|Year : 2020 | Volume
| Issue : 4 | Page : 161-166
Outcome after surgical management of tropical and alcoholic chronic pancreatitis - A Indian tertiary centre experience
Maulik Shaileshbhai Bhadania, Hasmukh B Vora, Premal R Desai, Mahendra S Bhavsar
Department of Surgical Gastroenterology, Smt. NHL Municipal Medical College, SVP Hospital, Ahmedabad, Gujarat, India
|Date of Submission||28-Jan-2021|
|Date of Acceptance||22-Jun-2021|
|Date of Web Publication||30-Dec-2021|
Premal R Desai
Department of Surgical Gastroenterology, SVP Hospital, Ellis Bridge, Ahmedabad - 380 007, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Chronic pancreatitis (CP) is an inflammatory disease of the pancreas characterized by progressive fibrosis, morphological changes, leading to exocrine and/or endocrine insufficiency. Tropical pancreatitis (TP) is seen mainly in the younger population with large ductal calculi and calcification. In this study, we evaluate the postoperative outcome and pain relief after Frey's and modified Puestow procedure (mPP) in patients of tropical and alcoholic pancreatitis.
Materials and Methods: This is a retrospective review of prospectively collected data of surgically treated cases of CP. A total of 44 surgeries were performed with Frey's procedure in 36 (81.82%) patients; and mPP in 8 (18.18%) patients. The pain had been evaluated by the Visual analog scale in preoperatively and at 1 year follow-up.
Results: The etiology of CP was related to chronic alcohol use in 16 patients (36.36%) and TP in 28 patients (63.63%). Abdominal pain relief was achieved in 86.36% of the patients. Postoperative pain relief was achieved in 91.66% and 62.5% of patients undergoing Frey's and mPP, respectively. Postoperative pain relief was better in TP (92.86%) as compared to alcoholic pancreatitis (75%) (P = 0.0968). Postoperative major complications over 30 days (Clavein Dindo Grade IIIa and above) were seen in 6.8%.
Conclusion: Frey's procedure was associated with better abdominal pain relief as compared to mPP. Patients of tropical CP experience better postoperative pain relief than alcoholic CP.
Keywords: Chronic pancreatitis, Frey's procedure, modified puestow procedure, tropical pancreatitis
|How to cite this article:|
Bhadania MS, Vora HB, Desai PR, Bhavsar MS. Outcome after surgical management of tropical and alcoholic chronic pancreatitis - A Indian tertiary centre experience. Saudi Surg J 2020;8:161-6
|How to cite this URL:|
Bhadania MS, Vora HB, Desai PR, Bhavsar MS. Outcome after surgical management of tropical and alcoholic chronic pancreatitis - A Indian tertiary centre experience. Saudi Surg J [serial online] 2020 [cited 2022 May 27];8:161-6. Available from: https://www.saudisurgj.org/text.asp?2020/8/4/161/334509
| Introduction|| |
Chronic pancreatitis (CP) is an inflammatory disease of the pancreas characterized by progressive fibrosis and irreversible morphological changes, leading to epigastric pain with or without exocrine and/or endocrine insufficiency. Clinical presentation of CP includes abdominal pain, exocrine pancreatic insufficiency (steatorrhea, weight loss, deficiency of fat-soluble vitamins) and/or diabetes. Abdominal pain is the most frequent and debilitating symptom with a variable pattern. Pain is often refractory to treatment, with frequent hospital visit, psychosocial problems, opioids dependence. The tropical CP (TCP) is a special type of CP seen mainly in tropical countries. It usually occurs in the younger population with involvement of the main pancreatic duct (MPD) resulting in large ductal calculi and calcification. The etiology of TCP is not known, but environmental and genetic factors (SPINK 1 mutation) are likely causes. Surgical treatment of CP reduces pain and subsequent complications so that patients return to their prior work activities as well as improved quality of life. Hybrid surgical procedures like Frey's procedure (FP) combining decompression of pancreatic duct and head coring; proved to be safe and effective, providing long-term pain relief with low peri-operative and long-term morbidity and mortality. In patients with alcoholic and TCP, we assess whether FP is more effective than modified Puestow procedure (mPP) in terms of postoperative pain relief or not and we also compare postoperative pain relief in alcoholic and TCP patients.
| Materials and Methods|| |
This was a retrospective review of prospectively collected data of surgically treated cases of tropical and alcoholic CP. Hemodynamically unstable, unfit for general anesthesia, lost to follow-up and pregnant females were not included in this study. A total of 44 surgeries were performed with FP in 36 (81.82%) patients; and mPP in 8 (18.18%) patients. Roux en Y hepaticojejunostomy was added in two patients of FP who had CP induced distal common bile duct (CBD) stricture causing obstructive jaundice. At our institute choice of surgical procedure depends on ductal morphology, pancreatic head enlargement, suspicious of malignancy, and associated locoregional complications. We offer surgical treatment in patients who experience abdominal pain even after medical therapy (with maximum oral opioids along with enzyme supplementation), developed complications or if suspicious of malignancy.
