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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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Shanbhogue KP, Pourvaziri A, Jeyaraj SK, Kambadakone A. Endoscopic and surgical treatment options for chronic pancreatitis: an imaging perspective. Abdom Radiol (NY) 2020; 45:1397-1409. [PMID: 31707437 DOI: 10.1007/s00261-019-02249-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic pancreatitis is a chronic fibro-inflammatory syndrome characterized by chronic pancreatic inflammation leading to fibrosis and scarring. Patients with this multifactorial debilitating illness often require endoscopic or surgical intervention for treatment. Radiologists play a crucial role in pre-therapeutic workup as well as post-treatment imaging of chronic pancreatitis. This review summarizes the most common surgical and endoscopic treatment options that are currently available for chronic pancreatitis, including the implications on imaging.
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Abstract
Chronic pancreatitis is a syndrome involving inflammation, fibrosis, and loss of acinar and islet cells which can manifest in unrelenting abdominal pain, malnutrition, and exocrine and endocrine insufficiency. The Toxic-Metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and Severe Acute Pancreatitis, Obstructive (TIGAR-O) classification system categorizes known causes and factors that contribute to chronic pancreatitis. Although determining disease etiology provides a framework for focused and specific treatments, chronic pancreatitis remains a challenging condition to treat owing to the often refractory, centrally mediated pain and the lack of consensus regarding when endoscopic therapy and surgery are indicated. Further complications incurred include both exocrine and endocrine pancreatic insufficiency, pseudocyst formation, bile duct obstruction, and pancreatic cancer. Medical treatment of chronic pancreatitis involves controlling pain, addressing malnutrition via the treatment of vitamin and mineral deficiencies and recognizing the risk of osteoporosis, and administering appropriate pancreatic enzyme supplementation and diabetic agents. Cornerstones in treatment include the recognition of pancreatic exocrine insufficiency and administration of pancreatic enzyme replacement therapy, support to cease smoking and alcohol consumption, consultation with a dietitian, and a systematic follow-up to assure optimal treatment effect.
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Affiliation(s)
- Angela Pham
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
| | - Christopher Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, USA
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Tillou JD, Tatum JA, Jolissaint JS, Strand DS, Wang AY, Zaydfudim V, Adams RB, Brayman KL. Operative management of chronic pancreatitis: A review. Am J Surg 2017; 214:347-357. [PMID: 28325588 DOI: 10.1016/j.amjsurg.2017.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/26/2016] [Accepted: 03/08/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach. RESULTS There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients. DISCUSSION Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.
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Affiliation(s)
- John D Tillou
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jacob A Tatum
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Joshua S Jolissaint
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Victor Zaydfudim
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth L Brayman
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA.
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Hafezi-Nejad N, Singh VK, Johnson SI, Makary MA, Hirose K, Fishman EK, Zaheer A. Surgical approaches to chronic pancreatitis: indications and imaging findings. Abdom Radiol (NY) 2016; 41:1980-96. [PMID: 27207476 DOI: 10.1007/s00261-016-0775-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic pancreatitis (CP) is an irreversible, inflammatory process characterized by progressive fibrosis of the pancreas that can result in abdominal pain, exocrine insufficiency, and diabetes. Inadequate pain relief using medical and/or endoscopic therapies is an indication for surgery. The surgical management of CP is centered around three main operations including pancreaticoduodenectomy (PD), duodenum-preserving pancreatic head resection (DPPHR) and drainage procedures, and total pancreatectomy with islet autotransplantation (TPIAT). PD is the method of choice when there is a high suspicion for malignancy. Combined drainage and resection procedures are associated with pain relief, higher quality of life, and superior short-term and long-term survival in comparison with the PD. TPIAT is a reemerging treatment that may be promising in subjects with intractable pain and impaired quality of life. Imaging examinations have an extensive role in pre-operative and post-operative evaluation of CP patients. Pre-operative advanced imaging examinations including CT and MRI can detect hallmarks of CP such as calcifications, pancreatic duct dilatation, chronic pseudocysts, focal pancreatic enlargement, and biliary ductal dilatation. Post-operative findings may include periportal hepatic edema, pneumobilia, perivascular cuffing and mild pancreatic duct dilation. Imaging can also be useful in the detection of post-operative complications including obstructions, anastomotic leaks, and vascular lesions. Imaging helps identify unique post-operative findings associated with TPIAT and may aid in predicting viability and function of the transplanted islet cells. In this review, we explore surgical indications as well as pre-operative and post-operative imaging findings associated with surgical options that are typically performed for CP patients.
