What are the differences between the Puestow procedure, Frey procedure, and Beger procedure?

From the Guidelines

The Beger procedure is recommended for patients with chronic pancreatitis due to its improved postoperative pain relief and quality of life compared to other procedures, as shown in recent studies 1. When considering surgical interventions for chronic pancreatitis, the choice between the Puestow, Frey, and Beger procedures depends on the patient's specific condition, including the extent of pancreatic duct dilation, the presence of inflammatory mass in the pancreatic head, and other complications.

• The Puestow procedure, a longitudinal pancreaticojejunostomy, is suitable for patients with a dilated pancreatic duct without significant head inflammation.
• The Frey procedure, which combines the Puestow technique with limited resection of the pancreatic head, is appropriate for patients with both ductal dilation and focal head disease.
• The Beger procedure, involving more extensive resection of the pancreatic head while preserving the duodenum and bile duct, is best for patients with significant inflammatory mass in the pancreatic head. According to a recent meta-analysis 1, the Beger procedure shows better postoperative pain relief and improved quality of life compared to conventional pancreaticoduodenectomy, although a recent large prospective RCT found no significant difference between procedures in long-term nutritional status, quality of life, and preservation of exocrine pancreatic function 1.
• Key factors influencing the choice of procedure include the extension of parenchyma resection, preservation of the duodenum and bile natural transit, and pancreatic secretion, which are crucial for endocrine and exocrine functions 1.
• A 2015 meta-analysis comparing outcomes of the Frey procedure with pancreaticoduodenectomy and the Beger procedure found that short-term quality of life and pancreatic function outcomes were more favorable in patients who had the Frey procedure than in those who had pancreaticoduodenectomy 1. However, long-term follow-up data from an RCT comparing the Frey and Beger procedures for chronic pancreatitis showed no significant difference in endocrine or exocrine insufficiency more than a decade after surgery 1. Ultimately, the decision between these procedures should prioritize the patient's individual needs and anatomy, aiming to relieve pain, preserve pancreatic function, and improve quality of life, with the Beger procedure being a preferred option based on recent evidence 1.

From the Research

Comparison of Surgical Procedures

• The Puestow, Frey, and Beger procedures are surgical options for the treatment of chronic pancreatitis, with each having its own advantages and disadvantages 2, 3, 4.
• A systematic review and meta-analysis compared the clinical efficacy of duodenum-preserving pancreatic head resection (DPPHR) strategies, including the Beger and Frey procedures, with pancreaticoduodenectomy (PD) 2.
• The results showed that DPPHR strategies had better outcomes in terms of operation time, blood transfusion, hospital stay, postoperation morbidity, weight gain, quality of life, and occupational rehabilitation compared to PD 2.
• The Frey procedure was found to have favorable outcomes compared to PD in terms of operation time, blood transfusion, overall morbidity, length of hospital and intensive care unit stay, pancreatic function, and quality of life 3.
• A retrospective review of patients who underwent surgery for chronic pancreatic pain found that the pain relief rate was 82.6% after surgery, with the highest pain relief rate achieved with the Beger procedure (90%) 4.

Procedure-Specific Outcomes

• The Beger procedure had a pain relief rate of 90% and a pain recurrence rate of 11.1% 4.
• The Frey procedure had a pain relief rate of 86.7% and a pain recurrence rate of 15.4% 4.
• The modified Puestow procedure had a pain relief rate of 83.1% and a pain recurrence rate of 27.8% 4.
• The distal pancreatectomy had a pain relief rate of 63.6% and a pain recurrence rate of 42.9% 4.

Surgical Options for Chronic Pancreatic Pain

• The choice of surgical procedure for chronic pancreatic pain depends on the anatomical morphological changes of the pancreas 4.
• The modified Puestow procedure, Frey procedure, Beger procedure, pancreaticoduodenectomy (PD), and pylorus preserving pancreaticoduodenectomy (PPPD) are all viable options for the control of chronic pancreatic pain 4.
• The distal pancreatectomy alone should be used cautiously for pain relief due to its lower pain relief rate and higher pain recurrence rate 4.