Inflammation of the Pancreas: Surgical Therapy

Acute pancreatitis

Biliary pancreatitis

If the pancreatitis is caused by an impacted gallstone (= biliary pancreatitis), immediate ERCP (“endoscopic retrograde cholangiopancreatography”: radiographic imaging of the biliary system and pancreatic duct) with papillotomy (“incision” of the opening of the papilla Vateri/mucosal fold in the duodenum) and stone removal should be performed. If the clinical course permits, cholecystectomy (gallbladder removal) should be performed thereafter during the same hospital stay. This approach is supported by the results of a study: later cholecystectomy (median 27 days) versus immediate surgery (median one day later). This showed the following result for the primary study endpoint (readmission due to acute gallstone problems or death within six months): a rate of 5% for early surgery and 17% for interval surgery. Thus, early cholecystectomy is clearly superior. Pancreatitis recurrence (recurrence of pancreatitis) had 2% of patients operated on immediately versus 9% of those operated on later.

Abdominal necrosis

Surgical necrosectomy (surgical removal of dead tissue) for severe acute pancreatitis in early stages results in a lethality (mortality) of approximately 50%. In contrast, conservative stabilization for as long as possible, and minimally invasive surgery only when necessary, results in a lethality of less than 20%. Conclusion: so-called step-up strategy should be applied: Antibiotics → drainage – possibly necrosectomy.

Complications such as cysts, hemorrhage, or necrosis may need to be removed or drained by surgical intervention.

Chronic pancreatitis

In approximately 30-40% of patients with chronic pancreatitis, developing complications of the disease necessitate interventional or surgical therapy:

  • Inflammatory space-occupying lesions
  • Strictures (high-grade constrictions) of the ductus hepatocholedochus (hepatic bile duct) → endoscopic stent placement (insertion of an artificial prosthesis, e.g., plastic) into the pancreatic duct; if this does not improve symptoms within 6-8 weeks → surgical procedure
  • Growing, compressing and recurrent pancreatic pseudocysts after drainage (drainage or aspiration of pathological or increased body fluids).
  • Pancreatic duct stones

Early surgical intervention for chronic pancreatitis is likely to result in complete postoperative pain relief. Furthermore, studies suggest that early surgery may prevent postoperative pancreatic insufficiency.

Duodenum-preserving (duodenum-preserving) surgery was found to increase long-term weight gain by 3 kg (p < 0.001; three studies), decrease median hospital length of stay by 3 days (p = 0.009; six studies), and decrease operative time by 2 hours (p < 0.001; five studies) compared with partial duodenopancreatectomy (surgical removal of the duodenum and pancreas).

Note: If malignancy is suspected (suspected to be malignant), oncologic duodenopancreatectomy should be performed.