Chronic Pancreatitis

Glucose - islet destruction makes these patients diabetic and brittle. Check a point-of-care glucose on arrival and hourly intraoperatively; the swing runs both ways, so treat hypoglycemia as seriously as hyperglycemia.

Nutrition - exocrine insufficiency causes malnutrition and predicts a rough recovery. Get a formal nutritional assessment and the weight trend, and note whether the patient is on pancrelipase, the enzyme replacement taken with meals for both digestion and pain.

Coagulation - fat malabsorption strips the fat-soluble vitamins, and vitamin K deficiency bleeds. Check an INR before neuraxial or a laparotomy, and give vitamin K if there is time.

Opioid tolerance - most of these patients arrive on chronic opioids with a high baseline requirement. Pull the home dose off the pharmacy record and build in the maintenance. Escalating opioids can make the abdominal pain worse rather than better (narcotic bowel syndrome), so lean on regional, ketamine and non-opioid adjuncts.

Celiac plexus block - the plexus carries preganglionic sympathetic fibers from the greater and lesser splanchnic nerves (T5 to T12) and supplies sensory innervation and sympathetic outflow to the pancreas and the rest of the upper abdominal viscera. It is an effective analgesic step, but the sympathectomy drops blood pressure — preload with fluid, have a vasopressor drawn, and keep monitoring after the block, not just during it.

Truncal blocks - bilateral erector spinae plane or transversus abdominis plane blocks reduce pain after abdominal surgery and are worth doing in an opioid-tolerant patient.

Alcohol - ask the date and volume of the last drink. Alcohol is a leading cause, and unrecognized withdrawal shows up as agitation and tachycardia a day or two postop, right after you have handed off.

Aspiration - chronic opioids slow the gut and a large pseudocyst sits against the stomach. A patient with pain, nausea or early satiety is a full stomach; do an RSI.

The big case - pancreaticoduodenectomy and pancreatojejunostomy drainage procedures for chronic pancreatitis are long, done open, laparoscopically or robotically, with real fluid shifts and blood loss. Arterial line, large-bore access, active warming, and an epidural or truncal catheter agreed with the surgeon.

Chronic pancreatitis is a progressive inflammatory disorder in which pancreatic parenchyma is irreversibly destroyed — atrophied and replaced by fibrous tissue — taking both the exocrine and the endocrine gland with it. Alcohol and gallstones lead the causes; drugs, infection, prior surgery and genetic mutations account for the rest. Three functional consequences drive the anesthetic: severe, unrelenting abdominal pain that has usually been treated with escalating opioids; diabetes as islet mass is lost; and malabsorption from exocrine enzyme failure, producing malnutrition and fat-soluble vitamin deficiency. Structural sequelae — ductal disease, an inflammatory head mass that can be indistinguishable from adenocarcinoma, and pancreatic pseudocysts — are what bring these patients to endoscopy, drainage procedures, or pancreaticoduodenectomy.