Abstracts
1997 Digestive Disease Week

Surgical splanchnicectomy for "small duct" chronic pancreatitis: patient selection by differential epidural analgesia.

EL Bradley III*, JA Reynhout*, GL Peer§. Departments of *Surgery and §Anesthesia, State University of New York (Buffalo) and Buffalo General Hospital.

Management of pain from "small duct" chronic pancreatitis has been problematic, often resulting in narcotic addiction and/or major pancreatic resection. Recently, denervation of sympathetic pain afferents from the pancreas by surgical splanchnicectomy (SS) has shown promise in relieving pain while preserving residual pancreatic function. Results, however, have been mixed as differentiation of "pancreatic" pain caused by drug seeking behavior, sympathetically mediated pancreatic pain, or various somatically innervated conditions can be difficult. PATIENTS & METHODS: Between 1992 - 1996, 22 patients with 20 prior pancreatic operations (14M/8F: age 42.9), unequivocal small duct chronic pancreatitis, and intractable "pancreatic" pain requiring narcotics were evaluated. Each underwent differential epidural analgesia (DEA) using standard techniques: placebo, low dose (sympathetic), and high dose (somatic) blocks. Pain responses were recorded before and after DEA and SS, using a visual analog scale (VAS). Six demonstrated >50% decrease in VAS pain during DEA following placebo injection and were eliminated from further study. In the 16 remaining patients, SS (greater and lesser splanchnicectomy) was performed 28 times (11 bilateral: 6 synchronous) (6 unilateral: 2R, 4L), using thoracoscopic techniques 26 times and open thoracotomy twice. RESULTS: No surgical or anesthetic complications were encountered. SS resulted in a significant reduction of pre-operative VAS scores (8.3 to 4.3; p<.05). Ten of 13 patients with DEA predicted sympathetic pain experienced >50% decrease in VAS after SS, however only 2 had complete relief. During an average follow-up of 20.8 months, initial good results from SS were maintained in 8/10 patients. None of 3 patients with DEA predicted somatic pain were benefited by splanchnicectomy. CONCLUSIONS: (1) SS is a safe, often effective technique for amelioration of intractable pain from "small duct" chronic pancreatitis, (2) DEA is a promising approach for identifying patients most likely to respond to SS.