Abstract
The management of any patient with recurrent pain following surgery for chronic pancreatitis is far from an easy problem. Even more careful assessment than that preceding the decision for the first operation will be necessary. In-hospital patient assessment is strongly recommended to ascertain the degree of the problem of pain in as objective a manner as possible. The effects of alcohol withdrawal and different analgesic treatments have to be carefully assessed while obtaining essential information on the size and shape of the pancreatic duct as well as the general pancreatic morphology.
Relatively simple procedures such as the removal of stones or the enlargement of a strictured anastomosis may be all that is required to ensure freedom from pain; however, there is a tendency for patients who have no obvious new pathology or simple failure of the first operation to move to more extensive resectional procedures. This, ultimately will lead to total pancreatectomy being recommended and long-term follow-up of such patients is under critical scrutiny. Unless the highest caliber of support services can be mustered for these patients subject to total pancreatectomy, the morbidity and mortality in the longer term can reach prohibitive levels. A plea is made for objective reassessment of the place of celiac ganglionectomy in the management of these difficult problems.
Résumé
Le traitement de la douleur persistente ou récidivée après une intervention pour pancréatite chronique est loin d'être simple. Le bilan préopératoire doit être encore plus poussé qu'après la première intervention. Chez ce type de patient, il faut évaluer l'importance du problème de la douleur de façon aussi précise que possible. Il faut tenir compte des effets de l'abstinence, de l'alcool et des analgésiques. Il faut obtenir des renseignements morphologiques sur la forme et la taille du canal de Wirsung ainsi que sur la glande en entier.
La simple ablation d'un calcul du Wirsung ou l'élargissement d'une anastomose sténosée suffit parfois à soulager la douleur. Cepedant il existe une certaine tendance chez ces patients à échecs à proposer des interventions de plus en plus mutilantes amenant souvent à pratiquer la pancréatectomie totale. Le devenir à long terme de ces patients est actuellement soumis à une critique sévère. Si on ne s'assure pas des meilleurs soins et d'un traitement substitutif, morbidité et mortalité atteignent des taux rédibitoires. On souhaite voir restaurer la place de la splanchnicectomie dans le traitement de ces difficiles problèmes.
Resumen
El manejo de cualquier paciente con dolor récurrente después de cirugía para pancreatitis crónica représenta un problema nada fácil. Se requiere una valoración aún más minuciosa que la realizada con anterioridad a la operación primaria, con especial recomendación a evaluar el problema del dolor en la forma más objetiva que sea posible. Debe valorarse cuidadosamente el efecto de la abstinencia de alcohol y de los diferentes tratamientos con analgésicos simultáneamente con la obtención de información sobre la forma y calibre del canal pancreático y sobre la morfología general del páncreas.
En ocasiones sólo es necesario realizar procedimientos tan simples como la remoción de cálculos o la dilatación de una anastomosis estenótica para lograr el control del dolor. Sinembargo, la tendencia es hacia procedimientos mas extensos de resección en los pacientes que no exhiben una patología nueva o que simplemente demuestran falla en el resultado de la primera operación. Esto, en ultima instancia, puede llevar a la pancreatectomía total; el seguimiento a largo plazo de tales casos actualmente es objeto de una investigación minuciosa. A menos que se disponga de los más altos nivelés de soporte para los pacientes sometidos a pancreatectomía total, las tasas de morbilidad y mortalidad a largo plazo pueden alcanzar cifras prohibitivas. Se invoca la conveniencia de efectuar una reevaluación del papel de la ganglionectomía celíaca en el manejo de tan difíciles problemas.
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Imrie, C.W. Management of recurrent pain following previous surgery for chronic pancreatitis. World J. Surg. 14, 88–93 (1990). https://doi.org/10.1007/BF01670551
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DOI: https://doi.org/10.1007/BF01670551