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## Complete Summary

#### GUIDELINE TITLE

Operative treatment for chronic pancreatitis.

#### BIBLIOGRAPHIC SOURCE(S)

Society for Surgery of the Alimentary Tract (SSAT). Operative treatment
for chronic pancreatitis. Manchester (MA): Society for Surgery of the
Alimentary Tract (SSAT); 2004. 3 p.

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates the previously issued version: Society for
Surgery of the Alimentary Tract. Operative treatment for chronic
pancreatitis. Manchester (MA): Society for Surgery of the Alimentary
Tract; 2000. 3 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Chronic pancreatitis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Internal Medicine\
Surgery

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To guide primary care physicians to the appropriate utilization of
surgical procedures on the alimentary tract or related organs

#### TARGET POPULATION

Adult patients with chronic pancreatitis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation for Surgery**

1.  Assessment of symptoms

2.  Computed tomography (CT) scan

3.  Magnetic resonance cholangiopancreatography (MRCP)

4.  Endoscopic retrograde cholangiopancreatography (ERCP)

5.  Measurement of CA-19-9 levels

6.  Angiography of the celiac and superior mesenteric arteries

7.  Baseline evaluation of pancreatic exocrine and endocrine function

8.  Baseline evaluation of nutritional status, pain severity, use of
    pain medication/narcotics, employment status, and quality of life

**Operative Treatment for Chronic Pancreatitis**

1.  Pseudocyst decompression, ductal decompression (Puestow
    pancreaticojejunostomy procedure), or resection

2.  Biliary-enteric decompression

3.  Partial pancreatic resection (such as distal pancreatectomy,
    pancreaticoduodenectomy, or duodenal preserving pancreatic head
    resection/decompression \[i.e. Beger or Frey procedures\])

**Note**: The following alternative treatment procedures are also
considered: endoscopic sphincterotomy and short-term stent placement.

#### MAJOR OUTCOMES CONSIDERED

-   Pain relief

-   Postoperative diabetes and steatorrhea (fatty stool)

-   Body weight

-   Length of hospital stay

-   Risks and complications associated with surgery

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not applicable

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The Society for Surgery of the Alimentary Tract (SSAT) guidelines are
based on statements and recommendations that were overwhelmingly
supported by clinical evidence. Each represents a consensus of opinion
and is considered a reasonable plan for a specific clinical condition.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B,
Levine BA. Practice guidelines for patients with gastrointestinal
surgical diseases. J Gastrointest Surg 1998;2:483-484.)

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were reviewed by several committee members and then by
the entire committee on several occasions. Each guideline was then sent
back to the original author for final comment and reviewed again by the
committee. Each guideline was approved by the Board of Trustees of the
Society for Surgery of the Alimentary Tract and final comments were
reviewed by the committee.

(See companion document Gadacz TR, Traverso LW, Fried GM, Stabile B,
Levine BA. Practice guidelines for patients with gastrointestinal
surgical diseases. J Gastrointest Surg 1998;2:483-484.)

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Symptoms and Diagnosis**

Pain is the major disabling symptom in patients with chronic
pancreatitis, often leading to associated weight loss and/or narcotic
dependency. Diabetes, jaundice, and problems with digestion are also
frequently seen.

Computed tomography (CT) scan, ultrasonography, magnetic resonance
cholangiopancreatography (MRCP), or endoscopic retrograde
cholangiopancreatography (ERCP) usually makes the diagnosis of chronic
pancreatitis and its complications. Typical findings can include a
dilated pancreatic duct or strictures with dilatations of the duct
(\"chain of lakes\"), pancreatic calcification, or pseudocyst. Biliary
or duodenal obstruction and evidence of portal hypertension may also be
present. It is difficult to distinguish between chronic pancreatitis and
pancreatic cancer, especially in patients without pancreatic
calcification. Marked elevation of serum CA 19-9 in a patient without
jaundice is highly suggestive of pancreatic cancer.

By clearly defining pancreatic and biliary ductal anatomy, ERCP and MRCP
can help to select patients who might benefit from surgery and to plan
the most appropriate operation. In patients with atypical
gastrointestinal bleeding and pancreatitis, angiography of the celiac
and superior mesenteric arteries can detect and embolize a
pseudoaneurysm. It is also important to establish a baseline of
pancreatic exocrine and endocrine function, nutritional status, pain
severity, use of pain medication or narcotics, employment status, and
quality of life. Continued ingestion of alcohol or narcotics should be
addressed in either a medical or surgical management plan.

