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Surgery_Schwartz. ultrasonography04080120160Time (min)206010014018004080120160200–40IR-pancreatic polypeptide (pmol/L)NLCPFigure 33-35. Pancreatic polypeptide (PP) response to a test meal. Immunoreactive PP (IR-PP) responses in control subjects (NL, n = 6) and patients with severe chronic pancreatitis (CP) accom-panied by PP deficiency (CP, n = 5) are shown. A test meal was administered at 0 minutes. Means ± standard error of the mean are shown. (Reproduced with permission from Brunicardi FC, Chaiken RL, Ryan AS, et al. Pancreatic polypeptide administration improves abnormal glucose metabolism in patients with chronic pancreatitis, J Clin Endocrinol Metab. 1996 Oct;81(10):3566-3572.)acid (PABA) is measured.185 Although the sensitivity of the test is as high as 100% in patients with severe chronic pancreati-tis, it identifies only 40% to 50% of patients with mild disease, and reduced PABA excretion is found in patients with a variety of other GI, hepatic, and renal diseases. The quantification of stool


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Surgery_Schwartz. it identifies only 40% to 50% of patients with mild disease, and reduced PABA excretion is found in patients with a variety of other GI, hepatic, and renal diseases. The quantification of stool fat has also been used as a measure of pancreatic lipase secretion, either through the direct measurement of total fecal fat levels while the subject consumes a diet of known fat con-tent, or by the measurement of exhaled 14CO2 after ingestion of [14C]-triolein or [14C]-olein. This so-called triolein breath test is less cumbersome than intubation methods and avoids the necessity of stool collections and analysis, but it also has a high false-negative rate.186Fecal levels of chymotrypsin187 and elastase188 have been proposed as simpler, less expensive tests of exocrine function and correlate well with loss of pancreatic function. As with other test methods, however, these tests lose their sensitivity in patients with mild to moderate chronic pancreatitis and may be more sensitive for other


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Surgery_Schwartz. with loss of pancreatic function. As with other test methods, however, these tests lose their sensitivity in patients with mild to moderate chronic pancreatitis and may be more sensitive for other causes of pancreatic dysfunction, including cystic fibrosis. Fecal elastase C1 measurements have become widespread in their use, and levels above 200 μg/g are considered normal, whereas levels below 100 μg/g are indica-tive of pancreatic exocrine insufficiency.189 The sensitivity and specificity of fecal elastase C1 measurements fall short of those needed for definitive diagnosis of pancreatic exocrine insuffi-ciency, however.190Radiologic imaging has become the principal method of diagnosis of chronic pancreatitis, with the codification of clas-sification systems that correlate with proven disease. ERCP has been considered the most sensitive radiologic test for the diagnosis of chronic pancreatitis, with specific ERCP findings that are highly correlative with the degree or stage of chronic


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Surgery_Schwartz. ERCP has been considered the most sensitive radiologic test for the diagnosis of chronic pancreatitis, with specific ERCP findings that are highly correlative with the degree or stage of chronic disease191 (Table 33-15). CT scanning is sensitive for the diag-nosis of chronic pancreatitis when calcification, duct dilata-tion, or cystic disease is present, but it is not accurate in the absence of these findings. CT is helpful as a screening study to guide interventional therapy or other diagnostic modalities,158 although EUS has become the preferred method for the diagno-sis of pancreatic disease and offers the advantage of very-high-resolution images of the pancreatic parenchyma, the main and secondary ductal systems, cystic lesions, and calcific changes. Table 33-15Cambridge classification of chronic pancreatitis by endoscopic retrograde cholangiopancreatographyGRADEMAIN PANCREATIC DUCTSIDE BRANCHESNormalNormalNormalSuggestiveNormal<3 AbnormalMildNormal≥3 AbnormalModerateAbnormal>3


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Surgery_Schwartz. of chronic pancreatitis by endoscopic retrograde cholangiopancreatographyGRADEMAIN PANCREATIC DUCTSIDE BRANCHESNormalNormalNormalSuggestiveNormal<3 AbnormalMildNormal≥3 AbnormalModerateAbnormal>3 AbnormalSevereAbnormal plus at least one of the following: large cavity, duct obstruction, dilation or duct irregularity, intraductal filing defects Reproduced with permission from Axon AT, Classen M, Cotton PB, et al: Pancreatography in chronic pancreatitis: international definitions, Gut. 1984 Oct;25(10):1107-1112.Brunicardi_Ch33_p1429-p1516.indd 146301/03/19 6:45 PM 1464SPECIFIC CONSIDERATIONSPART II246810060NonalcoholicsPancreatico-duodenectomyalcoholicsAlcoholics; 40–80%distal pancreatectomyAlcoholics; 80–95%distal pancreatectomyYears after surgical procedurePercent surviving1214708090100Figure 33-36. Effect of alcohol use on survival after surgical procedures. The cumulative survival of patients with chronic pancreatitis fol-lowing pancreaticoduodenectomy or distal pancreatectomy


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Surgery_Schwartz. 33-36. Effect of alcohol use on survival after surgical procedures. The cumulative survival of patients with chronic pancreatitis fol-lowing pancreaticoduodenectomy or distal pancreatectomy is shown for nonalcoholic and alcoholic patients. (Reproduced with permission from Frey CF, Child CG, Fry W. Pancreatectomy for chronic pancreatitis, Ann Surg. 1976 Oct;184(4):403-413.)EUS findings may be inconclusive in mild or “minimal change” pancreatitis, however, and improved criteria for an EUS-based diagnosis are still a work in progress.192 Most importantly, EUS is highly reliable in ruling out pancreatic carcinoma when CT findings are normal or equivocal.Prognosis and Natural History. The prognosis for patients with chronic pancreatitis is dependent on the etiology of the disease, the development of complications, and on the age and socioeconomic status of the patient. The influence of treat-ment is less evident in long-term studies, although the general absence of randomized, prospective


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Surgery_Schwartz. of complications, and on the age and socioeconomic status of the patient. The influence of treat-ment is less evident in long-term studies, although the general absence of randomized, prospective trials clouds the issue of whether specific forms of therapy alter the long-term outlook for patients with the disease.Several studies have demonstrated that, although symp-toms of pain decrease over time in about half of the patients, this decline is also accompanied by a progression of exocrine and endocrine insufficiency.193 In general, the likelihood of eventual pain relief is dependent upon the stage of disease at diagnosis, and the persistence of alcohol use in patients with alcoholic chronic pancreatitis. Miyake and colleagues found that pain relief was achieved in 60% of alcoholic patients who suc-cessfully discontinued drinking, but in only 26% who did not.194The long-term survival of patients with chronic pancreatitis is less than for patients without pancreatitis. In an


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Surgery_Schwartz. patients who suc-cessfully discontinued drinking, but in only 26% who did not.194The long-term survival of patients with chronic pancreatitis is less than for patients without pancreatitis. In an international multicenter study of >2000 patients, Lowenfels and colleagues found that the 10and 20-year survival rates for patients with chronic pancreatitis were 70% and 45%, respectively, compared to 93% and 65% for patients without pancreatitis.195 The mortality risk was found to be 1.6-fold higher in patients who continued to abuse alcohol, compared to those who did not. Continued alcohol abuse has a similar effect on the response to surgical treatment (Fig. 33-36), and results in a twofold increase in mortality over a 10to 14-year follow-up period.195In addition to progressive endocrine and exocrine dysfunc-tion, and the risk of the specific complications outlined here and in Table 33-16, the other significant long-term risk for the patient with chronic pancreatitis is the development


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Surgery_Schwartz. exocrine dysfunc-tion, and the risk of the specific complications outlined here and in Table 33-16, the other significant long-term risk for the patient with chronic pancreatitis is the development of pancre-atic carcinoma.196 There is a progressive, cumulative increased risk of carcinoma development in patients with chronic pancre-atitis, which continues throughout the subsequent lifetime of the patient (Fig. 33-37). The incidence of carcinoma in patients with chronic pancreatitis ranges from 1.5% to 6%,196 which is at least 10-fold greater than that of patients of similar age seen in a hospital setting. In patients with chronic pancreatitis accom-panied by diabetes, the risk of carcinoma has been found to be increased 12to 33-fold compared to healthy, comparably aged controls.197,198 In patients with advanced chronic pancreatitis referred for surgical therapy, indolent, undiagnosed carcinoma can be seen in as many as 10% of patients.199The development of carcinoma in the setting of


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Surgery_Schwartz. patients with advanced chronic pancreatitis referred for surgical therapy, indolent, undiagnosed carcinoma can be seen in as many as 10% of patients.199The development of carcinoma in the setting of chronic pancreatitis is no doubt related to the dysregulation of cellu-lar proliferation and tissue repair processes in the setting of chronic inflammation, as is seen throughout the alimentary tract and elsewhere. In the setting of chronic pancreatitis, car-cinoma development can be especially cryptic, and the diagno-sis of early-stage tumors is particularly difficult. Awareness of this risk justifies close surveillance for cancer in patients with chronic pancreatitis. Periodic measurement of tumor markers such as CA19-9, and periodic imaging of the pancreas with CT scan and EUS seem logical in order to detect the development Table 33-16Complications of chronic pancreatitisIntrapancreatic complications Pseudocysts Duodenal or gastric obstruction Thrombosis of splenic


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Surgery_Schwartz. EUS seem logical in order to detect the development Table 33-16Complications of chronic pancreatitisIntrapancreatic complications Pseudocysts Duodenal or gastric obstruction Thrombosis of splenic vein Abscess Perforation Erosion into visceral artery Inflammatory mass in head of pancreas Bile duct stenosis Portal vein thrombosis Duodenal obstruction Duct strictures and/or stones Ductal hypertension and dilatation Pancreatic carcinomaExtrapancreatic complications Pancreatic duct leak with ascites or fistula Pseudocyst extension beyond lesser sac into mediastinum, retroperitoneum, lateral pericolic spaces, pelvis, or adjacent visceraBrunicardi_Ch33_p1429-p1516.indd 146401/03/19 6:45 PM 1465PANCREASCHAPTER 33Table 33-17Definitions of pancreatic fluid collectionsTERMDEFINITIONPeripancreatic fluid collectionA collection of enzyme-rich pancreatic juice that occurs early in the course of acute pancreatitis, or that forms after a pancreatic duct leak; located in or near the


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Surgery_Schwartz. fluid collectionA collection of enzyme-rich pancreatic juice that occurs early in the course of acute pancreatitis, or that forms after a pancreatic duct leak; located in or near the pancreas; it lacks a well-organized wall of granulation or fibrous tissueEarly pancreatic (sterile) necrosisA focal or diffuse area of nonviable pancreatic parenchyma, typically occupying >30% of the gland and containing liquefied debris and fluidLate pancreatic (sterile) necrosisAn organized collection of sterile necrotic debris and fluid with a well-defined margin or wall within the normal domain of the pancreasAcute pseudocystA collection of pancreatic juice enclosed within a perimeter of early granulation tissue, usually as a consequence of acute pancreatitis that has occurred within the preceding 3–4 wkChronic pseudocystA collection of pancreatic fluid surrounded by a wall of normal granulation and fibrous tissue, usually persisting for >6 wkPancreatic abscessAny of the above in which gross


