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Chronic Pancreatitis

 

Chronic inflammation of the pancreas

 

Chronic inflammation as the most frequent disease of the pancreas

The pancreatitis is characterized by an intermittently reappearing inflammation of the organ, in most cases in the region of the head of the pancreas. Because of the repeated inflammation, the tissue of the pancreas is damaged in the long run. It is also degraded and substituted by scar tissue and calcifications. The main causes of chronic pancreatitis lie in an elevated consumption of alcohol for several years, calculosis of the bile ducts, trauma, or genetic defect. For part of the patients, the reasons remain unknown. From the above mentioned function of the pancreas result also certain complications that occur later: impaired digestion in form of fatty stools, diarrhoea or obstipation, disturbance of the drainage of the bile, failures in the glucose system, persistent tissue defects after healing in form of great cysts (pancreatic pseudocysts) and abscesses, vascular occlusion of the neighbouring arteries and veins as well as chronic pain in the upper abdomen that is worst for the patient to endure.

How do I recognize chronic pancreatitis?

Unfortunately, the complaints with which the patients consult a doctor are very different. What is the reason? The cardinal symptoms of this disease are pains, which radiate in such a way from the upper abdomen to the shoulder or to the lumbar vertebrae that the afflicted patient often consults an orthopaedist first. The attacks of pain are relatively short at the beginning, but with the disease progressing, they occur more often and last longer until they lead to a case of "burn-out" inflammation. At the beginning, patients often complain of nausea and vomiting, indigestibility of food and bloating, however without feeling pain. That is why the doctor has to diagnostically confirm chronic pancreatitis against other diseases of the stomach or the bowels by an exact questioning of the patient. Important questions in this context are about nutritional habits, consummation of alcohol, loss of weight, and pain in the upper abdomen. The physical examination consists mainly of the palpitation of the upper abdomen, along with an assessment of the gall bladder and the liver. Further, the colour of the skin has to be evaluated (yellow skin in the case of bile stasis). The next step will be a blood analysis to establish the values of the two most important substances of the pancreas, lipase and amylase. Of further interest are the glucose level and some liver values, so that a bile stasis can be ruled out. Finally, some other methods are used to confirm the diagnosis: an ultrasound examination of the abdomen provides the doctor with a good orientation concerning all organs in the upper abdomen. At the same time, calcifications in the pancreas can be diagnosed and provide first hints for a disorder. Yet, an exact assessment of the size and status of the pancreas can only be made after a CT-examination of the abdomen (Fig. 2, 2b, and 3). If considered necessary, an ERCP-examination will be used to visualize the common bile duct and the pancreatic duct. This more complicated but exact method of diagnostics is used to make sure that there is "only" a chronic pancreatitis and not a tumour causing the complaints.

 

What is the treatment of chronic pancreatitis?

The treatment of chronic pancreatitis is based on two different therapies: first, there is the conservative therapy applying several medicines and a diet. Surgery follows only if the patient's pains don’t stop. The conservative therapy demands absolute abstinence of alcoholic drinks, a balanced diet with a limitation of fats (possible also a diet which is suitable for diabetics), substituting digestive enzymes, and taking medicine to block the production of digestive juice. In some cases, the liposoluble vitamins A, D, E, and K have to be substituted by means of intravenous injections. The main focus of conservative therapy is, however, the individually adapted analgesic therapy applying pain killers, which are centrally and/or peripherally active (morphine/panadol). For many years, the increase of pressure in the pancreatic duct as well as the calcification of the tissue was held responsible for the pains accompanying chronic pancreatitis. But more recent studies have also shown changes in local nerves. If these measures taken against pain should not be successful, one would resort to an ERCP-examination as an interventional therapy. Interventional means that this is a method between a conservative and a surgical one. Here, it means an endoscopically controlled widening of the pancreatic duct and/or of the bile duct.

