**Surgical Indications and Techniques to Treat the Pain in Chronic Pancreatitis Chronic Pancreatitis**

**Surgical Indications and Techniques to Treat the Pain in** 

Alejandro Serrablo, Mario Serradilla Martín, Leyre Serrablo and Luis Tejedor Leyre Serrablo and Luis Tejedor Additional information is available at the end of the chapter

Alejandro Serrablo, Mario Serradilla Martín,

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/67032

#### **Abstract**

Chronic pancreatitis (CP) is a progressive inflammatory process, of the pancreatic gland and leads to damage and decrease in glandular tissue. Clinically, the pain is the most outstanding and incapacitating sign (95% of patients), as well as exocrine pancreatic insufficiency. The two main objectives in CP treatment are pain relief and complication management. Pain is the main surgical treatment indication. Patients with pancreatic duct dilation require surgical drainage, which provides an important pain relief (70–80%). Decompression (drainage), resection and neuroablation are the most commonly used surgical treatment options of CP. Derivative surgical procedures as Puestow-Gillesby or its modification, Partington-Rochelle, are the best options if the Wirsung duct is dilated, and Izbiki procedure if it is not. Resection is the choice when there is an important affectation of the head of pancreas with repercussion in bile duct or duodenum, as well as those patients with suspicion of carcinoma or in those ones who cannot be ruled a malignant tumour. The resection surgical procedures are Whipple, Traverso-Longmire, Frey (resective-derivative) and Beger (resective-derivative). To conclude, surgeon must know not only every surgical procedure indications but also be familiarised with all of them. The surgical procedure must be individualised to the patient and the disease stage.

**Keywords:** chronic pancreatitis, pain, surgical management

#### **1. Introduction**

Chronic pancreatitis (CP) is a progressive inflammatory process, which affects pancreatic gland and leads to damage and decrease in glandular tissue [1]. Clinically, the pain is the most outstanding and incapacitating sign (95% of patients), as well as exocrine pancreatic

insufficiency. The most important pathologic finding in CP is the replacement of normal pancreatic tissue for irreversible fibrosis [2–6]. The CP incidence is between 2 and 200 per 100,000 persons and shows an increasing trend year by year. Historically, excess alcohol consumption plays the leading cause role in Western countries, accounting for 60% of CP cases, although tobacco consumption, usually joined to alcohol consumption, plays the most important role in pancreas cell injury [7].

On the basis of the histopathological changes in the pancreas, CP can be classified into three types: (1) chronic obstructive pancreatitis, (2) chronic calcifying pancreatitis (the most common type of CP, which includes alcoholic CP) and (3) chronic inflammatory pancreatitis, including CP resulting from chronic inflammation of the biliary tract and stenosis induced by scar formation [8, 9].

In principle, patients with CP need medical treatment for long periods of time or indefinitely, as long as the medical treatment relieves symptoms and patients do not develop any complication requiring surgery. Disabling pain, analgesic treatment refractory or cause opiate dependence, is the most frequent symptom sets the surgical indication. However, other wellestablished surgical prescriptions are the complications of adjacent organs such as bile duct or duodenum stenosis, associated pseudocysts with ductal anomalies, pancreatic fistulas, ascites, gastrointestinal bleeding from oesophageal varices secondary to segmental thrombosis of the splenic vein and portal hypertension or inability to differentiate whether a pancreatic mass is really a focal CP or a neoplasia [10–13].

Furthermore, several authors suggest the superiority of surgical therapy over endoscopic therapy for chronic pancreatitis and pancreatic duct obstruction. However, many papers have been published on the possibilities offered by interventional endoscopy nevertheless the endoscopic therapy only reach a rate of 32% in pain relief, the worse result than any surgery procedure [14–20].

The two main objectives in CP treatment are pain relief and complications management. An optimum treatment must provide social and occupational rehabilitation as well as no pain recurrence. The problem is that there is neither an exact or validated measure of pain control nor randomised clinical studies comparing surgery with conservative treatment to help establish the indication of surgery [10]. It is usually recommended to consider surgery when the patient needs major opioids for more than 3 months and in case of treatment side effects or lack of obvious benefit [21–24].
