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The Surgeon’s Role in Treating Chronic Pancreatitis and Incidentally Discovered Pancreatic Lesions

  • Evidence-Based Current Surgical Practice
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Chronic pancreatitis and incidentally discovered pancreatic lesions present significant diagnostic and therapeutic challenges for surgeons. While both decompressive and resection procedures have been described for treatment of chronic pancreatitis, optimal management must be tailored to each patient’s individual disease characteristics, parenchymal morphology, and ductal anatomy. Surgeons should strive to achieve long-lasting pain relief while preserving native pancreatic function. For patients with incidentally discovered pancreatic lesions, differentiating benign, pre-malignant, and malignant lesions is critical as earlier treatment is thought to result in improved survival. The purpose of this evidence-based manuscript is to review the presentation, workup, surgical management, and associated outcomes for patients with chronic pancreatitis or incidentally discovered solid and cystic lesions of the pancreas.

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Statement of Author Contribution

All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to or published in any other publication before its appearance in the Journal of Gastrointestinal Surgery.

Category 1

Conception and design of study:

VK Dhar, BT Xia, SA Ahmad.

Acquisition of data:

VK Dhar, BT Xia, SA Ahmad.

Analysis and/or interpretation of data:

VK Dhar, BT Xia, SA Ahmad.

Category 2

Drafting the manuscript:

VK Dhar, BT Xia, SA Ahmad.

Revising the manuscript critically for important intellectual content:

VK Dhar, BT Xia, SA Ahmad.

Category 3

Final approval of the version of the manuscript to be published:

VK Dhar, BT Xia, SA Ahmad.

Category 4

Agreement to be accountable for all aspects of the work:

VK Dhar, BT Xia, SA Ahmad.

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0558, SRU Room 1466, Cincinnati, OH, 45219, USA

    Vikrom K. Dhar, Brent T. Xia & Syed A. Ahmad

Authors
  1. Vikrom K. Dhar
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  2. Brent T. Xia
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  3. Syed A. Ahmad
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Corresponding author

Correspondence to Syed A. Ahmad.

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Disclosure Information

Authors: Syed A. Ahmad, M.D., has nothing to disclose. Vikrom K. Dhar, M.D., M.S., has nothing to disclose. Brent T. Xia, M.D., has nothing to disclose. Editors-in-Chief: Richard A. Hodin, M.D., and Timothy M. Pawlik, M.D., MPH, PhD, has nothing to disclose. CME Overseers: Arbiter: Timothy M. Pawlik, M.D., MPH, PhD, has nothing to disclose; Vice-Arbiter: Melanie Morris, M.D., has nothing to disclose; Question Reviewers: Peter Lopez, M.D., and Melanie Morris, M.D., has nothing to disclose.

CME questions for this article available to SSAT members at http://ssat.com/jogscme/

CME/MOC Questions:

1. A 40-year old female with recurrent acute abdominal pain and two previous episodes of acute pancreatitis undergoes ERCP demonstrating pancreas ductal dilation >7 mm due to a distal stricture without evidence of head disease. She should be recommended to undergo:

a. Puestow

b. Pancreaticoduodenectomy

c. Total pancreatectomy with islet cell autotransplantation

d. Distal pancreatectomy

2. A 62-year old male with history of alcohol abuse presents with abdominal pain radiating to the back as well as 30-lb. weight loss. CT scan demonstrates an enlarged inflammatory mass in the head of the pancreas. He should be recommended to undergo:

a. Puestow

b. Pancreaticoduodenectomy

c. Total pancreatectomy with islet cell autotransplantation

d. Distal pancreatectomy

3. A 45-year old male with chronic pancreatitis is scheduled to undergo duodenal sparing head resection for refractory abdominal pain. The risk of him requiring subsequent intervention due to failure of the index operation to adequately resolve his symptoms is approximately:

a. 5%

b. 25%

c. 75%

d. 90%

4. A 57-year old male with history of chronic pancreatitis has previously undergone duodenal sparing head resection for large duct, head predominant disease. He now presents with persistent, refractory abdominal pain consistent with recurrent chronic pancreatitis. He should be recommended to undergo:

a. Puestow

b. Pancreaticoduodenectomy

c. Total pancreatectomy with islet cell autotransplantation

d. Distal pancreatectomy

5. A 69-year old female is incidentally found to have a 4 cm cystic lesion in the head of the pancreas associated with main duct dilation of 9 mm. Cyst fluid analysis demonstrates high viscosity, high amylase, variable CEA, and presence of mucin. This lesions is most likely:

a. Serous cyst adenoma

b. Mucinous cystic neoplasm

c. Intraductal papillary mucinous neoplasm

d. Pseudocyst

6. A 55-year old female is incidentally found to have a 2 cm cystic lesion in the body of the pancreas without main duct involvement. Cyst fluid analysis demonstrates low viscosity, low amylase, low CEA, and no evidence of mucin. This lesions is most likely:

a. Serous cyst adenoma

b. Mucinous cystic neoplasm

c. Intraductal papillary mucinous neoplasm

d. Pseudocyst

7. A 61-year old female is incidentally found to have a 3 cm cystic lesion in the body of the pancreas without main duct involvement. Cyst fluid analysis demonstrates high viscosity, low amylase, high CEA, and presence of mucin. This lesions is most likely:

a. Serous cyst adenoma

b. Mucinous cystic neoplasm

c. Intraductal papillary mucinous neoplasm

d. Pseudocyst

8. All the following are high-risk features associated with intraductal papillary mucinous neoplasms, EXCEPT:

a. Obstructive jaundice with cystic lesion of head of pancreas

b. Enhancing solid component within cyst

c. Main pancreatic duct >10 mm in size

d. Cyst ≥3 in size

Learning Objectives

1. To review current practices in the diagnosis and surgical treatment of patients with chronic pancreatitis

2. To understand outcomes associated with resection and decompression for patients undergoing surgical intervention for chronic pancreatitis

3. To review the workup and indications for operative management of incidentally discovered solid and cystic lesions of the pancreas

4. To understand factors associated with differentiating benign, premalignant, and malignant pancreatic lesions

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Dhar, V.K., Xia, B.T. & Ahmad, S.A. The Surgeon’s Role in Treating Chronic Pancreatitis and Incidentally Discovered Pancreatic Lesions. J Gastrointest Surg 21, 2110–2118 (2017). https://doi.org/10.1007/s11605-017-3534-7

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  • DOI: https://doi.org/10.1007/s11605-017-3534-7

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