Operative procedures for chronic pancreatitis are performed to alleviate chronic pain, improve the patient’s quality of life, and prevent complications that can arise from chronic inflammation of the pancreatic tissue. The cause of the pain is believed to be due to obstruction of the pancreatic duct and increased pressure of pancreatic juice in the canalicular system, compression of the nerve plexuses located behind the pancreas, or an inflammatory mass, typically found in the head of the pancreas.
The type of operative procedure that will be applied in the treatment of the patient depends on the degree of inflammation of the pancreatic tissue, the presence of calculi in the pancreatic ducts, their localization and number, and the presence of obstruction at the level of the pancreatic or biliary duct caused by calculus or fibrosis of the pancreatic tissue.
Operative procedures are classified into drainage, resection, and drainage-resection procedures.
Enlargement of the pancreatic duct by more than 7mm in patients with chronic pancreatitis can often be the cause of chronic abdominal pain. Adequate drainage of the pancreatic duct, reduction of pressure in the pancreatic ducts, and reduction of pain can be achieved through a drainage surgical procedure.
This is the most common drainage procedure for chronic pancreatitis in clinical practice. It involves a longitudinal opening of the pancreatic duct with maximum preservation of pancreatic tissue. The created opening is then connected to the small intestine (pancreatico-jejunostomy), allowing the unhindered discharge of pancreatic juice into the small intestine. Follow-up of patients in the early postoperative period showed that in more than 70% of those operated on, this drainage procedure leads to the complete removal of abdominal pain.
Cephalic duodenopancreatectomy, distal pancreatectomy, as well as total pancreatectomy are resection procedures used in patients with chronic pancreatitis. These operations are typically used for malignant pancreatic tumours and are rarely performed in chronic pancreatitis.
Duodenum-preserving resection of the head of the pancreas (Beger’s procedure)
This procedure involves cutting the head of the pancreas at the level of the neck and forming a junction of the rest of the pancreas with the small intestine (pancreatico-jejunostomy). Resection of the inflamed head of the pancreas achieves a decompression effect on the main bile duct and pancreatic duct. The advantage of this procedure is that, despite the removal of the head of the pancreas, the blood vessels that feed the duodenum, which are located in the immediate vicinity of the operation, are preserved, thus preserving biliodigestive integrity.
This procedure is a modified combination of the Beger and Partington Rochelle procedures. Compared to Beger’s procedure, it involves a smaller extent of pancreatic head resection. In addition to the resection of the pancreatic head, this procedure also involves the longitudinal opening of the pancreatic duct with the creation of a connection between the open pancreatic duct and the small intestine. This achieves a decompressive effect on the bile duct in the region of the head of the pancreas with unhindered outflow of pancreatic juice through the created pancreatico-jejunostomy.
If there are inflammatory tissue changes in the neck of the pancreas or portal hypertension, cutting the pancreas at the neck level, as in the Beger procedure, poses a risk. In such cases, a modified Bern procedure is performed, where the head of the pancreas is cut while preserving its neck. The junction with the intestine is created on the resected surface of the pancreas.
The primary indication for operative treatment is pain caused by chronic pancreatitis. Initially, conservative, non-operative therapy using various analgesics is employed. If the pain becomes unresponsive to analgesic therapy, surgery is carried out. The previously mentioned procedures successfully alleviate pain in over 90% of patients. Operative treatment is also necessary for compressive syndrome due to an enlarged fibro-inflammatory mass, primarily in the region of the head of the pancreas, which can lead to compression on the duodenum, bile duct and portal venous system.
Surgical complications that are specific to these procedures are rare. Bleeding, extremely rare pancreatic juice spillage, portal vein thrombosis or bile leakage are possible in the postoperative course.
The patient spends one night in the intensive care unit. On the first day, fluid intake begins. The average hospital stay is five days.
