Chronic pancreatitis

Chronic pancreatitis (CP) is a progressive, disabling, fibro-inflammatory disease of the pancreas of variable clinical course and is usually associated with permanent loss of exocrine and endocrine function over a period of time. The incidence is increasing. There are various aetiological risk factors that cause CP, chronic alcoholism being the most common risk factor. The TIGAR-O classification identifies all the risk factors and aetiology. Most susceptible patients have a sentinel acute pancreatitis event which initiates chronic progressive inflammation, scarring and fibrosis, though some may present insidiously with symptoms of functional loss – diabetes or steatorrhoea. Intractable abdominal pain, steatorrhoea, weight loss and (type 3c) diabetes mellitus are late manifestations of the disease. Diagnosis is made with a combination of clinical history, examination, cross sectional imaging combined with pancreatic function tests (in equivocal cases). Complications include gastric and biliary obstruction, pseudocyst formation, pancreatic ascites, pseudoaneurysms and venous thrombosis. Patients with CP have increased risk of developing pancreatic adenocarcinoma. Management includes making the diagnosis, identifying the aetiology, instituting life-style changes to abstain from alcohol and smoking, and involving the specialist multidisciplinary team (including pain team, dietician, clinical psychologist, endoscopist, gastrointestinal physician and pancreatic surgeon) if initial steps do not control the symptoms.     

Chronic pancreatitis

Chronic pancreatitis is distinguished by structural and functional criteria. Alcohol is the major aetiological factor, but about 20% of patients have another cause such as hereditary pancreatitis. Abdominal pain is the usual presenting feature, often as recurrent attacks of acute pancreatitis but chronic pancreatitis may be clinically silent. The pathogenesis of chronic pancreatitis is incompletely understood. Diagnosis is usually made on imaging (CT, magnetic resonance cholangiopancreatography, endoscopic ultrasound). Complications include exocrine and endocrine insufficiency, obstructive jaundice, duodenal obstruction, left-sided portal hypertension, and the development of pancreatic cancer. Overall management is difficult and depends upon symptoms, morphological characteristics and complications. Treatment options include medical, endoscopic, and surgical strategies; the latter is reserved for patients with complications. Early involvement of a specialist centre in the care of patients with complicated chronic pancreatitis is important and should be encouraged.     

Chronic pancreatitis

Chronic pancreatitis is distinguished by structural and functional criteria. Alcohol is the major aetiological factor, but other causes (for example including hereditary pancreatitis) must be considered. Abdominal pain is the usual presenting feature, but chronic pancreatitis is clinically silent in many patients. The pathogenesis of chronic pancreatitis is incompletely understood. Diagnosis is usually made on imaging (computed tomography, magnetic resonance cholangiopancreatography, endoscopic ultrasound). Complications include exocrine and endocrine insufficiency, obstructive jaundice, duodenal obstruction, left-sided portal hypertension, and the development of pancreatic cancer. Overall management is difficult and depends upon symptoms, morphological characteristics and complications. Treatment options include medical, endoscopic, and surgical strategies; the latter is reserved for patients with complications. Early involvement of a specialist centre in the care of patients with complicated chronic pancreatitis is important and should be encouraged.     

Chronic pancreatitis

Chronic pancreatitis is distinguished by structural and functional criteria. Alcohol is the major aetiological factor, but about 20% of patients have another cause such as hereditary pancreatitis. Abdominal pain is the usual presenting feature, often as recurrent attacks of acute pancreatitis but chronic pancreatitis may be clinically silent. The pathogenesis of chronic pancreatitis is incompletely understood. Diagnosis is usually made on imaging (CT, magnetic resonance cholangiopancreatography – MRCP, endoscopic ultrasound). Complications include exocrine and endocrine insufficiency, obstructive jaundice, duodenal obstruction, left-sided portal hypertension, and the development of pancreatic cancer. Overall management is difficult and depends upon symptoms, morphological characteristics and complications. Treatment options include medical, endoscopic, and surgical strategies; the latter is reserved for patients with complications. Early involvement of a specialist centre in the care of patients with complicated chronic pancreatitis is important and should be encouraged.     

