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Pancreatitis

Necrotizing pancreatitis. When we get a patient with necrotizing pancreatitis probably only about 30% of them ever come to operation. The things we use as selection criteria - and I’m going to start from the bottom up because it’s much easier - if we can diagnose infected necrosis with percutaneous aspiration that is an indication, but probably not right away unless the patient is decompensating. Extravisceral air is diagnostic of infected necrotizing pancreatitis.

Hemorrhagic complications: that’s a misnomer. Hemorrhagic pancreatitis does not occur. This is an ischemic phenomenon but colonic complications do, from an ischemic pathology. The hardest part is, how do you deal with patients who just aren’t getting better? This is quite a controversial topic. What we tend to do is wait at least six weeks so that they have walled off this necrosis and then if they aren’t getting better, operate then. What are our goals? We want to do a complete necrosectomy.

Let’s switch to chronic pancreatitis, and again I’m going to try to hit what’s new from a surgical standpoint here. And I’m going to go through this in this fashion: what have been the changes in the mortality of pancreatic resection and how that has affected our approach to surgical problems. Some of these new operations, so-called Bager and Frye procedures.

Prior to 1985 the common dictum was that the amount of pain in patients with chronic pancreatitis is directly related to the amount of gland involved. So resection started from the left towards the right 60%, 80%, 95%, all the time trying to avoid the so-called Whipple operation where you have to take out the duodenum and then restore biliary, pancreatic and gastric drainage. What changed is the concept that the pacemaker of the pain was in the head of the gland.

Well, what’s new now? Well, these operations are difficult. There is a lot of chronic inflammation around there and this concept of the pancreas being a compartment syndrome led to the concept of, "Why don’t we take out the pacemaker of the gland but do it in a way that we preserve the duodenum?" So this is going to be called a duodenal-preserving head resection. I’ll orient you. Here’s stomach, C-loop of duodenum, here’s the head of the pancreas and this is the bile duct. This is called the Bager procedure and what you do is you take out a chunk of the head of the gland, leaving the duodenum and then you bring this up and sew it to this remnant of pancreas and this remnant along the duodenum. There has been a modification of this called the Frye procedure where it’s, in essence, a Puestow-like procedure but in addition you core out the head of the gland where the pacemaker is, again preserving the duodenum. This is the technically much easier operation and one that I prefer. It’s kind of fun to do but it also has pretty good results.

How about this concept of small duct disease? Classically the way we went about dealing with these patients is that if they have a big duct you drain it, if they have a small duct - prior to 1985 - you worked from the tail towards the head. Post 1985 you did a Whipple resection. Note the years here. There was a study in 1974 that showed relatively lousy pain relief, 36%.

Now, how about the concept of neurotomies? Back in the 1940’s to 1960’s surgeons approached chronic painful pancreatitis not by resecting the pancreas, because the mortality was sky-high back then, but rather in taking out the nerves. And it seems to make sense. The problem is that there was relatively high morbidity and very poor long term results.

Let’s go on to pancreatic cancer. Again, this is a topic that’s great for a surgeon because we can talk about laparoscopy and angiography, resecting it, palliating it, bypassing it, intraoperative radiotherapy, there’s a ton of things to talk about. But I thought I’d concentrate on two things primarily to start with.

So how do we pick the patients we want to operate on? I’m going to get a little controversy with some of the gastroenterologists in the audience because I’m going to address the use of ERCP and/or MRCP because in essence they do the same thing, angiography preoperatively, the role or need for a preoperative biopsy, and this is the one where the most discussion might occur, the role of preoperative biliary decompression. The fact that we can do it doesn’t necessarily mean that we should. Then the use of a staging laparoscopy to try and select patients who have a much higher rate of being resected.

What’s the role of ERCP in the staging - not the diagnosis - the staging of patients with pancreatic cancer? Well I maintain that there is no role for this. This is a diagnostic procedure and if you have a patient that has a mass on CT, has an appropriate clinical setting and you can see the hepatic extent of the biliary obstruction, there is no role for any ERCP. It’s a diagnostic procedure, not a staging procedure. And we can put a slash, MRCP here as well.

How about the role of preoperative angiography to select out those patients who have advanced disease? Well the suggested benefits are that it delineates the vascular anatomy. Any good pancreatic surgeon should know the differences in the anomalies in pancreatic vascular anatomy. So this is not a good justification for it. The other "justification" is that it defines unresectability. Well this is also not true because not all pancreatic cancers are invaders. Some are pushers. They push the vein and narrow it but they don’t necessarily invade it. It has potential morbidity, it’s expensive and it delays treatments. The studies that have looked at this have found that when the angiography suggests that it is unresectable due to narrowing of the mesenteric vein, nevertheless 30% of the time the tumor is resectable.

How about the role of a preoperative biopsy, either through the EUS or percutaneously? Well, the sensitivity of a biopsy is only about 60-80% and my response to this is, "So what?" If it’s positive and they are clinically resectable you are going to operate on them. If it’s negative and they look clinically resectable, you are going to operate on them anyway.