FP was first described by Frey and Smith in 1987 which is a hybrid procedure that includes resection of the anterior aspect of the head of the pancreas (coring) combined with drainage of the MPD using longitudinal pancreatojejunostomy. Surgical procedure entails a full exposure of the anterior surface of the pancreas from head to tail after entering the peritoneal cavity through left subcostal or upper midline incision depending on the body habitus of the patient. After confirming the dilated MPD by fine-needle puncture or occasionally by ultrasonography (in difficulty), MPD is fully incised from the anterior aspect approaching from tail up to head. Hemostatic suture placed and maximum coring (excision) of pancreatic parenchyma in the head and uncinate region is done leaving a thin rim of tissue around duodenum. Stones must be cleared from duct and parenchyma in the head region. After this Roux en Y longitudinal side-side pancreatojejunostomy is performed by single-layer interrupted nonabsorbable suture. Careful hemostasis is very important in the FP following which a single abdominal drain is kept. It is advised that to prevent recurrence, complete decompression of the pancreatic ducts in the head of the pancreas and full-length drainage of the MPD from the head to the tail is the most important part of the surgery. In mPP longitudinal pancreatojejunostomy done the same as Frey procedure without head coring of the head of the pancreas. Postoperative analgesia was given by parenteral route followed by oral analgesia for 5-7 days. Third-generation cephalosporin was routinely used as prophylactic at the time of induction, which later on continued for 3 days in the postoperative period. Deep vein thrombosis prophylaxis used in selected high-risk cases. Drain is usually taken out after day three after the normal drain fluid amylase value along with clinical judgment and drain amount. Patients were discharged after the assumption of oral diet, after removal of drain, and being fully mobilized.
The primary outcomes of this study are:
- Postoperative pain relief after FP and modified Puestow's procedure
- Relation between etiology of CP (alcohol and tropical) and postoperative pain relief.
Secondary outcomes of this study are:
- Postoperative complication, morbidity, and mortality after surgical management of CP
- Weight gain, endocrine function after surgical management of CP
- Effect of the duration of symptoms, gender, and MPD diameter on postoperative pain relief.
The pain had been evaluated by visual analog scale (VAS) defined as a scale of 0–10, where 0 indicated no pain and 10 indicated severe, unbearable, continuous pain in preoperatively and at 1 year follow-up. The exocrine pancreatic function was evaluated with the presence of steatorrhea which had been defined as more than three stools per day with a nauseating smell and greasy and pale appearance. Similarly, endocrine pancreatic function had been evaluated as the presence of diabetes mellitus (DM) which had been defined based on fasting sugar (more than or equal to 126 mg/dl), postprandial sugar (more than or equal to 200 mg/dl), and/or the level of glycosylated hemoglobin (more than 6.5). Postoperative complications had been defined as per Clavien-Dindo's classification system of surgical complications. Major complications were defined as events occurring within 30 days requiring intervention (III a – under local anesthesia, III b – under general anesthesia), intensive care organ support (IV a – single organ, IV b – multiorgan), and death (V). Furthermore, the number of postoperative hospital stays was noted.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 24.0 software (SPSS Company, Chicago, IL, USA). Quantitative data were expressed as mean and range. Statistical difference between preoperative and postoperative pain scores was examined using the paired t-test. The Chi-square test or Fisher's exact test were used to compare categorical variables, as appropriate. P < 0.05 were considered statistically significant.
| Results|| |
The clinical characteristics of patients undergoing surgery are shown in [Table 1]. A total of 28 men (63.6%) and 16 women (36.4%) were evaluated; their mean age was 32.8 years (range, 10–65 years) [Chart 1]. The etiology of CP was related to chronic alcohol use in 16 patients (36.36%) and tropical pancreatitis (TP) in 28 patients (63.63%). Persistent abdominal pain was present in 44 patients (100%) and jaundice in two patients (4.54%). DM was present in 10 patients (22.7%). Pancreatic parenchymal calcification was identified in 34 patients (77.27%). A total of 16 patients (36.36%) had pancreatic head mass. Out of 41 patients who had pancreatic duct calculus 32 patients had multiple calculi. The mean diameter of the MPD was 10 mm. Two patients had distal CBD stricture [Table 2].
The postoperative outcomes are listed in [Table 3] and [Table 4]. Postoperative pain relief in 38 (86.36%) patients (VAS <5). After FP and modified Puestow's procedure 91.66% and 62.5% of patients experienced pain relief, respectively.
