6.

Chronic Pancreatitis

‘A benign disease but with a progressive course’

Indications
What is the treatment of chronic pancreatitis?
Most patients with chronic pancreatitis can be managed conservatively with
abstinence from alcohol, low-fat diet, pancreatic enzyme replacement therapy
(PERT) (30,000-40,000 units of lipase with each major meal and 15,000-20,000
units with snack) with or without acid suppression with H2 blockers or proton pump
inhibitors (PPIs), analgesics (SOS) and antioxidants (e.g. ascorbic acid, retinoic acid,
beta carotene, tocopherol, methionine, selenium, etc).
NOTE Most pancreatic enzyme preparations are enteric-coated to protect the
enzymes from the gastric acid; these preparations help to reduce steatorrhea. Non-
enteric coated pancreatic enzyme preparations suppress cholecystokinin (CCK)
secretion thus reducing pancreatic enzyme secretion resulting in pain relief.
NOTE All surgical procedures in chronic pancreatitis are palliative only – no cure!
Except total pancreatectomy and islet cell transplantation (which also does not take
care of the exocrine insufficiency) or pancreas transplantation.
What are the indications of surgery in chronic pancreatitis?
1. Unrelenting pain not relieved by conservative treatment (vide supra) or
requiring frequent and/ or persistent use of opiate analgesics, side effects of narcotic
analgesics, narcotic addiction and/ or interfering with the activities of daily living
(ADL) or the quality of life (QoL)
2. Complications e.g. pseudocyst, biliary obstruction, duodenal obstruction,
pancreatic ascites, pseudoaneurysm, splenic or portal vein thrombosis, portal
hypertension
3. Suspicion of malignancy – pancreatic head ‘mass’
How do you measure pancreatic pain?
Izbicki score – includes the severity and frequency of pain, analgesic
requirements and quality of life (QoL)
What is head ‘mass’?
Lesion (>3-4 cm) seen on US/ CT/ MRI/ EUS with different echotexture/
density/intensity from the normal pancreas
It can be inflammatory e.g. chronic pancreatitis, groove pancreatitis; infective
e.g. tuberculosis (TB), autoimmune (e.g. autoimmune pancreatitis [AIP]) or
malignant (adenocarcinoma, lymphoma, pancreatic neuro-endocrine tumor [PNET]
or cystic pancreatic neoplasm [CPN] e.g. intraductal papillary mucinous neoplasm
[IPMN]).
How (when) do you suspect malignancy in a head ‘mass’?
Elderly, recent change in the nature of the pain (from recurrent to
continuous), recent significant weight loss, recent onset or worsening of diabetes
Common bile duct (CBD) >15 mm, pancreatic duct (PD) >10 mm
High (>10 mg) bilirubin, elevated (>100 U) CA 19-9
CP but no pancreatic pain; dilated CBD. What will you do?
Dilated common bile duct (CBD) alone, without pancreatic pain, is not an
indication for surgery in chronic pancreatitis. However, if the patient is being
operated for pancreatic pain – dilated CBD may also be tackled at the same time e.g.
by choledocho-duodenostomy or choledocho-jejunostomy.
Any non-surgical interventions for the management of chronic pancreatitis?
1. Endoscopic pancreatic sphincterotomy, balloon dilation of the pancreatic
duct strictures, pancreatic stone extraction and pancreatic duct stenting; large
pancreatic stones may be broken by extra-corporeal shock wave lithotripsy (ESWL)
before extraction
2. Neuroablation e.g. celiac plexus block or neurolysis (CPB or CPN) –
preferably EUS-guided
Which cases are suitable for endoscopic intervention?
Single proximal (head) stricture, no mass, not much stone load
Any other indication of endoscopic intervention in chronic pancreatitis?
Pancreatic fistula, pancreatic ascites
NOTE Endoscopic management is the treatment of choice for a communicating
pseudocyst, pancreatic ascites.
What are the expected benefits of operation for chronic pancreatitis?
1. Relief of pain
2. Doubtful improvement of exocrine and endocrine functions of the pancreas
(only after drainage procedures)
What specific information will you give to the patient before taking the consent for
the operation?
1. Not all patients will get pain relief
2. Pain can recur in the long term
What are the principles of operation for chronic pancreatitis?
