From the Guidelines
Surgical intervention is the preferred treatment option for patients with painful obstructive chronic pancreatitis, as it has been shown to provide superior pain relief compared to endoscopic therapy. The main surgical options include drainage procedures, such as the Puestow procedure (lateral pancreaticojejunostomy), which is suitable for patients with a dilated pancreatic duct 1. Resection procedures, including pancreaticoduodenectomy (Whipple procedure), distal pancreatectomy, or total pancreatectomy, are considered when there is significant tissue damage, inflammatory mass, or suspicion of malignancy. The Frey procedure, which combines drainage and limited head resection, is an option for patients with both ductal dilation and an inflammatory head mass. The Beger procedure involves resection of the pancreatic head while preserving the duodenum.
The decision to proceed with surgery should be based on the patient's anatomy, disease distribution, presence of complications, and the surgeon's expertise, with the goal of preserving pancreatic function while addressing the underlying pathology 1. Early surgical intervention has been shown to be superior to endoscopic therapy for pain relief in patients with obstructive chronic pancreatitis, with a recent study demonstrating higher complete or partial pain relief in the early surgery group compared to the endotherapy group during 18 months of follow-up 1.
Key considerations in the management of chronic pancreatitis include:
- Pain management: Surgical intervention can provide durable symptom improvement by reducing pancreatic duct pressures 1
- Preservation of pancreatic function: The choice of procedure should aim to preserve as much pancreatic tissue as possible while addressing the underlying pathology
- Management of potential complications: Post-operative care should include managing potential complications like diabetes, exocrine insufficiency requiring enzyme supplementation, and nutritional deficiencies 1
From the Research
Surgical Options for Chronic Pancreatitis
The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity 2.
- Pancreatic Ductal Drainage: Pancreatic ductal drainage with pancreaticojejunostomy is suitable for patients with a dilated pancreatic duct and produces good early postoperative pain relief 2, 3.
- Resection: Resection for chronic pancreatitis should be considered when the main pancreatic duct is not dilated, when the pancreatic head is enlarged, when there is suspicion of a malignancy, or when previous pancreaticojejunostomy has failed 2.
- Types of Resection: Resection strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure) 2, 4, 5.
- Comparison of Surgical Procedures: A prospective study compared the results of distal pancreatectomy plus end-to-side pancreaticojejunostomy and pancreaticoduodenectomy, and found that the former provided better outcomes with increased body weight and no steatorrhea or diabetes mellitus, and complete pain relief 6.
- Current Therapies: Current operative management of chronic pancreatitis includes drainage procedures, resection, and combined drainage/resection procedures, as well as total pancreatectomy with islet autotransplantation and minimally invasive options 4, 5.
Indications and Techniques
The optimal surgical intervention should provide effective pain relief, improve/maintain quality of life, preserve exocrine and endocrine function, and manage local complications 5.
- Pancreaticoduodenectomy: Once the standard operation for patients with chronic pancreatitis, but now other procedures such as duodenum-preserving pancreatic head resections have been introduced with good long-term results 2, 5.
- Duodenum-Preserving Pancreatic Head Resections: Procedures such as the Beger procedure and its variants have been introduced with good long-term results 5.
- Pancreatic Duct Drainage: Continues to be effective in ameliorating symptoms and expediting return to normal lifestyle in many patients 5.