Chirurgische therapie der chronischen pankreatitis

Abstract

In patients with chronic pancreatitis, surgical treatment is required when conservative approaches are unsuccessful in treating symptoms and complications of the disease. The indications for surgery are 1) recurrent abdominal pain which does not respond to analgesics and 2) duodenal, common bile duct and/or main pancreatic duct obstruction or stenosis. In addition, obstruction of the retropancreatic vessels with subsequent portal hypertension is an indication to operate. Over the last decades the surgical standards in the treatment of chronic pancreatitis have changed. Due to disappointing long-term results, pancreatic left reseclion and drainage procedures of the main pancreatic duct are limited only to a small number of patients. In a number of patients with chronic pancreatitis, inflammatory enlargement of the pancreatic head causes complications which require surgical treatment. In the past, the classical Whipple resection has served as the standard operation in these patients. However, the classical Whipple resection was initially inaugurated for pancreatic head malignancies, and in addition to resection of the pancreatic head it includes resection of the complete duodenum, the extra hepatic bile system and 2/3 of the stomach. The Whipple procedure's disappointing long-term results and especially its disappointing quality of life have led to the development of newer organ- -preserving procedures designed to treat complications caused by chronic pancreatitis. The pylorus-preserving Whipple resection is a modification of the classical Whipple resection which avoids the resection of the stomach. Since its initial publication by Watson in 1945 and Traverso and Longmire in 1978, pylorus- preserving Whipple resection has been performed by many surgeons for the treatment of chronic pancreatitis. However, the high incidence of postoperative diabetes mellitus following this operation is a major drawback that has limited its use. The duodenum-preserving pancreatic head resection was developed to selectively remove the pancreatic head subtotally by preserving the body and tail of the pancreas as well as the pylorus, the duodenum, and the extrahepatic biliary tract. With this organpreserving operation all the pancreatic head-related complications of chronic pancreatitis can be abolished without inducing diabetes mellitus. Excellent short- and long-term follow-up results prove the superiority of the duodenum-preserving pancreatic head resection over the classical and the pylorus-preserving Whipple resections in patients with chronic pancreatitis. Therefore, the duodenum- -preserving pancreatic head resection should be adopted as a new standard operation in patients with chronic pancreatitis and pancreatic head-related complications.