Treatment of chronic calcific pancreatitis endoscopy versus surgery

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1 Treatment of chronic calcific pancreatitis endoscopy versus surgery 35 - year old ladypresented to LPC Mumbai with intermittent abdominal pain. Pain was intermittent, colicky, more in epigastrium and periumbilical region & radiating to back, mainly postprandial & accompanied by vomiting. She also had intermittent loose motions & significant weight loss. There was no history of anorexia, GI bleed (hematemesis / melena), constipation, yellow discoloration of sclera, dark urine, or pale stool (indicators of jaundice). She had history of tobacco usage. However there was no history of alcohol abuse, surgery and major illness. She did not have history of diabetes, hypertension, TB, heart disease or any other illness in the past. She did not have urinary and gynecological symptoms. She had undergone a pancreatic duct stenting for chronic pancreatitis (CP) 2 years back. Stents were exchanged thrice over a period of 1 year and then finally removed. She had relief from symptoms for few months and then had recurrence of her complaints. She was poorly nourished, pale, anicteric & had mild epigastric tenderness. There was no organomegaly, lump in abdomen, ascites, hernia or findings of portal hypertension. Per rectal examination was also normal. Investigations with the patientshowed anemia but otherwise normal hemogram, renal function & liver function tests. Serum amylase and lipase were mildly elevated suggesting a low-grade pancreatic inflammation. USG of the abdomen showed a significantly dilated pancreatic duct with stones within. Gall bladder & common bile duct (CBD) were normal. Portal vein and splenic vein were patent and there was no evidence of portal hypertension. Rest of the abdomen was normal. Based on this she was diagnosed as chronic calcific pancreatitis (CCP) and was further worked up for etiology and treatment. Her serum calcium & lipid profile was normal. Since calcium was normal, parathyroid hormone levels were not done. Since it was calcific pancreatitis, immune markers were not done. Her CT scan of abdomen & pelvis (oral + iv contrast triple phase pancreas protocol) showed a dilatedpancreatic duct with large stones within it & enlarged head of pancreas with mild inflammation (inflammatory head mass) & large calcific foci within it. There was no evidence of a malignancy in head of pancreas, biliary or duodenal obstruction and portal hypertension. MRCP showed a dilated PD with filling defect (stone) & a stricture in the PD in head of pancreas (prepapillary region)

2 There was no evidence of pancreas divisum or any other congenital anomaly of pancreatobiliary tree, which could have caused chronic pancreatitis. Other findings were consistent with CT scan. Her serum CA19-9 levels were normal indicating that a background malignancy was less likely. Based on these findings diagnosis of CCP with inflammatory head mass without biliary & enteric obstruction or portal hypertension was confirmed. Prior to visit to LPC, Mumbai, she had received pancreatic enzyme supplements & analgesics. She had been through multiple endotherapy sessions and a long endotherapy trial. However she did not have relief. Endoscopyagain was not a good option because she had a tight stricture, multiple large stones in the duct beyond the stricture, significant parenchymal calcification in the head &an inflammatory head mass and previous poor result.the inflammatory head mass is the most important cause of pain and this cannot be tackled by endoscopic treatment. Additionally cost of endotherapy sessions is significant.in view of this, she was suggested a surgery. She was operated and a Frey procedure was performed. Frey procedure involves coring out central calcification bearing parenchyma of pancreatic head. This opens up the strictured section of pancreatic duct& tributaries in the head of pancreas. Along with this pancreatic duct is widely opened longitudinally along its length in the neck and body of pancreas. A Roux loop of small intestine is prepared and anastomosed to the pancreatic duct including the cored out head area. Frey procedure - stone being removed from pancreatic duct Frey procedure - widely opened pancreatic duct and cored out head Frey procedure - pancreatojejunostomy completed This allows the pancreatic duct to drain pancreatic juice freely into the small intestine. Coring of pancreatic head opens the blocked ducts allowing the inflammation to settle down. This and opening the duct also relieves ductal hypertension. These measures provide long-term pain relief. She recovered well after surgery and was discharged on 9 th postoperative day. She had excellent pain relief. She is under regular follow up after the surgery every 3 months to diagnose if pain recurs and if a malignancy develops in the remnant pancreatic parenchyma. She was put on pancreatic enzyme supplements after the surgery. POINTS TO REMEMBER IN TREATMENT OF CCP Identify cause of CCP whenever possible. Various etiology of CP include alcohol abuse, hypercalcemia, hyperlipidemia, tropical pancreatitis, autoimmune pancreatitis, congenital anomalies of pancreatobiliary tree (choledocal cyst, abnormal pancreatobiliary duct

