What are the surgical options for pain management in chronic pancreatitis?

Surgical Options for Pain Management in Chronic Pancreatitis

Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis, as it provides better long-term outcomes for pain relief and quality of life. 1

Primary Surgical Approaches

• Longitudinal pancreaticojejunostomy is the most appropriate surgical management for chronic pancreatitis with pancreatic duct ectasia 1
• Duodenum-preserving resections offer benefits compared to pancreaticoduodenectomy for patients with an expanded pancreatic head 2
• Pancreaticoduodenectomy (Whipple procedure) should be reserved for cases with suspected malignancy or inflammatory mass in the head of pancreas 1, 3
• Distal pancreatectomy may be appropriate for a small population with focal stricture and tail-only disease, though long-term results are generally poor 2
• Total pancreatectomy with islet cell autotransplantation represents the only valid surgical option for small duct/minimal change disease, producing excellent long-term results for pain control 2

Timing of Surgery

• Postponing surgical interventions for more than 4 weeks after the onset of acute pancreatitis results in less mortality 4
• Recent evidence suggests that surgical intervention should not be considered only as last-resort treatment, as earlier intervention can mitigate disease progression, achieve better pain control, and preserve pancreatic function 5

Step-Up Approach for Necrotizing Pancreatitis

• In infected pancreatic necrosis, percutaneous drainage as the first line of treatment (step-up approach) delays surgical treatment to a more favorable time or may even result in complete resolution of infection in 25-60% of patients 4
• Minimally invasive surgical strategies, such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD), result in less postoperative new-onset organ failure but require more interventions 4

Endoscopic Alternatives in Select Cases

• Endoscopic intervention may be considered as an alternative to surgery for suboptimal surgical candidates or those who prefer a less invasive approach 4, 1
• For pancreatic duct stones causing obstruction:
  • Small (≤5 mm) main pancreatic duct stones can be treated with pancreatography and conventional stone extraction maneuvers 4
  • For larger stones, extracorporeal shockwave lithotripsy (ESWL) and/or pancreatoscopy with intraductal lithotripsy may be required 4
• For pancreatic duct strictures:
  • Prolonged stent therapy (6-12 months) is effective for treating symptoms and remodeling main pancreatic duct strictures 4
  • The preferred approach is to place and sequentially add multiple plastic stents in parallel (upsizing) 4

Celiac Plexus Block for Pain Management

• Celiac plexus block should not be routinely performed for pain management in chronic pancreatitis 4
• This procedure may be considered in selected patients with debilitating pain in whom other therapeutic measures have failed, but only after discussion of the unclear outcomes and procedural risks 4
• Available observational studies suggest pain relief may be achieved in 50-60% of patients with a duration of benefit of 6 months or less 4
• Common adverse events include diarrhea and orthostatic hypotension; major adverse events (e.g., abscess formation, intravascular injection, paralysis) occur in <1% of patients 4

Factors Affecting Surgical Outcomes

• Risk factors for poor pain control after surgery include:
  • Pancreaticoduodenectomy procedure type
  • Preoperative narcotic dependence
  • Previous abdominal operations
  • Absence of gallstone pancreatitis history 3

Mechanisms of Pain in Chronic Pancreatitis

• Two main complementary pathogenetic theories explain pain mechanisms in chronic pancreatitis:
  • Neurogenic theory: alterations of pancreatic/peripancreatic nerves exposed to noxious substances and/or activated immune cells ("neuroimmune interaction") 6
  • Intraductal/intraparenchymal hypertension theory: pain generated from increased pressures within the pancreatic ductal system and/or parenchyma, similar to compartment syndrome 6

The surgical approach should be selected based on the specific morphological disease variant present in the individual patient, with consideration of the underlying pain mechanism, disease progression, and patient-specific factors affecting surgical outcomes.