Extrahepatic portal hypertension in chronic pancreatitis: an old problem revisited.

OBJECTIVE: To evaluate the impact of concomitant nonhepatic portal hypertension in chronic pancreatitis on immediate and long-term outcome after major pancreatic surgery.

METHODS: A total of 154 patients (96 male, 58 female) with a history of pancreatitis of at least 12 months, severe incapacitating pain, and radiologic evidence of pancreatic head enlargement was evaluated. One hundred thirty-five patients underwent duodenum-preserving resections of the pancreatic head according to Beger or Frey, and 19 patients underwent pancreatoduodenectomy without (classical Whipple) or with pyloric preservation (PPPD) in cases of suspected malignancy. Outcome parameters included operative time and blood loss, early and late complications and death, recurrent pancreatitis, professional rehabilitation, and alterations in portal venous flow. Median follow-up in this prospective study was 51 months.

RESULTS: Patients with portal hypertension required significantly more blood transfusions and had longer operative times than their counterparts. The overall postoperative complication rate was significantly higher in this subgroup. Restoration of postoperative portal venous blood flow was complete after Beger, Whipple, and PPPD procedures but was little affected by Frey procedures. There was no evidence of variceal hemorrhage during the observation period in all operative groups.

CONCLUSIONS: Concomitant extrahepatic portal hypertension entails a substantial risk in pancreatic surgery for chronic pancreatitis. When surgery is considered in a symptomatic patient, surgical strategy is determined more by pancreatic morphology than by the intent to restore portal blood flow.