 1. Relieve pancreatic ductal hypertension by draining the pancreatic duct
2. Remove pancreatic ductal calculi
3. Remove the pacemaker of pain in the pancreatic head (in Frey’s and
resectional procedures)
4. Preserve as much of the pancreatic parenchyma as possible
5. Relive obstruction of the adjacent organs
6. Deal with complications
How do you manage biliary obstruction in CP?
Management of the biliary obstruction in chronic pancreatitis depends on
i. etiopathology - whether caused by inflammatory edema of acute-on-chronic
pancreatitis (transient and reversible); fibrosis and stricture of chronic pancreatitis;
cyst or ‘inflammatory mass’
ii. severity – whether only elevation of alkaline phosphatase (ALP), intrahepatic
biliary radicle dilatation (IHBRD)/ common bile duct (CBD) dilatation, jaundice,
cholangitis, secondary biliary cirrhosis (SBC), portal hypertension
iii. philosophy of management - whether ductal drainage/ decompression alone is
enough (lateral pancreatico-jejunostomy [LPJ], Frey’s procedure anterior to the main
pancreatic duct) or whether the pacemaker in the head of the pancreas needs to be
taken care of (Frey’s procedure up to the posterior capsule)
For example:
Asymptomatic ALP elevation – no intervention
If intervening for chronic pancreatitis and the CBD is dilated – choledocho-
jejunostomy (CDJ) in the same loop as is used for the lateral pancreatico-
jejunosotomy (LPJ)
If doing Frey’s – pre and post Frey’s preoperative cholangiography (POC) to see if
the CBD got decompressed by the coring of the parenchyma in the head
i. CBD may get decompressed or even get opened in the cored out cavity of
pancreas head
ii. CBD may be intentionally opened and sutured to the pancreas
Mass – resection
Indications for intervention for biliary obstruction in CP
1. Symptoms e.g. cholangitis
2. Worsening LFT especially bilirubin, alkaline phosphatase (ALP) and gamma
glutamyl transpeptidase (GGTP)
3. Dilated CBD
4. Long CBD stricture
Investigations
What investigations (before operation)?
US
Contrast-enhanced (pancreatic protocol) CT – benign mass is diffuse, it
shows homogenous increased enhancement and calcification in the mass; malignant
mass is discrete, it is heterogeneously hypodense, there is no calcification within the
mass.
TIP CT also shows the amount (thickness) of the pancreatic parenchyma in front of
the pancreatic duct thus indicating the relative ease/difficulty of identifying the
pancreatic duct at operation.
MRCP (Secretin induced MRCP is preferred but secretin is not available in
India), Diffusion weighted MRI to differentiate between benign and malignant mass
TIP Many patients with chronic pancreatitis are young – the Author (VKK) tries to
avoid CT in them and prefers MRI/ MRCP. CT is better for evaluation of the mass
while MRCP is better for evaluation of the duct.
NOTE ERCP is NOT required for the diagnosis alone; it should be performed only
as a part of a therapeutic intervention (vide supra).
PET to differentiate between benign and malignant mass (though not very
useful)
UGIE to look for varices due to portal hypertension caused by splenic vein
thrombosis (SVT)
Contrast-enhanced US (CEUS) - a malignant mass does not enhance (cf. an
inflammatory mass, which does).
EUS guided FNAC
Tumor marker CA 19-9 (in pancreatic head mass)
NOTE CA19-9 may be normal in about 30% of patients with pancreatic cancer and
may be elevated in chronic pancreatitis without cancer.
NOTE The key issue in presence of a mass is to know whether it is inflammatory or
malignant.
Evaluation of pancreatic function – endocrine (blood sugars, preferably
glucose tolerance test [GTT]), HbA1C and exocrine (fecal fat, fecal chymotrypsin
and fecal elastase)
Why contrast-enhanced CT?
To detect vascular complications e.g. pseudo-aneurysm, splenic vein
thrombosis (SVT)
Pseudo-aneurysm of which vessels?
Splenic artery, gastro-duodenal artery, arteries of the pancreatico-duodenal
arcade
What if an aneurysm is found?
It needs to be angioembolised.
Any special technique of embolization for the aneurysm of the gastro-duodenal
artery?
It needs to be done form both sides viz. celiac and superior mesenteric
Why?
Because of the presence of extensive collaterals between the branches of the
gastro-duodenal artery and the pancreato-duodenal arteries around the pancreas
Any other option? Vascular radiologist is on leave?