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Surgery_Schwartz. 3–4 wkChronic pseudocystA collection of pancreatic fluid surrounded by a wall of normal granulation and fibrous tissue, usually persisting for >6 wkPancreatic abscessAny of the above in which gross purulence (pus) is present, with bacterial or fungal organisms documented to be presentModified with permission from Baron TH, Harewood GC, Morgan DE, et al. Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts, Gastrointest Endosc. 2002 Jul;56(1):7-17.Years after diagnosis of pancreatitisCumulative incidence of pancreatic cancer (%)12345605101520(1160)(599)(244)(64)Figure 33-37. Cumulative risk of pancreatic cancer in patients with chronic pancreatitis. The number of patients evaluated at different time intervals is shown in parentheses. (Reproduced with permis-sion from Lowenfels AB, Maisonneuve P, Cavallini G, et al. Pancre-atitis and the risk of pancreatic cancer. International Pancreatitis Study Group, N


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Surgery_Schwartz. is shown in parentheses. (Reproduced with permis-sion from Lowenfels AB, Maisonneuve P, Cavallini G, et al. Pancre-atitis and the risk of pancreatic cancer. International Pancreatitis Study Group, N Engl J Med. 1993 May 20;328(20):1433-1437.)of carcinoma in the patient with chronic pancreatitis, although no evidence exists to indicate that this alters the outcome of patients who develop pancreatic cancer. Surgical procedures, particularly drainage procedures performed for presumed chronic pancreatitis, should always include biopsy of the tissue to exclude the diagnosis of malignancy.ComplicationsPseudocyst. A chronic collection of pancreatic fluid surrounded by a nonepithelialized wall of granulation tissue and fibrosis is referred to as a pseudocyst. Pseudocysts occur in up to 10% of patients with acute pancreatitis, and in 20% to 38% of patients with chronic pancreatitis, and thus, they comprise the most com-mon complication of chronic pancreatitis.200-202 The identification and


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Surgery_Schwartz. patients with acute pancreatitis, and in 20% to 38% of patients with chronic pancreatitis, and thus, they comprise the most com-mon complication of chronic pancreatitis.200-202 The identification and treatment of pseudocysts requires definition of the various forms of pancreatic fluid collections that occur (Table 33-17). In chronic pancreatitis, a pancreatic duct leak with extravasa-tion of pancreatic juice results in a peripancreatic fluid collection (PPFC). Over a period of 3 to 4 weeks, the PPFC is sealed by an inflammatory reaction that leads to development of a wall of acute granulation tissue without much fibrosis. This is referred to as an acute pseudocyst. Acute pseudocysts may resolve spontane-ously in up to 50% of cases, over a course of 6 weeks or longer.203 Pseudocysts >6 cm resolve less frequently than smaller ones but may regress over a period of weeks to months. Pseudocysts are multiple in 17% of patients,202 or they may be multilobulated. They may occur


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Surgery_Schwartz. >6 cm resolve less frequently than smaller ones but may regress over a period of weeks to months. Pseudocysts are multiple in 17% of patients,202 or they may be multilobulated. They may occur intrapancreatically or extend beyond the region of the pancreas into other cavities or compartments (Fig. 33-38).Pseudocysts may become secondarily infected, in which case they become abscesses. They can compress or obstruct adjacent organs or structures, leading to superior mesenteric-portal vein thrombosis or splenic vein thrombosis.204 They can erode into visceral arteries and cause intracystic hemorrhage or pseudoaneurysms (Fig. 33-39). They also can perforate and cause peritonitis or intraperitoneal bleeding.205Figure 33-38. Extensive pseudocyst disease. A computed tomo-graphic scan in a patient with alcoholic chronic pancreatitis dem-onstrates multiloculated pseudocyst disease.Pseudocysts usually cause symptoms of pain, fullness, or early satiety. Asymptomatic pseudocysts can be managed


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Surgery_Schwartz. with alcoholic chronic pancreatitis dem-onstrates multiloculated pseudocyst disease.Pseudocysts usually cause symptoms of pain, fullness, or early satiety. Asymptomatic pseudocysts can be managed expectantly and may resolve spontaneously or persist without complication.201,203 Symptomatic or enlarging pseudocysts require treatment, and any presumed pseudocyst without a documented antecedent episode of acute pancreatitis requires investigation to determine the etiology Brunicardi_Ch33_p1429-p1516.indd 146501/03/19 6:45 PM 1466SPECIFIC CONSIDERATIONSPART IIFigure 33-39. Pseudoaneurysm of the gastroduodenal artery. A pseudocyst can erode into an adjacent artery, which results in contained hemorrhage otherwise known as a pseudoaneurysm. A contrast-injected computed tomographic scan reveals active bleed-ing (area marked B) into a pseudocyst (arrows) as a result of this process. (Reproduced with permission from Balthazar EJ: CT diagnosis and staging of acute pancreatitis, Radiol Clin


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Surgery_Schwartz. active bleed-ing (area marked B) into a pseudocyst (arrows) as a result of this process. (Reproduced with permission from Balthazar EJ: CT diagnosis and staging of acute pancreatitis, Radiol Clin North Am. 1989 Jan;27(1):19-37.)of the lesion, including a cystic neoplasm.205 Although pseudocysts comprise roughly two-thirds of all pancreatic cystic lesions, they resemble cystadenomas and cystadenocarcinoma radiographically. An incidentally discovered cystic lesion should be examined by EUS and aspirated to determine whether it is a true pancreatic cystic neoplasm or a pseudocyst.The timing and method of treatment requires careful con-sideration. Pitfalls in the management of pseudocysts result from the incorrect (presumptive) diagnosis of a cystic neoplasm masquerading as a pseudocyst, a failure to appreciate the solid or debris-filled contents of a pseudocyst that appears to be fluid filled on CT scan, and a failure to document true adherence with an adjacent portion of the stomach


Surgery_Schwartz

Surgery_Schwartz. failure to appreciate the solid or debris-filled contents of a pseudocyst that appears to be fluid filled on CT scan, and a failure to document true adherence with an adjacent portion of the stomach before attempting transgas-tric internal drainage.If the pseudocyst has failed to resolve with conserva-tive therapy and symptoms persist, internal drainage is usu-ally preferred to external drainage to avoid the complication of a pancreaticocutaneous fistula. Pseudocysts communicate with the pancreatic ductal system in up to 80% of cases,206 so external drainage creates a pathway for pancreatic duct leak-age to and through the catheter exit site. Internal drainage may be performed with either endoscopic methods (transgastric or transduodenal puncture and multiple stent placements, with or without a nasocystic irrigation catheter), or surgical methods (a true cystoenterostomy, biopsy of cyst wall, and evacuation of all debris and contents). Surgical options include a cystogastros-tomy


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Surgery_Schwartz. without a nasocystic irrigation catheter), or surgical methods (a true cystoenterostomy, biopsy of cyst wall, and evacuation of all debris and contents). Surgical options include a cystogastros-tomy (Fig. 33-40), a Roux-en-Y cystojejunostomy, or a cysto-duodenostomy. Cystojejunostomy is the most versatile method, and it can be applied to pseudocysts that penetrate into the trans-verse mesocolon, the paracolic gutters, or the lesser sac. Cys-togastrostomy can be performed endoscopically207 (Fig. 33-41), laparoscopically,208 or by a combined laparoscopic-endoscopic method.209Because pseudocysts often communicate with the pan-creatic ductal system, two newer approaches to pseudocyst management are based on main duct drainage, rather than pseu-docyst drainage per se. Transpapillary stents inserted at the time Figure 33-40. Cystogastrostomy drainage of a retrogastric pancre-atic pseudocyst. A larger opening is made through the common wall of a retrogastric pseudocyst, and a portion of the


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Surgery_Schwartz. at the time Figure 33-40. Cystogastrostomy drainage of a retrogastric pancre-atic pseudocyst. A larger opening is made through the common wall of a retrogastric pseudocyst, and a portion of the pseudocyst wall is submitted for histologic confirmation of the diagnosis. Suture reinforcement of the communication is performed to avoid the com-plication of bleeding. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)StomachFNAneedlePseudocystDuodenumPancreasLiverPseudocystDoublepigtailedstentsPancreasStomachEUSscopeABFigure 33-41. Technique of endoluminal cystogastrostomy. A. Endoscopic ultrasound (EUS)-guided transgastric puncture of pancreatic pseudocyst. B. Transgastric stents placed across fused posterior wall of stomach and anterior wall of pseudocyst. (Repro-duced with permission from Chauhan SS, Forsmark CE. Evidence-based treatment of pancreatic pseudocysts,


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Surgery_Schwartz. stents placed across fused posterior wall of stomach and anterior wall of pseudocyst. (Repro-duced with permission from Chauhan SS, Forsmark CE. Evidence-based treatment of pancreatic pseudocysts, Gastroenterology. 2013 Sep;145(3):511-5113.)Brunicardi_Ch33_p1429-p1516.indd 146601/03/19 6:45 PM 1467PANCREASCHAPTER 33ABFigure 33-42. Transpapillary drainage of a pancreatic pseudocyst. A. Endoscopic passage of a flexible wire through the major papilla, through the pancreatic duct, and into a communicating pseudocyst. B. Placement of a stent over the wire into the pseudocyst with transpapillary drainage. (Reproduced with permission from Kozarek RA, Brayko CM, Harlan J, et al. Endoscopic drainage of pancreatic pseudocysts, Gastrointest Endosc. 1985 Oct;31(5):322-327.)of ERCP may be directed into a pseudocyst through the ductal communication itself (Fig. 33-42), or they can be left across the area of suspected duct leakage to facilitate decompression and cyst drainage, analogous to the


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Surgery_Schwartz. into a pseudocyst through the ductal communication itself (Fig. 33-42), or they can be left across the area of suspected duct leakage to facilitate decompression and cyst drainage, analogous to the use of common bile duct stents in the setting of a cystic duct leak.206 In a surgical series of patients with chronic pancreatitis, ductal dilatation, and a coex-isting pseudocyst, Nealon and Walser showed that duct drainage alone, without a separate cystoenteric anastomosis, was as suc-cessful as a combined drainage procedure.92 Furthermore, the “duct drainage only” group enjoyed a shorter hospital stay and fewer complications than the group who underwent a separate cystoenterostomy. These observations suggest that transductal drainage may be a safe and effective approach to the manage-ment of pseudocystic disease.The complications of endoscopic drainage of pseudocysts often require surgical intervention. Bleeding from the cystoenterostomy and inoculation of a pseudocyst with failure of


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Surgery_Schwartz. of pseudocystic disease.The complications of endoscopic drainage of pseudocysts often require surgical intervention. Bleeding from the cystoenterostomy and inoculation of a pseudocyst with failure of resolution and persistence of infection may require surgical treatment. Bleeding risks may be lessened by the routine use of EUS in the selection of the site for transluminal stent placement.210 Endoscopic treatment of pseudocysts requires large-bore catheters or multiple stents and an aggressive approach to management for success to be achieved. Failure of nonsurgical therapy, with subsequent salvage procedures to remove infected debris and establish complete drainage, is associated with increased risks for complications and death.211,212 The most experienced therapeutic endoscopists report a complication rate of 17% to 19% for the treatment of sterile pseudocysts, and deaths as a result of endoscopic therapy have occurred.212 Therefore, the use of endoscopic methods to treat sterile or


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Surgery_Schwartz. a complication rate of 17% to 19% for the treatment of sterile pseudocysts, and deaths as a result of endoscopic therapy have occurred.212 Therefore, the use of endoscopic methods to treat sterile or infected pancreatic necrosis has a higher complication rate and is limited to specialized centers.Resection of a pseudocyst is sometimes indicated for cysts located in the pancreatic tail or when a midpancreatic duct disruption has resulted in a distally located pseudocyst. Distal pancreatectomy for removal of a pseudocyst, with or without splenectomy, can be a challenging procedure in the setting of prior pancreatitis. An internal drainage procedure of the com-municating duct or of the pseudocyst itself should be considered when distal resection is being contemplated.Pancreatic Ascites. When a disrupted pancreatic duct leads to pancreatic fluid extravasation that does not become sequestered as a pseudocyst, but drains freely into the peritoneal cavity, pan-creatic ascites occurs.


