Modern Solutions in Treating Chronic Pancreatitis

Chronic pancreatitis is an inflammatory disease of the pancreas, affecting 50 out of 100,000 people. It occurs especially in men aged between 30 and 40 years, and the disease is not reversible., Over the time, inflammation of the pancreas can progress and lead to total organ dysfunction resulting in diabetes and pancreatic insufficiency. Up to now there is unfortunately no causal therapy of the disease, therefore physicians dealing with chronic pancreatitis are more dealing with the treatment of the concomitant complications as evidenced by Prof. Dr. Güralp Ceyhan, one of the top physicians at ACIBADEM clinics, internationally known for its success in the surgical approach to pancreatic diseases.

“There are different causes for chronic pancreatitis. The main cause is alcohol abuse. Here it is interesting, that not only those who suffer from long-term alcoholism are at risk of getting pancreatitis, but also patients who drink in a normal or even reduced pattern. Other etiologies are described by the autoimmune and hereditary form of chronic pancreatitis. Unfortunately, there are also a lot of patients, where we do not know the exact cause. These patients suffer from the so called idiopathic chronic pancreatitis. Patients with hereditary chronic pancreatitis have a proven higher risk for pancreatic cancer.”

Pain is the most annoying and cardinal symptom of chronic pancreatitis. Here usual analgetics are often not helpful so that patients need stronger pain medications including opiods and anti-depressants. Du to the frequent acute attacks of the disease with frequent hospitalizations and the long-term addiction to strong pain killers, patients with chronic pancreatitis often suffer from social stigmata with unemployment and depression. Along with severe abdominal pain, malaise, lack of appetite, diarrhea, the presence of fatty faeces can be signs of chronic pancreatitis. In addition, patients with chronic pancreatitis lose weight due to malabsorption of the nutrients induced by the pancreatic enzyme disruption.

“Even if it does not seem important at first sight, pain is the most serious complication of the disease. This causes great suffering to patients and can not be controlled with normal analgesics. Another frequent complication is jaundice due to ,narrowing of the duodenum or the common bile duct via an inflammatory tumor mass in the pancreatic head or often via stones in the main pancreatic duct close to the ampulla,.Another frequent complication of long-term disease is the affection of the portal, mesenteric and, splenic veins leading often to venous thrombosis, and concomitant . varicose veins, with high risk of intraabdominal bleeding. All these problems can be avoided by early consultation of the patient with the colleges of Gastroenterology and select patients who profit best from an early surgical therapy”, says Prof. Dr. Güralp Ceyhan.

So, the advice of top specialists, including Prof. Ceyhan, is that patients should go as soon as possible to a multidisciplinary specialized center for pancreatic disease. The challenge of the experienced pancreatic surgeon here is to resect in an organ-preserving way to so that the gastrointestinal function may maintain.

“Patients with chronic pancreatitis often develop strictures, stenosis of the main pancreatic ducts or the common bile ducts. Lastly may cause jaundice and the closure of the main pancreatic duct due to the inflammatory mass or stones lead to increase of intraductal pressure and consecutive severe pain. Depending on the situation, patients can be primarily treated with stents to reduce pain and jaundice. But to keep the pain under control in the long term and preserve pancreatic function, the cause of this situation has to be removed by a surgeon . who has wide experience with all the different organ preserving surgical techniques in chronic pancreatitis surgery. Due to the present chronic inflammation of the pancreas surrounding area and structures chronic pancreatitis surgery can be much more complex than for pancreatic cancer. In pancreatic cancer, to obtain oncological rules the surgeon must resect some organs e.g. when you have a pancreatic tumor in the pancreatic head one hast to resect the pancreatic head, duodenum, common bile duct, the gall bladder and then performs the anastomoses. In chronic pancreatitis surgery, an experienced surgeon, will try to preserve all the organs as much as they can. Practically in a patient with chronic pancreatitis in the head with concomitant complications, only the affected portions of the pancreatic head will be removed without resecting the duodenum or the bile duct. In another example, if there is a stone in the middle of the pancreatic duct and consecutive painful disease, we do not remove the pancreas at this are, we are only opening the pancreatic main duct, remove the stones and close the pancreas through a jejunal loop and drain the pancreatic juice directly to the small intestine. These skilled and advanced techniques allow us to treat our patients without resecting the entire pancreas. This is the modern approach to chronic pancreatitis, the effectiveness of which has been demonstrated by 3 randomized controlled clinical trials “.,

The top ACIBADEM physician has another strong argument for early intervention with surgery.

“Patients with chronic pancreatitis develop the characteristic pancreatic neuropathy. During the disease the nerves that innervate the pancreas undergo certain neuropathic changes. The chronic inflammation of the pancreas affects the intrapancreatic nerves:, they increase in their size, number and are targeted infiltrated by inflammatory cells causing the characteristic pancreatic neuritis, which all in all lead to the neuropathic pain syndrome which is not easy to treat. However, the problem does not remain only in the pancreas. As a result of the neuropathic signals sent by the nerves to the brain, the pain is centrally memorized with generation of distinct pathological pain centers in the brain. Even if you operate a patient with long-term disease and in an advanced stages, the pain is already memorized. and the success rate of the surgical approach is decreasing. Therefore, this is another important reason why these patients should be evaluated as early as possible in an interdisciplinary team at a specialized centre and get a tailored therapy. says the surgeon.

Ideally, any patient with chronic pancreatitis should go and visit a specialized pancreatic centre in treating these conditions as soon as possible. Especially regarding surgery the associated pancreatic surgeon should be trained in complex chronic pancreatitis surgery to avoid serious postoperative complications like the feared risk of postoperative pancreatic fistula.

“The most dangerous complication after pancreatic surgery remains postoperative pancreatic fistula. In general, the pancreas is important for two things: it produces and secretes insulin to regulate blood glucose levels and pancreatic enzymes for optimal digestion. Pancreatic enzymes pass into the duodenum via the pancreatic duct, the first part of the small intestine, where they get activated and digest proteins and fats etc. After partial resection of the pancreas an anastomosis must be performed to obtain the pancreatic-intestinal connection., Pancreatic fistula occurs if an anastomosis does not heal well and leaks. A firm and stabil pancreatic ananstomosis is of high importance since when it leaks and pancreatic enzyme get into the abdominal cavity, then this aggressive pancreatic juice can severely damage surrounding tissue. The worst scenario is when these enzymes get to close contact to vessels and arteries, erode them and lead to severe and life-threatining bleedings,. Thus, these enzymatic leaks must be avoided at all costs. Therefore, the surgeon’s experience in resection and anastomosis is highly importance. The number of pancreatic fistulae can tell you whether a pancreatic surgery center is good or not. In patients with chronic pancreatitis with years of active disease, the pancreatic tissue gets firm so that the risk of pancreatic fistula is lower than compared to pancreatic cancer surgery but still remains an important issue”, describes Prof. Dr. Güralp Ceyhan the highest risk of the intervention.

“If chronic pancreatitis surgery is not done by an experienced pancreatic surgeon, , there is also the risk – of disease relapse. Chronic pancreatitis surgery has to be done cautiously but also in a very radical way so that the patient should not need any intervention after the operation, otherwise the therapy has failed.”