Quality of life after bilateral thoracoscopic splanchnicectomy: Long-term evaluation in patients with chronic pancreatitis

We prospectively evaluated quality of life and visual analogue scale pain scores after bilateral thoracoscopic splanchnicectomy in 55 patients with small-duct chronic pancreatitis and abdominal pain. The perioperative morbidity rate was 11% and there were no perioperative deaths. Four late deaths occurred (7%), and three patients were lost to follow-up. Patients were divided into those who had prior operative or endoscopic interventions (N=38) and those who did not (N=17). Preoperatively there were no significant differences between the two groups with regard to age, sex, etiology, pain score, or narcotic use. Pain score, narcotic use, and symptoms scales improved significantly in both groups at 3 and 6 months postoperatively (P<0.0001). The group with no prior surgical or endoscopic intervention did significantlybetter initially (P< 0.007), and the improvements in their quality-of-life and pain scores continued for the remainder of the study. In contrast, quality-of-life and pain scores in patients who had undergone prior surgical or endoscopic intervention returned to baseline by 12 months postoperatively and remained poor throughout the remainder of the study. Bilateral thoracoscopic splanchnicectomy appears to work best in patients who have had no prior operative or endoscopic interventions. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Caerulein-induced pancreatitis and islet blood flow in anesthetized rats

BACKGROUND: Microcirculatory mechanisms have been suggested to be involved in the development of acute pancreatitis. Islet blood flow has not previously been studied in this disease. The present study aimed to investigate the effects of caerulein-induced pancreatitis on pancreatic blood perfusion, especially islet blood flow. MATERIALS AND METHODS: Continuous 4 h caerulein-infusion was used to induce mild, edemateous pancreatitis in anesthetized Sprague-Dawley rats. Some animals were then given an additional 2 h infusion of saline. Thus, at 4 or 6 h after initiating caerulein infusion the blood flow to the pancreas, pancreatic islets, and intestines was measured with a microsphere technique. RESULTS: All infused animals demonstrated an edemateous pancreatitis, without hemorrhages. Both total pancreatic and islet blood flow was increased after the 4-h infusion. However, the increase was less pronounced in the islets. After an additional 2 h with only saline infused, the blood flow values in rats initially infused with caerulein were lower than at 4 h, but total pancreatic blood was still higher than in control rats. No effects on intestinal blood flow values were seen. CONCLUSIONS: Pancreatic islet blood flow in rats with mild edematous pancreatitis is increased, but not to the same extent as that in the whole pancreas.     

Results of mobilization and drainage of the pancreas for acute pancreatitis

The surgical treatment of acute pancreatitis remains controversial. Since 1969, we treated 62 patients with acute pancreatitis. In 34 with severe acute pancreatitis who were not responding adequately to intensive medical care, surgical intervention was made by mobilization of the pancreas from retroperitoneal tissue and drainage of the pancreatic bed (M-D procedure). Thirty-four operative cases were classified into 7 edematous, 7 hemorrhagic, and 20 necrotizing. Macroscopic findings of the pancreas did not correlate either to the severity of the acute pancreatitis or to the mortality rate. Eight of 34 who underwent M-D procedure died (23 per cent), but the rate became 14.7 per cent after excluding 3 who died of unrelated causes. These data suggest that the M-D procedure is highly effective in the treatment of early cases of severe acute pancreatitis. There was an associated marked reduction in the mortality rate with the prophylatic use of broad spectrum antibiotics. With M-D procedure, there was a low incidence of late sequelae of pancreatic or peripancreatic abscess.     

慢性胰腺炎疼痛的发生机制及处理对策

疼痛是慢性胰腺炎病人的主要症状之一,反复发作的顽固性疼痛使病人痛苦不堪,极大地降低了病人的生活质量。然而,人们对于慢性胰腺炎疼痛原因的研究甚少,治疗水平更是参差不齐。21世纪以来,随着分子生物学和胰腺外科的深入发展,慢性胰腺炎的多重疼痛机制逐渐被人们所认识。药物、内镜、手术等多元化治疗方案已成为临床医生处理慢性胰腺炎疼痛的重要手段。     

