Failure of symptomatic relief after pancreaticojejunal decompression for chronic pancreatitis. Strategies for salvage
J. S. Markowitz, D. W. Rattner and A. L. Warshaw
Surgical Services, Massachusetts General Hospital, Boston.
OBJECTIVE: To evaluate causes of intractable recurrent pain following
pancreaticojejunostomy for chronic pancreatitis and to evaluate treatment
strategies aimed at lasting pain relief. DESIGN: Case series. SETTING:
Tertiary care referral center. PATIENTS: Fifteen selected patients having
severe pain associated with chronic pancreatitis with onset 0 to 60 months
(median, 5 months) following pancreaticojejunostomy. Each patient underwent
computed tomography and endoscopic retrograde cholangiopancreatography. Two
patients (13%) were found to have pancreatic cancer, two (13%) had
inadequate pancreatic duct decompression, two (13%) had biliary stenosis,
and 10 (67%) had presumed neuropathy in the pancreatic head. INTERVENTIONS:
Fourteen (93%) of the 15 patients underwent the following reoperations:
distal pancreatectomy and splenectomy (one patient), extension of the
pancreaticojejunostomy and choledochojejunostomy (one patient), biliary
stenting followed by choledochojejunostomy (one patient), and Whipple-type
resection of the pancreatic head (14 patients). Two patients subsequently
underwent a completion pancreatectomy. MAIN OUTCOME MEASURES: Pain relief,
functional capacity, and pancreatic exocrine and endocrine status were
determined. The median follow-up after reoperation was 39 months. RESULTS:
Of the 14 patients who underwent reoperation, 13 were long-term survivors.
One died of pancreatic cancer. Ten of the other 13 have had
satisfactory-to-excellent relief of pain, with resumption of a normal level
of function. Of the 10 previously euglycemic patients who underwent
pancreatic head resection, eight remain free of diabetes mellitus to date.
CONCLUSIONS: The causes of recurrent or persistent pain following
pancreaticojejunal decompression for chronic pancreatitis are complex and
include neuropathic changes, residual or evolving pancreatic and biliary
duct obstruction, and unrecognized pancreatic cancer. Acceptable outcomes
can usually be achieved by following a treatment strategy aimed at
addressing identified residual disease while maximally preserving
pancreatic tissue.
