Surgical Options for Chronic Pancreatitis
Surgical intervention should be considered over endoscopic therapy for long-term treatment of patients with painful obstructive chronic pancreatitis. 1, 2
Indications for Surgery
- Intractable pain unresponsive to medical management
- Suspicion of malignancy
- Complications affecting adjacent organs
- Obstructive pancreatic duct disease
Surgical Approach Based on Ductal Anatomy
Large Duct Disease (≥7 mm dilated pancreatic duct)
- First-line option: Lateral pancreaticojejunostomy (Puestow procedure) 2, 3
- Involves longitudinal opening of the pancreatic duct and anastomosis to a Roux-en-Y jejunal limb
- Provides effective drainage of the dilated pancreatic duct
Pancreatic Head Enlargement/Inflammatory Mass
Preferred options: Combined drainage and resection procedures 2, 4
- Frey procedure: Local resection of pancreatic head combined with longitudinal pancreaticojejunostomy
- Beger procedure: Duodenum-preserving pancreatic head resection
- Berne procedure: Modified duodenum-preserving pancreatic head resection
These duodenum-preserving procedures offer better outcomes than pancreaticoduodenectomy (Whipple) in terms of:
- Shorter operative time
- Reduced blood transfusion requirements
- Shorter hospital stay
- Lower postoperative morbidity
- Better weight gain and quality of life 5
Small Duct Disease/Minimal Change Disease
- Recommended option: Pancreatic resection procedures 6, 3
- Whipple procedure (pancreaticoduodenectomy) for disease confined to the pancreatic head
- Total pancreatectomy with islet cell autotransplantation for diffuse small duct disease 6
- Previously avoided due to brittle diabetes
- Now showing excellent long-term results for pain control and quality of life with islet autotransplantation
Groove Pancreatitis (Specific Variant)
- Recommended option: Pancreaticoduodenectomy 4
Timing of Surgical Intervention
- Early surgical intervention is favored over delayed surgery 4
- Provides better long-term pain relief
- May preserve pancreatic function
- Prevents disease progression
Special Considerations
- Hereditary chronic pancreatitis: Consider prophylactic resection due to high lifetime risk (40-55%) of pancreatic cancer 4
- Sporadic chronic pancreatitis: Risk of pancreatic cancer too low (2% in 10 years) to recommend prophylactic surgery 4
Outcomes of Surgical Management
- Pain relief achieved in majority of patients with appropriate procedure selection
- Long-term outcomes favor duodenum-preserving procedures over traditional pancreaticoduodenectomy 5
- Total pancreatectomy with islet autotransplantation showing promising results for diffuse small duct disease 6
Postoperative Management
- Continued pancreatic enzyme replacement therapy
- Monitoring for diabetes development
- Nutritional support and supplementation
- Alcohol and tobacco cessation essential to prevent disease progression 2
The choice of surgical procedure should be guided by the specific morphological variant of chronic pancreatitis, with duodenum-preserving techniques preferred when possible for better quality of life outcomes.