Exocrine function following the whipple operation as assessed by stool elastase

What impact does pancreaticoduodenectomy (PD) have on exocrine function? Does the pancreatic anastomosis remain patent? When stool elastase became available for testing in November 2001, we began preoperative assessment and then increasingly employed postoperative measurements. From December 2001 until March 2006, 182 patients underwent PD by the same surgeon. Preoperative stool elastase was measured in 138 (76%) patients and was repeated postoperatively at 3±1 month, 12±2 months, and 24±3 months. At the same time periods, an abdominal CT scan was used to assess patency of the pancreatic anastomosis as implied by pancreatic duct dilation in the remnant (dilation = duct >3 mm or, if duct dilated preoperatively, then duct that failed to decrease in size). All cases were reconstructed with duct-to-mucosa pancreaticojejunostomy. Stool elastase was expressed as normal (>200 μg/gram stool), moderately reduced (100–200 μg/gram), or severely reduced (<100 μg/gram). Preoperative stool elastase values were “normal” in 78% (pancreatic cancer 32% normal vs. all other groups >78%; P⩽0.001). As compared with preoperative values, the percent of cases with reduced elastase levels at 3 months, 1 year, and 2 years postoperatively was 48%, 73%, and 50%, respectively. The CT scans at the time of the 69 stool elastase measurements after PD showed pancreatic duct dilation in the pancreatic remnant in 9 of 69 (9%) stools but was not more frequent in the group with decreased elastase. Based on cases elastase, one third of patients about to have PD will have exocrine insufficiency, an observation most common among the patients with pancreatic cancer (68%). Stool elastase levels are further depressed in the majority of cases after PD from parenchymal loss because we could not implicate an occluded pancreatic anastomosis. These results suggest that, after PD, exocrine supplementation should be given to all patients with pancreatic cancer, especially those with impending adjuvant therapy. To further improve the long-term results after PD, each surgeon should assess the effect of their own type of pancreaticoenteric technique on exocrine function. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, Los Angeles, California, May 20–24, 2006 (oral presentation).     

慢性胰腺炎的胰酶替代治疗

慢性胰腺炎是由于各种原因造成的胰腺组织结构和功能慢性进行性损害。在慢性胰腺炎的发生发展过程中,早期主要症状为疼痛,晚期则疼痛症状减轻,代之以胰腺外分泌功能不全所引起的进行性消化不良和营养不良,严重影响到病人的生活质量和疾病预后。目前,对于慢性胰腺炎的治疗方法包括一般治疗、胰酶替代治疗和外科治疗(包括减压术、切除术和神经阻断术)。随着对慢性胰腺炎发生发展机制的深入研究和各种不同胰酶制剂的相继问世,人们对胰酶替代治疗在慢性胰腺炎治疗中的地位有了新的认识。     

慢性胰腺炎胰,胆管梗阻的处理：附6例报告

在３７例慢性胰腺炎病人中，８例合并胆道梗阻（２２％），４例合并主胰管梗阻（１１％）；６列同时或异时合并胰、胆管梗阻（１９％）。其中１例在发现胰管扩张１年后，出现胆管梗阻；２例同时发现胰、胆管梗阻。３例因黄疸在外院先行胆道手术，术后腹痛持续，影像检查证实尚伴有胰管梗阻，而再次行胰管减压手术。未合并胆石和（或）胆管炎的单纯胆道梗阻一般不引起严重的腹痛。对腹痛症状较重，而又无胆管结石的慢性胰腺炎病人应特别警惕是否同时合并胰管梗阻。     

Chronic pain after hysterectomy

Background: Chronic pain is a well-known adverse effect of surgery, but the risk of chronic pain after gynaecological surgery is less established.
Method: This review summarizes studies on chronic pain following hysterectomy. The underlying mechanisms and risk factors for the development of chronic post-hysterectomy pain are discussed.
Results and conclusion: Chronic pain is reported by 5–32% of women after hysterectomy. A guideline is proposed for future prospective studies.     

