Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis

Objective To determine whether surgical intervention prevents recurrent acute exacerb ations in chronic pancreatitis (CP). Summary Background Data The primary goal of surgical intervention in the treatment of CP has been r elief of chronic unrelenting abdominal pain. A subset of patients with CP h ave intermittent acute exacerbations, often with increasing frequency and o ften unrelated to ongoing ethanol abuse. Little data exist regarding the ef fectiveness of surgery to prevent acute attacks. Methods From 1985 to 1999, all patients identified with a diagnosis of CP were recr uited to participate in an ongoing program of serial clinic visits and func tional and clinical evaluations. Patients were offered surgery using standa rd criteria. Data were gathered regarding ethanol abuse, pain, narcotic use , and recurrent acute exacerbations requiring hospital admission before and after surgery. Patients were broadly categorized as having severe unrelent ing pain alone (group 1), severe pain with intermittent acute exacerbations (group 2), and intermittent acute exacerbations only (group 3). Results Two hundred fifty-nine patients were recruited. One hundred eighty-five pat ients underwent 199 surgical procedures (124 modified Puestow procedure [LP J], 29 distal pancreatectomies [DP], and 46 pancreatic head resections [PHR ; 14 performed after failure of IPJ]). There were no deaths. The complicati on rate was 4% for LPJ, 15% for DP, and 27% for PHR. Ethanol abuse was caus ative in 238 patients (92%). Mean follow-up was 81 months. There were 104 p atients in group 1 (86 who underwent surgery), 71 patients in group 2 (64 w ho underwent surgery), and 84 in group 3 (49 who underwent surgery). No pat ient without surgery had spontaneous resolution of symptoms. Postoperative pain relief (freedom from narcotic analgesics) was achieved in 153 of 185 p atients (83%) overall: 106 of 124 (86%) for LPJ, 19 of 29 (67%) for DP, and 42 of 46 (91%) for PHR. The mean rate of acute exacerbations was 6.3 +/- 2 .1 events per year before surgery in group 2 and 7.8 +/- 1.8 events per yea r in group 3. After surgery, no acute exacerbations occurred in 42 of 64 (6 6%) group 2 patients and in 40 of 49 (82%) group 3 patients. The mean numbe r of episodes of acute exacerbation after surgery was 1.6 +/- 2.3 events in group 2 and 1.1 +/- 1.9 events in group 3. Only four patients in group 2 a nd one patient in group 3 had an equal or increased frequency of attacks af ter surgery. Preventing attacks was most effective with IPJ (58/64, 91%) an d least effective for DP (6/18, 33%). Conclusions Surgical intervention prevents recurrent acute exacerbations. The overall f requency of events was reduced in nearly ail patients. Therefore, surgical intervention is indicated in patients with CP whose disease is characterize d by recurrent acute exacerbations.