US guided percutaneous puncture and injection obliteration of the
pseudoaneurysm by glue or thrombin
Genetics of chronic pancreatitis?
PRSS, SPINK, CFTR genes
Technique
What are the operative findings (in CP)?
Gland - irregular shrunken atrophic firm rubbery or woody (cf. soft normal),
diffuse (cf. localised in cancer) involvement, ‘mass’ may be present
Pancreatic duct - dilated, calculi (in the main or the secondary ducts)
Presence of pseudocyst
CBD may be dilated
What are the types of operations (for CP)?
Drainage procedures, resectional procedures and hybrid procedures
That is all? No other?
Silence!
For pain?
Celiac plexus block, thoracoscopic splanchnicectomy
How do you choose a surgical procedure in a given patient?
Choice of the surgical procedure depends on the ductal morphology, presence
or absence of a ‘mass’ and suspicion of malignancy.
How?
For dilated duct and thin atrophic parenchyma – drainage; inflammatory mass
in the head of the pancreas – Frey or Beger, suspicion of malignancy –
pancreatoduodenectomy
Indications for drainage procedures?
Drainage procedures are indicated primarily for ductal disease with dilated
(>6 mm) pancreatic duct and pancreatic ductal calculi.
Name a commonly performed drainage procedure?
Lateral pancreatico-jejunostomy (LPJ)
What is Duval’s procedure?
Amputation of the tail of pancreas with splenectomy to expose the pancreatic
duct on the cut surface and anastomosis of the cut surface (stump) of the pancreas to
the end of a Roux-en-Y limb of the jejunum
Duval described this procedure in 2 patients in 1954 – it is not performed these
days!
Any disadvantage?
It does not take care of the strictures in the remaining pancreatic duct.
What is Puestow Gillesby (1958) procedure?
Duval + opening of the pancreatic duct up to the neck of the pancreas – the
opened pancreatic duct in the body of the pancreas is anastomosed to the side of a
Roux-en-Y limb of the jejunum
Not performed these days.
So which drainage procedure is performed/ preferred these days?
Partington Rochelle modification (1960) of the Puestow Gillesby procedure - lateral
(longitudinal) pancreatico-jejunostomy (LPJ)
NOTE LPJ does not involve pancreatic tail amputation and there is no
splenectomy (cf. Duval).
What is it? How is it done?
Pancreatic duct is opened along its entire length from the head to the tail,
stones are removed and the opened pancreatic duct is anastomosed side-to-side to a
Roux-en-Y limb of the jejunum.
NOTE Stones in the secondary branches of the main pancreatic duct (MPD), in
minor pancreatic ducts and duct of the uncinate process are very likely to be missed
unless they are specifically looked for and removed.
Advantage of LPJ?
Preservation of the pancreatic parenchyma and function (cf. resection); may
be, even improvement of the pancreatic function
Problem/ limitation (of LPJ)?
Complete drainage of the ducts in the head and uncinate process is not
possible in presence of a bulky head of the pancreas – this is responsible for failure
after LPJ; such patients need a Frey’s.
Indications for resectional procedures?
Resectional procedures are indicated primarily for parenchymal disease and
undilated ducts (small duct disease); also for a pancreatic head ‘mass’ suspicious of
cancer (inflammatory pseudotumor).
Which resectional procedure?
Pancreatoduodenectomy (PD) - Whipple’s classical PD or pylorus preserving
PD (PPPD) or pylorus resecting PD (PRPD)
Any other? What is DPPHR?
Duodenum-preserving pancreatic head resection (Beger’s procedure 1972)
What is it?
Subtotal resection of the pancreatic head anterior to the portal vein (most –
almost 95% - of the parenchyma in the head of the pancreas is removed) - small rim
of pancreatic parenchyma within the C loop of the duodenum is preserved in order to
protect the pancreato-duodenal arcades and the duodenal blood supply – pancreas is
transected at its neck (in front of the superior mesenteric vein - portal vein) – the
remaining pancreas (head on one side and the body on the other) is anastomosed to a
Roux-en-Y limb of the jejunum – there are, thus, two pancreatico-jejunal
anastomoses (one to the end of the distal pancreas and other to the rim of the
pancreatic tissue in the head).
There is no opening of the pancreatic duct in the body and tail and there is
no LPJ in Beger’s.
