Failure of symptomatic relief after pancreaticojejunal decompression for chronic pancreatitis. Strategies for salvage.
OBJECTIVE
To evaluate causes of intractable recurrent pain following pancreaticojejunostomy for chronic pancreatitis and to evaluate treatment strategies aimed at lasting pain relief.


METHODS
Case series.


METHODS
Tertiary care referral center.


METHODS
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.


METHODS
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.


METHODS
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.
Markowitz
J S
JS
Surgical Services, Massachusetts General Hospital, Boston.
Rattner
D W
DW
Warshaw
A L
AL
D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000009:adverse effects; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002908:Chronic Disease; D004322:Drainage; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain; D010179:Pancreas / Q000473:pathology / Q000601:surgery; D010180:Pancreatectomy / Q000009:adverse effects / Q000379:methods; D010183:Pancreatic Ducts / Q000473:pathology / Q000601:surgery; D010193:Pancreaticojejunostomy / Q000009:adverse effects / Q000379:methods; D010195:Pancreatitis / Q000473:pathology / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D016879:Salvage Therapy; D013997:Time Factors; D017211:Treatment Failure