Surgery for Chronic Pancreatitis
Most patients with severe pain chronic pancreatitis eventually require surgery for pain relief. The surgery for treatment of pain is complex and should be tailored to the individual patient’s specific requirements. An absolute requirement in patients with alcoholic chronic pancreatitis is abstinence from drinking.
Surgical results in patients with chronic pancreatitis who continue to drink are very poor and therefore we do not offer surgery to the un rehabilitated alcoholic patient.
Why do patients with chronic pancreatitis develop chronic severe pain?
The reason for the pain in chronic pancreatitis is not completely understood. Two mechanisms have been proposed:
The surgery procedures offered for pain from chronic pancreatitis at USC are:
- Obstruction of the main pancreatic duct: patients with chronic pancreatitis have multiple areas of blockage of their pancreatic duct. It is thought that this obstruction cause backup of the pancreatic juices in the pancreas duct that gives rise to the severe pain. Opening the pancreatic duct through a large opening and directing the flow of pancreatic juice into the intestine relieves this obstruction and provides relief of the pain in a procedure called the Peustow procedure.
- Inflammation in the head (the first part) of the pancreas: this is thought to be the main reason for pain in chronic pancreatitis. The inflammatory changes injure the nerves to the pancreas causing the pain. The Whipple operation and pancreatic head resection remove this portion of the pancreas that is most severely involved in the inflammatory process leading to pain relief.
In this operation the pancreatic duct is open all the way from the head (beginning of the pancreas) to the tail (end) of the pancreas. The small intestine is then brought up to the pancreas and is sutured to the pancreatic duct. The pancreatic juice is therefore drained directly into the small intestine.
We perform the Peustow’s procedure both by an open surgical approach and through a laparoscopic approach. The laparoscopic approach which utilizes small incisions is now preferred at USC for this procedure due to shorter length of stay in the hospital and early recovery from surgery.
Patients who are candidates for a Peustow’s operation include patients with severe pain who are diabetic, have markedly increased pancreatic duct and who have documented abstinence from alcohol abuse.
Pancreatic Head Resection
This is a highly specialized surgical procedure that is performed in only a few institutions in the United States. At USC we have utilized this as our primary procedure for treatment of pain in patients with severe chronic pancreatitis. In this delicate operation only the head of pancreas is removed preserving the duodenum and the bile duct. This procedure leads to a much shorter recovery compared to the Whipple operation since the duodenum and the bile duct are preserved.
We often combine the pancreatic head resection procedure with a Peustow procedure to the body and tail of the pancreas thereby offering advantages of both operations to the the patients. The pancreatic head resection procedure provides complete relief of severe pain from chronic pancreatitis in approximately 70% of patients, in addition 15-20% of patients will have a substantial relief of the pain with a reduction in the amount of pain medication after surgery.
The majority of patients who undergo this operation are rehabilitated and have a normal and a fairly active life after the surgery. We would not offer this operation to patients whose chronic pancreatitis is from alcohol abuse unless there is documented evidence of complete abstinence from alcohol.
The Whipple Operation
We have offered the Whipple operation to only a selected patients with chronic pancreatitis who have documented abnormalities in the head of pancreas. The Whipple operation at USC is performed both by open surgical techniques and by the laparoscopic surgical approach.
For patients with chronic pancreatitis our preference is to do the procedure laparoscopically if feasible since laparoscopic surgical procedures in general are associated with shorter length of stay in the hospital and much earlier post-operative recovery. Patients also have much smaller surgical incisions compared to the incisions required for open surgery.