Figure 54-2. Contrasted CT scan in venous phase, coronal images showing (A), dilated main pancreatic duct with intraductal

stones and (B), significant fibrotic disease burden in the head of the pancreas with intraparenchymal and intraductal calcifications.

RADIOGRAPHIC EVALUATION

Radiography is useful in both diagnosis and treatment planning in CP. The most relevant imaging

modalities include contrast-enhanced computed tomography (CT), secretin-stimulated magnetic

resonance imaging with cholangiopancreatography (MRCP), endoscopic retrograde

cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS).

Abdominal CT can show pancreatic parenchymal changes including edema, fibrosis, or atrophy.

Pancreatic ductal dilation may be evident, as well as intraparenchymal and intraductal calcifications

(Fig. 54-2). CT can also be helpful in recognizing intra-abdominal complications of pancreatitis such as

biliary or duodenal obstruction, pancreatic pseudocysts or ascites, or thrombosis or pseudoaneurysms of

the mesenteric vasculature. Similarly, MRCP can be very useful in showing parenchymal changes in

enhancement and secretion (T1-weighted images) and ductal anatomy (T2-weighted images),

particularly with the addition of secretin stimulation (Fig. 54-3). With the increased capabilities of MR

technology over the past couple of decades, MR imaging has largely replaced ERCP for diagnostic

imaging in CP. ERCP is the classic imaging modality for CP. The ERCP Cambridge classification system,

derived from an international consensus, remains the gold standard of CP staging (Table 54-2).26 In the

modern era, ERCP is primarily utilized as a therapeutic modality. EUS is useful for evaluation of

pancreatic parenchyma and ductal anatomy, while being less invasive than ERCP. EUS also has a

grading system to objectify and document pancreatitis disease severity, although the modality still

maintains interobserver variability (Table 54-3). With the addition of fine needle aspiration, EUS can be

helpful in the differentiation of pancreatic neoplasms from CP.27

Figure 54-3. T2-weighted magnetic resonance imaging with secretin stimulation demonstrate a pathologically dilated pancreatic

duct in the body of the pancreas (A), and cystic changes and dilated ducts in a fibrotic and inflammatory head of the pancreas (B).

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Table 54-2 Cambridge Classification System for Chronic Pancreatitis by ERCP

Imaging

CONSIDERATIONS IN MANAGEMENT

3 Frontline management of CP includes risk factor modification, such as alcohol and tobacco cessation.

Primary medical interventions entail pain management, including adjunctive behavioral therapy, and

nutritional optimization, including pancreatic enzyme replacement.

Pancreatic enzymes are the mainstay of medical management of CP despite controversy about their

efficacy. Enzyme replacement is presumed to improve pain by feedback inhibition of cholecystokinin

(CCK) release from the duodenum, leading to decreased pancreatic exocrine secretions. A meta-analysis

of six randomized, placebo-controlled trials did not reveal a significant benefit for supplemental

pancreatic enzyme therapy for pain relief.28 Antioxidant therapy has been proposed as a treatment for

CP, based on the theory that antioxidants will reduce oxygen free radicals and ameliorate oxidative

stress and pancreatic acinar cell injury. Prospective randomized trials have shown conflicting results in

antioxidant therapy for CP.29

Table 54-3 EUS Criteria for Chronic Pancreatitis

Because CP pain is associated with extrapancreatic neuronal remodeling, neuromodulation with

anticonvulsant or antidepressant medications similar to gabapentin have been utilized for CP pain

management with limited success in patients with ongoing pancreatic inflammation.

Avoidance of narcotic analgesia in the management of CP pain is uniformly recommended. Analgesic

management with nonsteroidal anti-inflammatory medication, acetaminophen, and tramadol is typically

recommended. However, because the severity of pancreatic pain is so incapacitating, most patients who

are evaluated for endoscopic or surgical management have been treated with narcotic analgesics and

have developed physiologic narcotic dependence.