Postoperative complications occurred in 8 (18.18%) patients. Postoperative major complications over 30 days (Clavein-Dindo grade IIIa and above) were seen in three cases (6.8%). Three out of six patients with surgical site infection requires secondary suturing in operation theatre with full aseptic protocol under local anesthesia (CD Grade IIIa) and one had urinary tract infection which was managed by antibiotic therapy (CD Grade II) and one had paralytic ileus managed conservatively (CD Grade I). There was no anastomotic leak or postoperative pancreatic fistula. There was no mortality during hospital admission. New onset of endocrine insufficiency in two patients. Mean postoperative hospital stay was 6.36 days [Table 4] and [Chart 3].
| Discussion|| |
CP is a progressive inflammatory disorder characterized by irreversible destruction of pancreatic tissue, associated with disabling chronic pain and impairment of endocrine and/or exocrine function. Alcohol is the most common etiology of CP worldwide. However, there is a form of idiopathic CP prevalent in tropical countries like India.
TP is chronic calcific, nonalcoholic pancreatitis seen almost exclusively in developing countries of the tropical world. Contrary to other forms, TP is characterized by younger-onset, presence of large intraductal calculi, accelerated course of the disease, and high susceptibility to pancreatic cancer.,, More than 90% of patients with TCP experience abdominal pain. Insulin-dependent diabetes developed in 25% of patients which is ketosis resistant. Painless diabetes is also another clinical presentation in some patients. Most patients develop malnutrition during the disease but steatorrhea is less common.
Long-standing complications of CP can be pseudocysts; CBD stricture causing obstructive jaundice; duodenal stenosis causing gastric outlet obstruction; portal-vein thrombosis; splenic vein thrombosis with fundal varices; pseudoaneurysm affecting the splenic, hepatic, gastroduodenal, and pancreaticoduodenal arteries; pancreatic ascites or pancreatic carcinoma.
Debilitating abdominal pain remains the most common presentation and indication for surgery in patients with CP. Three mechanisms are suggested for pain in CP in the absence of local complications:
- Inflammatory changes of pancreatic parenchyma with intrapancreatic and peripancreatic neural alterations
- Ductal and intraparenchymal hypertension
- Altered nociception of pain.
Management of painful TCP includes conservative treatment including analgesics, enzymatic supplementation along with dietary modification. Despite this, if pain persists, endoscopic or surgical treatment should be advised in the form of drainage of the pancreatic duct and removal of ductal stones. The main goal of the surgical treatment of CP is to alleviate severe abdominal pain and to manage pancreatitis-related locoregional complications. Avoidance of precipitating factors such as alcohol and tobacco consumption is very important in the management of ACP.
FP is very useful for CP patients with dense calcification or stones in the head of the pancreas and dilation of the MPD and mPP for dilated MPD without head mass. However, a proper selection of patients is the most integral part of achieving good results.
In our study, abdominal pain relief was achieved in 86.36% of the patients during 1 year follow-up period. 91.66% of patients undergoing FP experience postoperative pain relief and 62.5% of patients undergoing mPP experience postoperative pain relief at 1 year follow-up. FP was associated with significant postoperative pain relief (P = 0.0296) as compared to the mPP. Gestic et al. found that 91% of patients undergoing FP had pain relief after median follow-up period of 77 months. Negi et al. reported pain relief in 75% of patients undergoing a FP [chart 2].
Postoperative pain relief was better in TCP (92.86%) as compared to alcoholic CP (75%) (P = 0.0968). Postoperative pain relief in 24 out of 28 male patients (85.71%) and in 14 out of 16 of female patients (87.5%). Rajendra et al. reported the effectiveness of FP in TP from India in reducing pain along with significant improvement in health-related quality of life.
In our study, the mean duration of symptoms was 3.1 years in patients who had pain relief after surgery but it was 6 years in patients who had not pain relief after surgery. Poor pain relief in patients who had long duration of symptoms. Also, patients who had poor pain relief had mean duct diameter 6.58 mm and who had pain relief had duct mean diameter 9.9 mm. Study from Amudhan et al. concluded that small duct disease was associated with poor pain relief.
In our series mean weight gain at 1 year after surgery was 3.2 kg and the new onset of DM in two cases (4%) which is better than previous reports after FP for CP. So, these procedures are safe in terms of preserving endocrine function postoperatively. It is thought that more pancreatic parenchyma could be preserved by modified FP or modified Puestow's procedure compared to other resectional procedures. In study by Amudhan et al. 12.5% of patents who had diabetes were free from anti-diabetes medication at 12 months postsurgery and increase in mean body weight was 3.5 kg but 12.5% patients had new onset of steatorrhea at 1 year after FP.
In our study, operative morbidity Clavien-Dindo Grade 1 in 8%, Grade 2 in 4%, Grade 3 in 6%, Grade 4 in 2%, and Grade 5 in none without any mortality. Major complications (Clavein-Dindo Grade IIIa and above) were seen in 8%. Our results are in accordance with recent reports with operative mortality of <1% and morbidity ranging from 4% to 40% (averaging 20%) after surgical drainage.
| Conclusion|| |
FP was associated with better abdominal pain relief as compared to the mPP. Patients of TCP experience better postoperative pain relief than alcoholic CP. FP and mPP can be a safe option for patients with CP, with acceptable perioperative morbidity with adequate pain relief without worsening of pancreatic function.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]