As a result, relevant surgical training is more focused on anatomic resections, such as the Whipple procedure, which removes the head of the pancreas; distal pancreatectomy, which removes the tail of the pancreas; and some of the duodenal-preserving resections, including the duodenum-preserving pancreatic head resection, a procedure with favorable short-term and long-term outcomes that has become the most common procedure.6
There is less emphasis on some of the traditional, less invasive pancreatitis operations, which include draining the pancreatic duct, removing parts of the pancreas, and the Frey procedure, which both drains and removes diseased tissue.
“I routinely do robotic Whipples. That’s probably the biggest kind of breakthrough and emerging technology in the field,” said Dr. Wilson, adding that he also has had exposure to both the traditional and anatomic approaches, offering flexibility for managing patients with chronic pancreatitis.
Another innovation is the total pancreatectomy with islet cell transplantation. This procedure is intended for patients with genetic mutations that put their entire pancreas at risk, or for some patients with recurrent acute pancreatitis.
In the total pancreatectomy with islet cell transplantation procedure, the entire pancreas is removed, then islet cells isolated from the patient’s pancreas are injected into the portal vein and take up residence in the liver. The islet cells help control and secrete hormones that control blood glucose. While less than a third of patients end up truly insulin independent with the operation, it allows most patients to have diabetes that can be controlled with medications.
Improved Outcomes
The advances and innovations in surgical management of pancreatitis have yielded a dramatic improvement in patient outcomes.
For acute pancreatitis patients, enhancement of critical care techniques, computed tomography (CT) scans, and percutaneous drains and minimally invasive debridement methods such as those described in this article have reduced mortality from 70% to 20%–30% over the last 50 years, according to Dr. Horvath.
“As we move toward later and more minimally invasive interventions, we see that after the patient recovers, pancreatic function is often preserved in a greater way than when we did maximal open surgery,” Dr. Horvath said.
Minimally invasive necrosectomy techniques have improved the long-term endocrine and exocrine functional outcomes as well as wound complications for these patients, which can be quite morbid, she added.
These improvements have not only helped save lives but have brought marked improvements in quality of life.
Surgical management also has improved quality of life and provided pain relief for chronic pancreatitis patients, many of whom are in serious condition at the time of operation.
“These patients will frequently live a life in which they’re just living from one hospitalization to the next,” explained Dr. Wilson “They can’t keep a job because they have too many sick days. An operation or an intervention can improve their quality of life—basically get them back to a life.”
For long-term results, 1 in 3 patients will die within 10 years, according to Dr. Wilson. Among the many causes of death are infections, cardiovascular disease, diabetes, cancer, end-stage liver disease, end-stage renal disease, and suicide. Major causal factors for suicide in this context are psychosocial issues, including narcotic dependence, substance abuse, and mental health. In fact, a key determinant of survival after surgery for chronic pancreatitis is whether or not patients were able to get off their narcotic medications.7
Multidisciplinary Care
Multidisciplinary care is important to both types of pancreatitis patients, and this cross-functional approach is especially important to chronic pancreatitis patients before, during, and after surgery.
The medical team may consist of the primary care doctor, gastroenterologist, surgeon, and mental health, pain management, and addiction care specialists.
“There is a plethora of evidence supporting that acute pancreatitis patient outcomes are better with a multidisciplinary team committed to the care of these complex patients,” Dr. Horvath explained.
Chronic pancreatitis patients often have been marginalized by the healthcare system. Even with advanced imaging, it can be difficult to diagnose chronic pancreatitis as compared with a gastrointestinal disorder. The severe abdominal pain experienced by these patients can be difficult to detect by imaging or other diagnostic techniques, so they are often labeled as “narcotics seekers,” Dr. Wilson said.
“They’re suffering, and they’re not getting treatment that’s helping them,” Dr. Wilson said. “They can require a lot of hands-on work—they’re in and out of the hospital, coming back or calling weekly.”
For acute pancreatitis patients, it’s essential to have a multidisciplinary team along the continuum of care, Dr. Horvath said. This team includes surgery, gastroenterology, critical care, internal medicine, and interventional radiology. Numerous studies have shown these multidisciplinary teams produce better morbidity and mortality outcomes and lower patient and health system costs.
“Acute pancreatitis patients are unique in how their disease evolves over time with many unexpected events,” Dr. Horvath said. “They can have catastrophic complications at the drop of a hat, like a pulmonary embolism or a bleeding pseudoaneurysm, as well as complex biliary complications. They benefit from a care team that’s familiar with the disease and all the typical pitfalls.”
Patients with severe acute pancreatitis and some with moderate acute pancreatitis should be transferred to a regional care center for the large-volume experience, she said. In fact, “it’s extremely difficult to understand this disease unless you see a large volume of patients,” explained Dr. Horvath.
“If we’re going to advance the management of these patients for the benefit of future generations, it will need to happen in large-volume regional centers solely because of the low disease prevalence and extremely unique and nuanced expression of complications,” Dr. Horvath said.
Improved Diagnostics and Preoperative Planning
Advanced imaging, including contrast-enhanced CT scans, magnetic resonance imaging, and endoscopic ultrasound, has been critical in improving the diagnosis of both acute and chronic pancreatitis and in helping to determine the most appropriate surgical procedure for the patient. CT scans, in particular, have completely changed the care of patients with pancreatitis.
Endoscopic ultrasound is an essential and necessary tool of the interventional endoscopist caring for pancreatitis patients, especially for classifying chronic pancreatitis patients.
“You want to make sure that you know the problem you’re dealing with and are not being fooled by something else that’s kind of mimicking it,” said Dr. Wilson.
Genomics also is a valuable diagnostic tool in identifying at-risk patients. For example, for acute pancreatitis patients, genetic testing can determine if the patient has hereditary pancreatitis or familial pancreatitis.
Unlike most forms of pancreatitis, patients with hereditary pancreatitis usually experience symptoms of acute pancreatitis in childhood with recurrent inflammation of the pancreas often progressing to chronic pancreatitis in early adulthood. This cohort has an increased risk (an estimated 40% lifetime risk) of developing pancreatic cancer, so patients with this gene need to be followed with more intensive cancer screening.
Familial pancreatitis is associated with families that have a higher-than-average incidence of pancreatitis and features at least two or more first- or second-degree family members with idiopathic pancreatitis not attributed to obstructive or environmental causes.
In chronic pancreatitis, three genetic mutations can help identify a genetically linked form of the disease. Dr. Wilson said the best approach for these patients is a total pancreatectomy with islet cell transplantation. More research needs to be done to better understand how to use the identification of some common mutations linked to chronic pancreatitis.
Preoperative Risk Stratification and Planning
For moderate-to-several acute pancreatitis patients, a key challenge is to determine when to perform surgery. Although, for most patients, the approach to surgery is to get the patient stronger and healthier before surgery, for severe acute pancreatitis patients, it’s often the weakening patient that is most appropriate for surgery. Although careful attention to nutrition is critical for these patients, often with enteral tube feeds, some patients remain in a catabolic state.
“We often need to go to surgery as the patient is getting weaker and their serum albumin is falling so that we can reverse the tide and get them better,” Dr. Horvath said. “We can’t wait for them to be strong for surgery because they will never be strong.”
For chronic pancreatitis patients, it’s important to optimize the patient’s nutrition before surgery. Often due to their increasing abdominal pain, they have avoided food and lost weight, so their resulting weak nutritional status puts these patients at risk of developing postoperative complications.
In addition, pain management strategies are important for these patients who are already likely to be on pain medicines and narcotics. “This means managing their pain after a big surgery can be quite difficult,” Dr. Wilson said.
