**5. Surgery for chronic pancreatitis – Resectional procedures**

With recognition that inflamed, fibrotic tissue containing damaged neural structures within the pancreatic head is critical in the generation of symptoms, pancreaticoduodenectomy became the gold standard in surgical treatment against which other procedures were measured. It has been assumed that outcomes concerning pain and quality of life are better than simple drainage procedures performed in isolation, however clear evidence of this is in randomized trials is lacking.

alternative option when communication with the pancreatic duct can be demonstrated. Surgery is indicated when endoscopic intervention fails or is not appropriate due to cyst morphology or patient factors. Surgical drainage of a pseudocyst may also be employed as part of an intervention planned for treatment of pain or additional complications. Pancreatic ascites is an uncommon but serious complication of CP which is managed in the first instance with paracentesis, nutritional support and endoscopic stenting of the pancreatic duct (Kozarek RA Gastrointest Endosc Clin North Am 1998; Bornman PC in Hepatobiliary and pancreatic surgery – a companion to specialist surgical practice 2009). Use of a somatostatin analogue remains controversial. Surgery is reserved for failures of conservative treatment. Bleeding from gastric varices related to segmental portal vein thrombosis is uncommon, thus the authors recommend intervention only once there is proven bleeding from gastric varices. Haemorrhage related to a pseudoaneurysm is best dealt with via selective angiography and embolisation due to the hazards of surgery in this setting.

For many years longitudinal pancreaticojejunostomy (LPJ) as described by Partington and Rochelle in 1960 was the favoured surgical option in the treatment of chronic pancreatitis. This involves entering and laying open of the pancreatic duct followed by a splenic preserving pancreaticojejunostomy without resection of the pancreatic tail (Partington PF, Rochelle REL. Ann Surg 1960). This procedure is relatively simple in comparison to many of the other available operations and has a low mortality and morbidity with maximal pancreatic tissue preserved. Pain relief in the short term approximates 75% but there is frequently recurrence in the long term (Bachmann K Best Pract and res Clin Gastro 2010). This is thought to be due to incomplete decompression of the main pancreatic duct, particularly in the head. There remains a residual inflammatory mass containing altered nerve fibres (Pessaux P Pancreas 2006) as well as obstructed second and third order ducts causing ongoing intraductal hypertension (Markowitz JS Arch Surg 1994). Current indications for this procedure are isolated dilatation of the pancreatic duct greater than 7mm or where the duct has a "chain of lakes" appearance without an inflammatory mass in the head (Yekebas EF Ann Surg 2006). Where the duct is undilated (less than 3mm) a longitudinal V-shaped excision of the ventral pancreas combined with a longitudinal pancreatico-jejunostomy has been described (Izbicki JR Ann Surg 1998, 227). This may be particularly useful when a sclerosing form of chronic pancreatitis results in so called small duct disease (Bachmann K Best Pract and res Clin Gastro 2010). Good results with pain relief in 89% of patients and comparable morbidity of 19.6% have been reported (Yekebas EF Ann

Surgery is reserved for failure of angiographic treatment.

Surg 2006).

randomized trials is lacking.

**4. Surgery for chronic pancreatitis – Drainage procedures** 

**5. Surgery for chronic pancreatitis – Resectional procedures** 

With recognition that inflamed, fibrotic tissue containing damaged neural structures within the pancreatic head is critical in the generation of symptoms, pancreaticoduodenectomy became the gold standard in surgical treatment against which other procedures were measured. It has been assumed that outcomes concerning pain and quality of life are better than simple drainage procedures performed in isolation, however clear evidence of this is in In the modern era, pylorus preservation as in a Pylorus Preserving Pancreaticoduodenectomy (PPPD) has been shown to result in less pain and nausea and improved quality of life when compared with the traditional Whipples pancreaticoduodenectomy (Mobius C Langenbecks Arch Surg 2007). This procedure can be performed with a mortality of 5-10% and morbidity of 20-40% and improves pain and quality of life in both the short and long term in up to 90% of patients (Bachmann K Best Pract and res Clin Gastro 2010). There are however a number of disadvantages relating to the sacrifice of functional pancreatic parenchyma and the nondiseased duodenum and common bile duct. The loss of natural bowel continuity and reduced endocrine and exocrine function result in side effects and reduced quality of life (Izbicki JR Ann Surg 1998 (228); Koninger J Surgery 2008). In order to allow organ preservation and reduce adverse effects, duodenum preserving resections of the pancreatic head (DPPHR) were developed. The Beger procedure was introduced in 1980 and was the first to include these principles (Beger HG Chirurg 1980). It consists of a subtotal resection of the head following transection of the pancreas above the portal vein. The Pancreas is then drained by an end-toside or end-to-end pancreaticojejunostomy using a Roux-en-Y loop. Physiological gastroduodenal passage and CBD continuity are therefore preserved. This procedure could be performed with low mortality (0-3%) and morbidity (15-32%) and long term pain relief in 75- 95% of patients (Izbicki JR Ann Surg 1995, Buechler MW J Gastrointest Surg 1997Frey CF Ann Surg 1994). The Frey procedure (Frey CF Pancreas 1987) subsequently combined an LPJ (as described by Partington and Rochelle) with a limited duodenum preserving excision of the head. Following exploration of the main pancreatic duct well into both the head and the tail, the head is cored out leaving a small cuff of parenchyma along the duodenal wall. This results in a lesser resection of the head than that described by Beger. In further contrast to the Beger operation, the pancreas is not divided over the SMV/portal vein complex making it an easier operation to perform. Care is taken not to enter the CBD. Drainage of the resection cavity within the head and from the opened main pancreatic duct within the body and tail is obtained with an LPJ using a Roux-en-Y loop (Frey CF Pancreas 1987). Good results have been obtained with substantial pain relief in more than 85% of patients while mortality is less than 1% and morbidity 9-39% (Izbicki JR Ann Surg 1995, Izbicki JR Ann Surg 1998, Beger HG Ann Surg 1989). Endocrine & exocrine function are well preserved and the operation may control complications such as CBD stenosis, duodenal stenosis and internal pancreatic fistulas. The Frey operation is currently the most widely performed operation for patients with an inflammatory mass in the head together with pancreatic duct dilatation while the Beger procedure is reserved for patients where the main pancreatic duct is not dilated (Bornman PC S Afr Med J 2010).

