of pancreatic pain
Clinical presentation
Pain, malabsorption, late diabetes, and the complications that reach beyond the gland
- Pattern and site of pain
- Weight loss and malnutrition
- Steatorrhoea and exocrine insufficiency
- Endocrine insufficiency
- Islet entrapment within pancreatic fibrosis
- Features of pancreatogenic diabetes
- Endocrine risk in non-alcoholic disease
- Extrapancreatic presentations
Diagnosis
History and imaging carry the diagnosis; laboratory tests add little
- Basis of the diagnosis
- Laboratory findings
- Computed tomography in chronic pancreatitis
- Calcification and the inflammatory head mass
- Dense calcification in the pancreatic head on CT
- Other CT findings and their meaning
- Pseudocyst compressing the splenic vein
- Role of pancreatic ductography
- Duct changes of chronic pancreatitis on ERCP
- Magnetic resonance cholangiopancreatography
- Dorsal duct stricture on secretin-stimulated MRCP
- The Cambridge classification
- Cambridge grades from main duct and side branch appearance
- Minimal change disease
- Endoscopic ultrasound
- Parenchymal and ductal criteria used at endoscopic ultrasound
- Limits of endosonographic criteria
- Tests of exocrine function
- Tests of endocrine function
- Serology in suspected autoimmune pancreatitis
- Role of genetic testing
- Value of CFTR and SPINK1 testing
Medical management
Removing the trigger, replacing the enzymes, and the long climb up the analgesic ladder
- Removing inciting agents and nutritional support
- Pancreatic enzyme replacement
- Enzyme therapy for pain in small-duct disease
- Antioxidants and corticosteroids
- Pain as the dominant clinical problem
- Pharmacotherapy for pain
- Adjuncts in pain management
- Celiac plexus block
- Outcomes of neurolytic procedures
Endoscopic therapy
Clearing stones and stenting strictures, and how it compares with surgery
- Endoscopic options and patient selection
- Limitations of endotherapy over time
- Biliary endoprosthesis in chronic calcifying pancreatitis
- Endoscopic stenting compared with surgery
- Randomized comparisons of stenting and surgery for main duct dilation
Principles of surgical management
Who needs an operation, and how the gland's shape decides which one
- Indications for operation
- Categories of operation
- Morphological patterns that drive the choice
- Risks and expected results of pancreatic surgery
- Matching the operation to the morphology
Large-duct disease
Unroofing a dilated duct along its whole length and draining it into a jejunal limb
- Definition of large-duct disease
- Origins of the Puestow procedure
- Partington-Rochelle modification
- Incision and mobilisation of the duodenum
- Entering the lesser sac
- Control of the gastroduodenal artery
- Locating and opening the pancreatic duct
- Extent of the ductotomy
- Preparing the Roux limb
- Constructing the pancreaticojejunostomy
- Cross-section of a lateral pancreaticojejunostomy
- Outcomes of lateral pancreaticojejunostomy
- Causes of failure after lateral pancreaticojejunostomy
Chronic pancreatitis with a dominant head mass
The Whipple operation and the three duodenum-preserving alternatives
- Limits of drainage alone
- Four operations in frequent use
- Evidence from randomized trials
- Long-term results of trials comparing head-dominant operations
- Practice patterns on the two continents
- Tailoring the operation to the anatomy
- Assessing resectability at pancreaticoduodenectomy
- Opening and inspection
- Mobilisation and the retropancreatic tunnel
- Portal dissection
- Test occlusion of the gastroduodenal artery
- Retroperitoneal anatomy exposed at pancreaticoduodenectomy
- Dividing the upper structures
- Standard versus pylorus-preserving resection
- Mobilising the proximal jejunum
- Transecting the neck and freeing the uncinate
- Reconstruction: the pancreatic anastomosis
- Duct-to-mucosa sutures placed over a stent
- Constructed and completed pancreaticojejunostomy
- Reconstruction: biliary and gastric anastomoses
- Gastrojejunostomy and closure
- Rationale for duodenum-preserving head resection
- Beger procedure: exposure and division of the neck
- Beger procedure: coring out the head
- Anatomy after removal of the pancreatic head
- Beger procedure: reconstruction
- Reconstruction after a Beger procedure
- 3.3%
- Interpreting the Beger series
- Randomized trial of head resection versus Whipple
- Long-term results of that comparison
- Limitation of the Beger operation
- Rationale for the Frey operation
- Frey procedure: technique
- Frey procedure: drainage of body and tail
- Pancreas after coring of the head in a Frey procedure
- Pancreaticojejunostomy in the Frey procedure
- Frey procedure compared with the Beger procedure
- Frey procedure compared with pylorus-preserving Whipple
- The Berne modification
- Evidence for the Berne modification
Small-duct disease and diffuse sclerosis
When there is no duct to drain and no mass to remove
- Small-duct disease and diffuse sclerosis
- Options in small-duct disease
- Total pancreatectomy: sequence of the operation
- Islet isolation from the resected pancreas
- Details of the isolation process
- Routes for islet infusion
- Outcomes of islet autotransplantation
- Caveats around islet autotransplantation
- Concerns about the transplanted islets in the liver
- Hereditary pancreatitis with PRSS1 mutation on CT
- Indications for total pancreatectomy with islet autotransplantation
- The Izbicki V-shaped resection
Summary
What is settled, what is not, and where these patients are best treated
- Summary of the disease
- Summary of risk and morphology
- Summary of treatment
- Points to carry away
- References
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- Maingot's Abdominal Operations, 12th Edition