What is the most appropriate treatment for a 58-year-old man with chronic epigastric pain, steatorrhea, and diabetes due to pancreatic duct stricture and dilated pancreatic duct?

Management of Pain in Chronic Pancreatitis with Dilated Pancreatic Duct

Lateral pancreaticojejunostomy (Puestow procedure) is the most appropriate treatment for this patient's pain given his dilated pancreatic duct (8 mm) with stricture confirmed by ERCP. 1

Rationale for Surgical Intervention

The patient presents with classic features of chronic pancreatitis:

• 58-year-old man with alcohol abuse history
• Chronic epigastric pain radiating to the back
• Steatorrhea and diabetes (pancreatic exocrine and endocrine insufficiency)
• Pancreatic calcifications on CT
• Dilated pancreatic duct (8 mm) with stricture confirmed by ERCP

Why Surgery is Preferred Over Endoscopic or Medical Management:

1. Guideline-Based Recommendation: The 2022 AGA Clinical Practice Update clearly states that "surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis" 1

2. Ductal Obstruction: The patient has a significantly dilated pancreatic duct (8 mm) with stricture, which is the primary indication for decompressive surgery 1

3. Long-term Outcomes: Surgical drainage procedures provide more durable pain relief compared to endoscopic management or medical therapy alone for patients with dilated ducts 1

Why Lateral Pancreaticojejunostomy (Puestow) is the Best Option

The Puestow procedure is specifically designed for patients with:

• Dilated pancreatic duct (>6-7 mm)
• Pancreatic duct strictures
• Pancreatic calcifications

This procedure involves:

• Opening the pancreatic duct from head to tail
• Removing calcifications and stones
• Creating a side-to-side anastomosis between the opened pancreatic duct and a Roux-en-Y jejunal limb 2, 3

Benefits of Lateral Pancreaticojejunostomy:

• Pain relief in approximately 80% of patients 4
• Preservation of remaining pancreatic function
• Low mortality rate (4%) 4
• Durable long-term results with patent anastomosis 5

Why Other Options Are Less Appropriate

1. Pancreatic enzyme supplementation alone (Option A):

   • While PERT is essential for managing steatorrhea and malnutrition in chronic pancreatitis 1
   • It is insufficient for pain management in patients with ductal obstruction and dilation 1
   • ESPEN guidelines note that "the role of enzyme products to manage pain is controversial" 1

2. Pancreaticoduodenectomy (Whipple procedure) (Option C):

   • More extensive resection with higher morbidity
   • Reserved for patients with inflammatory mass in the pancreatic head or suspected malignancy
   • Unnecessary for patients with diffuse ductal dilation without head-predominant disease 1

3. Celiac plexus block (Option D):

   • The 2022 AGA guidelines explicitly state: "Celiac plexus block should not be routinely performed for the management of pain due to chronic pancreatitis" 1
   • Limited duration of effect (typically <6 months)
   • Should only be considered after other therapeutic measures have failed 1

Post-Surgical Management

After lateral pancreaticojejunostomy, the patient will require:

• Continued pancreatic enzyme replacement therapy for steatorrhea 1
• Diabetes management
• Nutritional support and monitoring
• Alcohol abstinence counseling

Key Considerations

• Long-term success depends on alcohol cessation
• Despite successful pain relief, progression of pancreatic insufficiency may still occur 5
• Pancreatic enzyme supplementation will still be needed for management of malabsorption 1

The evidence strongly supports lateral pancreaticojejunostomy as the most appropriate intervention for this patient with chronic pancreatitis, dilated pancreatic duct, and ductal stricture.