An algorithmic approach to the treatment of pain in chronic pancreatitis

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An algorithmic approach to the treatment of pain
in chronic pancreatitis
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Need for intervention
Sood Algorithmic approach to the treatment of
pain in CP

• About 50 of patients with pain in chronic
  pancreatitis will ultimately require intervention

Need for intervention in chronic pancreatitis
MCLDD 8/15 needed intervention
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Sood Algorithmic approach to the treatment of
pain in CP

• Low fat diet, oral pancreatic enzymes, acid
  suppression, attention to triglycerides, NSAIDS,
  avoid exacerbating drugs

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Sood Algorithmic approach to the treatment of
pain in CP
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Endoscopy
Sood Algorithmic approach to the treatment of
pain in CP

• Stenting safe, minimally invasive, often
  effective, does not hinder further surgery,1 can
  be repeated, 50-65 pain relief at 5 years2-4
• a 1st line approach to improving the clinical
  condition of patients early in the course of
  chronic pancreatitis5

Long-term pain relief with stents
1 Boerma et al, 2002 2. Dite et al, 2004 3.
Binmoeller et al, 1995 4. Roche et al, 2002, 5.
Delhaye et al, 2003
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Endoscopy
Sood Algorithmic approach to the treatment of
pain in CP

• 21 M, 5 mm duct, pain every year for 5 years, has
  been stented 5 times, including one definite
  episode of acute pancreatitis during stenting,
  and has come for surgery.

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Endoscopy
Sood Algorithmic approach to the treatment of
pain in CP

• Disadvantages of endoscopic treatment
• Stent survival 6 months1,2
• lt40 pain relief without stent2
• Pancreatitis, strictures3,4

Stent survival
1. Pellicer Bautista et al, 1998 2. Binmoeller
et al, 1995 3. Izbicki et al, 1999 4. Morgan et
al, 2003
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Endoscopy
Sood Algorithmic approach to the treatment of
pain in CP

• Stenting probably has the best role in patients
  with a single stricture, in the hope that it can
  be permanently dilated, in a patient who is not
  fit or not accepting surgery

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Sood Algorithmic approach to the treatment of
pain in CP
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Neural block
Sood Algorithmic approach to the treatment of
pain in CP

• Celiac plexus block transient relief results
  are poor as compared to surgery 50 benefit
  immediate, 30 at 24 weeks1
• Splanchnicectomy Pain relief at 12 months is
  65,2 and at 48 months is 46.3 However, pain
  relief is rarely complete, and long term results
  are poor, especially in patients earlier operated
  or stented

Cumulative pain relief after neural block
1. Gress et al, 1999 2. Hammond et al, 04 3.
Buscher et al, 2002
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Sood Algorithmic approach to the treatment of
pain in CP
Patient not fit/ not accepting surgery
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Surgery
Sood Algorithmic approach to the treatment of
pain in CP

• Duct drainage by lateral pancreaticojejunostomy
  (LPJ) is standard procedure for chronic
  pancreatitis with dilated ducts (about half of
  the patients have dilated ductsgt7 mm)1,2
• The other surgical option is resection total
  pancreatectomy (TP), or pancreatoduodenectomy
  (PD), or distal pancreatectomy (DP).
• Long-term results of surgery are superior to
  those achieved by endoscopy 86 vs 65 pain
  relief 3
• 1. Izbicki et al, 1999 2. Sakorafas et al, 2000
  3. Dite et al, 2004

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Surgery
Sood Algorithmic approach to the treatment of
pain in CP

• Long term pain relief
• Drainage 65-88
• Drainage with head resection (Beger, Frey)
  75-88
• Resection 67-93
• !

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Surgery for nondilated ducts (lt7 mm)
Sood Algorithmic approach to the treatment of
pain in CP

• Several authors recommend resection procedures,
  because small ducts are presumed unamenable to
  drainage
• However, the results of drainage procedures are
  excellent even in patients with small ducts.
  Dilated or non-dilated ducts, gt 90 patients had
  pain relief following Freys procedure, 30
  months follow up1
• the small duct is small only for the surgeon 2
• 1. Ramesh et al, 2003 2. Izbicki et al, 1999

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Sood Algorithmic approach to the treatment of
pain in CP
Patient not fit/ not accepting surgery
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Recurrence after surgery
Sood Algorithmic approach to the treatment of
pain in CP

• Individualize treatment
• Rule out recidivism to alcohol
• Look for pseudocyst, tumour
• Failed drainage can be treated by resection1
• Nerve blocks work poorly
• 1. Izbicki et al, 1999

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Sood Algorithmic approach to the treatment of
pain in CP
Patient not fit/ not accepting surgery