A chronic alcoholic presents with repeated episodes of severe intractable abdominal pain. At evaluation, the pancreatic duct was found to be dilated and stones were noted in the tail of the pancreas. The most appropriate management is:
Here this patient is presenting with repeated attacks of severe intractable pain, thus he is a candidate for surgical intervention. Longitudinal pancreatico jejunostomy with side-to-side anastomosis is the most suitable surgical option for this patient. (As his ductal system is dilated, a drainage procedure would be helpful) Surgical options for Chronic pancreatitis Drainage procedures Drainage procedures for patients with small ducts Patients with small (< 4-6 mm) pancreatic ducts, but in whom pancreatitis is caused by obstruction at the ampullary level, may benefit from transduodenal sphincteroplasty of the CBD with the division of the septum that lies between the MPD & CBD (pancreatic septectomy). However, most patients with chronic pancreatitis have multiple areas of duct stricture throughout the pancreas and are unlikely to benefit from these transduodenal procedures. Drainage procedures for patients with dilated ducts. A dilated duct system reflects obstruction. Thus the ideal treatment for these patients with dilated ducts is creating an anastomotic connection between the dilated ducts and the intestinal lumen. Longitudinal pancreatico jejunostomy (Puestow procedure) is the most commonly used drainage procedure. Entire pancreatic duct is longitudinally opened and anastomosed side to side to a Roux-en-Y segment of jejunum. Pancreatectomy Painful chronic pancreatitis can be treated with resection of the body and tail of the pancreas (distal pancreatectomy), resection of the head and uncinate process (Whipple procedure), subtotal pancreatectomy that spares a rim of the pancreas along with the inner curve of the duodenum, or total pancreatectomy. Many surgeons believe that it is the inflammatory process in the head of the pancreas that controls both the severity of the symptoms and fuher progression of the disease in the remaining gland. Resection of the pancreatic head can be achieved by Whipple procedure (pancreaticoduodenectomy) or its pylorus preserving modification or duodenum preserving pancreatic head resection. A good no. of pts. (70-80%) are completely relieved of pain. Distal pancreatectomy is the ideal surgical procedure for patients whose disease is confined to the pancreatic tail. Total or near total pancreatectomy is indicated in patients in whom a previous operative procedure like distal pancreatectomy or pancreaticoduodenectomy has failed to control pain. However, its role is not clear, as several patients even after total pancreatectomy continues to experience severe pancreatic pain. Celiac plexus block Celiac plexus nerve blocks performed either percutaneously or endoscopically have been employed to relieve chronic pancreatic pain with inconsistent results. A newer and more effective variant of this approach is thoracoscopic splanchnicectomy - resection of the segments of the greater and lesser splanchnic nerves as they enter the thorax from the abdomen. Ref : Sabiston 18/e, p 1608
Pancreatic Tail Resection
Pancreatico Jejunostomy
Percutaneous removal of stone
Medical management
G.I.T