Different modalities of treatment of chronic pancreatitis Original Research Article ISSN: 2394-0026 (P) A study of 50 cases in different modalities of treatment of chronic pancreatitis Jayesh Gohil, Pallav Patel 2,Jaydeep Gadhavi 2, Hiren Parmar * A Associate Professor, 2 Assistant Professor General Surgery Department, GMERS Medical College, Gandhinagar, Gujarat, India *Corresponding author email: drhirenparmar@gmail.com How to cite this article: Jayesh Gohil, Pallav Patel, Jaydeep Gadhavi, Hiren Parmar. A study of 50 cases in different modalities of treatment of chronic pancreatitis. IAIM, 205; 2(4): 64-69. Available online at www.iaimjournal.com Received on: 24-03-205 Accepted on: 3-03-205 Abstract Background: Chronic pancreatitis was defined by features consistent with irreversible pancreatic inflammation, i.e., clinical, structural or functional abnormality of the pancreas. The presence of pancreatic calculi or ductal irregularity/parenchymal atrophy was determined at imaging using ultrasonography, CT scan, MRI, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS). Material and methods: The profile of 50 patients with chronic pancreatitis seen in the General Surgery, Gastro surgery Department of Civil Hospital, Ahmedabad, from May 2007 to September 2009 were included. The diagnosis of chronic pancreatitis was based on clinical, biochemical (serum amylase, serum criteria and anti-diabetic treatment requirement) and imaging. Various treatment modalities like conservative, endotherapy and surgical were evaluated. Results: Out of 50 patients, 33 underwent surgery, underwent endotherapy, 6 underwent external drainage via pigtail catheterization and 4 were kept on medical therapy that later on underwent surgery due to partial or no relief of abdominal pain. The indication for surgery was in these 33 patients and the surgical procedures were performed. 5 (0%) patients had postoperative complications; major among these being wound dehiscence (n=2), pancreatic fistula (n=), gastrointestinal bleed (n=) and intra abdominal bleed (n=). There were four postoperative death (3 post whipple s and post triple bypass). Conclusion: Idiopathic pancreatitis is the most common form of chronic pancreatitis seen at our hospital, and in general, the majority of these subjects showed a good responsee to endotherapy and surgery of chronic pancreatitis. Pancreatic endotherapy is effective as short-term intervention, can be used at an early stage and has limited indications. Key words Chronic pancreatitis, Different treatment strategies, Results, Complications. Page 64
Introduction (64%), alcoholic in 7 (34%) and hyperlipidemia in 2%. Pain (n=; 22%), lump (n=9; 38%), weight loss (n=24; 32%), nausea/vomiting (n=5, 30%), gastrointestinal (GI) bleed (n=; 0.5%) were usual symptoms with eighteen (36%) 7 (4%) had clinical Chronic pancreatitis (CP) was defined by features consistent with irreversible pancreatic inflammation, i.e., clinical, structural or functional abnormality of the pancreas []. The presence of pancreatic calculi or ductal irregularity/parenchymal atrophy was determined at imaging using ultrasonography, CT scan [2], MRI, magnetic resonance cholangiopancreatography (MRCP) [3], endoscopic retrograde cholangiopancreatography (ERCP) [4] or endoscopic ultrasound (EUS) [5]. Ultrasound and CT were the usual initial investigations. Other imaging modalities were carried out when indicated. Diabetes mellitus was diagnosed if the fasting plasma glucose value was equal to, or greater than, 26 mg/dl confirmed on two occasions and/or a plasma glucose value equal to, or greater than, 200 mg/dl after a two-hour glucose load confirmed on two occasions, and/or requirements for nsulin or oral hypoglycemic drugs. Alcohol intake was considered significant in chronic pancreatitis patients who had been taking the equivalent of 80 