Introduction: Endoscopic therapy has alleviated symptoms and decreased the need for operative intervention in patients with acute and chronic pancreatitis. However, recurrent or persistent symptoms occur in a significant proportion of endoscopically-treated patients and definitive surgical management is required. Our aim was to determine which patients are likely to fail endoscopic therapy and to assess the clinical outcome of surgical management following initial endoscopic therapy.
Methods: Patients were identified by comparing institutional databases searching for ICD-9 pancreatic disease codes and CPT codes for endoscopic therapy followed by surgical procedures. Patients with neoplastic disease were excluded. Nine-hundred twenty-five patients with pancreatic disease and interventional management were identified over a ten-year period. Patients that had well-documented acute or chronic pancreatitis treated by endoscopic therapy prior to surgical therapy were included for analysis of demographic data, etiology of pancreatitis, endoscopic management, and surgical therapy.
Results: Eighty-nine (10%) patients of the 925 screened were included in the study. Sixty-four percent of patients had chronic pancreatitis with alcohol-induced disease in 40 of 89 patients. The common indications for surgery were: persistent symptoms (28%), anatomy not amenable to further endoscopic treatment (26%), common bile duct or pancreatic duct stricture (18%), infection or clinical deterioration (16%), and persistence or recurrence of a pseudocyst (16%). Definitive surgical procedures included internal drainage of a pseudocyst or an obstructed pancreatic duct in 41 (46%) patients, debridement or pancreatic abscess drainage in 22 (25%) patients and pancreatic resection in 27 (30%) patients. Eight (7%) patients had duodenal-sparing pancreatic head resection. Death occurred in 3% of patients and reoperation was necessary in 4%. The most common complications were hemorrhage (16%), ARDS/pneumonia (11%) and wound infection 12%.
Conclusion: Chronic pancreatitis with persistent or newly-developed symptoms is the most common reason for pancreatic surgery following endoscopic therapy. Surgical therapy can largely be accomplished by drainage procedures but pancreatic resection is common. These complex procedures can be performed with acceptable mortality but significant risk for morbidity.