Surgical/specialist management

Seek specialist advice

Surgery may be considered if ERCP demonstrates localised chronic pancreatitis or focal lesions, e.g. calculi; it may also be considered for intractable pain, pancreatic cysts and pseudocysts, and recurrent gastrointestinal haemorrhage.

Options include:

• cholecystectomy with clearance of duct stones - essential if gallstones present
• sphincterotomy of the accessory papilla in patients with pancreas divisum
• drainage - percutaneous or surgical drainage of a pseudocyst or abscess
  • surgical (laparoscopic or open) drainage of pseudocysts that need intervention should be considered if endoscopic therapy is unsuitable or has failed (1)
• partial resection - body and tail may be resected if pathology is limited to them. In other patients, a Whipple's procedure may be necessary
• pancreatic duct obstruction (1)
  • surgery (open or minimally invasive) should be considered as first-line treatment in adults with painful chronic pancreatitis that is causing obstruction of the main pancreatic duct
  • consider extracorporeal shockwave lithotripsy for adults with pancreatic duct obstruction caused by a dominant stone if surgery is unsuitable
• pancreatic ascites and pleural effusion (1)
  • consider referring a person with pancreatic ascites and pleural effusion for management in a specialist pancreatic centre
• total pancreatectomy - total pancreatectomy has been considered a treatment of last resort because it leads to development of postoperative "brittle diabetes"
  • however, advances such as improved autologous islet cell transplantation have resulted in more-frequent use of total pancreatectomy in patients with disabling symptoms whose pancreatic morphology is not conducive to resection or decompressive surgery

References:

1. NICE. Pancreatitis. NICE guideline NG104. Published September 2018, last updated December 2020
2. Dominguez-Munoz JE, Drewes AM, Lindkvist B, et al. Recommendations from the United European Gastroenterology evidence-based guidelines for the diagnosis and therapy of chronic pancreatitis. Pancreatology. 2018 Dec;18(8):847-54.
3. Garcea G et al. Total pancreatectomy with and without islet cell transplantation for chronic pancreatitis: A series of 85 consecutive patients. Pancreas 2009 Jan; 38:1