Any specific adjacent vessels to be preserved?
Gastro-duodenal artery (GDA), superior pancreato-duodenal artery (SPDA)
and right gastro-epiploic artery (RGEA)
Advantage (of Beger’s procedure)?
It relieves biliary obstruction also.
Disadvantages (of Beger’s procedure)?
Technically difficult especially the step of making the tunnel behind the neck
of the pancreas before dividing the neck of the pancreas; bleeding
NOTE In Beger’s procedure, the dissection is around (behind) the pancreas cf.
Frey’s where it is within the pancreas.
 NOTE Beger’s procedure is mainly indicated for inflammatory head mass; it may
also be performed for benign tumors in the head of the pancreas.
What are various modifications of Beger’s?
Berne modification (described by Buechler in 2001) - resection of the
pancreatic head anterior to the portal vein - small rim of pancreatic parenchyma
within the C loop of duodenum is preserved – pancreas is NOT transected at its neck
– the remaining pancreas (i.e. the cored head) is anastomosed to a Roux-en-Y limb
of the jejunum – there is, thus, only one anastomosis.
There is no opening of the pancreatic duct in the body and tail and, hence,
there is no LPJ in Berne.

Table. Comparison of various surgical procedures for chronic pancreatitis

Pancreatic Pancreas Parenchymal Pancreatico-

duct is neck is resection in the jejunal
opened transected head of the anastomosis
along its pancreas
entire length
Frey’s Yes No Coring One
End-to-side
Beger’s No Yes Subtotal 95% Two
(DPPHR)
Berne’s No No Subtotal 95% One
Pancreato No Yes Total (all) One
duodenectomy

Any other (resectional procedure)?

Total pancreatectomy with islet cell auto-transplantation
How is resection in CP different from that in cancer?
 Chronic pancreatitis is difficult to resect (because of the peripancreatic
fibrosis and presence of collaterals due to portal hypertension) but easy to
reconstruct (because of low risk of pancreatic leak due to a firm pancreas, dilated
pancreatic duct and pancreatic parenchymal atrophy).
Disadvantage (of resections)?
Higher risk of exocrine (steatorrhea) and endocrine (diabetes) insufficiency
What are hybrid procedures?
Hybrid procedures are combination of the drainage and the resectional
procedures
Name some (hybrid procedure).
1. Frey’s (1987) - coring (unroofing of the pancreatic ducts) of the pancreatic
parenchyma in the head and uncinate process of the pancreas anterior (some
surgeons will core the parenchyma posterior to the ducts also right up to the posterior
capsule) to the pancreatic ducts (major and minor pancreatic ducts and the ducts of
the uncinate process) + opening of the entire pancreatic duct in the body and tail pf
the pancreas + LPJ (no transection of the pancreas at the neck cf. Beger’s where
there is no LPJ and the neck of the pancreas is transected ).
CAUTION The parenchyma posterior to the ducts may, however, be very thin
(atrophic) – there is a definite risk of going out of (behind) the posterior capsule
causing injury to the superior mesenteric vein/ portal vein.
NOTE In the cored pancreatic head and the uncinate process, the anastomosis is to
the pancreatic parenchyma (pancreato-jejunostomy) while in the body and tail, it is
to the pancreatic duct (pancreatico-jejunostomy).
2. Izbicki - Excision of a V-shaped wedge of the parenchyma anterior to the
pancreatic duct to expose the undilated pancreatic duct for jejunal anastomosis –
performed for undilated ducts
What are the various modifications of Frey’s?
Hamburg modification – Izbicki procedure + head coring
Advantages of Frey’s?
1. Helps identify an undilated pancreatic duct
2. Opens and drains all the ducts in the head and the uncinate process of the
pancreas (for this only anterior coring is enough)
3. Removes the pacemaker of the pain in the head of the pancreas (for this,
posterior coring is also required)
4. May decompresses the obstructed common bile duct (CBD)
NOTE Some pancreatic surgeons perform Frey’s (and NOT LPJ) as a routine in all
patients with chronic pancreatitis.
What are the options for head ‘mass’?
In presence of a pancreatic head ‘mass’, drainage or hybrid procedures are
contra-indicated – resection should be done because malignancy can not be ruled
out.
NOTE Risk of malignancy is much higher in idiopathic (tropical) pancreatitis seen
in India than in alcoholic pancreatitis seen in the West.
