Surgical management of chronic pancreatitis

The management of chronic pancreatitis continues to achieve only limited success. A lack of understanding of the basic pathogenic mechanism of this disease limits our therapy to treatment of symptoms, sequelae, and complications. The diagnosis of chronic pancreatitis usually is based on a history of classic pain plus some objective findings of pancreatic disease. Imaging techniques, such as ultrasonography or CT, are helpful in defining the size of the gland and the presence of masses and collections of fluid. Endoscopic pancreatography, however, remains the most helpful tool for diagnosis. The information that it provides about the pancreatic ductal system can help in selecting a procedure that achieves the best result with the lowest morbidity and mortality. The principle to follow in the surgical management of this condition is to tailor the procedure in each patient to preoperative clinical information, information provided by pancreatography, operative findings, exocrine and endocrine status of the patient, presence or absence of drug addiction and alcoholism, and the personality of the patient as well as his or her ability to manage the possible metabolic complications of surgery. Although management of pain is the main goal, the morbidity and late mortality that can result from different procedures must be a major consideration in selecting therapy. Pancreaticojejunostomy is the procedure of choice at this time for patients with a dilated pancreatic duct sphincterotomy or sphincteroplasty for the occasional patient with proved ampullary obstruction of the pancreatic duct, and internal drainage for pseudocyst. Different degrees of pancreatic resection are indicated for patients with severe disease and small pancreatic ducts, in patients in whom decompressive operations have failed, in patients with lateralized disease to the head or tail of the gland, in some instances of pseudocyst or pancreatic fistulas, and for some patients when cancer cannot be ruled out. Attempts are being made to improve the limited results of our current therapy. Endoscopic occlusion of the pancreatic duct, pancreatic segmental autotransplantation, islet cell autoimplantation, use of the pyloric-preserving operation, and use of continuous subcutaneous insulin infusion are being tried. Further experience with these techniques is required to determine their value in the management of patients with chronic pancreatitis.