A new surgical approach for control of pain in chronic pancreatitis: complete denervation of the pancreas

With the aim of pain control in chronic pancreatitis without the morbidity of insulin-dependent diabetes, a new procedure was devised to completely resect the postganglionic pancreatic nerves and to totally free the pancreas from the posterior abdominal wall. This procedure was performed on two patients with follow-up periods of 24 and 10 months. Pain was resolved in both patients, and their blood glucose levels were substantially unchanged. This new approach offers a means of relieving pain with preservation of endocrine function in selected patients with chronic pancreatitis, especially in patients who have a small pancreatic duct.     

Pancreatic denervation for pain relief in chronic alcohol associated pancreatitis

To denervate the pancreas of sensory afferents, 15 patients with intractable pain of chronic alcohol induced pancreatitis underwent left transthoracic splanchnicectomy with concomitant bilateral truncal vagotomy. All were malnourished and 11 were addicted to opiates. No respite had been obtained from 33 previous operative procedures. Each patient experienced almost immediate pain relief. Five, however, later had return of pain, but only to the right epigastrium. These five then underwent right transthoracic splanchnicectomy, after which four noted complete and apparently permanent disappearance of pain. In those 14 with a successful outcome there has been a 29 per cent mean increase in body weight, break of hard drug addition in ten of the 11 so afflicted, and return to gainful work or a relatively normal lifestyle in all 14 at a mean follow-up of 16 months. Although 11 of the 14 do have delayed gastric emptying, only one has required a drainage procedure. There have been no other late complications. This approach for control of incapacitating pain in chronic pancreatitis is both safe and simple and at the same time it appears to be reasonably reliable.     

Duodenum-Preserving resection of the head of the pancreas with denervation of the body and tail of the pancreas in patients with severe chronic pancreatitis

Duodenum-preserving resection of the head of the pancreas with denervation of the body and tail of the pancreas was performed in 41 patients with severe chronic pancreatitis. The major advantage of this procedure is that only the small head of the pancreas is resected, leaving the endocrine and exocrine systems functioning normally, along with the pancreas, duodenum, and bile duct. This procedure provides complete pain relief. Ninety-two percent of the patients experienced complete alleviation of pain and no recurrent pain due to postoperative pancreatitis; 76% of the patients were able to work well postoperatively, and 87% maintained their preoperative body weight. Postoperative glucose tolerance with a normal or glucose tolerance impairment pattern remained unchanged in 67% of the patients, with deterioration occurring in 33% of the patients between 3 months and 3 years postoperatively. However, 21% of the patients with a diabetic pattern preoperatively changed to a glucose tolerance impairment pattern between 3 months and 3 years postoperatively. Our procedure, which includes the dissection of the nerve plexus on the remnant pancreas and a near total resection of the head of the pancreas, allows the patient to maintain a good nutritional state as well as allowing for good endocrine function of the pancreas.     

Operative treatment for chronic pancreatitis pain

BACKGROUND: Management of pain is the most frustrating problem associated with chronic pancreatitis. Pain is progressive and difficult to quantify. Uncontrolled, it eventually destroys the patient's quality of life, leading to drug addiction. STUDY DESIGN: This study reports the results of 258 operations on 239 consecutive patients treated for pain related to chronic pancreatitis between 1969 and 1999. The operations performed were 42 pancreaticoduodenectomies, 48 side-to-side pancreaticojejunostomies, 68 distal pancreatectomies, 21 85% to 95% distal pancreatectomies, 70 cystenterostomies and 9 sphincteroplasties. Efforts were made to choose the operation most appropriate for the pathological conditions encountered in each patient. Results of treatment were satisfactory if patients were entirely relieved of pain and unsatisfactory if there was any residual pain. Presence or absence of pain was based on patient's own evaluation at the time of their last followup examination. RESULTS: Results were overall satisfactory in 71% of patients after pancreaticoduodenectomy, 68% after side-to-side pancreaticojejunostomy, 69% after distal pancreatectomy; 69% after 85% to 95% distal pancreatectomy, 51% after cystenterostomy, and 44% after sphincteroplasty. The mean followup of patients was 4 y (range 0 to 23 y). CONCLUSIONS: The cause of chronic pancreatitis is obscure. As a consequence, there have been few advances in the treatment of this condition. There are new techniques to resect the pancreas, but the results are little better than those obtained with older methods. Advances in the treatment of chronic pancreatic pain will come from knowledge concerning its cause. Discovery of mechanisms stimulating the pathways that lead to the perception of pain and methods for interruption of these mechanisms may provide new treatments.     

