Surgical Management of CHRONIC PANCREATITIS
Chronic pancreatitis (CP) is a progressive, destructive, inflammatory process that ends in total destruction of the pâncreas and results in malabsorption, diabetes mellitus, and severe pain. The incidence and prevalence of CP are increasing in the worldwide and incidence is between 1.6 and 23 per 100 000 with increasing prevalence. The treatment of CP is complex; in the majority of cases na interdisciplinary approach is indicated that includes conservative, endoscopic, and surgical therapy. The surgical treatment of CP is based on two main concepts:preservation of tissue via drainage aims to protect against further loss of pancreatic function, and pancreatic resection is performed for nondilated pancreatic ducts, pancreatic head enlargement,or if a pancreatic carcinoma is suspected in the setting of CP.
The vast majority of patients are seen with a ductal obstruction in the pancreatic head, frequently associated with an inflammatory mass. In these patients, pancreatic head resection is the procedure of choice; The partial pancreatoduodenectomy (PD) or Kausch-Whipple procedure, in its classic or pylorus-preserving variant, has been the procedure of choice for pancreatic head resection in CP for many years (Jimenez et al, 2003). The duodenum-preserving pancreatic head resections and its variants—the Beger (1985), Frey (1987), and Bern procedures (Gloor et al, 2001)—represent less invasive, organsparing techniques with equal long-term results. Only very few patients come to medical attention with smallduct disease (diameter of the pancreatic duct ❤ mm) and no mass in the pancreatic head. Possibly, a large majority of those patients from former series had unknown autoimmune pancreatitis. In these cases, a V-shaped excision of the anterior aspect of the pancreas is a safe approach, with effective pain management (Yekebas et al, 2006). In the rare case of a patient seen with segmental CP in the pancreatic body or tail, such as that seen as a result of posttraumatic ductal stenosis, a middle segment pancreatectomy or a pancreatic left resection may be the best approach.
The adequate therapy of CP is adjusted to the symptoms of the patient, the stage of the disease, and the morphology of pathologic changes of the pancreas. The surgical technique must be adjusted to the pathomorphologic changes of the pancreas. For patients with CP and an inflammatory mass in the head of the pancreas, the DPPHR is less invasive than a PD and is associated with comparable long-term results. The Bern modification of the DPPHR represents a technical variation that is equally effective but technically less demanding. Whether total pancreatectomy with islet cell transplantation is a viable therapy of CP remains to be proved by further studies. Surgical therapy provides effective long-term pain relief and improvement of quality of life, but it may not stop the decline of endocrine or exocrine pancreatic function. Strategies to improve or maintain endocrine and exocrine function in CP remain an interesting field of research.