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Surgery_Schwartz. a disrupted pancreatic duct leads to pancreatic fluid extravasation that does not become sequestered as a pseudocyst, but drains freely into the peritoneal cavity, pan-creatic ascites occurs. Occasionally, the pancreatic fluid tracks superiorly into the thorax, and a pancreatic pleural effusion occurs. Referred to as internal pancreatic fistulae, both compli-cations are seen more often in patients with chronic pancreatitis rather than after acute pancreatitis. Pancreatic ascites and pleu-ral effusion occur together in 14% of patients, and 18% have a pancreatic pleural effusion alone.213Patients demonstrate the general demographics of chronic pancreatitis and usually present with a subacute or recent his-tory of progressive abdominal swelling despite weight loss. Pain and nausea are rarely present. The abdominal CT scan discloses ascites and the presence of chronic pancreatitis or a partially collapsed pseudocyst (Fig. 33-43). Paracentesis or thoracente-sis reveals noninfected fluid


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Surgery_Schwartz. present. The abdominal CT scan discloses ascites and the presence of chronic pancreatitis or a partially collapsed pseudocyst (Fig. 33-43). Paracentesis or thoracente-sis reveals noninfected fluid with a protein level >25 g/L and a markedly elevated amylase level. Serum amylase may also be elevated, presumably from reabsorption across the parietal membrane. Serum albumin may be low, and patients may have Figure 33-43. Pancreatic ascites. Computed tomographic scan of a patient with a ruptured pancreatic pseudocyst resulting in intra-peritoneal pancreatic fluid. (Reproduced with permission from Cameron JL, Cameron AM: Current Surgical Therapy, 11th ed. Philadelphia, PA: Elsevier; 2014.)Brunicardi_Ch33_p1429-p1516.indd 146701/03/19 6:45 PM 1468SPECIFIC CONSIDERATIONSPART IIFigure 33-44. Internal drainage for leaking pancreatic duct. A Roux-en-Y pancreaticojejunostomy is performed at the site of duct rupture to accomplish internal drainage of the pancreatic duct leak. (Reproduced with


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Surgery_Schwartz. drainage for leaking pancreatic duct. A Roux-en-Y pancreaticojejunostomy is performed at the site of duct rupture to accomplish internal drainage of the pancreatic duct leak. (Reproduced with permission from Beger HG: The Pancreas. London: Blackwell-Science; 1998.)coexisting liver disease. Paracentesis is therefore critical to dif-ferentiate pancreatic from hepatic ascites.ERCP is most helpful to delineate the location of the pan-creatic duct leak and to elucidate the underlying pancreatic duc-tal anatomy. Pancreatic duct stenting may be considered at the time of ERCP, but if nonsurgical therapy is undertaken and then abandoned, repeat imaging of the pancreatic duct is appropriate to guide surgical treatment.Antisecretory therapy with the somatostatin analogue octreotide acetate, together with bowel rest and parenteral nutrition, is successful in more than half of patients.214,215 Reap-position of serosal surfaces to facilitate closure of the leak is considered a part of therapy, and


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Surgery_Schwartz. with bowel rest and parenteral nutrition, is successful in more than half of patients.214,215 Reap-position of serosal surfaces to facilitate closure of the leak is considered a part of therapy, and this is accomplished by com-plete paracentesis. For pleural effusions, a period of chest tube drainage may facilitate closure of the internal fistula.214 Surgi-cal therapy is reserved for those who fail to respond to medical treatment. If the leak originates from the central region of the pancreas, a Roux-en-Y pancreaticojejunostomy is performed to the site of duct leakage215 (Fig. 33-44). If the leak is in the tail, a distal pancreatectomy may be considered, or an internal drainage procedure can be performed. The results of surgical treatment are usually favorable if the ductal anatomy has been carefully delineated preoperatively.Pancreatic-Enteric Fistula. The erosion of a pancreatic pseu-docyst into an adjacent hollow viscus can result in a pancreatic-enteric fistula. The most common


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Surgery_Schwartz. been carefully delineated preoperatively.Pancreatic-Enteric Fistula. The erosion of a pancreatic pseu-docyst into an adjacent hollow viscus can result in a pancreatic-enteric fistula. The most common site of communication is the transverse colon or splenic flexure. The fistula usually presents with evidence of GI or colonic bleeding and sepsis. If the fis-tula communicates with the stomach or duodenum, it may close spontaneously or persist as a pancreatic-enteric fistula. When the fistula involves the colon, operative correction is usually required.215Head-of-Pancreas Mass. In up to 30% of patients with advanced chronic pancreatitis, an inflammatory mass develops in the head of the pancreas.216 The clinical presentation includes severe pain and frequently includes stenosis of the distal common bile duct, duodenal stenosis, compression of the portal vein, and stenosis of the proximal main pancreatic duct (Table 33-18). Mutations and polymorphisms of p53 have been found in these


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Surgery_Schwartz. common bile duct, duodenal stenosis, compression of the portal vein, and stenosis of the proximal main pancreatic duct (Table 33-18). Mutations and polymorphisms of p53 have been found in these patients, and a focus of ductular carcinoma was found in 3.7% of patients with pancreatic head enlargement in one series.217 It was concluded that an accelerated transformation from hyperplasia to dysplasia exists in patients with pancreatic head enlargement, although the etiology for this process remains unclear.Splenic and Portal Vein Thrombosis. Vascular complications of chronic pancreatitis are fortunately infrequent because they are difficult to treat successfully. Portal vein compression and occlusion can occur as a consequence of an inflammatory mass in the head of the pancreas, and splenic vein thrombosis occurs in association with chronic pancreatitis in 4% to 8% of cases.218 Variceal formation can occur as a consequence of either portal or splenic venous occlusion, and splenic vein


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Surgery_Schwartz. vein thrombosis occurs in association with chronic pancreatitis in 4% to 8% of cases.218 Variceal formation can occur as a consequence of either portal or splenic venous occlusion, and splenic vein thrombosis with gas-tric variceal formation is referred to as left-sided or sinistral por-tal hypertension. Although bleeding complications are infrequent, the mortality risk of bleeding is >20%. When gastroesophageal varices are caused by splenic vein thrombosis, the addition of splenectomy to prevent variceal hemorrhage is prudent when sur-gery is otherwise indicated to correct other problems.TreatmentMedical Therapy. The medical treatment of chronic or recurrent pain in chronic pancreatitis requires the use of analgesics, a cessation of alcohol use, oral enzyme therapy, and the selective use of antisecretory therapy. Interventional procedures to block visceral afferent nerve conduction or to treat obstructions of the main pancreatic duct are also an adjunct to medical


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Surgery_Schwartz. the selective use of antisecretory therapy. Interventional procedures to block visceral afferent nerve conduction or to treat obstructions of the main pancreatic duct are also an adjunct to medical treatment.Analgesia. Oral analgesics are prescribed as needed, alone or with analgesia-enhancing agents such as gabapentin.168 Ade-quate pain control usually requires the use of narcotics, but these should be titrated to achieve pain relief with the lowest effective dose. Opioid addiction is common, and the use of long-acting analgesics by transdermal patch together with oral agents for pain exacerbations slightly reduces the sedative effects of high-dose oral narcotics.Table 33-18Signs and symptoms of chronic pancreatitis with and without a pancreatic head massSIGNS AND SYMPTOMSWITH HEAD ENLARGEMENT (n = 138) (%)WITHOUT HEAD ENLARGEMENT (n = 141) (%)Daily severe pain6740Cholestasis4611Duodenal obstruction307Diabetes mellitus1830Vascular involvement158Reproduced with permission from


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Surgery_Schwartz. ENLARGEMENT (n = 138) (%)WITHOUT HEAD ENLARGEMENT (n = 141) (%)Daily severe pain6740Cholestasis4611Duodenal obstruction307Diabetes mellitus1830Vascular involvement158Reproduced with permission from Beger HG: The pancreas: an integrated textbook of basic science, medicine, and surgery. London: Blackwell-Science; 1998.Brunicardi_Ch33_p1429-p1516.indd 146801/03/19 6:45 PM 1469PANCREASCHAPTER 33It is essential for patients to abstain from alcohol. In addition to removing the causative agent, alcohol abstention results in pain reduction or relief in 60% to 75% of patients with chronic pancreatitis.219 Despite this benefit, roughly half of alcoholic chronic pancreatitis patients continue to abuse alcohol.Enzyme Therapy. Pancreatic enzyme administration serves to reverse the effects of pancreatic exocrine insufficiency. Adequate pancreatic enzyme replacement reverses the exo-crine insufficiency seen in most patients, and it prevents sec-ondary complications such as metabolic bone


Surgery_Schwartz

Surgery_Schwartz. pancreatic exocrine insufficiency. Adequate pancreatic enzyme replacement reverses the exo-crine insufficiency seen in most patients, and it prevents sec-ondary complications such as metabolic bone disease due to inadequate absorption of the fat-soluble vitamins A, D, E, and K. In addition, pancreatic enzyme replacement may reduce or alleviate the pain experienced by patients. The choice of enzyme supplement and the dose should be selected based on whether malabsorption or pain (or both) are the indica-tions for therapy220 (Table 33-19). Conventional (nonen-teric-coated) enzyme preparations are partially degraded by gastric acid but are available within the duodenal and jejunal regions to bind to CCK-releasing peptide and downregulate the release of CCK. This theoretically reduces the enteric sig-nal for pancreatic exocrine secretion, which reduces the pres-sure within a partially or completely obstructed pancreatic duct.221 Enteric-coated preparations result in little to no pain


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Surgery_Schwartz. enteric sig-nal for pancreatic exocrine secretion, which reduces the pres-sure within a partially or completely obstructed pancreatic duct.221 Enteric-coated preparations result in little to no pain relief, presumably due to their reduced bioavailability in the proximal gut. Due to the loss of pancreatic enzymes by acid hydrolysis and proteolysis, relatively large doses are required to achieve effective levels of enzyme within the proximal small bowel. Enteric-coated preparations are protected from acid degradation but are presumably not released in the criti-cal proximal gut in sufficient quantity to inhibit the stimulus for endogenous pancreatic enzyme secretion. Nonalcoholic patients may experience more effective pain relief than alco-holic patients, but it is recommended that all patients with chronic pancreatitis pain begin a trial of nonenteric-coated enzyme supplements together with an acid-suppressive medi-cation for 1 month. If pain relief is achieved, therapy is con-tinued.


