The role of surgery for chronic pancreatitis and its complications.

Chronic alcoholism is the etiologic factor leading to most instances of chronic pancreatitis and its complications. Impairment of exocrine and endocrine function parallels the severity of the chronic pancreatitis. Ultrasound and CT scan are the most accurate tests for the identification of gross anatomic changes in the pancreas. ERCP is critical in the evaluation of pancreatic ductal anatomy. Severe, persistent abdominal and back pain requiring narcotics is significantly relieved in approximately 80 percent of patients receiving a pancreatic drainage operation. Pancreatic resection is an acceptable alternative procedure if pancreatic ductal dilation is absent or if the disease is concentrated in the body and tail of the pancreas. A high incidence of insulin-dependent diabetes remains the main drawback of pancreatic resection, a problem often difficult to manage in the alcoholic. Late mortality is high, and is primarily related to diseases associated with chronic alcoholism. Internal drainage of pancreatic pseudocysts is favored whenever possible. If the contents of the pseudocyst are infected or the cyst walls are immature, external drainage is indicated. Resection of the pseudocyst and the contiguous pancreas effectively treats the pseudocyst but at the price of higher morbidity and mortality. The role of percutaneous aspiration of pseudocysts has not yet been adequately tested. The correction of pancreatic ascites and pancreatic pleural effusions is directed at internal drainage or resection of the leaking pseudocyst or disrupted pancreatic duct. Additional complications involving the biliary tract and gastrointestinal tract require an individual approach based on the site and cause of the problem. Generally, treatment is directed initially at the pseudocyst, if one is present. On the other hand, if biliary or gastrointestinal tract obstruction is secondary to long-standing chronic pancreatitis, a bypass procedure will probably be necessary to correct the problem.