Reconstructive pancreas surgery in chronic pancreatitis

An account is given in this paper of possibilities for reconstructive procedures, primarily in the wake of partial pancreatectomy, with reference being made to experience obtained by the author form surgical treatment of chronic pancreatitis. Benefits and setbacks of various methods are discussed in some detail, for example, duodenum or stomach preservation. The author continues to support cephalic duodenopancreatectomy with pancreaticogastrostomy on patients with chronic pancreatitis, however, with due observance of stringent criteria. That approach is considered equal to drainage methods.     

胰十二指肠切除术在胰头部慢性胰腺炎治疗中的应用和选择

目的 探讨胰十二指肠切除术在胰头部慢性胰腺炎治疗中的应用和选择。方法 回顾性分析我院1988年7月至1999年11月经胰十二指肠切除术和病理证实的10例胰头部慢性胰腺炎临床资料。结果 本组病人男性7例，妇性3例，年龄41－75岁，平均57.2岁。主要临床表现为腹痛、黄疸。影像学检查（B超、CT和ERCP）发现胰头部局限性肿大。9例行典型的Whipple手术，1例行保留幽门的胰十二指肠切除术。7例随访均无腹痛、糖尿病。结论 胰头部慢性胰腺炎早期诊断困难，重要的是与胰头癌相鉴别。胰十二指肠切除术治疗胰头部慢性胰腺炎的手术效果良好，其手术适应证的选择和手术时机的掌握至关重要。     

Mechanisms of pain in chronic pancreatitis

Pain is a leading symptom in chronic pancreatitis (CP) and often its management necessitates surgical intervention. Nevertheless the presence of different hypotheses, the pathophysiology of pain is not understood, thus the indications for therapy remain controversial. Increased pressure within the ductal system and/or the parenchyma has been suggested to be one of the causes of pain. This controversial theory has been substantiated by the demonstration of a relationship between intrapancreatic pressure and intensity of pain. On the other hand, recent studies have shown the inflammatory involvement of intrapancreatic nerve fibres in a so called "neuroimmune interaction". In fact, infiltration of inflammatory cells around the nerves together with an increase in the number of nerve fibres in the fibrotic pancreatic tissue have been proposed as a possible cause of pain in chronic pancreatitis. Moreover, immunohistological studies have shown that the amount of neurotransmitters, such as substance P and calcitonin gene related peptide, is increased in afferent pancreatic nerves and a close interrelationship between pain and immune cell infiltration of the nerves has been reported in CP. In addition to these hypothesis, extrapancreatic causes such as common bile duct obstruction and duodenal stenosis are discussed. This article review points to the different pathogenic mechanisms of pancreatic pain in CP.     

Percutaneous facet denervation in chronic thoracic spinal pain

Summary In 40 patients with chronic thoracic spinal pain of more than 12 months duration which failed to respond to conservative treatment and with a previous evaluation by specialists, mainly neurologists and orthopaedic surgeons, the diagnosis of facet syndrome was made. This diagnosis was based on clinical criteria and a transient positive response to a prognostic blockade of the medial branch of the dorsal ramus of the thoracic spinal nerve. They were selected to undergo percutaneous radiofrequency denervation of the facet joints. The short and long-term results of 51 percutaneous thoracic facet denervations in 40 patients are described. After 2 months, 19 patients (47.5%) were pain-free, 14 patients (35%) had more than 50% pain-relief, and 7 patients (17.5%) had no relief. After a follow-up of 18–54 (average 31) months in 36 cases (3 patients had died because of malignancy, and 1 had undergone a spinal fusion), 16 patients (44%) were pain-free, 14 patients (39%) had more than 50% pain-relief and in 6 cases (17%) the result was poor. Adverse effects consisted of postoperative pain in 5 patients (12.5%). When conservative treatment fails, percutaneous thoracic facet denervation can be a safe and beneficial therapy in chronic thoracic spinal pain originating from the facet joints.     