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Surgery_Schwartz. with chronic pancreatitis pain begin a trial of nonenteric-coated enzyme supplements together with an acid-suppressive medi-cation for 1 month. If pain relief is achieved, therapy is con-tinued. If enzyme therapy fails, further investigation of the pancreatic ductal system by ERCP guides the therapy based on specific anatomical findings (Fig. 33-45).Antisecretory Therapy. Somatostatin administration has been shown to inhibit pancreatic exocrine secretion and CCK Table 33-19Pancreatic enzyme preparationsPRODUCTFORMULATIONMANUFACTURERLIPASE CONTENT (USP)/PILL OR CAPSULEZenpepEnteric-coated porcineAptalis3000, 5000, 10,000, 15,000, 20,000CreonEnteric-coated porcineAbbott3000, 6000, 12,000, 24,000PancreazeEnteric-coated porcineOrtho-McNeil-Janssen4200, 10,500, 16,800, 21,000PertzyeEnteric-coated porcine mixed with bicarbonate granulesDigestive Care8000, 16,000UltresaEnteric-coated porcineAptalis13,800, 20,700, 23,000ViokaceTablet non-enteric-coated porcineAptalis10,440, 20,880Note: USP =


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Surgery_Schwartz. porcine mixed with bicarbonate granulesDigestive Care8000, 16,000UltresaEnteric-coated porcineAptalis13,800, 20,700, 23,000ViokaceTablet non-enteric-coated porcineAptalis10,440, 20,880Note: USP = United States Pharmacopeia, the standard for lipase content in the United States. An average meal requires roughly 90,000 USP units of lipase for fat digestion. Enzyme therapy of exocrine deficiency typically begins with a dose of 50,000 USP units per meal with subsequent adjustment.Reproduced with permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.release.222 The somatostatin analogue octreotide acetate has therefore been investigated for pain relief in patients with chronic pancreatitis. In a double-blind, prospective, randomized 4-week trial, 65% of patients who received 200 μg of octreotide acetate subcutaneously three times daily reported pain relief, compared with 35% of placebo-treated subjects.223 Patients who had the best


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Surgery_Schwartz. trial, 65% of patients who received 200 μg of octreotide acetate subcutaneously three times daily reported pain relief, compared with 35% of placebo-treated subjects.223 Patients who had the best results were patients with chronic abdominal pain, suggestive of obstructive pancreatopathy. However, in another trial that used a 3-day duration of treatment, no significant pain relief was observed.224 Anecdotal reports suggest that severe pain exacerbations in chronic pancreatitis can benefit from a combination of octreotide therapy and TPN, and a pilot study of the effectiveness of the sustained-release form of octreotide suggested that it was as effective as three-times-per-day admin-istration of the short-acting form of the drug.225Neurolytic Therapy. Celiac plexus neurolysis with alcohol injection has been an effective form of analgesic treatment in patients with pancreatic carcinoma. However, the use of radio-logically or endoscopically guided celiac plexus blockade in chronic


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Surgery_Schwartz. injection has been an effective form of analgesic treatment in patients with pancreatic carcinoma. However, the use of radio-logically or endoscopically guided celiac plexus blockade in chronic pancreatitis has been disappointing. Due to the risk of alcohol injury and the need for repeated injections, celiac plexus blockade in chronic pancreatitis has used short-acting analgesics or other drugs rather than 50% alcohol. A trial of EUS-guided celiac plexus blockade revealed successful pain relief in 55% of patients, but the benefit lasted beyond 6 months in only 10% of patients.226 The procedure therefore appears safe, but the effect is short lived in those patients who obtain pain relief.Endoscopic Management. The techniques of endoscopic treat-ment of pancreatic duct obstruction, stone disease, pseudocyst formation, pancreatic duct leak, and for the diagnosis and man-agement of associated pancreatic tumors have expanded greatly over the past 20 years. Newer endoscopes with expanded


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Surgery_Schwartz. disease, pseudocyst formation, pancreatic duct leak, and for the diagnosis and man-agement of associated pancreatic tumors have expanded greatly over the past 20 years. Newer endoscopes with expanded thera-peutic capabilities have been introduced, and the role of EUS and EUS-guided needle and catheter insertion has expanded the abil-ity of the therapeutic endoscopist in the diagnosis and treatment of chronic pancreatitis and its complications.227Pancreatic duct stenting is used for treatment of proxi-mal pancreatic duct stenosis, decompression of a pancreatic duct leak, and for drainage of pancreatic pseudocysts that can be catheterized through the main pancreatic duct. Pancreatic duct stents can induce an inflammatory response within the Brunicardi_Ch33_p1429-p1516.indd 146901/03/19 6:45 PM 1470SPECIFIC CONSIDERATIONSPART IIMake a correct diagnosis • Appropriate history • Corroborating imaging tests • MRI/MRCP • EUS • CT • Functional tests if imaging tests equivocal •


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Surgery_Schwartz. 6:45 PM 1470SPECIFIC CONSIDERATIONSPART IIMake a correct diagnosis • Appropriate history • Corroborating imaging tests • MRI/MRCP • EUS • CT • Functional tests if imaging tests equivocal • Tube-based secretin test • Endoscopic-based secretin test • Assess for alternative diseases and complications and treat if present • Pancreatic cancer or IPMN • Pseudocyst • Bile duct obstruction • Duodenal obstructionMedical therapy • Measure pain severity, character, and impact on QOL • Refer for formal structured smoking and alcohol cessation programs • Counsel on good nutrition and initiate supplementation with vitamin D and calcium • Baseline bone mineral density tasting • Provide information on local and national support groups • Initiate analgesics (starting with Tramadol) • Increase dose and potenay slowly as required • Initiate adjunctive agents in those with persistent pain or requiring higher dosages or potency of narcotics • Pregabalin, Gabapentin • SSRI •


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Surgery_Schwartz. • Increase dose and potenay slowly as required • Initiate adjunctive agents in those with persistent pain or requiring higher dosages or potency of narcotics • Pregabalin, Gabapentin • SSRI • SSNRI • Tricyclic antidepressants • Assess for evidence of coexistent exocrine or endocrine insufficiency and treat if present • Fecal elastase or serum trypsin • HgB A1C or GTT • Initiate steroids if autoimmune pancreatitisInflammatory mass in pancreatic head • With or without dilated pancreatic duct • With or without duodenal or biliary obstructionSurgical therapy in ÿt patients • DPPHR • Berger operation • Frey operation • Berne operation • Whipple operationDiscuss options with patient, includingthat data supports superiority of surgery.Surgery remains an option for failure ofendoscopic therapy • Endoscopic therapy • Pancreatic and biliary sphincterotomy • Stricture dilation and stenting • Lithotripsy • Stone extraction • Surgical therapy • Modified Puestow or Frey


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Surgery_Schwartz. therapy • Endoscopic therapy • Pancreatic and biliary sphincterotomy • Stricture dilation and stenting • Lithotripsy • Stone extraction • Surgical therapy • Modified Puestow or Frey operation• Continued medical therapy• Surgical therapy • “V-plasty” • Total pancreatectomy, with islet cell autotransplantationDilated pancreatic duct (° 6 mm)Small duct disease (pancreatic duct˛ 6 mm)Treatment effective?Continue treatment with periodicreassessmentYesNoAssess anatomy of pancreas andpancreatic ductFigure 33-45. Management algorithm for chronic pancreatitis. IPMN = intraductal papillary mucinous neoplasm; QOL = quality of life; SSRI = selective serotonin reuptake inhibitor; SSNRI = selective serotonin-norepinephrine reuptake inhibitor; GTT = glucose tolerance test. (Reproduced with permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.)Brunicardi_Ch33_p1429-p1516.indd 147001/03/19 6:45 PM 1471PANCREASCHAPTER 33duct, so


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Surgery_Schwartz. permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.)Brunicardi_Ch33_p1429-p1516.indd 147001/03/19 6:45 PM 1471PANCREASCHAPTER 33duct, so prolonged stenting is usually avoided. Patients with sphincter of Oddi dyskinesia are at high risk for developing post-ERCP pancreatitis after biliary sphincterotomy, and the prophylactic placement of a pancreatic duct stent or the admin-istration of rectal indomethacin reduces the amylase level and development of pancreatitis after biliary sphincterotomy.33,228 Pancreatic duct leaks are seen in 37% of patients with acute pancreatitis, and pancreatic duct stenting appears to facilitate the resolution of the leak.229 Similarly, pancreatic duct stenting has been used to treat postsurgical pancreatic duct leaks and posttraumatic leaks.229-231Pancreas divisum (see Fig. 33-3) is thought to cause pain and chronic pancreatitis due to functional or mechanical obstruc-tion of the dorsal duct


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Surgery_Schwartz. pancreatic duct leaks and posttraumatic leaks.229-231Pancreas divisum (see Fig. 33-3) is thought to cause pain and chronic pancreatitis due to functional or mechanical obstruc-tion of the dorsal duct draining exclusively, or predominantly, through the lesser papilla. A study from Marseille reported good long-term results in 24 patients after minor papilla sphinc-terotomy and dorsal duct stenting.232 The number of patients with chronic pain decreased from 83% before stenting to 29% after stenting, but pancreatitis or recurrent papillary stenosis occurred in 38%. Patients that responded best were those with intermittent pain, and this subset may be preferentially treated with endoscopic therapy. Patients with recurrent pain and a dilated dorsal duct may be candidates for internal drainage of the obstructed duct with either an extended Puestow procedure or a Frey procedure (see later in this section).Idiopathic pancreatitis patients have been treated with endoscopic stenting, pancreatic


