Treatment of chronic pancreatitis complicated by obstruction of the common bile duct or duodenum
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Abstract
In patients with chronic pancreatitis, common bile duct obstruction is reported in 3.2–45.6% of patients; however, only 5–10% of all patients with chronic pancreatitis require operative decompression of the bile duct. The cause of the intrapancreatic stricture of the common bile duct may be either a fibrotic inflammatory restriction, or compression by a pseudocyst. Obstruction of the duodenum is much less common than common bile duct obstruction in chronic pancreatitis occurring in less than 1-2% of patients with chronic pancreatitis. Colonic obstruction secondary to pancreatitis is very infrequent.
The intrapancreatic strictures of chronic pancreatitis are characteristically smooth and tapering on endoscopic retrograde cholangiopancreatography (ERCP), but in some patients, they may have a sharp cut-off and closely resemble the appearance of carcinoma of the pancreas invading the bile duct. The natural history of these intrapancreatic strictures is variable. They may progress and be associated with cholangitis, biliary cirrhosis, common duct stones, or may remain stable for years or regress. Prior pancreaticojejunostomy is not protective against the development of intrapancreatic biliary strictures which may follow in 5–30% of patients, with most authors reporting an incidence of less than 10%. Evaluation of alkaline phosphatase, bilirubin, the presence of jaundice, or the appearance of an intrapancreatic stricture on ERCP is not predictive of whether cholangitis or biliary cirrhosis may or may not develop. The incidence of cholangitis and biliary cirrhosis in patients with intrapancreatic stricture is 9.4% and 7.3%, respectively. Laennec's cirrhosis occurs in a similar number of patients.
Operation is indicated in patients with intrapancreatic strictures of the common bile duct in association with chronic pancreatitis in patients developing cholangitis, biliary cirrhosis, common duct stones, progression of the stricture, persistent high elevations of alkaline phosphatase and/or bilirubin for over a month or inability to rule out cancer of the pancreas or periampullary region. The operation of choice is choledochoduodenostomy or Roux-en-Y choledochojejunostomy to bypass the obstructed intrapancreatic portion of the common bile duct. Persistentduodenalobstruction for over 3 or 4 weeks is an indication for gastrojejunostomy.
Pain is not a feature of common bile duct obstruction in the absence of cholangitis. In the presence of pain associated with chronic pancreatitis, longitudinal pancreaticojejunostomy is the operation of choice combined with Roux-en-Y choledochojejunostomy. Some of the newer operations, e.g., the Beger and Frey procedures, may make the necessity of a separate operation for biliary decompression superfluous.
Keywords
Pancreatitis Common Bile Duct Chronic Pancreatitis Cholangitis Biliary StrictureRésumé
Chez les patients ayant une pancréatite chronique, l'obstruction de la voie biliaire principale se recontre chez 3.2% à 45.6% des patients. Cependant, 5% à 10% seulement des patients ayant une pancréatite chronique nécessitent une décompression chirurgicale des voies biliaires. La cause de la sténose de la voie biliaire principale intrapancréatique peut être soit la fibrose inflammatoire, soit la compression par un pseudokyste. La sténose duodénale est beaucoup moins fréquente que celle de la voie biliaire principale puisqu'elle se rencontre chez 1% à 2% ayant une pancréatite chronique. Une sténose colique est exceptionnelle au cours de la pancréatite chronique.
L'aspect de la pancréatite chronique par la cholangiopancréaticographie rétrograde endoscopique est typiquement une sténose régulière en pointeau, mais chez certains patients, on peut voir une interruption brutale qui ressemble beaucoup à celle d'un cancer pancréatique qui envahit les voies biliaires. L'histoire naturelle de ces sténoses est variable. Elles peuvent évoluer et provoquer angiocholite, cirrhose biliaire, lithiase de la voie biliaire principale, ou au contraire rester stables pendant des années ou régresser. L'anastomose pancréaticojéjunale ne protège pas contre l'évolution vers la sténose des voies biliaires intrapancréatiques qui peut se voir dans 5% à 30% des cas; l'incidence dans la plupart des séries se situe autour de 10%. Les dosages des phosphatases alcalines, de la bilirubine, la présence d'ictère ou l'apparition d'une sténose à la cholangiographie endoscopique ne sont pas un élément prédictif. La fréquence d'angiocholite ou de cirrhose biliaire chez les patients ayant une sténose intrapancréatique est respectivement de 9.4% et 7.3%. La fréquence de la cirrhose de Laennec est sensiblement la même.