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Bachmann J, Büchler MW, Friess H, Martignoni ME. Cachexia in patients with chronic pancreatitis and pancreatic cancer: impact on survival and outcome. Nutr Cancer 2014; 65:827-33. [PMID: 23909726 DOI: 10.1080/01635581.2013.804580] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chronic pancreatitis (CP) and pancreatic adenocarcinoma (PDAC) are the most common diseases of the pancreas. Cachexia-weight loss exceeding 10% of stable body weight-is present in up to 80% of patients with PDAC. Because the mechanisms of cachexia are not well known, this provides a possibility to compare clinical courses of benign and malignant cachexia. In this study, 382 patients-242 with a PDAC stage UICC II/ 140 with CP-were documented regarding the prevalence of cachexia and its influence on perioperative morbidity and mortality with a special interest to postoperative weight gain and survival. Cachexia was present in 41.4% of CP and 31% of cancer patients. We could demonstrate more pronounced systemic effects of cachexia in patients with PDAC. Weight loss was faster in PDAC patients, the amount of weight loss did not differ significantly between the groups. Cachexia had a significant impact on survival and the postoperative course in patients with PDAC and tumor resection. The development of cachexia is faster in patients with a malignant disease and the systemic effects are more pronounced. Therefore, tumor cachexia should be considered as a different entity than cachexia in benign diseases.
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Affiliation(s)
- Jeannine Bachmann
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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Brook OR, Abedin S, Mortele KJ. Magnetic resonance imaging of the postoperative pancreas. Semin Ultrasound CT MR 2013; 34:325-35. [PMID: 23895905 DOI: 10.1053/j.sult.2013.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography provides the comprehensive evaluation of patients following pancreatic surgery regarding parenchymal pancreatic changes, ductal abnormalities, evaluation of anastomoses, and detection of tumor recurrence. Normal and pathologic MRI presentations in patients who underwent pancreatic surgery are reviewed. The MRI/magnetic resonance cholangiopancreatography techniques used in the patients after pancreatic surgery are presented, and a concise review of the current array of pancreatic surgical procedures is provided.
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Affiliation(s)
- Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Yamauchi FI, Ortega CD, Blasbalg R, Rocha MS, Jukemura J, Cerri GG. Multidetector CT evaluation of the postoperative pancreas. Radiographics 2012; 32:743-64. [PMID: 22582357 DOI: 10.1148/rg.323105121] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Several pancreatic diseases may require surgical treatment, with most of these procedures classified as resection or drainage. Resection procedures, which are usually performed to remove pancreatic tumors, include pancreatoduodenectomy, central pancreatectomy, distal pancreatectomy, and total pancreatectomy. Drainage procedures are usually performed to treat chronic pancreatitis after the failure of medical therapy and include the Puestow and Frey procedures. The type of surgery depends not only on the patient's symptoms and the location of the disease, but also on the expertise of the surgeon. Radiologists should become familiar with these surgical procedures to better understand postoperative changes in anatomic findings. Multidetector computed tomography is the modality of choice for identifying normal findings after surgery, postoperative complications, and tumor recurrence in patients who have undergone pancreatic surgery.
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Affiliation(s)
- Fernando I Yamauchi
- Department of Radiology, Hospital das Clínicas, School of Medicine, University of São Paulo, Av Dr Enéas de Carvalho Aguiar 255, 3rd Floor, Cerqueira Cesar, São Paulo, SP, Brazil 05403-001
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Itoi T, Kurihara T, Sofuni A, Itokawa F, Tsuchiya T, Ishii K, Tsuji S, Ikeuchi N, Umeda J, Moriyasu F, Sakai Y. Endoscopic pancreatic sphincterotomy plus large-balloon dilation for removal of a large impacted pancreatic duct stone (with video). Dig Endosc 2010; 22:345-7. [PMID: 21175494 DOI: 10.1111/j.1443-1661.2010.01029.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pancreatic duct stones are a common complication of chronic pancreatitis. We describe successful endoscopic removal of a large pancreatic duct stone using large-balloon dilation in combination with pancreatic sphincterotomy. A 63-year-old woman was admitted for endoscopic treatment of acute on chronic pancreatitis with diabetes and epigastric pain with liver dysfunction due to a large impacted stone within the distal main pancreatic duct. Endoscopic pancreatic sphincterotomy was carried out using a wire-guided pull-type sphincterotome. Although we could carry out a relatively large incision, the stone could not be extracted. We therefore carried out papillary dilation using a large balloon (diameter 12 to 15 mm) to make room alongside the stone. A 10 × 20-mm white pancreatic duct stone was extracted during the process of pulling a dilating balloon into the working channel of the endoscope. Eventually, the second stone was removed without any procedure-related complication.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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Büchler MW, Martignoni ME, Friess H, Malfertheiner P. A proposal for a new clinical classification of chronic pancreatitis. BMC Gastroenterol 2009; 9:93. [PMID: 20003450 PMCID: PMC2804657 DOI: 10.1186/1471-230x-9-93] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 12/14/2009] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The clinical course of chronic pancreatitis is still unpredictable, which relates to the lack of the availability of a clinical classification. Therefore, patient populations cannot be compared, the course and the outcome of the disease remain undetermined in the individual patient, and treatment is not standardized. AIM To establish a clinical classification for chronic pancreatitis which is user friendly, transparent, relevant, prognosis- as well as treatment-related and offers a frame for future disease evaluation. METHODS Diagnostic requirements will include one clinical criterion, in combination with well defined imaging or functional abnormalities. RESULTS A classification system consisting of three stages (A, B and C) is presented, which fulfils the above-mentioned criteria. Clinical criteria are: pain, recurrent attacks of pancreatitis, complications of chronic pancreatitis (e.g. bile duct stenosis), steatorrhea, and diabetes mellitus. Imaging criteria consist of ductal or parenchymal changes observed by ultrasonography, ERCP, CT, MRI, and/or endosonography. CONCLUSION A new classification of chronic pancreatitis, based on combination of clinical signs, morphology and function, is presented. It is easy to handle and an instrument to study and to compare the natural course, the prognosis and treatment of patients with chronic pancreatitis.
