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Mechanisms of Primary Operative Failure and Results of Remedial Operation in Patients with Chronic Pancreatitis

  • 2008 ssat plenary presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Introduction

Resection and drainage operations achieve long-term pain relief in approximately 85% of patients with chronic pancreatitis (CP). In patients who develop recurrent pain, a few data exist on the long-term results of remedial operations.

Materials and methods

Over an 18-year period (1988–2006), 316 patients with CP had primary resection or drainage operations at our institution. Thirty-nine developed recurrent pain and were treated by a remedial resection or drainage operation. Patient demographics, time to symptom recurrence, radiographic anatomic abnormalities, type of remedial operation, postoperative morbidity, and long-term outcomes were analyzed.

Results

Thirty-nine patients, 56% female with a mean age of 41 years (range 16–61 years) had either remedial resection: total pancreatectomy (TP; N = 8), pancreaticoduodenectomy (PD; N = 6), distal pancreatectomy (DP; N = 5), or drainage operation: duodenal preserving pancreatic head resection (DPPHR; N = 8), revision of pancreaticojejunostomy (N = 12). TP achieved pain relief in 88% with postoperative complications greater than or equal to grade III in 38% and diabetes in 100%. Drainage operations achieved pain relief in 67% of patients with postoperative complications greater than or equal to grade III in only 8%. Partial parenchymal resections (DPPHR, PD, DP) as a remedial procedure achieved pain relief <50% of the time.

Conclusion

Drainage procedures, when anatomically feasible, are the preferred reoperation to treat patients with recurrent pain after failed primary operation for chronic pancreatitis.

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Authors and Affiliations

  1. Department of Surgery and Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA

    Thomas J. Howard, Jeffrey S. Browne, Nicholas J. Zyromski, Harish Lavu, Marshall S. Baker, Changyu Shen & James A. Madura

  2. 545 Barnhill Drive, EM #517, Indianapolis, IN, 46202, USA

    Thomas J. Howard

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  1. Thomas J. Howard
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  2. Jeffrey S. Browne
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  4. Harish Lavu
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Correspondence to Thomas J. Howard.

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Discussion

David B. Adams, M.D. (Charleston, SC): Persistent pain and suffering afflicts patients who fail surgical management of chronic pancreatitis, which is a disease, as you know, characterized by heightened trypsinogen activation, exaggerated fibrosis, and neural hypersensitivity. Chronic pancreatitis has not one cause and is not one disease, thus, surgical treatment based upon phenotypic expressions of the disease is marked by frequent failure and the need for reoperation.

Now, postoperative pain, recurrent pancreatitis, exocrine and endocrine insufficiency, and death are reminders that chronic pancreatitis surgery is palliative surgery. You must understand then why I am so excited about today’s report, which has the optimistic take-home message that remedial operations in patients with chronic pancreatitis work. Revising obstructed pancreatojejunal anastomoses and resecting damaged tissue with completion pancreatectomy are particularly successful. I am a great admirer of the patient and thoughtful work of Dr. Howard and Madura and thank them for bringing their art and science to this careful analysis, and for Dr. Browne, who did a superb job of presenting, I have three questions.

One, do you have any data on the cause of death in the patients who died in the follow-up period? Second, in the four patients lost to follow-up, which is a terrific follow-up rate, do you think they disappear from follow-up because they are doing well, doing poorly, or doing both? That is, are they dead? How many of these subjects do you think are patients not solely with pancreatitis but patients with concomitant visceral hypersensitivity disorder, which is related to their operative failure?

Again, thanks for a superb job.

Jeffrey S. Browne, M.D. (Indianapolis, IN): Dr Adams, on behalf of Dr. Howard, myself, and the other authors of the paper thank you for your questions. I will speak first regarding our mortality. In mentioning our 33% mortality, you noted our 1-, 5-, and 10-year mortality rates which were 8%, 18%, and 33%, respectively. We had one patient we know that died of pancreatic cancer. Concerning the other patients, in those we could not tract down by last known address or through their family members, we used the Social Security Death Index in order to evaluate our mortality rates, and unfortunately, cause of death is not a part of this index.

Concerning the four patients lost to follow-up, we believe they are alive as we have been unable to locate them through multiple attempts at following them through forwarding addresses, and they have not shown up on the Social Security Death Index.