g or more ethanol/day for at least five years. Material and methods The profile of 50 patients with chronic pancreatitis seen in the General Surgery, Gastro surgery Department of Civil Hospital, Ahmedabad, from May 2007 to September 2009 were included. The diagnosis of chronic pancreatitis was based on clinical, biochemical (serum amylase, serum criteria and anti-diabetic treatment requirement) and imaging. Various treatment modalities like conservative, endotherapy and surgical were evaluated. Results The median age of our patients was 42 (0-62) years. There were 38 men and 2 women. The etiology of CP was idiopathic pancreatitis in, 32 patients had diabetes and steatorrhea. Patients were evaluated with X-ray abdomen, ultrasonography (USG), contrast enhanced computed tomography (CECT), ERCP and MRCP depending upon the presentation and associated complications. On evaluation, biliary obstruction was diagnosed in (22%), pseudocyst was present in 23 (46%) and pancreatic cancer in association with CP was diagnosed in (22%) patients with dilated main pancreatic duct (MPD) in 5 (30%) and pancreatic calcifications in 7 (4%). Treatment modalities Out of 50 patients, 33 underwent surgery, underwent endotherapy, 6 underwent external drainage via pigtail catheterization and 4 were kept on medical therapy that later on underwent surgery due to partial or no relief of abdominal pain. Medical therapy 4patients were treated with pancreatic enzyme supplements for abdominal pain and followed for a minimum period of 6 months. None had complete relief of pain, 6 (42.85%) had partial relief and 8 (57.4%) did not respond to therapy. Endotherapy out of 50 patients (22%) underwent endotherapy for relief of abdominal pain. Eight (72.72%) had complete response and 3 (27.27%) had partial response as per Table and Table 2. Surgery 33 out of 50 patients (66%) underwent surgery for abdominal pain. The operated patients were Page 65
followed for to 5 years. About 26 (78.78%) had alcoholic patients. Majority of patients (95.%) complete relief of pain and 7 (2.2%) had had pain [7]; however this could reflect selection partial response. The indicationn for surgery was bias as most patients with persistent pain were in these 33 patients and the surgical procedures referred to our hospital. were performed. 5 (0%) patients had postoperative complications; major among Diabetes mellitus was significantly more these being wound dehiscence (n=2), pancreatic common in calcific pancreatitis group as fistula (n=), GI bleed (n=) and intra abdominal compared to the non-calcificc group [8]. This may bleed (n=). There were four postoperative reflect that calcification develops in late stages death (3 post whipple s and post triple of chronic pancreatitis associated with advanced bypass). On follow up, all patients with jaundice, endocrine deficiency. Patients with alcoholic cholangitis and bleeding had relief of their pancreatitis had significantly shorter duration of symptoms. Patients underwent a prospective symptoms as compared to idiopathic study to assess the effect of ductal pancreatitis. decompression on pancreaticc exocrine and endocrine function. Pancreatic endocrine Surgery was the mainstay of therapy in most function was evaluated by improvement in patients (n=33) [9]. Patients (n=4) were diabetic status. Patients underwent the initiated with medical therapy but due to evaluation preoperatively and on follow up at partial/no response were later on treated with least after six months of surgery. In this study, surgery. Failure of conservative management in there was some improvement in the status of this study may due to presentation of patients in beta cell function (in some patients, dose of advance stages of the disease (huge cyst insulin was reduced or patients on insulin were compressing surrounding structures, pancreatic shifted on oral hypoglycemic drugs) on follow up mass, common bile duct (CBD) strictures due to of 6-2 months. (Table 3, Table 4 and Table pancreatitis, MPD calculi with dilatation) [0]. 