Surgery for pain in chronic pancreatitis

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Surgery for pain in chronic pancreatitis

• Timing and indications

Dr Sujoy Pal Dept of GI Surgery, AIIMS
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Background

• Pain is the commonest indication 70-90
• Other established indications
• Complications
• Mass/ suspicion of malignancy
• Biliary obstruction
• Duodenal stenosis
• Pseudocysts
• Internal pancreatic fistulae
• Vascular problems
• Controversial
• prevention of exocrine/endocrine deficiency

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Aims of surgical treatment

• Pain relief
• Control of complications
• Preservation of endocrine and exocrine function
• Social and occupational rehabilitation
• Improvement of quality of life

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Indication Pain

• Prime indication in NACP/ACP
• Issues related to surgery
• Problems Subjective
• Severity grading often arbitrary
• Pains scoring systems
• Natural history
• Alc CP burn-out theory
• Lack of stringent level I evidence
• Timing of surgery

Lankisch PG et al, Digestion 1993 Ammann RW et
al, Gastroentrology 1984
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Assessment Pain severity
The need Selection of patients for
surgery Objective documentation of pain
relief Assessment of treatment
efficacy Comparison of data The tools Pain
scoring systems Quality of life
assessment Function scales Symptom scales
Bloechle C et al, Pancreas 1995, Izbicki JR et
al, Ann Surg 1998
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Pain scoring systems

• Parameters assessed
• Intensity
• Visual analog scale
• Pain medication
• Narcotic addiction
• Frequency
• Trials gt 1 episode per month
• Duration
• Most surgical series gt 1 year
• Consequences
• absence from work
• number of hospitalizations

Rai RR et al, Gastroenterol Jap 1988 Bloechle C
et al, Pancreas 1995
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Evidence in the literature

• Pancreatic burn-out syndrome
• Study n Follow up Exo-/endocrine Pain relief
• (years) insufficiency () ()
• Ammann 145 10.4 100/100 83
• Layer 192 14.6 77
• Lankisch 152 gt 10 46/78 65
• Drawbacks
• Selection bias
• Evaluation of patients at a given period during
• their natural course
• Continued alcoholism higher incidence of panc
  insufficiency

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Literature based evidence for surgery

• Large prospective surgical series 75-90
  success in
• pain relief and improved QOL
• Pain relief with surgery vs medical Rx 63 vs
  43 at 10 y
• Pain relief is unpredictable (both ALCP NACP)
• Pancreatic insufficiency pain relief
• imperfect correlation
• Patients with severe pain at onset
• less chance of pain relief
• Young patients with NACP more severe pain
• NACP slower deterioration of pancreatic function

Scuoro LA et al, AJG 1983Bornmann PC et al,
World J Surg , 2003
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The case for surgery
.. seems unreasonable to adopt a conservative
approach in the hope that pain relief will be
obtained sometime in the future, at which stage
the risk of narcotic addiction increases and
the results of surgery are invariably
poor. Andrew Warshaw
Warshaw AL, Gastroenterology 1984
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Surgical decision making

• Anatomy of the disease
• Large duct disease
• Small duct disease
• Location of inflammatory mass
• Associated complications
• Biliary obstruction
• Duodenal stenosis
• Pseudocysts
• GI bleeding/ Left sided portal hypertension
• Malignancy
• Etiology

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Timing of surgery

• Patients with associated complications Early
  surgery
• For pain relief
• Early surgery ( lt 4years) may delay progress of
• Exocrine/ endocrine insufficiency (Alc CP)
• Patel AG et al, Ann Surg 1999 Nealon WH et
  al, Ann Surg 1993
• Early surgery in NACP/ Tropical CP improves
• nutritional status, weight gain, decreased
  insulin
• requirement
• 
  Tripathy BB et al, 1987
• Contrary evidence
• Sikora SS et al, WJS 2002 Greenlee HB et al,
  WJS 1990
• Controversies How early what surgery drainage
• or resection?

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Timing and need for surgery

• Contentious issues
• Mild to moderate pain in patients with small
• duct disease
• Non abstinent alcoholics with continuing
  behavioral
• problems/ addictions

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Indication Complications of CP

• Biliary obstruction
• Incidence
• Admitted patients 6 (3-23)
• Radiological screening 33 (21-46)
• Operated patients 35 (15-60)
• Indication for intervention
• Persistent jaundice and/or cholangitis
• Biliary cirrhosis
• mass lesion
• ? Radiological/ biochemical derangement

Prinz RA et al, WJS 2003
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Indication Complications of CP

• Duodenal obstruction/stenosis
• Incidence
• Admitted patients 2 (1-13)
• Operated patients 12 (2-36)
• Indication for treatment
• Failure of conservative trial
• Mass Lesion
• Associated biliary obstruction

Vijungco JD, Prinz RA et al, WJS 2003
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Other complications

• Splenic vein thrombosis
• Majority asymptomatic
• Incidence is variable 4-45
• Prospective study (n266) 13
• Gastric varices 17
• Variceal hage 1 patient
• Bernades P et al, Dig Dis Sci 1992
• Management
• Bleeders Splenectomy
• ? Prophylactic splenectomy
• Only 4 of patients with gastric varices bleed
• Pseudocysts and ductal disruptions
• Retention cysts require surgical drainage

Heider TR et al, Ann Surg 2004
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Pancreatic mass Inflammatory or malignant ?

• Clinical
• Radiological
• Helical CT/ MRI
• ERCP/MRCP
• EUS
• Pancreatic duct/ fluid
• CA19-9
• p 53 immunohistochemistry
• Preoperative /Intraoperative FNAC
• Operative evaluation/biopsy

In case of doubt resection is the best option
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GI Surgery AIIMS data1985-2004 (n170)
Pain as the main indication
90 Pain duration 1-30
years Biliary obstruction alone 10 NACP 95
Alc CP 75 Drainage procedures 115 LPJ
62 LPJ biliary bypass 30 Cystoenterosto
mies 23 Resections 19 Whipples 11 Whippl
es LPJ 3 Distal pancreatectomy 5
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Lessons learnt

• Pain relief is sustained in NACP (gt 85)
• Duration of pain does not necessarily correlate
  with
• surgical outcome
• No consistent documentation of recovery of
  pancreatic
• function following ductal drainage
• Need for biliary bypass frequent ( 50)
• Associated SVT/ PHT makes surgery difficult
• Late deaths occur due to malignancy, continued
  alcoholism

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Summary and conclusions
Pain relief and QOL issues are the main concerns
in patients with chronic pancreatitis undergoing
treatment Surgery is indicated for relief of
intractable pain and associated complications of
chronic pancreatitis Failure of non surgical
treatment and presence of complications
influence the timing and need for surgical
intervention Jury is still out early surgery
for mild to moderate pain