Recurrent Acute Exacerbations in
Chronic Pancreatitis
William H. Nealon, MD, and Sina Matin, MD
From the Department of Surgery, The University of Texas Medical Branch, Galveston, Texas
Objective
To determine whether surgical intervention prevents recurrent
acute exacerbations in chronic pancreatitis (CP).
Summary Background Data
The primary goal of surgical intervention in the treatment of
CP has been relief of chronic unrelenting abdominal pain. A
subset of patients with CP have intermittent acute exacerbations,
often with increasing frequency and often unrelated to
ongoing ethanol abuse. Little data exist regarding the effectiveness
of surgery to prevent acute attacks.
Methods
From 1985 to 1999, all patients identified with a diagnosis of
CP were recruited to participate in an ongoing program of
serial clinic visits and functional and clinical evaluations. Patients
were offered surgery using standard 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 unrelenting 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 patients underwent 199 surgical procedures (124
modified Puestow procedure [LPJ], 29 distal pancreatectomies
[DP], and 46 pancreatic head resections [PHR; 14 performed
after failure of LPJ]). There were no deaths. The complication
rate was 4% for LPJ, 15% for DP, and 27% for PHR.
Ethanol abuse was causative in 238 patients (92%). Mean
follow-up was 81 months. There were 104 patients in group 1
(86 who underwent surgery), 71 patients in group 2 (64 who
underwent surgery), and 84 in group 3 (49 who underwent
surgery). No patient without surgery had spontaneous resolution
of symptoms. Postoperative pain relief (freedom from narcotic
analgesics) was achieved in 153 of 185 patients (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 6 2.1 events per year before surgery in group 2
and 7.8 6 1.8 events per year in group 3. After surgery, no
acute exacerbations occurred in 42 of 64 (66%) group 2 patients
and in 40 of 49 (82%) group 3 patients. The mean number
of episodes of acute exacerbation after surgery was
1.6 6 2.3 events in group 2 and 1.1 6 1.9 events in group 3.
Only four patients in group 2 and one patient in group 3 had
an equal or increased frequency of attacks after surgery. Preventing
attacks was most effective with LPJ (58/64, 91%) and
least effective for DP (6/18, 33%).
Conclusions
Surgical intervention prevents recurrent acute exacerbations.
The overall frequency of events was reduced in nearly all patients.
Therefore, surgical intervention is indicated in patients
with CP whose disease is characterized by recurrent acute
exacerbations.
ANNALS OF SURGERY
Vol. 233, No. 6, 793–800© 2001 Lippincott Williams & Wilkins, Inc.
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