Behavioral therapy is a keystone of therapy in CP, particularly since many patients who are

debilitated by CP are young and have previously been in good health. Behavioral modification is

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effective in modulating pain perceptions in many chronic disorders. In addition, behavioral therapy is

important in patients at risk for opioid misuse.30

Patients who have failed medical management, have continued debilitating pain or nutritional failure,

and are physiologically fit are candidates for therapeutic interventions.

ENDOSCOPIC MANAGEMENT

ERCP is the primary endoscopic modality for therapy in CP. The principle goal with ERCP is to relieve

any obstructive process. Potential maneuvers include sphincterotomy, stone extraction, stricture

dilation, and stenting.

EUS can be utilized for endoscopic pseudocyst drainage procedures and for celiac plexus neurolysis.

Percutaneous and endoscopic-guided celiac nerve blockade has been utilized to manage CP pain. Metaanalysis studies of EUS-guided celiac plexus blockade found short-term pain relief in about one-half of

the subjects.31

In general, the endoscopic approach is undertaken prior to consideration of surgery, given the

perceived advantages of lower morbidity with a less invasive approach. Two prospective, randomized,

controlled trials have compared endoscopy and surgery in patients with obstructive CP. Dite and

colleagues randomized 72 patients with CP, pancreatic duct obstruction and pain to endoscopic or

surgical intervention. Endoscopic therapy consisted of ERCP with 52% undergoing sphincterotomy and

stenting and 23% stone removal. Operative management was 20% drainage procedure and 80%

resection. At 5-year follow-up, the surgical group had a greater proportion of patients that were pain

free (34% vs. 15%).32 In another study Cahen and colleagues from randomized 39 patients with dilated

duct CP and pain to endoscopic or surgical management. Endoscopic treatment was ERCP with

sphincterotomy and stenting, and operative therapy was a drainage procedure (longitudinal

pancreaticojejunostomy). At 5-year follow-up, the surgical group had a greater proportion of patients

that had pain relief (80% vs. 38%, p = 0.001), had larger improvements in quality of life, and

underwent fewer procedures, despite equivalent morbidity, length of stay, and preserved pancreatic

function.33,34

SURGICAL MANAGEMENT

4 Approximately two-thirds of patients with debilitating pain from CP fail medical and endoscopic

managements and are candidates for consideration for operative therapy. The primary indication for

surgical intervention in CP is intractable pain, and the goals of surgery are to effectively relieve pain

while minimizing morbidity, including minimizing perioperative complications and preserving

pancreatic parenchyma. As the underlying cause of CP pain is not well understood, operative decisionmaking can be difficult. The pancreatic anatomy is the primary determinant in surgical planning.

Patients with a dilated (greater than 6 to 7 mm diameter) main pancreatic duct are assumed to have

obstructive pathology and are candidates for a drainage-type procedure (lateral pancreaticojejunostomy,

Frey procedure). In patients with a small-diameter main pancreatic duct, resection of fibrotic and poorly

drained parenchyma is undertaken. Patients with head-predominant or tail-centered disease can undergo

a directed partial resection. In patients with diffuse parenchymal involvement a TP with islet

autotransplantation may be considered (Algorithm 54-1).

Parenchymal fibrosis associated with CP may involve adjacent organs and lead to complications

requiring operative management. Other indications for surgical management of CP include terminal

biliary stenosis, duodenal stenosis, gastric variceal hemorrhage due to splenic vein thrombosis, stenosis

of the transverse colon, and symptomatic pancreatic pseudocysts. These complications are managed by a

variety of bypass or resection procedures depending on the underlying pancreatic ductal disorder.