Two further modifications of the above procedures have been described. The Hamburg operation employs subtotal excision of the pancreatic head including the uncinate process( a more extensive resection than the Frey operation but comparable to Beger's procedure) together with a V-shaped excision of the ventral aspect of pancreas into the pancreatic duct. Pancreatic-enteric continuity is re-established with an LPJ using a Roux-en-Y loop (comparable to the Partington-Rochelle and Frey reconstructions).This operation combines aspects of the Frey and Beger procedures, without transection of gland over SMV/portal vein. The extent of resection is customized to pancreatic morphology while the V-shaped excicion creates a trough-like new ductal system allowing better drainage of ductal side branches (Izbicki JR Ann Surg 1998, 227, Bachmann K Med Sci Monit 2008). In the Berne operation, an extensive duodenum-preserving resection of the head is performed (as in the

The Surgical Management of Chronic Pancreatitis 439

QOL= quality of life; pre-op= pre-operative; post-op= post-operative; FU= follow up; PPPD= pylorus preserving pancreatico-duodenectomy; NS= not significant; IDDM= insulin dependant diabetes mellitus; DM= diabetes mellitus: Prof rehab= professional rehabilitation; EORTC= European Organisation for Research and Treatment of Cancer; QLQ= Quality of Life Questionnaire; s.d= standard deviation

Table 1. Outcomes of Pylorus preserving pancreaticoduodenectomy (PPPD) vs duodenum

Buchler MW Am J Surg 1995 Klempa I Chirurg 1995 Izbicki JR Ann Surg 1998; 228

Muller MW Br J Surg 2008 Strate T Gastroenterology 2008

Farkas G Langenbecks Arch Surg 2006

preserving pancreatic head resection (DPPHR)

Beger procedure), but without division of pancreas anterior to superior mesenteric / portal vein complex and without laying open the pancreatic duct in the body and tail. In biliary obstruction a longitudinal opening may be made in the CBD within the cavity created in the pancreatic head. Drainage of the cavity is achieved with a pancreatic-enteric anastamosis to small bowel in a Roux-en-Y reconstruction similar to the reconstructions described above. Results of the Berne procedure are comparable to the other duodenum preserving resections (Gloor B Dig Surg 2001).

Little comparative data is available to guide choice between the various available procedures in CP. Four randomized controlled trials have been conducted comparing PPPD with DPPHR, with 2 providing long term follow up (table 1). In the short to medium term,



Beger procedure), but without division of pancreas anterior to superior mesenteric / portal vein complex and without laying open the pancreatic duct in the body and tail. In biliary obstruction a longitudinal opening may be made in the CBD within the cavity created in the pancreatic head. Drainage of the cavity is achieved with a pancreatic-enteric anastamosis to small bowel in a Roux-en-Y reconstruction similar to the reconstructions described above. Results of the Berne procedure are comparable to the other duodenum preserving resections

Little comparative data is available to guide choice between the various available procedures in CP. Four randomized controlled trials have been conducted comparing PPPD with DPPHR, with 2 providing long term follow up (table 1). In the short to medium term,

(Gloor B Dig Surg 2001).

