Symptoms and Diagnosis
Pain is the major disabling symptom in patients with chronic pancreatitis, often leading to associated weight loss and/or narcotic dependency. Diabetes, jaundice, and problems with digestion are also frequently seen.
Computed tomography (CT) scan, ultrasonography, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) usually makes the diagnosis of chronic pancreatitis and its complications. Typical findings can include a dilated pancreatic duct or strictures with dilatations of the duct ("chain of lakes"), pancreatic calcification, or pseudocyst. Biliary or duodenal obstruction and evidence of portal hypertension may also be present. It is difficult to distinguish between chronic pancreatitis and pancreatic cancer, especially in patients without pancreatic calcification. Marked elevation of serum CA 19-9 in a patient without jaundice is highly suggestive of pancreatic cancer.
By clearly defining pancreatic and biliary ductal anatomy, ERCP and MRCP can help to select patients who might benefit from surgery and to plan the most appropriate operation. In patients with atypical gastrointestinal bleeding and pancreatitis, angiography of the celiac and superior mesenteric arteries can detect and embolize a pseudoaneurysm. It is also important to establish a baseline of pancreatic exocrine and endocrine function, nutritional status, pain severity, use of pain medication or narcotics, employment status, and quality of life. Continued ingestion of alcohol or narcotics should be addressed in either a medical or surgical management plan.
Treatment
Patients with disabling abdominal pain, evidence of chronic pancreatitis, and pancreatic ductal dilatation are best managed by pseudocyst decompression or ductal decompression (Puestow pancreaticojejunostomy procedure), while patients without ductal dilatation are best treated with resection. Biliary-enteric decompression may also be required in patients with chronic pancreatitis and bile duct obstruction. Although preservation of pancreatic tissue is desired to maintain both exocrine and endocrine function, partial pancreatic resection (such as distal pancreatectomy, pancreaticoduodenectomy, or duodenal preserving pancreatic head resection/decompression [i.e. Beger or Frey procedures]) is at times the preferred treatment. While alternative procedures such as endoscopic sphincterotomy, short-term stent placement in the major pancreatic duct, or pancreatic pseudocyst may provide short-term relief of symptoms, long-term results are as yet unknown.
Qualifications for Performing Day Surgery
At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for pancreatitis. These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the pancreas. Pancreatic surgery should preferably be performed by surgeons with special knowledge, training, and experience in the management of pancreatic disease. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery of the pancreas is important to assess. The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes.