3 junction, pancreas divisum, annular pancreas), obstructive pancreatitis (tumor, stricture due to old pancreatic trauma / previous surgery / intervention / heterotopic pancreas CDHP, wirsungocele, santorinicele), recurrent acute pancreatitissphincter of Oddi Dysfunction, CP due to alcohol, tropical pancreatitis, hypercalcemia, PD obstruction &RAP have associated calcifications/stones. Calcification is usually not seen with autoimmune pancreatitis. Also pancreatic duct is usually not dilated in autoimmune pancreatitis. The work up of a patient with CP is directed towards identifying the etiology &complications of CP and planning the therapy. This includes Blood tests LFT, calcium, parathormone, lipid profile, CA19-9, ANA, IgG4, Imaging work-up --- CT scan, MRCP /MRI, PET Endoscopy OGD scopy, endoscopic ultrasound (EUS), ERCP (endoscopic retrograde cholangio-pancreatography) CT scan & MRCP give morphological information to diagnose & plan treatment. EUS is useful to diagnose early CP and to take biopsy in case of a doubt of coexisting pancreatic cancer. Role of ERCP is purely therapeutic and rarely diagnostic. PET-CT scan is occasionally used to differentiate inflammation (CP) from cancer. Upper GI scopy is done to rule out esophageal varices& portal hypertension. If patient with CP has a suspicious pancreatic mass on imaging with / without obstructive jaundice & raised CA19-9, obtain EUS guided biopsy of the mass. The findings can completely change the nature of treatment An early malignancy may co-exist with CP without mass, jaundice or elevation in CA19-9. Jaundice, sudden weight loss and recent onset back pain in a case of CCP should raise suspicion of pancreatic cancer. Patient with CCP may have associated complications like pancreatic pseudocyst, pancreatopleural fistula, pancreatic ascites, portal hypertension, duodenal stenosis, bile duct stenosis, pseudo-aneurism of peripancreatic vessels (splenic artery, gastroduodenal artery etcetera), pancreatic cancer. These impact the decision making for treatment. Treatment of CCP depends on multiple factors like presence of symptoms, morphological changes in the pancreas, associated complications, underlying etiology etc. Incidentally detected CCP in an otherwise asymptomatic patient does not require invasive treatment. Pancreatic enzyme supplements are added. However even asymptomatic patients requireregular OPD follow since there is risk of cancer. The treatment optionsin symptomatic patients are conservative treatment, endotherapy, lithotripsy (ESWL) and surgery. Conservative treatment includes analgesics, pancreatic enzyme supplements, dietary adjustment (low fat diet), celiac ganglion block& vitamin supplements. This is part of treatment in all symptomatic patients. Conservative treatment alone is used for early CP patients. These patients have minimal parenchymal & duct changes and have minimal parenchymal calcification. They may or may not have intraductal stones. Head of pancreas may be normal or bulky. (No inflammatory head mass). Celiac ganglion block is given by endoscopic route or percutaneous route. Pancreatic endotherapy for CP includes dilatation of stricture, stenting the pancreatic duct, stone extraction, drainage of pseudocyst etc. One or more stents or nasopancreatic catheters may be used. Treatment is divided into multiple sessions and may require long time.

4 ESWL (lithotripsy)alone is not useful in pancreatic stones since invariably there is a proximal stricture. This is in contrast to the renal stones where ESWL alone may suffice in small stones. It is performed prior to endotherapy to break the stones into small size, thus facilitating stone extraction. Endotherapy is ideal for patients with solitary stricture, few & small intraductal stones or communicating pseudocyst. However it is not a good treatment option for multiple tight strictures, multiple stones, large stones, parenchymal calcifications, large stone load in the head or tail, inflammatory head mass, non-communicating pseudocyst orportal hypertension.surgery is the right option for such patients. When used in unfavorablesituations,endotherapy goes on for long time, over multiple sessions, incurs high cost and has high treatment failure rates. This was seen in our patient who was advised elsewhere endotherapy, which failed even after repeated and prolonged sessions and significant expense.endotherapy failed patient requires a surgeryto solve the problem of recurrent pain. Surgery for CCP is planned depending on whether the stone load is in the head or body-tail of pancreas,whether there are associated complications like pancreatic pseudo cyst/s, pancreatic fistula, presence of inflammatory head mass / biliary stenosis / duodenal stenosis / portal hypertension / suspicious or confirmed malignancy / presence of pseudoaneurism. Various surgeries used for CP are 1. Pancreatoduodenectomy (PD / Whiple s procedure) In this pancreatic head, duodenum & bile duct are excised and reconstruction is done. 2. Duodenum preserving pancreatic head resection (Beger procedure) Here only the head of pancreas is removed. Remaining pancreas is joined to a loop of jejunum. 3. Head coring and lateral pancreatojejunostomy (Frey procedure) Here central portion of head of pancreas is cored out, duct is opened in the body and tail and a loop of jejunum is attached along the full length. 4. Lateral pancreatojejunostomy (LPJ / Puestow procedure) Duct is opened in the body and tail and a loop of jejunum is attached along the length. 5. Distal pancreatectomy & splenectomy (DP +/- S) Portion of pancreas beyond its neck in removed with or without spleen. 1 st three are applied when there is an inflammatory head mass with large stone load in the head of pancreas and dilated duct in the neck, body and tail of pancreas. The results (pain relief) of all 3 procedures are comparable. However morbidity of a PD is more than the other 2 procedures. Also Beger & Frey procedure preserve pancreatic parenchyma thereby reducing the chances /worsening of diabetes & pancreatic exocrine insufficiency. We prefer Frey procedure. Our patient underwent Frey procedure and had excellent long-term pain relief. When there is synchronous malignancy in the head of pancreas or suspicion of it, PD is the procedure of choice. LPJ is the procedure of choice when there is no inflammatory head mass or stone load in the head; but there is a solitary tight stricture in the head / neck with a dilated duct beyond. DP+/- S is treatment of choice for distal body-tail disease, pseudocyst in the tail /splenic hilum, internal PF (pleural/ascites) arising from a duct leak in distal pancreas & left sided portal hypertension.

5 Any of the above operations may be done as a primary treatment modality or following failure of pancreatic endotherapy. Occasionally interventional radiology services are required when faced with a problem like pseudoaneurism of one of the peripancreatic vessels. Common one to get involved is splenic artery and gastroduodenal artery. This is treated by percutaneous coil embolization of the pseudoaneurism or the feeding vessel. In short, chronic pancreatitis treatment demands involvement of multidisciplinary specialists like gastroenterologist, endoscopist, pancreatic surgeon & interventional radiologist. Choosing the right treatment modality is very importantfor long-term symptom control. Referral to a specialist pancreatic unit improves the outcome. Disclaimer: The views expressed in this article solely belong to the author. The information provided here is for Educational and informational purposes only. This newsletter is for private circulation only.