Pancreatic regeneration in chronic pancreatitis requires activation of the Notch signaling pathway

Chronic pancreatitis as an inflammatory process characterized by morphological changes, pancreatic dysfunction, and pain. During pancreatic injury and repair the Notch signaling pathway is reinstated. The current study analyzed this pathway in chronic pancreatitis and characterized its influence on fibrogenesis. Real-time quantitative PCR and immunohistochemistry were used for expression studies. Notch activation was determined by a specific luciferase-HES-1-reporter gene constructs. Cells were stimulated with alcohol, glucose, bile acids, and steroids. Notch-2, -3, and -4 mRNA, were overexpressed in chronic pancreatitis specimens. The ligands Jagged-1, -2, and Delta-1 were highly overexpressed. Jagged-1 and Notch receptors were observed in nerves, regenerating exocrine cells, and endocrine cells. Delta staining was present in ductal but not in acinus cells and not in nerves. Activation of Notch signaling was detectable upon cell stimulation with glucose, steroids, and bile acids. High glucose levels were further associated with increased collagen-I production. The Notch pathway is reactivated during chronic pancreatitis. Among the stimuli activating the Notch pathway are steroids, high glucose levels, and bile acids. These findings suggest a possible role of the Notch pathway during pancreatic regeneration since Jagged-1 inhibits inducible collagen-1 production, suggesting a new mechanism of tissue repair in this disease. Presented at the Forty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, May 20–24, 2006, Los Angeles, California. The first three authors (Y.S., B.P., and A.G.) contributed equally to this paper.     

Frey手术治疗慢性胰腺炎的临床疗效分析

目的探讨Frey手术治疗慢性胰腺炎(CP)的疗效。方法回顾性分析我院2000年6月至2009年10月期间32例行Frey手术的CP患者临床资料,观察围手术期并发症发生率和疼痛缓解率,着重了解胰腺内、外分泌功能。结果 32例患者术后无死亡病例。围手术期并发症发生率为9.4%(3/32)。其中2例患者出现伤口脂肪液化,经对症处理后痊愈;1例患者术后第4天出现胰瘘,经禁食、营养支持治疗康复出院。住院时间(11±2)d。术后患者均获随访,随访时间平均43个月,16例(50.0%)患者疼痛完全消失,14例(43.8%)患者疼痛明显缓解,2例无效,术后疼痛缓解率为93.8%。5例糖尿病患者术后病情无加重,术后新发糖尿病患者3例。3例术前伴消化不良、脂肪泻患者中,1例术后口服胰酶制剂后症状缓解,2例无变化;新增脂肪泻患者4例。结论在严格掌握手术指证的前提下,采用Frey手术治疗CP是一种安全、有效的方法。     

Steroid celiac plexus block for chronic pancreatitis: Results in 16 cases

Sixteen cases in which celiac plexus block with depot steroid was used to treat chronic pancreatitis pain were reviewed. Only 4 of 16 patients reported pain relief with the procedure. Of the 12 patients who did not obtain relief, narcotic dependence was present in 11 of 12. No patients in the “relief” group were narcotic dependent. Prior pancreatic surgery was present in 9 of the 12 patients without relief and in 1 of 4 patients with relief. It is postulated that refractory chronic pancreatitis pain may be an extreme form of what has been termed “abnormal illness behavior.” Furthermore, these results underscore the poor results experienced using neural blockade for the relief of chronic pain when narcotic dependence is present.     

Surgical treatment of pancreas divisum causing chronic pancreatitis: The outcome benefits of duodenum-preserving pancreatic head resection

Pancreas divisum (PD) represents a duct anomaly in the pancreatic head ducts, leading frequently leading to recurrent acute pancreatitis (rAP) or chronic pancreatitis (CP). Based on endoscopic retrograde cholangiopancreatography, pancreas divisum can be found in 1% to 6% of patients with pancreatitis. The correlation of this abnormality with pancreatic disease is an issue of continuing controversy. Because of the underlying duct anomalies and major pathomorphological changes in the pancreatic head, duodenumpreserving pancreatic head resection (DPPHR) offers an option for causal treatment. Thirty-six patients with pancreatitis caused by PD were treated surgically. Thirty patients suffered from CP, 6 from rAP. The mean duration of the disease was 47.5 and 49.8 months, respectively. The age at the time of surgery was 39.2 years in the CPgroup, and 27.6 years in the rAP group. Median hospitalization since diagnosis was 18.8 weeks for CP patients and 24.6 weeks for rAP patients. Previous procedures performed in these patients included endoscopic papillotomy (30%), duct stenting (14%), and surgical treatment (17%). The median preoperative pain score was 8 on a visual analog scale. According to the classification of pancreas divisum, 10 patients demonstrated a complete PD, 25 had a functionally incomplete PD, and 1 had a dorsal duct type. The pain status as well as the endocrine (oral glucose tolerance test) and exocrine (pancreolauryl test) function were evaluated preoperatively and early and late postoperatively with a median follow-up time of 39.3 months. There was no operative-related mortality. The follow-up was 100%; 4 patients died (1 from suicide, 1 from cardiac arrest, and 2 from cancer of the esophagus). Fifty percent of the patients were completely pain-free,31%hada significant reduction of pain with a median pain score of 2 (P < 0.001). Six patients (5 CP, 1 rAP) had further attacks of acute pancreatitis with a need for hospitalization. DPPHR reduced pain and preserved the endocrine function in the majority of patients with pancreas divisum. Therefore, DPPHR is an alternative to other resective or drainage procedures after failure of interventional treatment.     