Finally, concerning visceral hypersensitivity syndromes and their role in this patient population, this focuses on the difficulty in trying to decide whether the patient has a structural process or a functional one. A structural process would be amenable to reoperation; however, a functional problem, such as visceral hypersensitivity syndrome will generally not respond to reoperation. Twenty-three of the 39 patients in this series had pain improvement based on stable narcotic use in our study. This would imply that these patients had a structural problem amenable to revision. In contrast, 16 of the 39 patients experienced either no change in their narcotic requirements or worsening pain requiring an increase in medication usage. These patients may in fact have had a visceral hypersensitivity syndrome as the major component of their pain.

Matthew R. Walsh, M.D. (Cleveland, OH): I want to be clear how you define recurrent pain. Did none of these people have visual analog pain assessment scores? If recurrent pain was diagnosed by a change in morphine equivalents, how many people are actually still on any amount of narcotics? My other question is, have you considered, since your patients were not diabetic before their revisional surgery, of doing auto-islet cell transplantation?

Dr. Browne: In addressing your first question, we had only 40% of this entire population that had complete pre- and postoperative quality of life data available using the EORTC instrument. Because of the incomplete nature of this assessment, we felt this data may be skewed to only patients who had a positive outcome and thus took the time to fill out this questionnaire and not be reflective of all the patients who underwent reoperation in this analysis. Looking for the next best objective measurement available, we felt that a patient’s stable narcotic regimen, when assessed both pre- and postoperatively and normalized to equivalent doses of morphine over the entire population of this study, would be a reasonable objective measure of outcome. Any decreases in narcotic medication use was deemed as an improvement in pain, and we did not have a specific threshold in which change was felt to be significant or nonsignificant except in the context of the changes in the mean normalized doses of the populations studied.

Finally, there were eight patients in our series that had total pancreatectomy, and three of these patients had autologous islet cell transplant at the time of their resection.

Syed Ahmed, M.D. (Cincinnati, OH): I want to congratulate you on a very nice presentation. I have two comments. The first is, in our experience, we found that patients who have recurrent pain after primary surgery, the cause of pain is usually multifactorial. Sometimes it is due to stricture of the anastomosis or progression of disease. Oftentimes, though, they have concomitant bowel dysfunction as a source of pain. So the first question I have is, what kind of workup do these patients undergo to determine the etiology of the pain and to determine whether the pancreas was in fact the cause of pain?

The second is a comment. At Cincinnati, we perform auto-islet transplants for recurrent pain, and it has similar results. We found that in the approximately 105 patients for whom we have now performed that operation, there is about a 70% improvement in abdominal pain. I wish to advocate auto-islet transplantation as the procedure of choice in patients who have recurrent abdominal pain without any strictures or lateralization of disease.

Dr. Browne: In speaking to the multifactorial nature of recurrent disease, I can assure you that these 39 patients were carefully selected as having anatomic abnormalities on postoperative imaging which was amenable to remedial surgery. Of the 316 patients operated on for chronic pancreatitis in our experience, a percentage had recurrent pain but no targeted abnormality amenable to reoperation, and they were not included for analysis. Furthermore, the anatomic abnormalities found in patients with recurrent pain were also complex and multifaceted, for example, in the 16 patients with strictured pancreaticojejunostomies, five also had progressive head disease requiring with a Whipple or total pancreatectomy, and three others had progressive disease in the tail requiring distal pancreatectomy. So our experience, much like yours, is that even in patients with identifiable anatomic abnormalities after primary operation, their recurrent disease tends to be multifactorial.

In addressing your question about what imaging is necessary in this patient population, we use three things to evaluate pancreatic anatomy before reoperative surgery: number one is good cross-sectional imaging from CT or MR exam, number two is ductography of both the bile and pancreatic ducts utilizing either MRCP or ERCP, and number three is a thorough intraoperative evaluation at the time of remedial surgery.

Katie S. Nason, M.D. (Pittsburgh, PA): I just have a comment to make rather than a question. Use of the Social Security Index as your only source of vital statistics on patients is inherently faulty because the Social Security Index only includes patients who have had submissions for claims made. So they do not include all patients who have died, and in fact in our series, we found several patients who were dead and did not show up as dead in the Social Security Index but were confirmed dead by family members. So I think it is important to be cautious using the Social Security Index as your only source of vital statistics.

Dr. Browne: Thank you very much for that comment.

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Howard, T.J., Browne, J.S., Zyromski, N.J. et al. Mechanisms of Primary Operative Failure and Results of Remedial Operation in Patients with Chronic Pancreatitis. J Gastrointest Surg 12, 2087–2096 (2008). https://doi.org/10.1007/s11605-008-0713-6

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