Surgeries for Pancreatitis: June 2007

Sphincteroplasty

A muscular sphincter that surrounds the duct (just before it drains into the intestines) can block off the pancreatic duct. At ERCP, it is possible to measure the pressures in this sphincter and if they are high and causing problems, then the sphincter can be cut with an endoscopy knife. After cutting the muscular sphincter, scarring may develop in the substance of the pancreas and block off the pancreatic duct at a later time. This type of scar can't be cut or opened up with an endoscope and surgery may be necessary. If the pancreatic duct is dilated, then the problem can be fixed with a Puestow procedure. If the pancreatic duct does not become dilated, then a Whipple procedure can be successfully used in treating this problem.

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Puestow Procedure (Lateral Pancreatico-jejunostomy)

During a Puestow procedure, also known as a lateral pancreatico-jejunostomy, the abdomen is opened with an incision from the lower breastbone to the umbilicus. The pancreas is exposed and the main pancreatic duct is opened from the head to the tail of the pancreas. The opened pancreatic duct is then connected to a loop of small intestine so that the pancreas drains directly into the intestines. This procedure has been done with much success in treating pain associated with chronic pancreatitis for over 50 years. With a success rate of 70 - 90 percent, this procedure has a low operative complication rate and a very low mortality rate. Dr. Adams' experience with this operation has been published and reported at national meetings in the past.

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Whipple Procedure

The Whipple procedure has been used increasingly over the last ten years in treating pain and other complications of chronic pancreatitis. Best known for its use in the treatment of pancreatic cancer, the procedure has a success rate of 70 - 80 percent in treating chronic pancreatitis. This operation involves removing the head of the pancreas that shares its blood supply with the first part of the small intestine. The first part of the small intestine is also removed along with the gallbladder and part of the bile duct. Things are put back together by connecting the small intestine to the remaining pancreas, the bile duct, and the stomach. When used in the treatment of cancer, the Whipple operation has a complication rate of 30 - 40 percent and a mortality rate of less than two percent. The complication and mortality rate may be similar or lower in its treatment for chronic pancreatitis depending on the severity of the pancreatitis and the medical condition of the patient.

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Frey Procedure and Distal Pancreatectomy

Frey Procedure: Failure of the Puestow procedure may be caused by poor drainage of the head of the pancreas. To improve drainage of the pancreatic head, the Puestow procedure may be combined with removal of part of the head of the pancreas resulting in what is called the Frey procedure). This operation is done by coring out the diseased portion of the head of the pancreas to improve drainage of ducts in the head of the pancreas that would not otherwise be drained doing the traditional Puestow operation. Dr. Frey has reported good outcome with this procedure and can be done without increasing the risks of the Puestow procedure.

Distal Pancreatectomy

The term distal pancreatectomy describes resection of variable amounts of the body and tail of the pancreas. Partial pancreatic resection is recommended for patients with diffuse (moderate to severe) parenchyma disease without ductal dilation, especially in the tail and body. Local resection of major pancreatic sites of involvement may be sufficient for those patients with regional disease, whereas a 95% distal resection is recommended for patients with diffuse disease. Ninety-five percent distal pancreatectomy entails removal of the spleen and almost all of the pancreas, except for a thin rim of tissue within the "C" loop of the duodenum. Splenic preservation is attempted, but often fails because dissection of splenic vessels from the chronically inflamed and scarred pancreas is extremely difficult. This procedure provides pain relief for 75–80% of patients and has a mortality rate less than 5%.

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Total Pancreatectomy With Auto Islet Cell Transplant

Total Pancreatectomy: Removal of the entire pancreas is utilized on occasion to treat chronic pancreatitis when other treatments are unsuccessful. This operation has no additional complication rate compared to the Whipple procedure. Removal of all the insulin-producing cells of the entire pancreas may cause a form of diabetes that is difficult to manage. Some hospitals and surgeons offer total pancreatectomy combined with transplantation of the patient's own insulin-producing cells, (Auto Islet Transplantation) in order to keep the patients from becoming diabetic. (TP/ICT)
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Auto Islet Transplantation: Transplantation of the pancreatic cells that produce insulin (islet cells) has been studied for many years, and usually involved transplanting healthy islet cells from a cadaver donor to a diabetic patient. This requires medicines to fight rejection of cells transplanted between different individuals.
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In patients with chronic pancreatitis, it is possible to remove the entire pancreas and to harvest islet cells from the pancreas.Patients can have their own insulin-producing cells transplanted and do not need to worry about rejecting these cells. This has been done with success since 1977, and is a promising new area in the treatment of chronic pancreatitis. In particular, it is useful in patients who have a pancreas that has healthy insulin-producing cells. This could include patients who have familial pancreatitis, pancreas divisum or sphincter of Oddi dysfunction.