The perception of pain is a common reason why patients see their physicians. Pain is also an important concern after surgery.
Treatment of patients with chronic (long-standing) pain is complex and often requires involvement of a multidisciplinary team that includes a pancreatic surgeon, gastroenterologist, pain physician and a psychiatrist. This comprehensive evaluation of pain is important for optimal outcome.
Treatment of postoperative (post surgical) pain
Over the past two decades there has been a significant improvement in the treatment of pain after surgery. Most patients are provided with excellent pain relief after surgery and experience only minimal discomfort.
Good management of postoperative pain is very important not only for comfort reasons, but also to encourage the patient to carry out chest physiotherapy exercises such as utilizing the incentive spirometer to prevent post operative pneumonia and collapse of the lung that is otherwise common with a large abdominal incision that are often made for big operations on the pancreas and the liver.
The following techniques are utilized for control of post-surgical pain
– Patient controlled analgesia (PCA): in this technique the patient uses an infusion pump that contains morphine or morphine type of narcotic pain medication. The pump provides a small continuous dose of pain medication to the patient. In addition to that the patient can inject him/her self with an additional doses of pain medication to control the pain. This is an excellent technique for the management of post-operative pain and the vast majority of patients obtain satisfactory pain relief with this technique.
– Epidural catheter: in selected patients an epidural catheter is placed and pain medication is delivered around the spinal nerves as they come out of the spinal cord. This type of treatment is similar to that used during labor and delivery by many obstetricians. This technique also provides excellent pain relief from postoperative pain and is an alternative to patient controlled analgesia.
– Oral pain medications: a variety of oral pain medications are available that provide the transition from intravenous pain medication to oral pain medication.
Pain in chronic pancreatitis:
Pain is the most common reason for presentation of a patient to a physician/surgeon with chronic pancreatitis and is the major reason for surgery in chronic pancreatitis. The cause for pain in chronic pancreatitis is complex and the exact reason for pain is not known.
It is thought that two major reasons contribute to pain in chronic pancreatitis:
– Increased pressure in the pancreatic duct: The inflammation and scarring in chronic pancreatitis causes multiple areas of narrowing of the main pancreatic duct and the small branches of the pancreatic duct. Blockage of pancreatic secretion causes build up of these secretions that are thought to give rise to pain.
– Inflammation of the pancreatic nerve: The pancreas is richly supplied with pancreatic nerves and inflammation in the pancreas may damage these nerves causing pain. Furthermore, chronic inflammation in the pancreas can release various substances that stimulate these nerves. The head of the pancreas appears to be most affected in chronic pancreatitis. Operations that remove that head of the pancreas provide excellent relief from severe pain associated with chronic pancreatitis.
Treatment of pain from chronic pancreatitis
A patient who presents with pain from chronic pancreatitis requires careful evaluation prior to any form of surgery. These patients have complex psychosocial problems associated with long usage of narcotic type of pain medications over many years for relief of their pain.
In many patients chemical dependency on alcohol and narcotic pain medication are difficult to distinguish from true pain originating from the pancreas. A careful evaluation of the patient for chemical dependency is critical for good outcome from surgery since patients who have chemical dependency would continue to be dependant on narcotic pain medication leading to poor results from the surgery. Furthermore, alcohol addiction is crucial to recognize prior to surgery since the results of the surgery for pain is not good if the pain continues to abuse alcohol. Removal of parts of the pancreas in a patient who continues to abuse alcohol may produce dangerous side effects associated with low blood sugar.
In many patients a careful psychiatric evaluation may be required to distinguish between a chemical dependency and severe pain from chronic pancreatitis. Furthermore many patients may have both severe pain from chronic pancreatitis and a chemical dependency that is difficult to resolve until the patient has undergone surgery. In these patients post-operative treatment for chemical dependency is critical for good long-term results.
Pain in pancreatic cancer
Severe abdominal and back pain is a significant complication in patients who develop unresectable (surgically not removable) pancreatic cancer. Management of pain is important for providing good palliation in patients with advanced pancreatic cancer.
The following options are available for treatment of chronic pain in pancreatic cancer:
– Percutaneous celiac nerve block: in this procedure the radiologist inserts a needle into the nerves around the pancreas utilizing images from the CT scan for guidance and alcohol is injected into the nerves to destroy the nerves.
– Radiation and/or chemotherapy: radiation and/or chemotherapy may provide good pain relief in selected patients
– Insertion of pain pumps: pumps may be placed for continuous release of pain medication in the epidural space around the spinal cord for continuous pain medication administration for chronic pain.
– Narcotic medications: narcotic medications in various forms such as patches and sentinel patches may provide some pain relief in some patients.
Utilizing a combinations of the these techniques, the majority of patients may obtain good or excellent relief from their pain. Careful evaluation and optimization of the different treatment modalities is important for the best results.