The Pylorus Preserving Whipple Procedure for the Treatment of Chronic Pancreatitis

Abstract

A schema is developed that outlines criteria to consider more than medical therapy for patients with severe pancreatitis that develop disabling abdominal pain. If the symptomatic patient has severe chronic pancreatitis that reaches the Cambridge Class V "marked" stage of image severity then endotherapy is indicated. If endotherapy fails then surgery is indicated. Usually these patients will have pathological changes centered in the pancreatic head and PPW is performed. After an average follow-up of > 4 years PPW was observed to provide either good to excellent relief of disabling abdominal pain. These patients were highly selected by the guidance of the anatomic profile of the composite pancreas. Long-term follow-up has never been available with cancer patients after the Whipple procedure. These chronic pancreatitis patients after PPW showed few GI side effects. In addition we did not observe a predisposition for diabetes other than that from the continued parenchymal destruction from smoldering chronic pancreatitis in the pancreatic remnant. Surgeons should avoid total pancreatectomy in patients, even if the patient is already diabetic. Marginal ulceration is highly associated with the total resection. From this personal experience using anatomic criteria and close follow-up, it is hoped that the long term outcomes of pain relief in virtually all patients after PPW will represent a benchmark for results after procedures which employ less resection. Therapy should be based on reliable imaging criteria to select patients. Then the outcomes of new and promising procedures such as lithotripsy or limited head resections can be compared to the benchmarks derived after PPW. None of the new procedures, however address the main problem after PPW of remnant pancreatitis in the pancreatic body/tail. Even though this discomfort is no longer disabling after head resection remnant pancreatitis does occur in approximately one out of four patients.