Surgery for pain in chronic pancreatitis

1. Surgery for pain in chronic pancreatitis Timing and indications Dr Sujoy Pal Dept of GI Surgery, AIIMS

2. Background • Pain is the commonest indication 70-90% • Other established indications: • Complications • Mass/ suspicion of malignancy • Biliary obstruction • Duodenal stenosis • Pseudocysts • Internal pancreatic fistulae • Vascular problems • Controversial: • prevention of exocrine/endocrine deficiency

3. Aims of surgical treatment • Pain relief • Control of complications • Preservation of endocrine and exocrine function • Social and occupational rehabilitation • Improvement of quality of life

4. Indication: Pain • Prime indication in NACP/ACP • Issues related to surgery • Problems: Subjective • Severity grading: often arbitrary • Pains scoring systems • Natural history: • Alc CP : ‘burn-out’ theory • Lack of stringent level I evidence • Timing of surgery Lankisch PG et al, Digestion 1993; Ammann RW et al, Gastroentrology 1984

5. Assessment: Pain severity The need Selection of patients for surgery ‘Objective’ documentation of pain relief Assessment of treatment efficacy Comparison of data The ‘tools’ Pain scoring systems ‘Quality of life’ assessment Function scales Symptom scales Bloechle C et al, Pancreas 1995, Izbicki JR et al, Ann Surg 1998

6. Pain scoring systems • Parameters assessed • Intensity • Visual analog scale • Pain medication • Narcotic addiction • Frequency • Trials: > 1 episode per month • Duration • Most surgical series: > 1 year • Consequences • absence from work • number of hospitalizations Rai RR et al, Gastroenterol Jap 1988; Bloechle C et al, Pancreas 1995

7. Evidence in the literature • Pancreatic ‘burn-out’ syndrome • Study n Follow up Exo-/endocrine Pain relief • (years) insufficiency (%) (%) • Ammann 145 10.4 100/100 83 • Layer 192 14.6 77 • Lankisch 152 > 10 46/78 65 • Drawbacks • Selection bias • Evaluation of patients at a given period during • their natural course • Continued alcoholism: higher incidence of panc insufficiency

8. Literature based evidence for surgery • Large prospective surgical series: 75-90% success in • pain relief and improved QOL • Pain relief with surgery vs medical Rx: 63% vs 43% at 10 y • Pain relief is unpredictable (both ALCP & NACP) • Pancreatic insufficiency & pain relief: • imperfect correlation • Patients with severe pain at onset: • less chance of pain relief • Young patients with NACP: more severe pain • NACP: slower deterioration of pancreatic function Scuoro LA et al, AJG 1983;Bornmann PC et al, World J Surg , 2003

9. The case for surgery…… “ …..seems unreasonable to adopt a conservative approach in the hope that pain relief will be obtained sometime in the future, at which stage the risk of narcotic addiction increases and the results of surgery are invariably poor.” Andrew Warshaw Warshaw AL, Gastroenterology 1984

10. Surgical decision making • Anatomy of the disease • ‘Large duct’ disease • ‘Small duct’ disease • Location of inflammatory mass • Associated complications • Biliary obstruction • Duodenal stenosis • Pseudocysts • GI bleeding/ Left sided portal hypertension • Malignancy • Etiology

11. Timing of surgery • Patients with associated complications: Early surgery • For pain relief: • Early surgery ( < 4years) may delay progress of • Exocrine/ endocrine insufficiency (Alc CP) • Patel AG et al, Ann Surg 1999; Nealon WH et al, Ann Surg 1993 • Early surgery in NACP/ Tropical CP improves • nutritional status, weight gain, decreased insulin • requirement • Tripathy BB et al, 1987 • Contrary evidence • Sikora SS et al, WJS 2002; Greenlee HB et al, WJS 1990 • Controversies: How early & what surgery: drainage • or resection?

12. Timing and need for surgery • Contentious issues • Mild to moderate pain in patients with small • duct disease • Non abstinent alcoholics with continuing behavioral • problems/ addictions

13. Indication: Complications of CP • Biliary obstruction • Incidence: • Admitted patients 6% (3-23) • Radiological screening 33% (21-46) • Operated patients 35% (15-60) • Indication for intervention • Persistent jaundice and/or cholangitis • Biliary cirrhosis • mass lesion • ? Radiological/ biochemical derangement Prinz RA et al, WJS 2003

14. Indication: Complications of CP • Duodenal obstruction/stenosis • Incidence: • Admitted patients 2% (1-13) • Operated patients 12% (2-36) • Indication for treatment • Failure of conservative trial • Mass Lesion • Associated biliary obstruction Vijungco JD, Prinz RA et al, WJS 2003

15. Other complications • Splenic vein thrombosis • Majority asymptomatic • Incidence is variable 4-45% • Prospective study (n=266) 13% • Gastric varices 17% • Variceal h’age 1 patient • Bernades P et al, Dig Dis Sci 1992 • Management • Bleeders: Splenectomy • ? Prophylactic splenectomy • Only 4% of patients with gastric varices bleed • Pseudocysts and ductal disruptions • Retention cysts: require surgical drainage Heider TR et al, Ann Surg 2004

16. Pancreatic mass: Inflammatory or malignant ? • Clinical • Radiological • Helical CT/ MRI • ERCP/MRCP • EUS • Pancreatic duct/ fluid • CA19-9 • p 53 immunohistochemistry • Preoperative /Intraoperative FNAC • Operative evaluation/biopsy In case of doubt: resection is the best option

17. GI Surgery AIIMS data1985-2004 (n=170) Pain as the main indication 90% Pain duration 1-30 years Biliary obstruction alone 10% NACP: 95; Alc CP: 75 Drainage procedures 115 LPJ 62 LPJ + biliary bypass 30 Cystoenterostomies 23 Resections 19 Whipple’s 11 Whipple’s + LPJ 3 Distal pancreatectomy 5

18. Lessons learnt • Pain relief is sustained in NACP (> 85%) • Duration of pain does not necessarily correlate with • surgical outcome • No consistent documentation of recovery of pancreatic • function following ductal drainage • Need for biliary bypass; frequent (~ 50%) • Associated SVT/ PHT makes surgery difficult • Late deaths occur due to malignancy, continued alcoholism

19. Summary and conclusions Pain relief and QOL issues are the main concerns in patients with chronic pancreatitis undergoing treatment Surgery is indicated for relief of intractable pain and associated complications of chronic pancreatitis Failure of non surgical treatment and presence of complications influence the timing and need for surgical intervention Jury is still out: early surgery for mild to moderate pain