Abstract
Chronic alcoholism is the etiologic factor initiating most instances of chronic pancreatitis and its complications in the United States of America. The goal of operative intervention is to relieve incapacitating abdominal and back pain, while preserving as much endocrine and exocrine function as possible. Ultrasound and computed tomography scans are helpful for the identification of gross anatomical changes in the pancreas, but endoscopic retrograde cholangiopancreatography is critical for the precise delineation of pancreatic ductal anatomy. In patients who exhibit dilation of the pancreatic duct secondary to single or multiple sites of obstruction, pancreatic ductal drainage will provide complete or significant relief of pain in greater than 80% of patients. Side-to-side pancreaticojejunostomy has evolved as the operation which permits the widest drainage of the entire pancreatic ductal system. Although, initially, it was hoped that pancreatic exocrine and endocrine function would improve or stabilize after pancreatic ductal drainage, follow-up studies show that the destructive process in the pancreatic islets and acinar cells initiated by chronic alcoholism continues during the years after operation with an increasing incidence of diabetes and steatorrhea. Late mortality is primarily related to continued alcoholism and death secondary to alcohol-(and smoking-) associated diseases. Correction of coexistent complications secondary to chronic pancreatitis including pseudocyst and biliary and/or duodenal obstruction should be considered at the time of pancreatic ductal drainage.
Résumé
L'alcoolisme chronique est le facteur étiologique principal de la pancréatite chronique et de ses complications, aux Etats Unis du moins. Le but de l'intervention chirurgicale est de soulager la douleur abdominale et dorsale invalidante tout en conservant au mieux la fonction pancréatique endocrine et exocrine. L'échographie et la tomodensitométrie aident à identifier les modifications anatomiques du pancréas, mais la pancréatographie endoscopique par voie rétrograde est essentielle pour définir l'anatomie du canal de Wirsung avec précision. En cas de dilatation du canal de Wirsung secondaire à une obstacle simple ou multiple, le drainage pancréatique procure un soulagement complet ou partiel de la douleur chez 80% des patients. L'anastomose pancréaticojéjunale latéro-latérale apporte de loin les meilleures possibilités de drainage du canal de Wirsung en entier. On espérait d'abord que la dérivation améliorerait ou stabiliserait la fonction endocrine et exocrine mais les études de contrôle montrent que la destruction des cellules pancréatiques insulaires et acinaires provoquée par l'alcoolisme chronique continue pendant des années et finit par provoquer diabète et stéatorrée. La mortalité tardive est surtout en rapport avec la continuation d'absorption d'alcool ou est provoquée par des maladies en liaison avec l'alcoolisme et le tabagisme. Il faut toujours envisager la cure de complications coexistantes, pseudokyste ou sténose biliaire et/ou duodénale, lors de l'anastomose pancréaticojéjunale.
Resumen
El alcoholismo crónico es el factor etiológico iniciador de la mayoría de los casos de pancreatitis crónica y sus complicaciones en los Estados Unidos de América. El propósito de la intervención operatoria es controlar el incapacitante dolor abdominal y de la espalda pero conservando tanta función endocrina y exocrina como sea posible. La ultrasonografía y la tomografía computadorizada son de utilidad para identificar cambios anatómicos mayores en el pancreas, pero es la colangiopancreatografía endoscópica retrograda el estudio crítico para delinear en forma precisa la anatomía ductal. En pacientes que exhiban dilatation del canal pancreático secundario a obstrucciones únicas o múltiples, el drenaje del canal resulta en control total o muy significativo en más de 80% de los casos. La pancreaticoyeyunostomía látero-lateral ha venido a convertirse en la operación que permite el más amplio drenaje de todo el sistema ductal pancreático. Aunque inicialmente se tuvo la esperanza de que la función exocrina y endocrina podría mejorarse o estabilizarse con el drenaje del canal pancreático, los estudios de seguimiento indican que el proceso destructivo de los islotes pancreáticos y de las células acinares iniciado por el alcoholismo crónico continúa a lo largo de años después de la operación y se manifiesta por una aumentada incidencia de diabetes y esteatorrea. La mortalidad a largo plazo aparece primordialmente relacionada con alcoholismo continuado y con causas relacionadas con el alcohol y el cigarrillo. La corrección de complicaciones coexistentes de la pancreatitis crónica tales como pseudoquistes y obstrucción biliar y/o pancreática debe ser considerada con ocasión del drenaje del canal pancreático.
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Greenlee, H.B., Prinz, R.A. & Aranha, G.V. Long-term results of side-to-side pancreaticojejunostomy. World J. Surg. 14, 70–76 (1990). https://doi.org/10.1007/BF01670548
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DOI: https://doi.org/10.1007/BF01670548