52 year old with no history of alcohol intake presents with 2 year history of upper abd pain radiating to back.
USG shows no cholelithiasis, but dilated CBD. LFTs normal.
MRCP - Dilated CBD (10 mm) with smooth stricture of distal CBD ?secondary to chronic pancreatitic changes in the pancreatic head, Irrerular MPD with maximal dilation of 7 mm at the body with some dilated side-branches, atrophic pancreas.
1) Could we proceed with a pancreatico-jejunostomy along with head coring?
2) Is there any need for ERCP to evaluate the CBD considering that the distal CBD stricture has no concerns for malignancy on imaging and LFTs are normal
3) Would a concomitant choledocho-duodenostomy along with the pancreatic drainage procedure be justified to prevent a possibility of future worsening of the stricture and biliary obstruction?
Amylase and lipase levels? Have you considered pancreatic endoscopy for the abdominal pain?
Difficult situation . If the patient has got severe pain he will benefits from the pancreaticojejunostomy and biopsy . Since the chronic pancreatitis progressive disease , it is better to do choledochoduodenostony with or without cholecystectomy . Endoscopic shicherotomy is not adequate . Advisable to do CA 19.9 .
Pancreatic endoscopy does not mean only pancretic sphincterotomy. Stent placement..main pancreatic dilation...stones removal... each patient is different from amother..but these procedure should be considered for reducing pain..this is my experience..than surgery is mandatory
for CP with impending biliary obstruction, I would like do pancreaticodudenectomy(open or laparoscopic) rather than pancreatico-jejunostomy along with head coring, for the following reason:
1) pancreatic head is the core for pain.
2) bile duct obstruction may not be resolved by pancreatic head coring.
3) 10-20 times higher risk for malignancy.
4) in our experience, good quality of life after PD
Another option is beger procedure, the distal bile duct is incised and exposed within pancreatico-duct-jejunostomy, so the bile can directly go into jejunum.
If abdominal pain is controled by nonsurgical methods i dont recomend pancreatojejunostomy neither pancreatic resection or pancreatic head coring. For biliary obstruction Cholecystectomy and bilioenteric anastomosis is the best choice.
This patient is above 50 , and had a double duct sign , pancreas became atrophied and developed calcification related to chronic pancreatitis so first exclude malignancy by any means which is not an easy job , at the end patient will have a surgery which could help him to know the cause and to relieve pain as well as overcome long term complications of chronic pancreatitis .
Would get EUS +/- spyglass to rule out occult malignancy first. pancreatico-jejunostomy along with head coring may not relieve pain, particularly if a lot of calcifications in the uncinate. Might be better off with pancreaticoduodenectomy. Whether it's done open or laparoscopic will depend on surgeon experience. Would check HA1c pre-op to get an idea if post op blood sugars will be an issue, particularly if patient smokes cigarettes .
An EUS and CT with pancreas protocol would be wise first steps. The EUS should look for microlithiasis and any cbd stones as well as abnormalities in the pancreas / CBD. MRCP might be an alternative depending on availability. Concerns for occult malignancy in the first instance. Management obviously depebds on findings but chronic pancreatitis related to alcohol sounds the most lilely diagnosis
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