**Treatment**

Patients with disabling abdominal pain, evidence of chronic
pancreatitis, and pancreatic ductal dilatation are best managed by
pseudocyst decompression or ductal decompression (Puestow
pancreaticojejunostomy procedure), while patients without ductal
dilatation are best treated with resection. Biliary-enteric
decompression may also be required in patients with chronic pancreatitis
and bile duct obstruction. Although preservation of pancreatic tissue is
desired to maintain both exocrine and endocrine function, partial
pancreatic resection (such as distal pancreatectomy,
pancreaticoduodenectomy, or duodenal preserving pancreatic head
resection/decompression \[i.e. Beger or Frey procedures\]) is at times
the preferred treatment. While alternative procedures such as endoscopic
sphincterotomy, short-term stent placement in the major pancreatic duct,
or pancreatic pseudocyst may provide short-term relief of symptoms,
long-term results are as yet unknown.

**Qualifications for Performing Day Surgery**

At a minimum, surgeons who are certified or eligible for certification
by the American Board of Surgery, the Royal College of Physicians and
Surgeons of Canada, or their equivalent should perform operations for
pancreatitis. These surgeons have successfully completed at least 5
years of surgical training after medical school graduation and are
qualified to perform operations on the pancreas. Pancreatic surgery
should preferably be performed by surgeons with special knowledge,
training, and experience in the management of pancreatic disease. The
level of training in advanced laparoscopic techniques necessary to
conduct minimally invasive surgery of the pancreas is important to
assess. The qualifications of a surgeon performing any operative
procedure should be based on training (education), experience, and
outcomes.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Initial pain relief following operative treatment for chronic
pancreatitis can be expected in 75 to 80% of patients and sustained in
selected patients for 3 to 5 years. Successful relief of pain after
operation is associated with weight gain in most patients.

**Subgroups Most Likely to Benefit**

Overall, the best outcomes occur in patients who are compliant with
pancreatic enzyme replacement and abstain from alcohol and narcotics
use.

#### POTENTIAL HARMS

Risks and complications associated with operation for chronic
pancreatitis, with a frequency in the range of 0.5 to 5%, include:

-   Infection

-   Bleeding

-   Biliary and pancreatic anastomotic leaks

-   Aggravation of existing acute pancreatitis

The mortality rate of pancreatic surgery is currently below 5% for major
resections and less for non-resective decompressive operations.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines have been written by the Patient Care Committee of the
Society for Surgery of the Alimentary Tract (SSAT). Their goal is to
guide primary care physicians to the appropriate utilization of surgical
procedures on the alimentary tract or related organs and they are based
on critical review of the literature and expert opinion. Both of the
latter sources of information result in a consensus that is recorded in
the form of these Guidelines. The consensus addresses the **range** of
acceptable clinical practice and should not be construed as a standard
of care. These Guidelines require periodic revision to ensure that
clinicians utilize procedures appropriately, but the reader must realize
that clinical judgment may justify a course of action outside of the
recommendations contained herein.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Society for Surgery of the Alimentary Tract (SSAT). Operative treatment
for chronic pancreatitis. Manchester (MA): Society for Surgery of the
Alimentary Tract (SSAT); 2004. 3 p.

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1996 (revised 2004 May 15)

#### GUIDELINE DEVELOPER(S)

Society for Surgery of the Alimentary Tract, Inc - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

Society of Surgery of the Alimentary Tract, Inc.

#### GUIDELINE COMMITTEE

Patient Care Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates the previously issued version: Society for
Surgery of the Alimentary Tract. Operative treatment for chronic
pancreatitis. Manchester (MA): Society for Surgery of the Alimentary
Tract; 2000. 3 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Society for Surgery of the
Alimentary Tract, Inc. Web
site](http://www.ssat.com/cgi-bin/guidelines.cgi).

Print copies: Available from the Society for Surgery of the Alimentary
Tract, Inc., 900 Cummings Center, Suite 221-U, Beverly, MA 01915;
Telephone: (978) 927-8330; Fax: (978) 524-0461.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Gadacz TR, Traverso LW, Fried GM, Stabile B, Levine BA. Practice
    guidelines for patients with gastrointestinal surgical diseases. J
    Gastrointest Surg 1998;2:483-484.

Electronic copies: Not available at this time.

Print copies: Available from the Society for Surgery of the Alimentary
Tract, Inc., 900 Cummings Center, Suite 221-0, Beverly, MA 01915;
Telephone: (978) 927-8330; Fax: (978) 524-8890.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 28, 2000. The information
was verified by the guideline developer as of May 30, 2000. This
guideline was updated by ECRI on September 8, 2004.

#### COPYRIGHT STATEMENT

For terms governing downloading, use, and reproduction of these
guidelines, please contact: <ssat@prri.com>.

### DISCLAIMER

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Date Modified: 11/10/2008