胰十二指肠切除术治疗胰头部慢性局限性胰腺炎的探讨

目的 探讨胰十二指肠切除术治疗胰头部慢性局限性胰腺炎的必要性与合理性。方法 对11例胰头部慢性局限性胰腺炎施行胰十二指肠切除术，其中7例行Whipple手术，4例行保留幽门的胰十二指肠切除术。结果 本组有1例并发应激性溃疡，1例切口感染，均经保守治疗痊愈。无胰瘘发生，术后生活质量良好。结论 胰十二指肠切除术治疗胰头部慢性局限性胰腺炎是合理、安全的，效果良好。     

Long-term follow-up of thoracoscopic splanchnicectomy for chronic pancreatitis pain

Background: Thoracoscopic splanchnicectomy (SPL) has been reported to give excellent short-term pain relief in chronic pancreatitis. This study prospectively evaluates the long-term efficacy of SPL in pancreatitis patients. Methods: Chronic pancreatitis patients with severe pain unrelieved by standard therapy completed a standard 10-point analogue pain scale prior to surgery and at postoperative visits. Midline and left-sided pain was treated with left SPL; right-sided pain was treated with right SPL. If pain recurred on the contralateral side, contralateral SPL was done. Results: Fifteen patients underwent SPL. Eleven of them required narcotics preoperatively. Follow-up is complete and ranges from 4.2 to 6.1 years (median, 5.75). All patients had constant pain prior to surgery. Following SPL, it decreased in the short term to a mean of 3.9 attacks a month. At long-term follow-up, the mean number of attacks was 8.6 per month. Preoperatively, the mean score for worst pain within the last 2 months was 9.1. This score decreased to 3.9, but at long-term follow-up it had increased to near preoperative values (8.6). Current severity of pain decreased from 7.2 preoperatively to 2.9 at short-term follow-up, but at long-term follow-up it had increased. The degree of disability decreased from 9.1 preoperatively to 5.1 at short-term follow-up, but in the long term it increased toward preoperative values. Although eight patients were narcotic free at early follow-up, only three remained narcotic free in the long-term. Conclusion: Thoracoscopic SPL offers short-term relief of pain from chronic pancreatitis, but the relief is not durable in most cases. Similarly, there are short-term improvements in degree of disability, mood, and freedom from narcotic use that are not sustained in the long-term. Nevertheless, two-thirds of patients stated that they would have the surgery again. apd: 11 May 2001     

Treatment of chronic painful pancreatitis by cryodestruction of the pancreas

The authors describe their method of treatment of chronic painful pancreatitis by means of cryodestruction of the pancreas at the site of entering the nerve trunks and visually altered portions of the organ. The effect of super low temperature on the nerves of the gland and its tissue was studied in experiments on dogs. Cryodestruction was found to cause death of nerve elements and regeneration sclerosis of the gland tissue. Operations were made on 15 patients with chronic painful pancreatitis. In all the patients the painful syndrome was liquidated or considerably reduced after cryodestruction. All the patients have recovered. The operation technique is described.     

Results of treating chronic pancreatitis with cryodestruction of the pancreas

An analysis of results of treatment followed-up during the period from 8 months to 7 years has shown that good and satisfactory results took place in 28 of 32 patients operated upon. Rather good nearest and long-term results allow cryodestruction to be recommended as a method of treatment of chronic painful pancreatitis.     

Partial resection of the pancreas in the treatment of chronic pancreatitis

On the basis of an experience with 1215 operations for chronic pancreatitis the authors came to a conclusion concerning expediency of partial resection (up to 40% of the volume) of the pancreas with a local damage of the organ. Such operations were fulfilled in 33 patients. Good and satisfactory results were obtained in 28 of 33 patients. There were no lethal outcomes. In all the operated patients subjected to selective suppression of the exocrine function of the retained part of the gland no recurrencies of pancreatitis were noted.