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Surgery_Schwartz. the obstructed duct with either an extended Puestow procedure or a Frey procedure (see later in this section).Idiopathic pancreatitis patients have been treated with endoscopic stenting, pancreatic duct sphincterotomy, and endo-scopic stone removal with good results. In a prospective ran-domized trial, 53% of idiopathic recurrent pancreatitis patients in the control group experienced continued episodes of pancre-atitis, although only 11% of the treated patients had continued symptoms.233Extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct stones, together with endoscopic stent-ing and stone removal.234 A single ESWL session was used in 35 patients with pancreatic duct stones, together with 86 ERCP sessions to complete the stone removal process. After 2.4 years, 80% of patients had significant relief of symptoms (Fig. 33-46). Also, endoscopic intraductal lithotripsy can now be performed in some specialized centers. However, due to the tendency for recurrent


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Surgery_Schwartz. 80% of patients had significant relief of symptoms (Fig. 33-46). Also, endoscopic intraductal lithotripsy can now be performed in some specialized centers. However, due to the tendency for recurrent stone formation, the use of ESWL or endoscopic litho-tripsy for long-term management of calcific pancreatitis remains uncertain.Surgical Therapy Indications and History The traditional approach to surgi-cal treatment of chronic pancreatitis and its complications has maintained that surgery should be considered only when the medical therapy of symptoms has failed. Nealon and Thomp-son published a landmark study in 1993, however, that showed that the progression of chronic obstructive pancreatitis could be delayed or prevented by pancreatic duct decompression.235 No other therapy has been shown to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-20). Small-duct disease or “minimal change chronic


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Surgery_Schwartz. to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-20). Small-duct disease or “minimal change chronic pancreatitis” are causes for uncertainty over the choice of operation, however. Major resections have a high complication rate, both early and late, in chronic alcoholic pancreatitis, and lesser procedures often result in symptomatic recurrence. Therefore, the choice of operation and the timing of surgery are based on each patient’s pancreatic anatomy, the likelihood (or lack thereof) that further ABFigure 33-46. Extracorporeal shock wave lithotripsy treatment of pancreatic duct stones. The endoscopic retrograde cholangiopancrea-tography images are shown (A) before and (B) after extracorporeal shock wave lithotripsy therapy of pancreatic duct obstruction due to calculus formation. (Reproduced with permission from Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who


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Surgery_Schwartz. shock wave lithotripsy therapy of pancreatic duct obstruction due to calculus formation. (Reproduced with permission from Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis, Gastrointest Endosc. 2002 Oct;56(4):496-500.)Table 33-20Effect of surgical drainage on progression of chronic pancreatitisTREATMENT GROUP24-MONTH EVALUATIONOperated (n = 47)Mild to moderate 48 (87%); severe 6 (13%)Nonoperated (n = 36)Mild to moderate 8 (22%); severe 28 (78%)Eighty-three patients with chronic pancreatitis were evaluated by exocrine, endocrine, nutritional, and endoscopic retrograde cholangiopancreatography studies, and all had mild to moderate disease and dilated pancreatic ducts. A Puestow-type duct decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.Reproduced with permission from Nealon WH, Thompson JC. Progressive loss of


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Surgery_Schwartz. decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.Reproduced with permission from Nealon WH, Thompson JC. Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modified puestow procedure, Ann Surg. 1993 May;217(5):458-466.Brunicardi_Ch33_p1429-p1516.indd 147101/03/19 6:45 PM 1472SPECIFIC CONSIDERATIONSPART IIFigure 33-47. Head-of-pancreas mass after Puestow procedure. The computed tomographic appearance of an inflammatory mass occupying the head of the pancreas, which developed 2 years after Puestow decompression of the body and tail of pancreas.medical and endoscopic therapy will halt the symptoms of the disease, and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeo-stasis,


Surgery_Schwartz

Surgery_Schwartz. and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeo-stasis, abstinence from alcohol and tobacco, and a detailed review of the risks and likely outcomes to establish a bond of trust and commitment between the patient and the surgeon.Historically, the surgery for chronic pancreatitis before the second half of the 20th century was a true demonstration of trial and error.236 Obtaining good surgical outcomes before the avail-ability of CT scans and ERCP was either the result of serendip-ity or due to the skill and creativity of the surgeon. In 1911, Link described an operation he devised on the spot, when a laparot-omy in a young woman with abdominal pain revealed a fluctu-ant, obstructed pancreatic duct. After performing a dochotomy and evacuating multiple stones, he inserted a rubber tube, and exteriorized the pancreatostomy just above her navel.237 He


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Surgery_Schwartz. a fluctu-ant, obstructed pancreatic duct. After performing a dochotomy and evacuating multiple stones, he inserted a rubber tube, and exteriorized the pancreatostomy just above her navel.237 He later described the operation as having been a success for the next 30 years of the patient’s life, during which the patient managed the care of the drainage tube without apparent problems.238With the demonstration in 1942 by Priestley that total pancreatectomy was technically feasible,239 and the report in 1946 by Whipple that proximal pancreatic resection was ben-eficial in (three) patients with chronic pancreatitis,240 the option of surgical resection as treatment for chronic pancreatitis was established. By the mid 1950s, however, growing disappoint-ment with the high risk of resection and the lack of long-term benefit overshadowed the surgical treatment of chronic pancre-atitis. The choice of resection vs. drainage was largely based on surgeon preference until the 1970s, when the


Surgery_Schwartz

Surgery_Schwartz. and the lack of long-term benefit overshadowed the surgical treatment of chronic pancre-atitis. The choice of resection vs. drainage was largely based on surgeon preference until the 1970s, when the widespread adoption of ERCP and CT scans provided the ability to pre-operatively diagnose obstructive and sclerotic disease, and this resulted in the rational selection of operative procedures. During this period, the major drawbacks to surgical therapy remained the recurrence of symptoms despite surgery, the correspond-ing development of an inflammatory (or malignant) mass in the undrained pancreatic head (Fig. 33-47), or the high morbidity and mortality of major resectional procedures that predisposed patients to a cascade of metabolic problems.241Sphincteroplasty The sphincter of Oddi and the pancreatic duct sphincter serve as gatekeepers for the passage of pancreatic juice into the duodenum (Fig. 33-48). Stenosis of either sphincter (scle-rosing papillitis), due to scarring from


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Surgery_Schwartz. and the pancreatic duct sphincter serve as gatekeepers for the passage of pancreatic juice into the duodenum (Fig. 33-48). Stenosis of either sphincter (scle-rosing papillitis), due to scarring from pancreatitis or from the passage of gallstones, may result in obstruction of the pancreatic duct and chronic pain.242 As gallstone pancreatitis became a popu-lar diagnosis in the 1940s and 1950s, attention was focused on the ampullary region as a possible cause of chronic symptoms, and surgical sphincteroplasty was advocated. Although endoscopic techniques are now used routinely to perform sphincterotomy of either the common bile duct or pancreatic duct, a true (permanent) PancreasCommon bile ductDuodenal wallMajor papillaSphincter of ampullaMucosaSubmucosa Sphincter of pancreatic duct Pancreatic ductSphincter of common bile ductLongitudinal muscleof duodenal wallCircular muscle of duodenal wallFigure 33-48. Schematic diagram of the ampullary, biliary, and pancreatic duct sphincters. The


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Surgery_Schwartz. ductSphincter of common bile ductLongitudinal muscleof duodenal wallCircular muscle of duodenal wallFigure 33-48. Schematic diagram of the ampullary, biliary, and pancreatic duct sphincters. The point of merger of the bile duct and pancreatic duct is highly variable, and a true sphincter of the pancreatic duct may be poorly developed. (Reproduced with permission from Yamada T, Alpers DH, Kalloo AN, et al: Textbook of Gastroenterology, 5th ed. Oxford: Wiley-Blackwell; 2009.)Brunicardi_Ch33_p1429-p1516.indd 147201/03/19 6:45 PM 1473PANCREASCHAPTER 33Figure 33-49. Operative sphincteroplasty of the biliary and pan-creatic duct. The ampullary and bile duct sphincters are divided, as is the pancreatic duct sphincter, with suture apposition of the mucosal edges of the incision. sphincteroplasty can only be performed surgically. Transduode-nal sphincteroplasty with incision of the septum between the pan-creatic duct and common bile duct may offer significant relief for the rare patient


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Surgery_Schwartz. can only be performed surgically. Transduode-nal sphincteroplasty with incision of the septum between the pan-creatic duct and common bile duct may offer significant relief for the rare patient with a focal obstruction and inflammation isolated to this region (Fig. 33-49).Drainage Procedures After the early reports of success with pancreatostomy for the relief of symptoms of chronic pancreatitis,238 Cattell described pancreaticojejunostomy for relief of pain in unresectable pancreatic carcinoma.243 Shortly thereafter, Duval244 and, separately, Zollinger and associates245 described the caudal Roux-en-Y pancreaticojejunostomy for the treatment of chronic pancreatitis in 1954 (Fig. 33-50). The so-called Duval procedure was used for decades by some surgeons, but it almost invariably failed due to restenosis and segmental obstruction of the pancreas due to progressive scarring. In 1958, Puestow and Gillesby described these segmental narrowings and dilatations of the ductal system as a


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Surgery_Schwartz. due to restenosis and segmental obstruction of the pancreas due to progressive scarring. In 1958, Puestow and Gillesby described these segmental narrowings and dilatations of the ductal system as a “chain of lakes,” and proposed a longitudinal decompression of the body and tail of the pancreas into a Roux limb of jejunum246 (Fig. 33-51). Four of Puestow and Gillesby’s 21 initial cases were side-to-side anastomoses, and 2 years after their report, Partington and Rochelle described a much simpler version of the longitudinal, or side-to-side Roux-en-Y pancreaticojejunostomy that became universally known as the Puestow procedure247 (Fig. 33-52).Successful pain relief after the Puestow-type decompres-sion procedure has been reported in 75% to 85% of patients for the first few years after surgery, but pain recurs in >20% of patients after 5 years due to progressive disease even in patients who are abstinent from alcohol.164Figure 33-50. Duval’s caudal pancreaticojejunostomy. (Reproduced


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Surgery_Schwartz. but pain recurs in >20% of patients after 5 years due to progressive disease even in patients who are abstinent from alcohol.164Figure 33-50. Duval’s caudal pancreaticojejunostomy. (Reproduced with permission from Greenlee HB: The role of surgery for chronic pancreatitis and its complications, Surg Annu. 1983;15:283-305.)Figure 33-51. Puestow and Gillesby’s longitudinal pancreatico-jejunostomy. Originally described as an invaginating anastomosis that drained the entire body and tail, the anastomosis was created after amputating the tail of the gland and opening the duct along the long axis of the gland. (Reproduced with permission from Greenlee HB: The role of surgery for chronic pancreatitis and its complica-tions, Surg Annu. 1983;15:283-305.)With the advent of therapeutic endoscopy and techniques for transluminal stone removal and lithotripsy, multiple series have reported the successful endoscopic treatment of pancreatic duct calculi, although the long-term outcomes of these