5) Endoscopic retrograde pancreatography Discussion followed by pancreatic endotherapy was done in 6 patients. Endotherapy was done via It is often difficult to differentiate recurrent transpapillary route in all these patients with acute pancreatitis from exacerbations of chronic either a pancreatic stent or nasopancreatic pancreatitis. Even today, in certain situations, drain. Extra corporeal shock wave lithotripsy the correct diagnosis can often be achieved only fragmentation of pancreatic duct calculi in on follow up of the patient. In all our patients, conjunction with endoscopic clearance of the the diagnosis of chronic pancreatitis was main pancreatic duct is associated with confirmed by imaging studies. In contrast to maximum pain relief and least complication western countries idiopathic pancreatitis is the []. Pancreatic stone lithotripsy was done in 3 leading etiology (4.8%), followed by alcoholism of our patients. Endoscopic (34.9%) in this study [6]. Alcohol intake is quite cystogastrostomy/cystoduodenostomy was uncommon in females, so all cases of done in 5 patients with complete/partial relief in pancreatitis due to alcohol were seen in men. all patients. Timing of endotherapy is best However 37.2% of idiopathic pancreatitis delayed approximately 4 weeks to allow the occurred in females. Calcification was present in pseudocyst to mature. Earlier intervention may 5.% of the idiopathic group and 38.8% of be necessitated by complications such as Page 66
infection, hemorrhage, enteric or billary has limited indications. The failure of ductal obstruction [2]. decompression to relieve pain in short term is consistent with the multifactorial etiology of Transmural drainage throughh the stomach pain in chronic pancreatitis. Surgical (cystogastrostomy) is preferred for psedocyst in decompression provides immediate pain relief in the body and tail of the pancreas while those in 70-90% of patients. However surgery remains the head are drained into the duodenum the mainstay of treatmentt of majority of our (cystoduodenostomy). An important concern in patients and had shown comparatively better transmural drainage is potential bleeding (n=) results of endotherapy and conservative from blood vessels interposed between the management. pseudocyst and gastroduodenal wall. Endoscopic ultrasound (EUS) or EUS-guided References puncture of the pseudocyst eliminates this risk.. Mayerle J, Hoffmeister A, Werner J, Witt When the cyst contains clear fluid, 0 Fr double H, Lerch MM, Mössner J. Chronic pigtail stent will adequately drain the cyst. In the pancreatitis - Definition, etiology, presence of necrotic debris, placement of a investigation and treatment. Dtsch naso-cystic catheter for irrigation in addition of Arztebl Int, 203; 0: 387-93. the tract using a controlled radial expansion 2. Grözinger G, Grözinger A, Horger M. The (CRE) balloon followed by removal of necrotic role of volume perfusion CT in the material with a dormia basket prevents diagnosis of pathologies of the pancreas. subsequent clogging of the stent. Rofo, 204; 86: 082-93. Transpapillary cyst drainage is cyst-duct communication is complication rates are lower with transpapillary access (6%) than after the transmural approach (39%). Stents may be placed into the pseudocyst; when technically not feasible, the stents should be advanced to the site of ductal commumication as close as possible to the pseudocyst. In the presence of associated ductal disruptions, stents may either bridge the disruptions or be placed into the pseudocyst [4, 5, 6, 7]. Conclusion preferred when evident [3]; Idiopathic pancreatitis is the most common form of chronic pancreatitis seen at our hospital, and in general, the majority of these subjects showed a good response to endotherapy and surgery of chronic pancreatitis. Pancreatic endotherapy is effective as short-term intervention, can be used at an early stage and 3. Liu K, Xie P, Peng W, Zhou Z. Magnetic resonance cholangiopancreatography: Comparison of two- and three- for the dimensional sequences assessment of pancreatic cystic lesions. Oncol Lett, 205; 9: 97-92. 