Frey Procedure: Surgical Steps
The Frey procedure combines local resection (coring out) of the pancreatic head with longitudinal pancreaticojejunostomy of the body and tail, designed to decompress both the enlarged fibrotic pancreatic head and the dilated main pancreatic duct in chronic pancreatitis. 1
Operative Technique
Step 1: Pancreatic Head Resection
- Excise the anterior surface of the pancreatic head overlying the ducts of Wirsung and Santorini, including the duct to the uncinate process and their tributary ducts 1
- This "coring out" removes the fibrotic tissue, small strictured ducts, impacted calculi, and small pseudocysts within the enlarged pancreatic head 2
- The resection is performed without transecting the pancreatic gland or dissecting along the portal/superior mesenteric vein, which distinguishes it from the Beger procedure and reduces bleeding risk 3
Step 2: Longitudinal Pancreaticojejunostomy
- Open the main pancreatic duct longitudinally along the body and tail of the pancreas 1
- Create a side-to-side anastomosis between the opened pancreatic duct and a Roux-en-Y jejunal limb 1
- This provides drainage for the entire ductal system from head to tail
Step 3: Biliary Bypass (When Indicated)
- Add a hepaticojejunostomy if common bile duct obstruction is present from compression by the inflammatory pancreatic head mass 2, 4
- The local resection often frees the common duct from compressing structures, potentially eliminating the need for separate biliary bypass 2
Key Technical Points
The procedure avoids portal vein dissection, making it particularly valuable when severe inflammation causes encasement of retropancreatic vessels 5. This represents a critical safety advantage over more extensive resections.
The operation is specifically indicated for patients with:
- Dilated pancreatic duct in the body and tail
- Enlarged fibrotic pancreatic head with small strictured ducts and/or impacted calculi
- Failed previous longitudinal pancreaticojejunostomy with persistent pain 2
Clinical Outcomes
Pain relief is achieved in approximately 87% of patients, with excellent results in 74.5% 1, 4. The procedure provides good decompression with modest increases in endocrine/exocrine insufficiency and significant weight gain in 64% of patients 1.