胰头部肿块型慢性胰腺炎的处理对策

近年来,随着对胰头部肿块型慢性胰腺炎的形成机制及其与胰腺癌关系的认识不断深入,大型胰腺治疗中心手术安全性也不断提高,胰头部肿块型慢性胰腺炎的处理有朝着积极手术干预方向发展的趋势。术前对胰头部肿块型慢性胰腺炎的鉴别诊断不断进步,对于术前EUS活组织病理检查阴性,诊断困难的患者,术中Tru—cut组织芯活组织病理检查正越来越多地被应用,其对决定胰头部肿块进行合适的手术方式有重要作用。外科医师应通过不断改进处理策略,尽可能在保证患者治疗效果的前提下,使患者的受益最大化。     

胰头肿块型慢性胰腺炎的治疗

胰头肿块型慢性胰腺炎已被视为胰腺癌的癌前病变,并且可以导致胰管、胆管及十二指肠梗阻,其与胰头癌的鉴别诊断困难,然而二者的预后截然不同。因此,胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,以切除病变,缓解疼痛症状,改善病人的生活质量。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple 手术）和保留十二指肠的胰头切除术（Beger手术及其改良术式）。手术方式尽可能采用胰十二指肠切除术,不仅切除了胰头部肿块、解除了胆道、胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除术有极大风险,可考虑行保留十二指肠的胰头切除术。     

Problems of pancreatitis

Pancreatitis is not one disease but several and perhaps many. Diagnosis is imperfect in all forms and the usual lack of histologic material has hampered attempts to understand the pathogenesis and possible interrelationships of the different forms of pancreatic inflammation. Acute pancreatitis does not as a rule evolve into chronic pancreatitis, even after multiple recurrences. Recurrent acute attacks can be ended by identifying and treating the factor causing the disease, including recently recognized entities such as accessory papilla stenosis associated with pancreas divisum. Attempts to improve the treatment of severe acute pancreatitis are focussing upon preventing injury to pancreatic cell structures, enhancing endogenous mechanisms for capture and disposal of activated enzymes, and upon early detection and debridement of damaged pancreatic and peripancreatic tissues. Pancreatic duct stricture or obstruction as a consequence of scarring from necrotizing pancreatitis may produce recurrent symptoms, now designated as obstructive pancreatitis. Obstructive pancreatitis has its own unique histologic characteristics and is appropriately treated by resection of the blocked segment of pancreas when the point of obstruction is distal to the papilla. Chronic pancreatitis differs from acute or obstructive pancreatitis in that it is difficult or impossible to halt its progression. The role of intraductal protein precipitates, whether of enzymes or perhaps of other unique pancreatic secretory proteins, in the pathogenesis of the disease is being evaluated. The goal of surgical treatment is not to cure, but to reduce pain, overcome associated obstruction of the bile duct or duodenum, and to treat pancreatic duct disruptions including pseudocysts and internal pancreatic fistulas. Because continuing deterioration of pancreatic function is to be expected in chronic pancreatitis, maximum conservation of pancreatic tissue by avoiding resectional procedures is advisable. This report is the gist of a paper read by A. L. W. at the 86th Annual Meeting of the Japanese Surgical Society, Tokyo, Japan, 1986