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Surgery_Schwartz. and techniques for transluminal stone removal and lithotripsy, multiple series have reported the successful endoscopic treatment of pancreatic duct calculi, although the long-term outcomes of these efforts has been uneven.248-251 Endoscopic removal of pancreatic duct stones is usually coupled to prolonged pancreatic duct stenting, Brunicardi_Ch33_p1429-p1516.indd 147301/03/19 6:45 PM 1474SPECIFIC CONSIDERATIONSPART IIABFigure 33-52. Longitudinal dochotomy in obstructing calcific pancreatitis. A longitudinal pancreatotomy typically discloses seg-mental stenosis of the pancreatic duct and the presence of intra-ductal calculi in a patient with chronic calcific pancreatitis (A). Following mobilization of a Roux limb of jejunum, a longitudinal pancreaticojejunostomy is performed to permit extensive drainage of the pancreatic duct system (B). This technique, described by Partington and Rochelle, is the typical method used for the Puestow procedure. which carries the risk of further


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Surgery_Schwartz. extensive drainage of the pancreatic duct system (B). This technique, described by Partington and Rochelle, is the typical method used for the Puestow procedure. which carries the risk of further inflammation.252,253 Despite the risk of perioperative complications, the surgical management of pancreatic duct stones and stenosis has been shown to be superior to endoscopic treatment in randomized clinical trials in which the long, side-to-side technique of pancreaticojejunos-tomy is used.254-256Resectional Procedures Distal Pancreatectomy For patients with focal inflammatory changes localized to the body and tail, or in whom no significant ductal dilatation exists, the technique of partial (40–80%) dis-tal pancreatectomy has been advocated (Fig. 33-53). Although distal pancreatectomy is less morbid than more extensive resec-tional procedures, the operation leaves untreated a major portion of the gland, and is therefore associated with a significant risk of symptomatic recurrence. It has


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Surgery_Schwartz. morbid than more extensive resec-tional procedures, the operation leaves untreated a major portion of the gland, and is therefore associated with a significant risk of symptomatic recurrence. It has been a more popular operation in British centers, where its success seems to be greater, perhaps due to the lower incidence of alcoholic chronic pancreatitis.257 However, long-term outcomes reveal good pain relief in only 60% of patients, with completion pancreatectomy required for pain relief in 13% of patients.Laparoscopic distal pancreatectomy has been shown to be feasible for the removal of focal lesions of the distal pancreas,258 but it is more difficult in the setting of chronic pancreatitis.Ninety-Five Percent Distal Pancreatectomy In 1965, Fry and Child proposed the more radical 95% distal pancreatectomy, which was intended for patients with sclerotic (small duct) disease and which attempted to avoid the morbidity of total pancreatectomy by preserving the rim of pancreas in the


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Surgery_Schwartz. distal pancreatectomy, which was intended for patients with sclerotic (small duct) disease and which attempted to avoid the morbidity of total pancreatectomy by preserving the rim of pancreas in the pancreaticoduodenal groove, along with its associated blood vessels and distal common bile duct.241 The operation was found to be associated with pain relief in 60% to 77% of patients long term, but it is accompanied by a high risk of brittle diabetes, hypoglycemic coma, and malnutrition. Although the operation was the first attempt to resect the pancreatic head while preserving the duodenum and distal bile duct, the extensive degree of metabolic complications led to its failure as viable treatment for the symptoms of pancreatic sclerosis.Proximal Pancreatectomy In 1946, Whipple reported a series of five patients treated with either pancreaticoduodenectomy or total pancreatectomy for symptomatic chronic pancreatitis, with one operative death.240 Subsequently, proximal pancreatectomy or


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Surgery_Schwartz. series of five patients treated with either pancreaticoduodenectomy or total pancreatectomy for symptomatic chronic pancreatitis, with one operative death.240 Subsequently, proximal pancreatectomy or pancreaticoduodenectomy, with or without pylorus preser-vation (Fig. 33-54), has been widely used for the treatment of chronic pancreatitis.259 In the three largest modern (circa 2000) series of the treatment of chronic pancreatitis by the Whipple Splenic arteryFigure 33-53. Distal (spleen-sparing) pancreatectomy. A distal pancreatectomy for chronic pancreatitis is usually performed with en bloc splenectomy, using either an open or laparoscopic tech-nique. In the presence of minimal inflammation, a spleen-sparing version can be performed, as shown here.Brunicardi_Ch33_p1429-p1516.indd 147401/03/19 6:45 PM 1475PANCREASCHAPTER 33procedure, pain relief 4 to 6 years after operation was found in 71% to 89% of patients. However, mortality ranged from 1.5% to 3%, and major complications


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Surgery_Schwartz. 6:45 PM 1475PANCREASCHAPTER 33procedure, pain relief 4 to 6 years after operation was found in 71% to 89% of patients. However, mortality ranged from 1.5% to 3%, and major complications occurred in 25% to 38% of patients at the Johns Hopkins Hospital,260 the Mayo Clinic,261 and the Massachusetts General Hospital.262 In follow-up, 25% to 48% of patients developed diabetes, and about the same per-centage required exocrine therapy. Advocates of the Whipple procedure as treatment for chronic pancreatitis suggest that the high rate of symptomatic relief outweighs the metabolic conse-quences and the mortality risk of the procedure, but increasingly this approach is being reserved for those patients with suspected occult malignancy.Total Pancreatectomy Priestley and associates first described successful total pancreatectomy in 1944 in a patient with hyperinsulinism,239 and two of Whipple’s original five cases of chronic pancreatitis reported in 1946 were treated with total


Surgery_Schwartz

Surgery_Schwartz. first described successful total pancreatectomy in 1944 in a patient with hyperinsulinism,239 and two of Whipple’s original five cases of chronic pancreatitis reported in 1946 were treated with total pancreatectomy.240 Subsequently, surgeons who used total pancreatectomy found that the operation produces no better pain relief for their patients than pancreaticoduodenectomy (about 80–85%). Moreover, the metabolic consequences of total pancreatectomy in the absence of islet cell transplantation can be profound and life-threatening. The patients have a “brittle” form of diabetes in which avoidance of hyperand hypoglycemia is problematic.263 In addition, lethal episodes of hypoglycemia are common in severe apancreatic diabetes. These are due to hypoglycemic unresponsiveness, due to the absence of pancreatic glucagon, and to hypoglycemia unawareness, despite an ongoing need to treat with exogenous insulin.177 In a series of >100 patients treated with total pancreatectomy, Gall and


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Surgery_Schwartz. absence of pancreatic glucagon, and to hypoglycemia unawareness, despite an ongoing need to treat with exogenous insulin.177 In a series of >100 patients treated with total pancreatectomy, Gall and colleagues showed that half of all the late deaths after this operation were due to (iatrogenic) hypoglycemia.264 Despite newer forms of insulin, insulin delivery systems, and continuous blood glucose monitoring systems, severe pancreatogenic diabetes remains an adverse outcome, as complete prevention of the physiologic consequences of total pancreatectomy remains an unfulfilled goal. Even with the growing acceptance of islet auto-transplantation as an adjunct to the procedure (see later in CholedochojejunostomyGastrojejunostomyPancreaticojejunostomyCholedochojejunostomyDuodenojejunostomyPancreaticojejunostomyABFigure 33-54. The pancreaticoduodenectomy (Whipple procedure) can be performed either with the standard technique, which includes distal gastrectomy (A), or with preservation of the


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Surgery_Schwartz. 33-54. The pancreaticoduodenectomy (Whipple procedure) can be performed either with the standard technique, which includes distal gastrectomy (A), or with preservation of the pylorus (B). The pylorus-sparing version of the procedure is used most commonly. (Repro-duced from Wu GY, Aziz K, Whalen GF: An Internist’s Illustrated Guide to Gastrointestinal Surgery. Totowa: Humana Press; 2003.)this section), total pancreatectomy itself is now used only rarely for the treatment of refractory chronic pancreatitis.Hybrid Procedures In 1980, Beger and associates described the Duodenum-preserving Pancreatic Head Resection or DPPHR265 (Fig. 33-55), and they published long-term results with DPPHR for the treatment of chronic pancreatitis in 1985266 and again in 1999.267 In 388 patients who were followed for an average of 6 years after DPPHR, pain relief was reportedly maintained in 91%, mortality was <1%, and diabetes developed in 21%, with 11% demonstrating a reversal of their preoperative


Surgery_Schwartz

Surgery_Schwartz. followed for an average of 6 years after DPPHR, pain relief was reportedly maintained in 91%, mortality was <1%, and diabetes developed in 21%, with 11% demonstrating a reversal of their preoperative diabetic sta-tus. These authors also compared the DPPHR procedure with the pylorus-sparing Whipple procedure in a randomized trial of 40 patients with chronic pancreatitis.268 The mortality was reportedly zero in both groups, and the morbidity was also com-parable. Pain relief (over 6 months) was seen in 94% of DPPHR patients, but in only 67% of Whipple patients. Furthermore, the insulin secretory capacity and glucose tolerance were noted to deteriorate in the Whipple group, but they actually improved in the DPPHR patients.The DPPHR requires the careful dissection of the gas-troduodenal artery and the creation of two anastomoses (Fig. 33-56), and it carries a similar complication risk as the Whipple procedure due to the risk of pancreatic leakage and intra-abdominal fluid collections.In


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Surgery_Schwartz. and the creation of two anastomoses (Fig. 33-56), and it carries a similar complication risk as the Whipple procedure due to the risk of pancreatic leakage and intra-abdominal fluid collections.In 1987, Frey and Smith described the local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ), which included excavation of the pancreatic head, including the ductal structures in continuity with a long dochot-omy of the dorsal duct269 (Fig. 33-57). The Frey procedure pro-vides thorough decompression of the pancreatic head as well as the body and tail of the gland, and a long-term follow-up suggested that improved outcomes are associated with this more extensive decompressive procedure. Frey and Amikura reported their results in 50 patients followed for >7 years, and they found complete or substantial pain relief in 87% of patients. There was no operative mortality, but 22% of patients developed postop-erative complications.270Brunicardi_Ch33_p1429-p1516.indd


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Surgery_Schwartz. they found complete or substantial pain relief in 87% of patients. There was no operative mortality, but 22% of patients developed postop-erative complications.270Brunicardi_Ch33_p1429-p1516.indd 147501/03/19 6:45 PM 1476SPECIFIC CONSIDERATIONSPART IICommonbile ductPancreaticductPancreaticremnantABFigure 33-55. The duodenum-preserving pancreatic head resection described by Beger and colleagues. A. The completed resection after transection of the pancreatic neck, and subtotal removal of the pan-creatic head, with preservation of the distal common bile duct and duodenum. B. Completion of the reconstruction with anastomosis to the distal pancreas and to the proximal pancreatic rim by the same Roux limb of jejunum. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-56. Intraoperative view of the Beger procedure. The gastroduodenal artery is encircled by a vessel


