40 year old ex-alcoholic with chronic pancreatitis, suffering from recurrent severe abdominal pain undergoes pancreatico-jejunostomy (Dilated MPD - around 10 mm with multiple ductal calculi). Head coring not done as there were no calculi in pancreatic head. Unfortunately returns a short time after surgery with recurrent abdominal pain. How to best manage - coeliac block, medical treatment with increasing analgesics, distal pancreatectomy?
Good question but difficult to manage,Imaging studies to assess the patency and extent of PJ,.Since the relapse is in a short period.If the pain is severe,recurrent and not responding to medical management try pancreatic duct sphincterotomy by ERCP.If the head was not decompressed earlier he may benefit with a stent.He will respond with his life style changes if not you can consider coeliac ganglion block.Ultimately he may require permanant solution by way of revising PJ or total pancreatectomy if he does not respond to the above less invasive proceedures.Distal pancreatectomy will not help.
Thank you Prof. Reddy for your clear and elaborate response. Very helpful!
We have experience of more than 500 procedures for CP. If the pancreatic head is enlarged, conservative treatment, ERCP, sphincterotomy, stenting, PJ and distal resection are ineffective procedures as a primary treatment and now as well. Our experience on this subject is just confirming the experience of our European colleagues.
The head enlargement is the key. No chance to treat pain in this case without head mass reduction. There are 95% reliable methods for such patients and all of them connected by the abovemetioned principle: Whipple, Beger, Bern variant, Frey (modification of 2003) or total pancreatic head resection (Imaizumi).
Best
I agree with dr Egorof We have more than 300 patients with CP treated with longitudinal pancreatojejunostomy with about 75 % of early good results however long term pain releave in patiens with enlarged pancreatic head are acquired i only by head subtotal(Frey procedure) or total resection (Beger or pancreaticoduodenectomy) distal pancreatic resection is not useful
I think that Bern modification of the Beger duodenum preserving pancreatic head resection is the best option for patients with cronic pancreatitis. When surgery is indicated, the trigger of the disease, which is the pancreatic head, should be adressed.
And the timing of surgery should be carefully chosen (early in the course of the disease), knowing that after a period of time the pain moves its origin from the fibrotic pancreas into the central nervos system. In this moment a local surgery has no major impact on symptomatology.
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