Pancreatic Resection

Patients with a normal diameter or narrowed duct may be candidates for pancreatic resection. This is especially true when the pancreatic head is enlarged and contains multiple cysts and calcifications. Pancreaticoduodenectomy (Whipple resection) or pylorus-preserving pancreatico-duodenectomy are performed most commonly, and we prefer the latter. Pylorus preservation is felt by many to allow for better postoperative nutrition and weight gain, but little objective data support this. The operative mortality rate is < 3% and permanent pain relief is to be expected in 85 to 90%. These operations are more likely to produce endocrine (22%) and exocrine (55%) insufficiency, which is their major drawback. Of course, some patients develop these problems anyhow as the disease progresses.

In an effort to design an operation that would provide permanent pain relief and avoid the exocrine and endocrine insufficiency of a major resection, surgeons have designed several new procedures that combine limited resection of the head of the pancreas with a pancreaticoje-junostomy. The so-called Beger or Frey operations remove most of the head of the pancreas except for a shell of pancreatic tissue posteriorly. The cavity thus created is drained into a Roux-en-Y limb of jejunum; gastroduodenal continuity is not disturbed. This operation can be performed whether or not the pancreatic duct is dilated. If it is, the

TABLE 137-2. Results of Resection for Chronic Pancreatitis

Number

Operative

Pain

New

New

Type of

of

Mortality

Relief

Onset DM

Endocrine

Study

Year

Resection

Patients

(%)

(%)

(%)

Insufficiency

Heise

2001

PPW

41

4.S

54

19

67

Drainage

59

-

59

16

54

DP

26

-

S9

21

50

Jimenez

2000

PPW

39

1.4

B0

10

63

SW

33

-

70

12

77

Martin

199B

PPW

45

2.2

92

46

77

Beger

1999

DPPHR

504

0.S

91

21

-

Frey

1994

LRLPJ

50

0

S7

11

11

DM = diabetes mellitus; DP = distal pancreatectomy; DPPHR = duodenum-preserving pancreatic head resection; LRLPJ = local pancreatic head resection with longitudinal pancreaticojejunostomy; PPW = pylorus-preserving Whipple; SW = standard Whipple.

DM = diabetes mellitus; DP = distal pancreatectomy; DPPHR = duodenum-preserving pancreatic head resection; LRLPJ = local pancreatic head resection with longitudinal pancreaticojejunostomy; PPW = pylorus-preserving Whipple; SW = standard Whipple.

pancreaticojejunostomy is extended over the body of the pancreas to incorporate the dilated duct in that area. Early results suggest that pain relief is excellent in 85 to 90% of patients, that the relief persists beyond several years, and that exocrine or endocrine insufficiency are not precipitated by the surgery. In those patients whose bile duct has also been obstructed by the fibrotic pancreas, this "coring" of pancreatic tissue from the head of the gland may decompress that duct as well. This operation is contraindicated if there is a concern about the presence of a malignant neoplasm in the head of the pancreas; a pancreaticoduo-denectomy should be performed in these cases.

Uncommonly, chronic pancreatitis is localized predominantly in the body or tail of the pancreas. In these cases, a distal pancreatectomy (with or without splenectomy) may be effective. The surgeon should investigate the possibility that an occult malignancy may have produced a more proximal duct obstruction, and that a neoplastic duct stricture is the reason for such localized pancreatitis. Otherwise in patients with predominantly distal disease, distal pancreatectomy is safe and pain relief can be expected in as many as 90% of patients after 4 years. For the usual patient who has diffuse disease involving the entire pancreas, distal pancreatectomy is ineffective, however. Because it results in a brittle diabetes which is often difficult to control, and because lesser procedures are likely to be effective, total pancreatectomy for chronic pancreatitis is almost never done today.

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