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Surgery_Schwartz. Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-56. Intraoperative view of the Beger procedure. The gastroduodenal artery is encircled by a vessel loop. Just below, the intrapancreatic portion of the common bile duct is exposed as it courses toward the ampulla. A rim of well-vascularized pancreatic tissue remains in the duodenal C-loop. Preservation of the posterior branch of the gastroduodenal artery is essential to preserve viability of these structures.Key steps in the performance of the LR-LPJ include pres-ervation of the pancreatic neck as well as the capsule of the posterior pancreatic head. In the pancreaticoduodenectomy and the DPPHR, the pancreatic neck is freed up from the portal and superior mesenteric vein confluence and divided. In the LR-LPJ, the neck of the pancreas is preserved intact as are the body and tail of the pancreas. Not having to divide the pancreatic neck, as in the pancreaticoduodenectomy or DPPHR, reduces


Surgery_Schwartz

Surgery_Schwartz. In the LR-LPJ, the neck of the pancreas is preserved intact as are the body and tail of the pancreas. Not having to divide the pancreatic neck, as in the pancreaticoduodenectomy or DPPHR, reduces the risk of the operation because it avoids intraoperative prob-lems with the venous structures lying posterior to the gland. To reduce the risk of penetrating the posterior capsule of the head, Frey recommended in his 1994 report that the posterior limit of resection be the back wall of the opened duct of Wirsung and duct to the uncinate (Fig. 33-58).Subsequent to Frey’s own modification of the technique, other surgeons have described modifications of the extent or technique of the LR-LPJ. Andersen and Topazian advocated performing the LR-LPJ as it was originally described, in which the entirety of the ducts are excised from the head (Fig. 33-59), and described the use of the ultrasonic aspirator and dissector for this purpose.271 This device permits precise removal of the ducts and adjacent


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Surgery_Schwartz. of the ducts are excised from the head (Fig. 33-59), and described the use of the ultrasonic aspirator and dissector for this purpose.271 This device permits precise removal of the ducts and adjacent tissue with good visualization and without complications. There is little pancreatic tissue behind these ducts, and the pancreatic capsule is continuously palpated as the dissection proceeds to ensure a safe margin of resection. The intrapancreatic portion of the common bile duct is usually exposed, and avoiding injury to it is enhanced by the ultrasonic aspirator. The majority of the parenchyma of the uncinate pro-cess is spared, and the excavation of the pancreatic head is made contiguous with a generous dochotomy of the dorsal duct. Whether merely unroofing as opposed to removal of the proximal ducts contributes to better pain relief is not known and awaits a randomized trial to compare the two versions of the LR-LPJ. Izbicki and colleagues at the University of Hamburg also recommend a


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Surgery_Schwartz. ducts contributes to better pain relief is not known and awaits a randomized trial to compare the two versions of the LR-LPJ. Izbicki and colleagues at the University of Hamburg also recommend a more extensive excavation of the pancreatic head, and they use a technique that they refer to as the Hamburg modification of the LR-LPJ272 (Fig. 33-60). This wider excavation of the pancreatic head is created in continu-ity with the dorsal dochotomy, and it is followed by a single, side-to-side pancreaticojejunostomy.In 2001, Ho and Frey subsequently described merely exca-vating the core of the pancreatic head and draining the exca-vation with a Roux-en-Y pancreaticojejunostomy, but without any effort to include the dorsal duct273,274 (Fig. 33-61). In 2003, Brunicardi_Ch33_p1429-p1516.indd 147601/03/19 6:45 PM 1477PANCREASCHAPTER 33Figure 33-57. Frey procedure. The local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ) provides complete decompression of


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Surgery_Schwartz. 6:45 PM 1477PANCREASCHAPTER 33Figure 33-57. Frey procedure. The local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ) provides complete decompression of the entire pancreatic ductal system. Reconstruction is performed with a side-to-side Roux-en-Y pan-creaticojejunostomy. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-58. Operative view of excavated head of the pancreas during the Frey procedure. The main pancreatic duct is opened widely down to the level of the ampulla, and the head of the pan-creas is excavated in a conical fashion so as to allow complete decompression of the chronically obstructed and inflamed pancre-atic ducts. (Reproduced with permission from Aspelund G et al. Improved outcomes for benign disease with limited pancreatic head resection, J Gastrointest Surg. 2005 Mar;9(3):400-409.)Figure


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Surgery_Schwartz. pancre-atic ducts. (Reproduced with permission from Aspelund G et al. Improved outcomes for benign disease with limited pancreatic head resection, J Gastrointest Surg. 2005 Mar;9(3):400-409.)Figure 33-59. Complete excavation of the pancreatic head and distal pancreatic dochotomy. A true excavation and removal of the proximal ductal system is combined with a distal pancreatic dochotomy. Reconstruction is performed with a single side-to-side Roux-en-Y pancreaticojejunostomy. (Reproduced with permission from Andersen DK, Topazian MD. Pancreatic head excavation: a variation on the theme of duodenum-preserving pancreatic head resection, Arch Surg. 2004 Apr;139(4):375-379.)Brunicardi_Ch33_p1429-p1516.indd 147701/03/19 6:46 PM 1478SPECIFIC CONSIDERATIONSPART IIFigure 33-60. The Hamburg modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy. (Reproduced with permission from Shackelford RT, Yeo CJ, Peters JH: Shackelford’s Surgery of the


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Surgery_Schwartz. modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy. (Reproduced with permission from Shackelford RT, Yeo CJ, Peters JH: Shackelford’s Surgery of the Alimentary Tract. New York, NY: Saunders/Elsevier; 2007.)Farkas and colleagues described a similar excavation of the cen-tral portion of the pancreatic head without any effort to include the duct of the body in the lateral pancreaticojejunostomy,275 and they reported excellent results with what they termed an organ-preserving pancreatic head resection (OPPHR) in a ran-domized comparison to the pylorus-preserving pancreaticoduo-denectomy (PPPD).276This approach was advocated by Gloor and associates in Bern as an alternative to the DPPHR procedure in patients with portal hypertension277 and was described as the Berne modifica-tion of the DPPHR (Fig. 33-62). Köninger and colleagues in Heidelberg subsequently published a randomized, controlled trial of the “Berne” version of the excavation


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Surgery_Schwartz. described as the Berne modifica-tion of the DPPHR (Fig. 33-62). Köninger and colleagues in Heidelberg subsequently published a randomized, controlled trial of the “Berne” version of the excavation method compared to the “classic” Beger procedure.278 Operative times and length of stay were shorter in the group undergoing excavation of the pancreatic head, while long-term outcomes and quality-of-life scores were identical over 2 years postoperatively.The common element of these variations on the theme of LR-LPJ remains the excavation or “coring out” of the central portion of the pancreatic head. It remains uncertain, however, whether and to what degree the dochotomy needs to be extended into the body and tail. The logical conclusion of all of these efforts is that the head of the pancreas is the nidus of the chronic inflammatory process in chronic pancreatitis and that removal of the central portion of the head of the gland is the key to the successful resolution of pain in the long


Surgery_Schwartz

Surgery_Schwartz. is the nidus of the chronic inflammatory process in chronic pancreatitis and that removal of the central portion of the head of the gland is the key to the successful resolution of pain in the long term.Complications Initial and long-term results of the LR-LPJ demonstrate pain relief that is equivalent to that of pancreati-coduodenectomy and the DPPHR.279,280 The observed mortal-ity rate has been virtually zero, and therefore, less than with the Whipple procedure. Major complications were less with the LR-LPJ (16%) than with pancreaticoduodenectomy (40%) or DPPHR (25%) in one single-site series, and the incidence of new postoperative diabetes after LR-LPJ was 8% with an aver-age follow-up of 3 years.1996Line of enterotomyJejunal limbsecured with 1strow of suturesNormal pancreatic ductPancreatic head cored outABFigure 33-61. Excavation of pancreatic head without longitudinal pancreaticojejunostomy. Comparisons of the Three Operative Procedures: Pancre-aticoduodenectomy (Whipple


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Surgery_Schwartz. head cored outABFigure 33-61. Excavation of pancreatic head without longitudinal pancreaticojejunostomy. Comparisons of the Three Operative Procedures: Pancre-aticoduodenectomy (Whipple procedure), DPPHR (Beger procedure), and LR-LPJ (Frey procedure). There has been considerable interest to apply evidence-based methods to the study of the three operations currently advocated for the treat-ment of chronic pancreatitis. The best studies, or level 1 data by the Strength of Recommendation Taxonomy, are prospective, randomized controlled trials comparing two or more operations from a single or multi-institutional study. Retrospective, cohort-based studies are regarded as level 2 data by the Strength of Recommendation Taxonomy criteria.To date, ten published level 1 studies268,276,278-285 and three level 2 studies199,286,287 have examined various comparisons between these three operations. In the level 1 study of Klempa and colleagues281 and that of Buchler et al,288 DPPHR patients had a


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Surgery_Schwartz. three level 2 studies199,286,287 have examined various comparisons between these three operations. In the level 1 study of Klempa and colleagues281 and that of Buchler et al,288 DPPHR patients had a shorter hospital stay, greater weight gain, less postopera-tive diabetes, and exocrine dysfunction than standard Whipple patients over a 3to 5-year follow-up. Pain control was similar between the two procedures. Similar results were observed in a Brunicardi_Ch33_p1429-p1516.indd 147801/03/19 6:46 PM 1479PANCREASCHAPTER 33Figure 33-62. The Berne modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy.recent level 2 retrospective study of 123 patients287 and in the level 1 study by Keck et al.287In a level 1 study of 61 patients randomized to PPPD or LR-LPJ, Izbicki and colleagues found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality-of-life scores (71%


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Surgery_Schwartz. LR-LPJ, Izbicki and colleagues found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality-of-life scores (71% vs. 43%, respectively).279 Both operations were equally effective in controlling pain over a 2-year follow-up. Similar results were seen in the study by Farkas and associates276 who employed a similar method of excavation of the pancreatic head that their group described as an organ-preserving pancreatic head resection (OPPHR) and found that OPPHR was associated with a shorter operating time, less postoperative morbidity, shorter hospital stay, and better quality of life than PPPD. The superior outcomes of the Frey procedure were found to be durable in a 15-year follow-up study by Bachmann et al285 who found that survival and function were superior after the Frey procedure.Late Morbidity and Mortality In 2005, Izbicki’s group reported on a level 1 study of 74 patients randomized to the


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Surgery_Schwartz. et al285 who found that survival and function were superior after the Frey procedure.Late Morbidity and Mortality In 2005, Izbicki’s group reported on a level 1 study of 74 patients randomized to the DPPHR or LR-LPJ who were then followed for an average of 8.5 years.286 There were no significant differences between the groups with regard to global quality of life, pain scores, late mortality, and exocrine or endocrine insufficiency. The level 1 study by Köninger, which compared the classic DPPHR with excavation of the pancreatic head, showed identical outcomes at 2 years after an initial reduction in morbidity associated with the excavation procedure.278 These results were echoed in the level 2 study by Aspelund and associates, which demonstrated fewer complications with both the DPPHR and LR-LPJ proce-dures compared to pancreaticoduodenectomy, a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no significant differences in