If resection is done, LPJ is added to drain the dilated duct in the body and the
tail of the pancreas.
What are the issues/ problems in a head mass?
Drainage done but histopathology reveals malignancy
Resection done but histopathology reveals no malignancy
How do surgical procedures for chronic pancreatitis affect the (pancreatic) function?
Drainage procedures may halt or even reverse the loss of function.
Resectional procedures worsen the loss of function.
How do you manage splenic vein thrombosis (SVT) in CP?
UGIE should be done to look for gastric varices. In presence of gastric
varices, if surgery is otherwise indicated for chronic pancreatitis, additional
splenectomy can be performed. Splenectomy alone is enough for SVT. Presence of
SVT and gastric varices alone are, however, not indications for surgery in chronic
pancreatitis.
How is obstructed (dilated) CBD in CP handled?
1. CBD may get decompressed by head coring alone in Frey’s (pre-and post-
coring intra-operative cholangiography [IOC] will confirm this)
2. CBD may get opened unintentionally into the cored out cavity in Frey’s
3. It may be marsupialized (opened) intentionally into the cored head of the
pancreas – the walls of the CBD may then be sutured to the pancreatic parenchyma
in order to keep it open
4. A formal choledocho-jejunostomy (CDJ) may be done into the same Roux
limb of the jejunum into which LPJ is done
5. Choledocho-duodenostomy (CDD) is an option if the duodenum is soft,
supple and mobilizable
6. CDJ or CDD alone, if pancreatic ductal surgery is not indicated (rare)
NOTE 1, 2 and 3 may work for a short (intrapancreatic) biliary stricture while a
long (suprapancreatic) biliary stricture may require 4 or 5.
Disadvantage of surgery
Short term pain relief is good but pain may recur after few weeks/ months
What are the reasons for failure after surgery for chronic pancreatitis?
Inappropriate choice of surgical procedure, incomplete drainage of the
pancreatic duct, incomplete coring of the head of the pancreas, residual calculi
Lateral Pancreatico-jejunostomy (LPJ)
Position
Supine
Anesthesia
General
Incision
Upper midline (most patients with CP are thin-built) or transverse, bilateral
(left > right) subcostal
What is required for a good LPJ?
Complete exposure of the head, body and the tail of the pancreas
How is the pancreas exposed?
Kocherisation of the second part (C loop) of the duodenum
Opening the lesser sac through the gastro-colic ligament (omentum);
adhesions between the posterior wall of stomach and the anterior surface of the
pancreas are divided. Transverse mesocolon is taken off the anterior surface of the
pancreas.
Which vessels need to be divided?
Gastro-colic trunk (GCT) of Henle
Some epiploic (omental) vessels and some short gastric vessels
Which vessels need to be saved (preserved)?
Right and left gastro-epiploic vessels and the gastro-epiploic arcade
NOTE Right gastro-epiploic vessels may sometimes have to be divided to
expose the head and the neck of the pancreas.
How do you identify the pancreatic duct?
1. A dilated pancreatic duct may even be seen or felt as a soft fluctuant
longitudinal bulge or depression on the anterior surface of the body of the pancreas
between its upper and lower borders through the thinned atrophic parenchyma
2. Needle puncture on the anterior surface of the body of the pancreas
midway between the superior and inferior borders of the body of the pancreas and
aspiration of clear watery pancreatic fluid or sounding of a large calculus in the main
pancreatic duct
3. Coring of the parenchyma in the head of the pancreas
4. Transverse or oblique (vertical) incision perpendicular to the long axis of
the body of pancreas (rarely required)
5. Amputation of the tail of pancreas (rarely done)
5. Duodenotomy and papillary cannulation (rarely done)
6. Preoperative placement of pancreatic stent/ENPD (rarely done)
Any gadgets/ investigations (to help identify the pancreatic duct)?
Intraoperative US (IOUS) – a fine needle is then passed into the pancreatic
duct under US guidance – the needle is left in situ and a pancreatotomy is made on
the needle to expose the pancreatic duct
Anything (drug) can help?
Secretin to stimulate pancreatic secretion so as to distend the duct
How is the Roux limb taken up?
Through a mesocolic window to the left of the middle colic artery
How is the Roux limb placed in relation to the pancreas?
The closed end of the Roux limb is taken to the tail of the pancreas.
