From the Guidelines
Surgical management is the preferred treatment for patients with painful obstructive chronic pancreatitis, as it offers superior pain relief compared to endoscopic therapy, as evidenced by recent studies 1. The primary surgical approaches for chronic pancreatitis include:
- Drainage procedures, such as the Puestow procedure (lateral pancreaticojejunostomy), which are suitable for patients with a dilated main pancreatic duct (>7mm)
- Resection procedures, including pancreaticoduodenectomy (Whipple procedure) for disease predominantly affecting the pancreatic head, distal pancreatectomy for disease limited to the tail, and total pancreatectomy in severe cases affecting the entire gland
- Hybrid approaches, such as the Frey procedure, which combines limited head resection with longitudinal pancreaticojejunostomy, and the Beger procedure, which involves resection of the pancreatic head with preservation of the duodenum The choice of procedure depends on the anatomical distribution of disease, presence of complications like pseudocysts or biliary/duodenal obstruction, and the patient's overall condition, as highlighted in a recent expert review 1. Recent randomized trials, including the ESCAPE trial, have demonstrated that early surgical intervention is superior to endoscopic therapy for pain relief in patients with obstructive chronic pancreatitis, with higher complete or partial pain relief rates (58% vs 39%) during 18 months of follow-up 1. Postoperatively, patients require close monitoring for complications such as anastomotic leaks, bleeding, and infection, and long-term management includes pancreatic enzyme replacement therapy for exocrine insufficiency and insulin for endocrine insufficiency, which commonly develop or worsen after pancreatic surgery. The goal of surgery is to relieve pain, preserve pancreatic function when possible, and address complications while minimizing morbidity, ultimately improving the patient's quality of life, as supported by the AGA clinical practice update 1.
From the Research
Surgical Management Options
- Surgical drainage procedures, such as pancreaticojejunostomy, are limited to patients with a dilated duct and no pancreatic head mass 2, 3
- Distal pancreatectomy may be successful for patients with a focal stricture and tail only disease 2, 3
- Duodenum-preserving resections, such as the Beger procedure, offer benefits compared to pancreaticoduodenectomy for the treatment of the expanded head 2, 3
- Total pancreatectomy with islet autotransplantation is a valid option for the treatment of pain in patients with small duct/minimal change disease 2, 4
Timing of Surgery
- Early surgical intervention is superior to a step-up approach with initial endoscopic treatment for long-term pain relief 5, 6
- Surgical intervention is the treatment of choice for the treatment of pancreatic pain in the midterm and long term 5
- The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience 4
Comparison of Treatment Options
- Surgical intervention is superior to conservative and endoscopic treatment for the treatment of chronic pancreatitis 2, 5, 6
- Endoscopic treatment is justified for short-term pain relief, but surgical intervention is the treatment of choice for long-term pain relief 5
- Pancreatic pseudocysts, solitary proximally situated pancreatic duct stones, and benign biliary strictures can be managed endoscopically, while distal pancreatic duct stones and symptomatic pancreatic duct stenosis require surgical treatment 5