Uncomplicated biliary stenosis is managed with biliary bypass with choledochoduodenostomy or Rouxen-Y hepaticojejunostomy.35 When associated with an inflammatory mass in the head of the pancreas,

pancreatic head resection may be indicated. When biliary stenosis is associated with CP and a

pseudocyst in the region of the pancreatic head, pseudocyst drainage should be undertaken prior to

performing biliary bypass as this may lead to resolution of the obstruction. Duodenal stenosis is usually

associated with biliary stenosis and an inflammatory pancreatic head mass and is best managed with

resection of the head of the pancreas.36 When patient factors make resection unsafe, a double bypass is

undertaken with gastrojejunostomy and biliary bypass. Gastric varices due to splenic vein occlusion are

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not an indication for operation unless associated with hemorrhage. When indicated for gastric variceal

bleeding complications, splenectomy is indicated. Preoperative splenic artery embolization or balloon

occlusion may diminish intraoperative blood loss when splenomegaly and fibrosis in the region of the

pancreatic tail make operative control of the splenic artery problematic.37 Fibrosing stenosis of the

transverse colon, a rare complication of CP, is managed with colonic resection and anastomosis or

colostomy, depending on the condition of the patient and the condition of the pancreas.38 Pancreatic

pseudocysts associated with CP and ductal obstruction are managed by addressing the underlying ductal

disorder with resection or drainage procedures.39

Lateral Pancreaticojejunostomy

Retrograde pancreatic drainage for relapsing pancreatitis was described by Puestow and Gillesby in

1958.40 A modification of this original drainage procedure that more closely resembles the modern-day

technique of the lateral pancreaticojejunostomy (LPJ) was reported by Partington and Rochelle in

1960.41 LPJ is the classic operation for pancreatic drainage and entails opening the pancreatic duct

anteriorly along its length, medially to the level of the gastroduodenal artery and laterally into the tail.

The opened pancreatic duct is then cleared of stones, including into the head, and anastomosed to a

Roux-en-Y jejunal limb for drainage.

Procedure-specific complications of note include intraoperative hemorrhage (due to splenic vein or

gastroduodenal artery injury), postoperative hemorrhage (often from the gastroduodenal artery), and

anastomotic leak (seen in 10% of cases).

Multiple retrospective single-institution case series have been reported while evaluating outcomes

with LPJ, with pain-relief rates of 48% to 91%.42–49 Morbidity rates are low (20% on average) and

endocrine and exocrine function is often preserved.50 LPJ is an effective and safe procedure for pain

relief in many patients with dilated duct pancreatitis. Recurrent pain does occur after LPJ, however,

likely due to disease in the head of the pancreas. Intraductal stone disease in the head of the pancreas

can be cleared with intraoperative pancreatoscopy and electrohydraulic lithotripsy, which has been

shown to improve outcomes (reduced readmissions, increased pain-relief rates).51 Alternatively,

combining a localized head resection with LPJ can help to reduce recidivism.

Localized Pancreatic Head Resection with Lateral Pancreaticojejunostomy

In 1987, Frey and colleagues described a localized pancreatic head resection with a lateral

pancreaticojejunostomy (LR-LPJ) with the goal of achieving pancreatic ductal drainage, resection of

damaged and poorly drained parenchyma in the head of the pancreas, and preservation of the

duodenum to minimize postoperative gastrointestinal dysfunction. The Frey procedure combines a

classic longitudinal ductotomy of the neck, body and tail of the pancreas with unroofing of the

pancreatic ducts in the head and uncinate process of the pancreas with a “coring” out of the overlying

ductal tissue and preservation of the pancreas parenchyma along the posterior and lateral margin of the

pancreas. Frey reported initially on 50 patients, describing a morbidity of 22% and a pain-relief rate of

84%.52 His outcomes have been validated in modern series, both at his own institution and at others,

with pain-relief rates of 62% to 88% and morbidity of 20% to 30% reported.53–56

Algorithm 54-1. Algorithm for operative decision-making in chronic pancreatitis. LPJ, lateral pancreaticojejunostomy; LR-LPJ,

local pancreatic head resection with lateral pancreaticojejunostomy; PD, pancreatoduodenectomy; DPPHR, duodenal-preserving

pancreatic head resection; DP, distal pancreatectomy; TPIAT, total pancreatectomy with islet autotransplantation.

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