How is the (PJ) anastomosis done?
1. Two layers (if the parenchyma is thick)
Outer layer pancreatic capsule and the outer part of the gland (parenchyma)
to the seromuscular layer of the jejunum
Inner layer pancreatic duct (mucosa) to the full-thickness of the jejunal wall
2. Single layer (if the parenchyma is thinned and atrophic) – the pancreatic
capsule, gland (parenchyma) and the pancreatic duct (mucosa) together to the full-
thickness of the jejunum
If there is a pseudocyst also (along with CP)?
It can also be drained in the same Roux limb which is used for the LPJ.
If there was a pseudo-aneurysm which could not be embolized?
It may either be excised or double (proximal and distal) ligated.
How can you get intraoperative tissue diagnosis in head ‘mass’?
Transduodenal fine needle aspiration cytology (FNAC) or core biopsy
Why not incisional biopsy?
Incisional biopsy from the surface may be negative even in the presence of a
tumor – due to the peritumoral fibrous desmoplasia.
Complications
Any intraoperative problems?
Splenic/ portal vein thrombosis causing splenomegaly and collaterals around
the pancreas
CASE Chronic calcific pancreatitis with splenic vein thrombosis (SVT) – taken up
for LPJ – extensive collaterals in the lesser sac – massive bleeding – pancreas could
not be accessed.
What will you do?
Non-surgical management in the form of extra-corporeal shock wave
lithotripsy (ESWL) for large pancreatic calculi combined with endoscopic
pancreatic sphincterotomy and pancreatic duct stenting
Intraoperative complications of LPJ?
Injury to the splenic vein lying posterior to the thinned pancreatic
parenchyma (while opening the pancreatic duct in the distal body or the tail of the
pancreas)
What will you do if such an injury/ bleed occurs?
Firm pressure with a sponge for at least 5-10 minutes – bleeding from a small
hole may get controlled with pressure alone because the vein is adherent to the
posterior surface of the pancreas due to extensive peripancreatic inflammatory
fibrosis.
(Bleeding) still not controlled?
Depending upon the location of the injury, the splenic vein may be exposed
from behind by mobilizing the spleen medially and then bleeding can be controlled.
ANECDOTE The Author (VKK) has once had such an injury; fortunately, the bleed
could be controlled with pressure. In another case, while looking for the pancreatic
duct, the pancreatic parenchyma got completely transected.
Problems after surgery
Residual pain (not all patients get pain relief), recurrence of pain after initial
relief, missed malignancy (especially in presence of a head mass)
This patient underwent LPJ for CP but continues to have pain. What could be the
possible cause?
Unopened, undrained duct with calculi
Where? In which part of the pancreas?
More commonly in the uncinate process
What about anastomotic leak?
 Anastomotic leak is uncommon after LPJ.
Why?
Because of atrophic parenchyma due to CP
Frey’s Procedure
Which patients are suitable candidates for Frey’s?
Undilated ducts, multiple small calculi in the thick parenchyma of the
pancreatic head
Which are not?
Atrophic parenchyma with dilated ducts and large calculi (such cases are
candidates for drainage procedure only) – coring of the parenchyma may worsen the
endocrine and exocrine insufficiency
What is an important prerequisite for Frey’s?
Complete kocherisation of the duodenum so that a hand can be placed behind
duodenum and the pancreatic head
Why?
To stabilize and push the head of pancreas anteriorly for better exposure and
access
For manual pressure to control the bleeding if it occurs
TIP The head of the pancreas should be in the left hand of the surgeon – four fingers
behind and the thumb in front. This pushes the pancreas head anteriorly for better
manipulation but, more importantly, any bleed in the cored parenchyma can be
easily temporarily controlled with bidigital pressure.
Gastro-duodenal artery (GDA) ligation in continuity (to decrease the
bleeding during the coring of the head of the pancreas)
Coring (removal in bits and pieces, layer by layer) of pancreatic parenchyma
in the head of the pancreas anterior to the ducts (minor, major and uncinate)
NOTE Some surgeons perform an extended (deep) Frey’s i.e. coring of the
parenchyma even behind (posterior to) the ducts reaching up to the posterior
pancreatic capsule.
NOTE Pancreas neck is not divided in Frey’s (cf. Beger’s, where it is divided).
