特別講演, 招待講演, インターナショナル・セッション, 会長講演
The Japanese Journal of Gastroenterological Surgery
The two overriding challenges of chronic pancreatitis are gland insufficiency (both exocrine and endocrine) and intractable pain. The latter not only creates a state of constant misery, but also adversely affects dietary intake and thereby diabetes management. In most cases, opiate addiction and its demeaning life style foilow. The pain has universally been assumed to arise from pancreatic duct obstruction by scar and/or concretions. More than half of patients will have their main pancreatic
... main pancreatic duct converted into a chain of lithic lakes. Distal duct drainage (Duval) has provided only temporary respite, while a more thorough duct decompression from pancreatic head to tip of tail (Puestow) has given true lasting relief to but a third. For those who have failed duct drainage or whose pathologic anatomy defies duct anastomosis, pancreatic resection has become the mainstay of patient salvage. However, a balance must be struck between near complete pancreatectomy with its attendent brittle diabetes-usually life-constraining and often life-threatening itself-and the less than ideal chance for pain elimination by a more conservative resection. As a general rule, ablation of 80% of pancreas, will provide considerable reduction in severity of pain at far less the cost in worsening an already fragile diabetic state. In an attempt to avoid the added risks of operation and subsequent complications of more difficult diabetic management, afferent nerve interruption has appeared to offer a reasonable alternative. Celiac plexus blocks with alcohol give only temporary relief, which unfortunately lasts for shorter and shorter periods after each repeat treatment. Surgical celiac ganglionectomy is seldom complete, is a major procedure, and has been inconsistent in pain control. Results with sympathectomy are no better. On the other hand, unilateral splanchnic nerve resection (greater and lesser) has produced a permanent freedom from pain in approximately two-thirds of patients, while recurrence of symptoms-almost always in the opposite upper quadrant of the abdomen-can be eliminated by contralateral splanchnicectomy, thereby finally achieving complete pain relief. Since the discomfort of a thorocotomy incision is significant, any fresh source of pain automatically becomes a major obstacle in breaking patient narcotic addiction. To offset this drawback, thorocoscopic splanchnic denervation has been adopted and, in an initial trial, has proven to be reliable. Only time will show whether this new approach will attain the desired result without complicating the patient's course by a major operation or a now more brittle diabetes.