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Chronic pancreatitis: Results of operations for relief of pain

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Abstract

Pancreaticojejunostomy is the method of choice for surgical treatment of pain in chronic pancreatitis in the case of ductal dilation. The operative risk is small and all remaining glandular tissue preserved. At 5 years postoperatively, about two-thirds of the patients still experience pain relief.

In the absence of dilated ducts, the surgical options are somewhat more controversial. Parenchyma-saving alternatives such as nerve-cutting procedures have not met expectations. Instead, percutaneous blockage of the celiac plexus using alcohol and phenol have been more commonly used for short-term pain relief. The relatively great number of different resective procedures probably reflects the dissatisfaction with the effect of each one of them. Neither left resection nor total pancreatectomy is, today, an attractive alternative due to the relatively high mortality and morbidity (short- and long-term) risks, especially when evaluated against the backdrop of the limited pain reduction in many patients. The Whipple procedure is still the best alternative, although it should be used with critical selection by both the patient and the surgeon.

As for the new operations presented during the 1980's, it is too early to foresee their possible future role. We feel, however, that we still have to await the operation which fulfills the criteria of an ideal operation for pain in chronic pancreatitis.

Résumé

Dans le traitement chirurgical de la douleur de la pancréatite chronique, l'anastomose pancréaticojéjunale reste la méthode de choix quand le canal de Wirsung est dilaté. Le risque opératoire est réduit et on conserve le parenchyme glandulaire restant. A 5 ans, 2/3 environ des patients ne souffrent toujours pas.

En l'absence de dilatation canalaire, les options thérapeutiques restent controversées. Les interventions ne comportant pas de sacrifice parenchymateux comme la splanchnectomie n'ont pas atteint leur but. Les traitements par injection percutanée d'alcool et de phénol sont réservés plutôt pour soulager la douleur de façon temporaire. Le grand nombre des procédés d'exérèse disponibles est probablement le reflet d'une certaine insatisfaction attachée à chacun d'eux. Ni les pancréatectomies gauches, ni les pancréatectomies totales ne sont une solution en raison de leur taux élevé de mortalité et de morbidité (à court et à long terme), surtout quand on sait que leur action sur la douleur est inconstante. La duodénopancréatectomie céphalique reste la meilleure intervention mais on doit la réserver à certains malades et à certaines équipes chirurgicales.

Quant aux interventions nouvelles proposées dans les années 80, il est encore trop tôt pour en prévoir l'impact. Nous pensons cependent que l'intervention idéale pour combattre la douleur dans la pancréatite chronique n'a pas encore vu le jour.

Resumen

La pancreaticoyeyunostomía es el método de elección en el tratamiento quirúrgico del dolor de la pancreatitis aguda en pacientes que exhiben dilatación ductal; el riesgo operatorio de este procedimiento es bajo y conlleva la conservación de todo el tejido glandular residual. A los 5 años de la operación dos tercios de los pacientes todavía se mantienen libres de dolor.

En ausencia de dilatación de los canales las opciones quirúrgicas vienen a ser motivo de controversia. Procedimientos alternativos orientados hacia la conservación del parénquima, tales como las operaciones para seccionar nervios, no han satisfecho las expectativas. El bloqueo percutáneo del plejo celiaco utilizando alcohol y fenol han sido los más utilizados para el control del dolor a corto término.

El relativamente elevado número de diversos procedimientos de resección es probable reflejo de la poca satisfacción con el efecto de cada uno de ellos.

Ni la resección izquierda ni la pancreatectomía total representan hoy una alternativa atrayente debido a los relativamente altos riesgos de mortalidad y morbilidad (a corto y a largo plazo), especialmente cuando son valorados contra el panorama del limitado control del dolor que se observa en muchos pacientes. La operación de Whipple representa todavía la mejor alternativa, pero debe ser utilizada solo mediante una selección crítica tanto del paciente como del cirujano.

En cuanto a las operaciones presentadas en los años 1980's, es todavía muy temprano para predecir su utilidad futura. Creemos, sin embargo, que todavía debemos esperar el advenimiento de la operación que llene los criterios de un procedimiento ideal para el control del dolor en la pancreatitis crónica.

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Authors and Affiliations

  1. Department of Surgery, University Hospital, S-581 85, Linköping, Sweden

    Ingemar Ihse M.D., Ph.D., Kurt Borch M.D., Ph.D. & Jörgen Larsson M.D., Ph.D.

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  1. Ingemar Ihse M.D., Ph.D.
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  2. Kurt Borch M.D., Ph.D.
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  3. Jörgen Larsson M.D., Ph.D.
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Ihse, I., Borch, K. & Larsson, J. Chronic pancreatitis: Results of operations for relief of pain. World J. Surg. 14, 53–58 (1990). https://doi.org/10.1007/BF01670546

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