If necessary, a small pipe is implanted to improve the drainage of the bile and of the digestive juice. Operative methods are only resorted to if the pains cannot be otherwise alleviated, if there is a significant congestion in the pancreatic duct or, in the case of an enlarged head of pancreas, if bile and digestive juice cannot drain into the duodenum. The already mentioned complications of chronic pancreatitis - pseudocysts, abscesses, and haemorrhage - make a surgical intervention necessary. Generally, one distinguishes between methods of draining and methods of resection. The aim of the surgeon, however, always remains to preserve as much tissue of the pancreas as possible, so that the gland’s function is not further restricted. It has to be emphasized that all these operations belong in the hands of a highly specialized surgeon because in such cases, excellent planning, high-tech materials, but, above all, immense surgical experience are essential. The most difficult part in the process is the stitching of different types of tissue, for instance of tissue of the pancreas and that of the small bowel, as their structure is entirely different. This explains the surgical challenge involved very well. If drainage is carried out, the congested and enlarged pancreatic duct is "only" deviated into the small bowel, but the chronically inflamed tissue of the head of the pancreas stays in its place. The technique is called pancreaticojejunostomy. The surgical methods are divided into the following categories:

Chronische PankreatitisClassical duodenopancreatectomy (Kausch/Whipple) see Fig. 4

The cervix of pancreas, the pylorus, the duodenum, the bile ducts, and the gall bladder are removed and their drains connected to the small bowel. This operation was believed to be very dangerous and of little success for many years. Today, the progress of surgery, modern methods of anaesthesia, intensive care, and intensive medicine have led to good results. The course of the operation is - in short - as follows: the surgeon gets access to the pancreas by a transverse incision in the upper abdomen or by a vertical incision. The head of the pancreas and of the nearby duodenum are exposed. At the lower rim of the pancreas, the portal vein (the big vein from the bowels to the liver) behind the neck of the pancreas is fully exposed. Then, the main bile duct is severed, and the gall bladder is removed. The cervix of the pancreas is also cut. The next step is to suture one part of the small bowel to the cervix of the pancreas. With a distance of about 15 cm, the bile duct is inserted. Finally, the gastric stump is sewn to the small bowel.

The resection of the pancreas with conservation of the duodenum (modified by Berger)

It means the excision of the head of the pancreas, the greater part of which is inflamed. But it conserves the close-by stomach and the duodenum, so that the food channel remains undisturbed. Then, the drains of the gall and the pancreas into the small bowel are restored. At the end of both surgical procedures, drains are implanted at the main places of link-up to run off the fluid from the wounds.

Pankreaskopfresektion

 

The resection of the pancreatic head with conservation of the duodenum (modified by Büchler)

The advantages of an Operation which preserves the duodenum are achieved by a technical difficult operation such as the division of the pancreatic neck. Especially when the pancreatic tissue and the portal vein are grown together and a dissection seem to be impossible. The modification by Büchler can achieve the advantages of the pancreatic head resection with the removal of any diseased pancreatic tissue, excluding the disadvantages of a pancreatic neck removal. Fig 10 shows a diseased pancreatic head affected by a large cyst and expanded calcifications which then give the impression of a chronic pancreatitis.

 

Bauchspeicheldruesen OP

 

The large cyst in the pancreatic head and the changes in the tissue can lead to chronic pain due to a compression in the pancreatic duct and the inflammation in the pancreatic head. These pains can hardly be treated with conventional painkillers (Fig 11).

 

 

 

 

Operation Bauchspeicheldruese

 

During surgery, everything inflammatory, scarring and pain causing tissue will be removed. The portal vein however stays in place, but again all the tissue up to the vein is being removed. The bile duct will then be opened within it and drained. The pancreatic body will undergo the same procedure as the bile duct (fig.12). The advantage of this method is that all inflammatory tissue will be removed and the bile duct and the pancreatic duct are disburdened rather than blocked without needing to cut through the pancreatic neck (fig.12)

Therefore only a connection to the pancreatic head has to be constructed through a small intestinal loop. This will then reduce the risk of leakage (Fig. 13).

 

What happens after the treatment?

