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Surgery

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GIT

Question
223 out of 286
 

A 30 yr old male presented to the clinic with history of acute severe epigastric pain since 2 days. He gave history of similar attacks of moderate intermittent pain in the past since 2 years which most of times use to get relieved with the prescribed analgesics. This time the pain was severe and not relieved by analgesics. His Ultrasound and CT abdomen studies were done which revealed diagnostic findings. With which of the following surgery the will be most benefited?



A Antrectomy with selective vagotomy

B Anterectomy with highly selective vagotomy

C Whipple’s operation

D Longitudinal pancreatico-jejunostomy

Ans. D Longitudinal pancreatico-jejunostomy. (Ref. Sabiston textbook of surgery 18th/pg. 1663)

Surgical Treatment of Chronic Pancreatitis

The two indications for surgical intervention are pain and concern about the possible presence of cancer.

After the diagnosis of chronic pancreatitis has been established, surgical intervention is considered when:

a. The pain is severe enough to limit the patient's lifestyle or reduce productivity, and

b. The pain persists despite complete abstinence from alcohol and administration of non-narcotic analgesics.

Imaging studies are performed to define pancreatic and ductal anatomy because that will determine the surgical options.

Finally, the risks and benefits of planned procedures must be clearly explained to the patient because, even with a technically successful operation, the pain may persist, and further deterioration in exocrine and endocrine function can still occur.

IF PATIENT IS RESPONDING TO ANALGESICS, SURGERY (perhaps Lateral pancreaticojejunostomy is our case) IS NOT INDICATED.

Treatment

a. A diet low in fat and with no alcohol is advised.

b. Pancreatic enzyme supplementation may reduce the frequency of painful crises.

c. Attention must be paid to nutrition to ensure that the patient gains weight and takes an adequately varied and nutritionally appropriate diet.

d. The use of morphineshould be avoided and tobacco smoking curtailed.

e. There is no single therapeutic agent which has been shown to relieve symptoms, although the use of antioxidants to mop up free oxygen radicals has been tried.

f. The role of surgery is in overcoming obstruction and removing mass lesions.

g. Most patients have a mass in the head of the pancreas, for which a resection of the head of the pancreas either by a pancreatoduodenectomy or a Beget procedure is appropriate.

h. If the duct is markedly dilated, then a longitudinal pancreatojejunostomy or Frey procedure can be of value.

i. The rare patient with disease limited to the tail will be cured by a distal pancreatectomy.

Prognosis

a. Correctly chosen surgery will relieve symptoms in 75 per cent of patients provided that the aetiological factor is removed.

b. Development of pancreatic cancer is a risk in those who have had the disease more than 20 years.

CURRENT TRENDS AND NEW DEVELOPMENTS IN THE SURGICAL MANAGEMENT OF CHRONIC PANCREATITIS

The operative strategy for chronic pancreatitis should take into account specific alterations in pancreatic morphology and ductal anatomy.

Preoperative evaluation of pancreatic endocrine and exocrine function should be done routinely, along with endoscopic retrograde cholangiopancreatography (ERCP).

a. Patients with major duct dilatation, which is determined preoperatively by ERCP or at operation by gross inspection or with intraoperative pancreatography, should be treated by duct drainage into a Roux-en-Y limb of the jejunum.

b. The major pancreatic duct should be filleted extensively to allow construction of an 8- to 10-cm-long pancreatico-jejunal anastomosis.

c. Concretions involving the primary and secondary pancreatic ducts should be removed to eliminate foci of smoldering pancreatitis. Patency of the ampulla of Vater should be confirmed with a probe to establish or improve antegrade duct drainage.

d. Although the relationship between duct decompression and pain relief is unclear, Warshaw and associates advocate direct apposition of pancreatic duct and jejunal mucosa to ensure long-term anastomotic patency and to prevent late stricture formation.

e. Duct drainage can be accomplished with low mortality and acceptable morbidity. However, progression of endocrine and exocrine pancreatic insufficiency after pancreaticojejunostomy and a reoperation rate of almost 20% for late failures indicate that duct drainage does not alter the natural history of chronic pancreatitis.

f. Despite the relatively high late failure rate following pancreaticojejunostomy, there is evolving evidence to suggest that early duct decompression "may" delay progressive loss of pancreatic function.

g. Near-total (80 to 95%) distal pancreatectomy or total pancreatectomy has generally been reserved for patients with severe pancreatic fibrosis and small or normal-sized major pancreatic ducts and for late failures after lesser resections or earlier duct drainage procedures.

h. Although satisfactory pain control has been achieved in most patients subjected to extensive pancreatic resection, these procedures have been criticized because of serious metabolic sequelae (e.g., insulin-dependent diabetes and steatorrhea).

i. Proximal pancreaticoduodenectomy (Whipple procedure)involving primarily the head of the pancreas. Despite the technical difficulty of the operation and the additional complexity of restoring biliary, pancreatic, and gastrointestinal continuity, the procedure can be accomplished with perioperative mortality and morbidity rates of 5 and 30%, respectively.

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