Prior Acute Pancreatitis Is the Most Common Cause of Obstructive Pancreatitis in Patients Undergoing Distal Pancreatectomy
Daniel Chan*1, Michael L. Kendrick2, Michael B. Farnell2, Santhi Swaroop Vege3
1Mayo Medical School, Mayo Clinic, Rochester, MN; 2Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN; 3Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
Background: The natural history of obstructive pancreatitis (OP) is currently poorly characterized. While it has been reported with a few retrospective cases of necrotizing acute pancreatitis, there is uncertainty as to whether it is the initial presentation of chronic pancreatitis, or a sequel from previous acute pancreatitis. Our study attempts to elucidate the pathogenesis of OP.Methods: We retrospectively reviewed all patients of OP undergoing distal pancreatectomy from 1990-2005 at a single institution. We defined OP as pancreatitis satisfying three criteria on imaging (CT, ERCP, MRI, MRCP, or EUS): 1. Stricture of the pancreatic duct, 2. Sparing of the pancreas downstream to the stricture, and 3. Dilatation of the pancreatic duct upstream to the stricture. Patient records were reviewed to determine prior history of acute pancreatitis, and patients were aggregated into one of two groups: with and without a history of prior acute pancreatitis. Demographics, GI and non-GI related co-morbidities, social history, symptoms, etiology, and surgical presentations were statistically analyzed between the two groups using Chi-square and Fisher’s exact methods.Results: Forty nine of 946 patients undergoing distal pancreatectomy from 1990-2005 had OP. All 49 patients presented at the time of surgery with evidence of chronic pancreatitis by operative or surgical pathology report. 35/49 (71.4%) patients had a history of acute pancreatitis, and 14/49 (28.6%) patients had no history of acute pancreatitis. There were no differences in the demographics, comorbidities, social history, or etiology between the two groups. Our data demonstrated that in individuals with a history of acute pancreatitis, necrotizing pancreatitis was a common finding. This group exhibited less weight loss as a presenting symptom, and they were also less likely to have had a prior cholecystectomy (See Table 1).Conclusions: Prior acute pancreatitis was the main cause for OP in patients undergoing distal pancreatectomy, and de novo chronic pancreatitis was a less common cause. The explanation for this is most likely due to the necrosis of the pancreas during acute pancreatitis resulting in subsequent stricture formation. A prospective longitudinal study of necrotizing pancreatitis would confirm this hypothesis.
Table 1: Main characteristics in patients with chronic obstructive pancreatitis with and without a history of acute pancreatitis
| History of Acute Pancreatitis | No History of Acute Pancreatitis | |
| DEMOGRAPHICS | ||
| Number of cases (N) | 35 | 14 |
| Gender M:F | 24 (68.6%): 11 (31.4%) | 7 (50%):7 (50%) |
| Mean Age at Surgery (years) | 46.8 ± 10.8 | 45.6 ± 15.7 |
| BMI (Mean) | 27.1 | 25.9 |
| CO-MORBIDITIES | ||
| Diabetes | 2 (5.7%) | 3 (21.4%) |
| Gallstones | 5 (14.3%) | 3 (21.4%) |
| Steatorrhea | 0 (0.0%) | 1 (7.1%) |
| SOCIAL HISTORY | ||
| Alcohol Use | 21 (60.0%) | 12 (85.7%) |
| Tobacco Use | 22 (62.9%) | 11 (78.6%) |
| SYMPTOMS | ||
| Abdominal Pain | 34 (97.1%) | 12 (85.7%) |
| Nausea/Vomiting | 3 (8.6%) | 3 (21.4%) |
| Weight Loss | 3* (8.6%) | 7* (50.0%) |
| SURGICAL PRESENTATION | ||
| Prior cholecystectomy | 10* (28.6%) | 9* (64.3%) |
| Prior necrotizing pancreatitis documented | 13* (37.1%) | 0* (0.0%) |
| Pseudocyst | 12 (34.3%) | 7 (50.0%) |
| Time between diagnosis of pancreatitis and obstructive pancreatitis | 892 days (2.4 years) | 1587 days (4.35 years) |
| *Denotes statistical significance with p< 0.05 | ||
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