La chirurgie est indiquée dans la pancréatite chronique chez les patients présentant sténose intrapancréatique de la voie biliaire principale, angiocholite, cirrhose biliaire, lithiase de la voie biliaire principale, évolution de la sténose, persistance des taux élevés de phosphatases alcalines ou de la bilirubine pendant plus d'un mois, ou impossibilité d'exclure un cancer de la région périampullaire. L'intervention de choix est soit une anastomose cholédochoduodénale, soit une anastomose cholédochojéjunale par l'intermédiaire d'une anse en Y, pour dériver la portion intrapancréatique de la voie biliaire principale. Une sténose duodénale durant plus de 3 ou 4 semaines est une indication d'anastomose gastrojéjunale.
La douleur ne fait pas partie du tableau habituel d'obstruction de la voie biliaire principale sauf pour l'angiocholite. La douleur associée à une pancréatite chronique est une indication d'anastomose cholédochojéjunale avec anse en Y. Les interventions plus modernes, anastomose médiopancréaticojéjunale de Beger ou longue anastomose pancréaticojéjunale de Frey, rendent souvent superflue une intervention pour la dérivation biliaire.
Resumen
En la pancreatitis crónica se reporta la obstrucción del colédoco en 3.2% a 45.6% de los pacientes. Sin embargo, solo 5–10% de la totalidad de los pacientes con pancreatitis crónica requieren descompresión operatoria del conducto biliar. La causa de la estenosis intrapancreática del canal colédoco puede ser una fibrosis inflamatoria o la compresión por un pseudoquiste. La obstrucción del duodeno es bastante menos común que la del colédoco y ocurre en menos del 1–2% de los pacientes con pancreatitis crónica. La obstrucción del colon secundaria a pancreatitis crónica es muy infrecuente.
Las estrecheces biliares intrapancreáticas que se desarrollan en la pancreatitis crónica aparecen en forma característica: regulares y de extremos adelgazados en la colangiopancreatografía endoscópica retrograda (CPER), pero en algunos pacientes exhiben extremos recortados simulando la apariencia de un carcinoma del páncreas que invade la vía biliar. La historia natural de estas estrecheces intrapancreáticas es variable. Pueden progresar y asociarse con colangitis, cirrosis biliar, cálculos coledocianos, o pueden permanecer estables por años o también regresar. Una pancreaticocoyeyunostomía previa no significa protección contra el desarollo de estrecheces biliares intrapancreáticas, las cuales pueden ocurrir en 5–30% de los pacientes; la mayoría de los autores reporta una incidencia menor de 10%. La valoración de la fosfatasa alcalina, bilirrubina, la presencia de ictericia, o la presencia de una estrechez en CPER no tienen valor de prediction sobre el eventual desarrollo de colangitis o de cirrosis biliar. La incidencia de colangitis y de cirrosis biliar en pacientes con estrechez biliar intrapancreática es de 9.4% y 7.3% respectivamente. La cirrosis de Laennec ocurre en un número similar de pacientes.
La operación esta indicada en pacientes con estrecheces intrapancreáticas del colédoco en asociación con pancreatitis crónica, en pacientes que desarrollan colangitis, cirrosis biliar, cálculos en el colédoco, progresión de la estrechez, elevación persistente de la fosfatasa alcalina y/o la bilirrubina por más de un año o incapacidad para descartar el diagnóstico de cáncer del páncreas o periampular. La operación de elección es la pancreaticoduodenostomía o la coledocoyeyunostomía de Roux-en-Y para derivar el flujo biliar de la porcíon intrapancreática obstruída del colédoco. La obstrucción duodenal que persiste por más de 3 o 4 semanas constituye indicación para gastroyeyunostomía.
El dolor es una característica de la obstrucción del canal colédoco en ausencia de colangitis. En presencia de dolor asociado con pancreatitis crónica se prefiere la pancreaticoyeyunostomía longitudinal combinada con coledocoyeyunostomía de Roux-en-Y. Algunas de las nue vas operaciones, por ejemplo los procedimientos de Beger y de Frey pueden hacer innecesario realizar una operación separada para efectuar la descompresión biliar.
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