A specific intra-operative complication of Frey’s
Bleeding from the cored parenchyma due to injury to the anterior
pancreatico-duodenal arcade of vessels between the head of the pancreas and the C
loop of the duodenum
How can this be prevented?
i. By taking multiple deep sutures in the pancreatic parenchyma about 1 cm
from the duodeno-pancreatic groove
ii. Ligation (in continuity) of the gastro-duodenal artery (GDA)/ anterior
superior pancreato-duodenal artery (ASPDA)
CAUTION This may, however, compromise the duodenal blood supply.
While doing coring in the head of the pancreas, you see bile?
This indicates that the CBD has got opened – it may be left as it is to drain
into the cavity in the cored head of the pancreas; a few interrupted sutures may be
taken between the opened CBD and the pancreatic parenchyma or a formal
choledocho-jejunal anastomosis may be done into the same limb which is used for
the LPJ (if the CBD is dilated).
The cored tissue is sent for frozen and is positive (for malignancy)?
The tumor has already been breached; prognosis is poor so I will not do
pancreatoduodenectomy but give chemo-radiotherapy (CRT).
NOTE Pancreatoduodenectomy may be done in some selected patients by an
experienced high-volume surgeon but the outcome is likely to be poor.
Final histopathology of the cored tissue shows cancer?
Chemo-radiotherapy (CRT) as the outcome is very poor.
Ward Rounds
This young man with recurrent upper abdominal pain was diagnosed as
chronic pancreatitis and underwent LPJ in 2006. He was alright until 2008 when he
started having pain again with steatorrhea. He also had UGI bleed – UGI endoscopy
showed gastric varices (due to splenic vein thrombosis [SVT]) and blood in the
duodenum (hemosuccus pancreaticus). CT angiography revealed an aneurysm in the
inferior pancreato-duodenal artery (IPDA) which was embolized with coils. Pancreas
was small and atrophic; there was no mass and the duct was not drainable.
Is it recurrence of CP or cancer? Which investigations will help?
Tumor marker CA 19-9, EUS, DW-MRI, PET and guided FNAC
Will he need a pancreatoduodenectomy?
It will be technically difficult; the gland is already atrophic and the patient
has steatorrhea which is likely to worsen after PD.
What will you do if a patient with CCP has a pseudo-aneurysm of the splenic artery?
Treatment of choice for pseudoaneurysm of the splenic artery is
angioembolization
Embolization where?
 Both proximal and distal to the pseudo-aneurysm
Why both?
If only proximal angioembolization is done, the pseudoaneurysm can get
filled from the collaterals
Any other option? Vascular radiologist is on leave.
US guided percutaneous puncture and injection obliteration of the pseudo-
aneurysm by glue or thrombin
Total Pancreatectomy
Islet Auto-transplantation (IAT)
Indication
End stage pancreatic disease (ESPD) – incapacitating chronic pancreatitis
(severe pain requiring narcotic analgesics)
NOTE Total pancreatectomy should be offered only when the patient has reached
incapacitation with no other surgical alternative – usually as a salvage for failure
after previous surgery.
Requirement
Preserved islet cell function (i.e. no diabetes)
How are islet cells separated from the parenchyma?
An islet suspension is prepared using the enzyme collagenase.
(Islets) Transplanted where?
Into the portal vein
Or (other than portal vein)?
Into the peritoneum or omentum
Postoperative monitoring
Strict glucose monitoring, insulin drip
Outcome
Good (80-90%) pain relief but poor (30-40%) insulin independence
Pancreas transplant
See Ch 31 Transplant

Pancreatic Ascites
Patient with known chronic pancreatitis presents with painless abdominal distension.
I would like to examine the abdomen.
Examination revels free fluid.
This is pancreatic ascites
TIP A better and complete answer should have been ‘I would like to examine the
abdomen to look for ascites’.
Treatment
Paracentesis, nil per oral (NPO), total parenteral nutrition (TPN), octreotide
Endsocopic pancreatic sphincterotomy and pancreatic duct stenting
Annular Pancreas
What is annular pancreas?
A ring of pancreatic tissue surrounds the second part of the duodenum
Where (how) is this ring divided?
Division of the annular pancreatic ring is not the treatment of annular
pancreas.
A catch question!
Why?
It may result in pancreatic juice leak and fistula.
So (what is done)?
Bypass of the duodenal (2nd part) obstruction in the form of duodeno (1st
part)-jejunostomy.