4. Pericleous S, Smith LI, Karim MA, Middleton N, Musbahi A, Ali A. Endoscopic retrograde cholangiopancreatography in Ayrshire, Scotland: A comparison of two age cohorts. Scott Med J, 205. Mar 6. pii: 003693305576695. 5. Rana SS, Vilmann P. Endoscopic ultrasound features of chronic pancreatitis: A pictorial review. Endosc Ultrasound, 205; 4: 0-4. 6. Muniraj T, Aslanian HR, Farrell J, Jamidar PA. Chronic pancreatitis, a comprehensive review and update. Part I: Epidemiology, etiology, risk factors, genetics, pathophysiology, and clinical features. Dis Mon, 204; 60: 530-50. Page 67
7. Olesen SS, Juel J, Nielsen AK, Frøkjær JB, 3. Ergun M, Aouattah T, Gillain C, Gigot JF, Wilder-Smith OH, Drewes AM. Pain Hubert C, Deprez PH. Endoscopic severity reduces life quality in chronic ultrasound-guided transluminal drainage pancreatitis: Implications for design of of pancreatic duct obstruction: Long- future outcome trials. Pancreatology, 20; 43: term outcome. Endoscopy, 204; 4: 497-502. 58-25. 8. Davison LJ. Diabetes mellitus and 4. Matsubayashi H, Kakushima N, Takizawa pancreatitis--cause or effect? J Small K, Tanaka M, Imai K, Hotta K, Ono H. Anim Pract, 205; 56: 50-9. Diagnosis of autoimmune pancreatitis. 9. Niedergethmann M, Nephuth O, World J Gastroenterol, 204; 20: 6559- Hasenberg T. Chronic pancreatitis. 69. Operation indications and procedures. 5. Tandan M, Nageshwar Reddy D. Chirurg., 204; 85(2): 23-3. Endotherapy in chronic pancreatitis. 0. Kwek AB, Ang TL, Maydeo A. Current World J Gastroenterol, 203; 9: 656- status of endotherapy for chronic 64. pancreatitis. Singapore Med J., 204; 6. Muniraj T, Aslanian HR, Farrell J, Jamidar 55(2): 63-20. PA. Chronic pancreatitis, a. Ahmed Ali U, Pahlplatz JM, Nealon WH, comprehensive review and update. Part van Goor H, Gooszen HG, Boermeester II: Diagnosis, complications, and MA. Endoscopic or surgical intervention management. Dis Mon, 205; 6: 5-37. for painful obstructive chronic 7. Ni Q, Yun L, Roy M, Shang D. Advances pancreatitis. Cochrane Database Syst in surgical treatment of chronic Rev, 205; 3: CD007884. pancreatitis. World J Surg Oncol, 205; 2. Bouwense SA, de Vries M, Schreuder LT, 3: 430. Olesen SS, Frøkjær JB, Drewes AM, van Goor H, Wilder-Smith OH. Systematic mechanism-orientated approach to chronic pancreatitis pain. World J Gastroenterol, 205; 2: 47-59. Source of support: Nil Conflict of interest: None declared. Table : Endotherapy. Type Sphincterotomy + stenting ESWL + Stenting 3 Sphincterotomy + Stone removal + Stenting Endoscopic CD/CG 5 No. 2 Percentage Complication 4 6 Acute pancreatitis 2 0 Gastrointestinal bleed Page 68
Different modalities of treatment of chronic pancreatitis Table 2: Results of endotherapy. ISSN: 2394-0026 (P) Results Complete pain relief Partial pain relief Shincterotomy + ESWL + stenting Stenting 2 None 2 Sphinterotomy + Stone Endoscopic CD/CG removal + Stenting 4 Table 3: Complications of surgery. Complication Wound dehiscence Pancreatic fistula G.I. bleed Biliary leakage No. 2 4 2 2 - - Percentagee Table 4: Surgical procedures. Surgery Whipples LPJ (Partington, Rochelle) Frey s Distal Pancreatectomy Triple bypass Cystogastrostomy/Roux-en-y cystojejunostomy Spleenectomy Biliary procedures No. 6 2 9 8 2 2 4 5 0 9 8 2 4 3 6 Percentage Table 5: Results of surgery. Result LPJ Pain relief 9 Morbidity Mortality Endo insufficiency status Whipples Frey s CG/RCJ DP 3 9 2 2 3 TBP 4 Page 69