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Surgery_Schwartz. and LR-LPJ proce-dures compared to pancreaticoduodenectomy, a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no significant differences in outcomes or pain relief between DPPHR and LR-LPJ.199 Finally, level 2 data support the efficacy of both DPPHR and LR-LPJ in patients with dilated as well as nondilated ducts.286,289,290Long-term exocrine and/or endocrine insufficiency in chronic pancreatitis patients treated surgically is a product of the surgical intervention as well as the progression of the underlying disease. Although the short-term (3-year) incidence of new diabe-tes after operation appears less with the LR-LPJ and DPPHR than with the PPPD, the late incidence of diabetes appears similar in all groups. After an average of 7 years of follow-up after LR-LPJ or PPPD, survival, pain relief, and pancreatic function were similar in both groups. The rate of diabetes was slightly lower after LR-LPJ (61%) than after PPPD


Surgery_Schwartz

Surgery_Schwartz. of 7 years of follow-up after LR-LPJ or PPPD, survival, pain relief, and pancreatic function were similar in both groups. The rate of diabetes was slightly lower after LR-LPJ (61%) than after PPPD (65%), but these had both more than doubled from their preoperative status.275-281 Therefore, although the limited pancreatic procedures of DPPHR and LR-LPJ have a lower initial rate of endocrine dysfunction, the long-term risk of diabetes is more related to the progression of the underlying disease than to the effects of operation.The level 1 studies confirm that the duodenum preserving options are associated with a lower immediate morbidity and mortality and therefore, in the absence of a mass or concerns about cancer, are better options than a Whipple procedure for chronic pancreatitis. The choice of LR-LPJ, DPPHR, or OPPHR depends largely on surgeon experience, and the LR-LPJ is most common in the United States.Total Pancreatectomy With Islet Auto-Transplantation Islet cell


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Surgery_Schwartz. The choice of LR-LPJ, DPPHR, or OPPHR depends largely on surgeon experience, and the LR-LPJ is most common in the United States.Total Pancreatectomy With Islet Auto-Transplantation Islet cell transplantation for the treatment of diabetes is an attractive adjunct to pancreatic surgery in the treatment of benign pancre-atic disease. Despite the difficulties in recovering islets from a chronically inflamed gland, Najarian and associates demonstrated the utility of autotransplantation of islets in patients with chronic pancreatitis in 1980.291 Subsequently, through refinements in the methods of harvesting and gland preservation, and through standardization of the methods by which islets are infused into the portal venous circuit for intrahepatic engraftment, the suc-cess of total pancreatectomy combined with islet autotransplan-tation has steadily increased to achieve insulin independence in the majority of patients treated in recent series.292,293 Although 2 to 3 million islets are


Surgery_Schwartz

Surgery_Schwartz. combined with islet autotransplan-tation has steadily increased to achieve insulin independence in the majority of patients treated in recent series.292,293 Although 2 to 3 million islets are required for successful engraftment in an allogeneic recipient, the auto-transplant recipient can usually achieve long-term, insulin-independent status after engraftment of only 300,000 to 400,000 islets (about one-third to one-half of the number of islets in the normal pancreas).294The ability to recover a sufficient quantity of islets from a sclerotic gland is dependent on the degree of fibrotic dis-ease present, so the selection of patients as candidates for autologous islet transplantation is important. The impressive improvement in quality of life measures and pain relief seen after total pancreatectomy with islet auto-transplantation (TP-IAT) indicate that it is a highly successful form of therapy for some patients (Fig. 33-63).295 The outcomes of TP-IAT are sig-nificantly better in


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Surgery_Schwartz. pancreatectomy with islet auto-transplantation (TP-IAT) indicate that it is a highly successful form of therapy for some patients (Fig. 33-63).295 The outcomes of TP-IAT are sig-nificantly better in pediatric patients than in adults, largely due to the prevalence of hereditary and idiopathic causes of chronic pancreatitis in pediatric patients.296 These studies suggest that further definition is needed regarding criteria for considering TP-IAT vs. hybrid or resectional procedures for patients with persistent symptoms. With the emerging evidence that hybrid procedures seem to offer better outcomes in patients with toxic etiologies of chronic pancreatitis, and that TP-IAT appears to Brunicardi_Ch33_p1429-p1516.indd 147901/03/19 6:46 PM 1480SPECIFIC CONSIDERATIONSPART II001224364860MonthsEffectNum DF1131252842994299Den DF0.26268.294.840.608<0.001<0.001F statisticP valueAgeTimeAge x TimePrevalence of narcotic use (%)72849610812020406080100Pediatric patientAdultFigure 33-63. Prevalence


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Surgery_Schwartz. DF1131252842994299Den DF0.26268.294.840.608<0.001<0.001F statisticP valueAgeTimeAge x TimePrevalence of narcotic use (%)72849610812020406080100Pediatric patientAdultFigure 33-63. Prevalence of narcotic use after total pancreatectomy with islet auto-transplantation (TP-IAT) in adult and pediatric patients. (Reproduced with permission from Chinnakotla S, Beilman GJ, Dunn TB, et al. Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases, Ann Surg. 2015 Oct;262(4):610-622.)preferentially benefit patients with hereditary and idiopathic forms of the disease, the importance of the careful definition of the etiology of chronic pancreatitis, including genetic testing, is steadily increasing.PANCREATIC NEOPLASMSNeoplasms of the Endocrine PancreasNeoplasms of the endocrine pancreas are relatively uncommon but do occur with enough frequency (five cases per million population) that most surgeons will encounter them in an urban


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Surgery_Schwartz. Endocrine PancreasNeoplasms of the endocrine pancreas are relatively uncommon but do occur with enough frequency (five cases per million population) that most surgeons will encounter them in an urban practice. The cells of the endocrine pancreas, or islet cells, origi-nate from neural crest cells, also referred to as amine precursor uptake and decarboxylation cells. Multiple endocrine neopla-sia (MEN) syndromes occur when these cells cause tumors in multiple sites. The MEN1 syndrome involves pituitary tumors, parathyroid hyperplasia, and pancreatic neoplasms. Although most pancreatic endocrine tumors are nonfunctional, some are functional, secreting peptide products that produce interesting clinical presentations. Neoplasms of the endocrine pancreas that are not associated with excess hormone levels and a recogniz-able clinical syndrome are considered nonfunctional. Special immunohistochemical stains allow pathologists to confirm the peptide products being produced within the cells of


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Surgery_Schwartz. levels and a recogniz-able clinical syndrome are considered nonfunctional. Special immunohistochemical stains allow pathologists to confirm the peptide products being produced within the cells of a pancre-atic endocrine tumor. However, the histologic characteristics of these neoplasms do not predict their clinical behavior, and malignancy is usually determined by the presence of local inva-sion and lymph node or hepatic metastases. Unfortunately, most pancreatic endocrine tumors are malignant, but the course of the disease is far more favorable than that seen with pancreatic exo-crine cancer. The key to diagnosing these rare tumors is recogni-tion of the classic clinical syndrome; confirmation is achieved by measuring serum levels of the elevated hormone. Localiza-tion of the tumor can be a challenging step, but once accom-plished, the surgery is relatively straightforward. The goals of surgery range from complete resection, often accomplished with insulinomas, to controlling symptoms


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Surgery_Schwartz. a challenging step, but once accom-plished, the surgery is relatively straightforward. The goals of surgery range from complete resection, often accomplished with insulinomas, to controlling symptoms with debulking proce-dures. Unresectable disease in the liver is often addressed with chemoembolization.As with pancreatic exocrine tumors, the initial diagnos-tic imaging test of choice for pancreatic endocrine tumors is a multidetector CT scan with four phases of contrast and fine cuts through the pancreas and liver. Neuroendocrine tumors of the pancreas often enhance with contrast. EUS can be superior to CT in localizing these tumors, which can produce dramatic symptoms despite their small (<1 cm) size. In contrast to pan-creatic exocrine tumors, many of the endocrine tumors have somatostatin receptors (SSTRs) that allow them to be detected by a radiolabeled octreotide scan. A radioactive somatostatin analogue is injected intravenously, followed by whole-body radionuclide scanning


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Surgery_Schwartz. receptors (SSTRs) that allow them to be detected by a radiolabeled octreotide scan. A radioactive somatostatin analogue is injected intravenously, followed by whole-body radionuclide scanning (Fig. 33-64). The success of this modal-ity in localizing tumors and detecting metastases has decreased the use of older techniques such as angiography and selective venous sampling.InsulinomaInsulinomas are the most common functional pancreatic endocrine neoplasms and present with a typical clinical Brunicardi_Ch33_p1429-p1516.indd 148001/03/19 6:46 PM 1481PANCREASCHAPTER 33syndrome known as Whipple’s triad. The triad consists of symptomatic fasting hypoglycemia, a documented serum glucose level <50 mg/dL, and relief of symptoms with the administration of glucose. Patients can present with a profound syncopal episode or less severe symptoms that are averted by frequent eating. Common symptoms include palpitations, trembling, diaphoresis, confusion or obtundation, and seizure, and family


Surgery_Schwartz

Surgery_Schwartz. profound syncopal episode or less severe symptoms that are averted by frequent eating. Common symptoms include palpitations, trembling, diaphoresis, confusion or obtundation, and seizure, and family members may report that the patient has undergone a personality change.Routine laboratory studies will uncover a low blood sugar, the cause of all of these symptoms. Serum insulin levels are elevated. C-peptide levels should also be elevated and rule out the unusual case of surreptitious administration of insulin or oral hypoglycemic agents because excess endogenous insulin pro-duction leads to excess C-peptide. The diagnosis can be clinched with a monitored fast in which blood is sampled every 4 to 6 hours for glucose and insulin levels until the patient becomes symptomatic. However, this can be dangerous and must be done with close supervision.Insulinomas are usually localized with CT scanning and EUS. Technical advances in EUS have led to preoperative identification of >90% of


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Surgery_Schwartz. this can be dangerous and must be done with close supervision.Insulinomas are usually localized with CT scanning and EUS. Technical advances in EUS have led to preoperative identification of >90% of insulinomas.297 Visceral angiography with venous sampling is rarely required to accurately localize the tumor. Insulinomas are evenly distributed throughout the head, body, and tail of the pancreas.298 Unlike most endocrine pancreatic tumors, the majority (90%) of insulinomas are benign Figure 33-64. Radioactive octreotide scan demonstrating pancre-atic endocrine tumor in the body of the pancreas (arrow).and solitary, and only 10% are malignant. They are typically cured by simple enucleation. However, tumors located close to the main pancreatic duct and large (>2 cm) tumors may require a distal pancreatectomy or pancreaticoduodenectomy. Intraop-erative US is useful to determine the tumor’s relation to the main pancreatic duct and guides intraoperative decision making. Approximately 90% of