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Affiliation(s)
- Markus W Büchler
- Department of General Surgery, University of Heidelberg, Germany
| | | | - Helmut Friess
- Department of Surgery, Technical University Munich, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
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Kiewiet JJS, Moret M, Blok WL, Gerhards MF, de Wit LT. Two Patients with Chronic Pancreatitis Complicated by a Pancreaticopleural Fistula. Case Rep Gastroenterol 2009; 3:36-42. [PMID: 20651963 PMCID: PMC2895174 DOI: 10.1159/000210442] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Two patients presented with dyspnea and signs of chronic pancreatitis. Patient B had pleural effusion on chest X-ray. Patient A developed pleural effusion during the course of disease. On further analysis these pleural effusions showed elevated amylase concentrations. This finding suggested the diagnosis of a pancreaticopleural fistula which was confirmed by magnetic resonance cholangiopancreatography. Because of the distinct localization of the fistulas the patients were treated differently. In patient A an endoprosthesis was successfully placed in the pancreatic duct, and patient B underwent distal pancreatic resection. Considering the rarity of pancreaticopleural fistula, there is no consensus on diverse aspects of treatment, such as length of treatment with octreotide. However, a rationale for the distinction between fistulas suited for treatment with endoprosthesis or surgery seems to provide some grip.
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Affiliation(s)
- Jordy J S Kiewiet
- Departments of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Yang XJ, Lin Y, Zeng X, Shi J, Chen YX, Shen JW, Xie WF. A minimally invasive alternative for managing large pancreatic duct stones using a modified expandable metal mesh stent. Pancreatology 2008; 9:111-5. [PMID: 19077461 DOI: 10.1159/000178881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 03/21/2008] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Endoscopic clearance of large or impacted stones in the main pancreatic duct (MPD) remains a clinical challenge. In this study, we attempted to technically modify the metallic stent to facilitate the clearance of large pancreatic stones in 4 patients, hoping to lower the operative risks and shorten hospital stay. PATIENTS AND METHODS Four patients with chronic pancreatitis and large stones in the MPD received endoscopic treatment. Inclusion criteria were: (1) pancreatic intraductal stones (number >3; diameter >or=10 mm) and strictures identified in the distal MPD; (2) calculi mainly located in the head, neck and/or body of the pancreas, and (3) failed clearance of stones using a balloon catheter or Dormia basket. Before clearing the pancreatic calculi completely, a technically modified uncovered self-expandable metallic pancreatic stent was implanted in the MPD for 4-7 days to dilate the ductal stenosis, and then drawn out through the working channel. RESULTS As the MPD had been sufficiently expanded by the stent, the calculi were removed completely and uneventfully by the balloon or Dormia basket in all 4 patients, without inducing major postoperative complications. A 9- to 15-month follow-up did not find major complications or recurrence of large calculi in the MPD. CONCLUSIONS Technically modified metallic stenting is a minimally invasive and clinically feasible alternative to extracorporeal shock wave lithotripsy in the management of large pancreatic duct stones.
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Affiliation(s)
- Xiu-Jiang Yang
- Department of Gastroenterology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
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Abstract
A prior study of pancreatic duct-arteriovenous relationships suggested that finding ducts near muscularized blood vessels without intervening pancreatic acini indicated adenocarcinoma was present. Because focal changes of chronic pancreatitis are often seen at autopsy, it seemed reasonable to use the autopsy to test the hypothesis that this finding might be nonspecific. An unselected, consecutive series of 81 adult decedent pancreases without known pancreas cancer was evaluated for the presence of ducts near muscularized blood vessels, for fibrosis and/or atrophy, for chronic inflammation, and for duct reduplication and/or proliferation. Autolysis precluded assessment of 26% of the cases. Of evaluable cases, 37% displayed ducts near muscularized blood vessels without intervening pancreatic acini, 23% chronic inflammation, 62% fibrosis and/or atrophy, and 55% duct reduplication and/or proliferation. The finding of ducts near muscularized blood vessels was closely associated with fibrosis and/or atrophy (odds ratio = 28.87, chi = 14.59, P = 0.0001), with duct reduplication and/or proliferation (odds ratio = 19.23, chi = 15.88, P = 0.0001), but not with chronic inflammation (odds ratio = 1.41, chi = 0.05, P > 0.30). Because changes of chronic pancreatitis are associated with ducts near muscularized blood vessels and because chronic pancreatitis can mimic pancreas cancer, care should be exercised when using the finding of ducts near muscularized blood vessels without intervening pancreatic acini as a criterion for the diagnosis of pancreas cancer.
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Affiliation(s)
- Mitchell S Wachtel
- Department of Pathology, Texas Tech University School of Medicine, Lubbock, TX, USA.
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