As after every great operation of the abdomen, the patients are treated at the intensive care unit for 2 - 3 days. The monitoring of respiration, blood circulation, and urinary outflow are done round the clock, and pain killers and infusions are administered. The patients receive an antibiotic for seven days and a special medicine to retard the secretion (somatostatin). At the same time, some blood-readings are controlled at short intervals: lipase, amylase, and blood glucose, which has to be regulated with additionally administered insulin, if necessary. After controlling of possible leaks and after a verification of amylase from the secretion of the abdominal drain, the drains are pulled out after four days. Then, slowly and carefully nourishment is started with the stomach drain still in place. At the beginning, some of the patients may suffer from disturbances of gastric emptying. In the course of the following days, it will be known to what extent the functioning of the pancreas has been reduced and whether a substitution of digestive enzymes and an administration of insulin will be permanently necessary.

What has to be paid attention to in future everyday life?

Investigations using the data of a large number of patients with chronic pancreatitis show that an operation can stop an imminent loss of functionality of the remaining tissue of the pancreas by which the quality of life is significantly improved for the patient. Even if the patient has to take digestive enzymes and insulin permanently after a total resection of the pancreas, he can lead an almost normal life. However, he has to avoid alcohol as it is the greatest risk for provoking another pancreatic disease.

History

Alexandria about 300 B.C.: In their hey-day, the Ptolemaic kings build a big university and library to let scientists, artists, and literary men do research work and teach. This is also where the physician and anatomist Herophilus of Chalcedon works because at this university, it is allowed to use corpses for anatomical studies, which is strictly forbidden in other countries. The first exact descriptions of the pancreas and the liver come from him. It was Johann Georg Wirsung, professor of anatomy at Padua, who in 1642 discovered the great excretory duct of the pancreas, which carries his name still today: Ductus Wirsungianus. Not knowing what he had actually found, he wrote to his teacher Jean Riolan: "But should I call it artery or vein? I did not find blood in it, however a turbid juice, which reacted on the silver searcher like an acid liquid…" The story had a bloody end: one year after his discovery, Wirsinganus was murdered in front of his door by a student. Had there been a dispute over who was the real discoverer of the duct? In 1869, it was the only 22 years old medical student Paul Langerhans who came across the islet cells of the pancreas while working on his doctor's thesis, but he did not know what function they had. About twenty years later, Oskar Minkowsaki and Joseph von Mering removed the pancreas from a dog to observe the consequences on the glycometabolism. The dog developed all symptoms of diabetes, and the two researchers furnished evidence of glucose and acetone in the urine. In this way, the connection between a malfunction of the pancreas followed by the development of diabetes had been proved. After Frederik Grant Banting and Charles Best had, around 1920, discovered the substance produced by the islet cells, namely insulin, it took only three years until the first insulin preparation appeared on the market. This meant salvation for the thousands of diabetics, for whom here had been no hope so far. The great surgeons of that time regarded the pancreas still as an organ hostile to surgeons because of its anatomical position and because of its fragile tissue. The operations were an extreme surgical challenge and the patient ran a high risk. But the surgeon Carl Gusenbauer, successor to Theodor Billroth at Vienna, was very innovative. Already as an assistant doctor, he had developed the first artificial larynx. He was not deterred by a delicate problem like that of the pancreatic pseudocyst, a complication of the chronic pancreatitis. He developed a technique which allows extracting the liquid from the cysts. In 1909, Walter Kausch opened new ways by carrying out the first radical pancreatectomy, which also entailed the removal of parts of the stomach and of the duodenum. Properly speaking, his technique established itself first as a therapy against tumours in the head of the pancreas. It was taken up by the famous Allen O. Whipple in the thirties, but it was later used quite often in the case of chronic and benign changes. The surgical aim to preserve as much of the organ as possible in the case of benign changes of the pancreas was achieved by Hans Georg Berger in 1971 through his new surgical method, maintaining the duodenum in the resection of the head of the pancreas. Its results bring along an inestimable advantage for the patient: a normal passage of the consumed food through the stomach and the bowels.


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