QOL= quality of life; pre-op= pre-operative; post-op= post-operative; FU= follow up; PPPD= pylorus preserving pancreatico-duodenectomy; NS= not significant; IDDM= insulin dependant diabetes mellitus; DM= diabetes mellitus: Prof rehab= professional rehabilitation; EORTC= European Organisation for Research and Treatment of Cancer; QLQ= Quality of Life Questionnaire; s.d= standard deviation Buchler MW Am J Surg 1995

Klempa I Chirurg 1995

Izbicki JR Ann Surg 1998; 228

Farkas G Langenbecks Arch Surg 2006

Muller MW Br J Surg 2008

Strate T Gastroenterology 2008

Table 1. Outcomes of Pylorus preserving pancreaticoduodenectomy (PPPD) vs duodenum preserving pancreatic head resection (DPPHR)


QOL= quality of life; pre-op= pre-operative; post-op= post-operative; GTT= glucose tolerance test; FU= follow up; NS= not significant; DM= diabetes mellitus: Prof rehab= professional rehabilitation; EORTC= European Organisation for Research and Treatment of Cancer; QLQ= Quality of Life Questionnaire

Table 2. Comparisons of duodenum preserving resections of the pancreatic head.

Izbicki JR Ann Surg 1995 Strate T Ann Surg 2005 Koninger J Surgery 2008


QOL= quality of life; pre-op= pre-operative; post-op= post-operative; GTT= glucose tolerance test; FU= follow up; NS= not significant; DM= diabetes mellitus: Prof rehab= professional rehabilitation; EORTC= European Organisation for Research and Treatment of Cancer; QLQ= Quality of Life Questionnaire Izbicki JR Ann Surg 1995 Strate T Ann Surg 2005 Koninger J Surgery 2008

Table 2. Comparisons of duodenum preserving resections of the pancreatic head.

The Surgical Management of Chronic Pancreatitis 443

with poor results and has fallen into disfavour. A Hepatico-jejunostomy may be included in the Roux loop used to drain the pancreatic duct in dedicated drainage, resection or hybrid procedures performed to relieve pain. Alternatively, the CBD may opened within the

Surgical relief of obstruction related to a fibrotic stricture involves duodenal mobilization by Kocher's maneouvre with division of all fibrotic tissue. Should this be insufficient to restore patency, duodeno-duodenostomy or a gastro-jejunostomy may be considered, although the latter may be associated with biliary reflux. Where biliary obstruction co-exists in the presence of duodenal obstruction together with an inflammatory mass in the head, two options exist: PPPD or gastric bypass with a gastro-jejunostomy as part of the Roux drainage

The choice of surgical procedure is dictated by the location of the pseudocyst and its proximity to a section of bowel suitable for drainage. Cyst-gastrostomy, cyst-duodenostomy and cyst-jejunostomy may all be employed depending on individual patient characteristics. Distal pancreatectomy may be employed for segmental disease within the body/tail together with an associated pseudocyst (Bornman PC S Afr Med J 2010). Surgery for pancreatic fistulae / ascites entails either a roux-en-Y jejunostomy to the fistula tract or an

Patients who have bled from gastric varices related to segmental portal hypertension as a consequence of splenic vein thrombosis can usually be managed with distal

Where angiographic embolisation has failed to control a bleeding pseudoaneurysm vascular control may be achieved using a Frey-type procedure in preference to a more extensive resection which may be hazardous under these circumstances, while bleeding from the tail can usually be dealt with safely by means of a distal pancreatectomy (Bornman PC S Afr

Surgery for suspected malignancy should utilize either a pancreatico-duodenectomy or distal pancreatectomy depending on tumour location and should be performed in keeping

The pathophysiology of chronic pancreatitis is complex and as yet incompletely understood, confounding attempts at effective management strategies. The clinical picture is dominated by progressive pain which may become intractable and pancreatic endocrine and exocrine

surgically created cavity in the pancreatic head during the Berne procedure.

**6.2 Duodenal obstruction** 

**6.3 Development of a pseudocyst** 

**6.4 Gastro-intestinal bleeding, related to** 

with the oncological principle of clear resection margins.

limb in a DPPHR.

appropriate resection.

**a. Portal hypertension** 

**b. Pseudoaneurysms** 

pancreatectomy.

Med J 2010).

**7. Conclusion** 

there was evidence for significant benefit of DPPHR over PPPD in terms of morbidity (2 trials), pain relief (2 trials), quality of life (1 trial), endocrine function (1 trial ), exocrine function (1 trial) and weight gain (2 trials). In addition, 2 trials showed a benefit for DPPHR in terms of operating time while hospital stay and requirement for blood transfusion were improved in 1 trial each. A Cochrane review on short term outcomes concluded that there was benefit for DPPHR in respect of quality of life and professional rehabilitation, exocrine insufficiency, weight gain, hospital stay and intra-operative blood replacement. There was also a trend towards reduced post-operative diabetes (Diener MK Ann Surg 2008). However, in the 2 studies examining long term outcomes, it was seen that many of the short term clinical benefits described above were not maintained. Proposed reasons for this were study error related to the small population sizes studied and that pancreatic gland burn-out might be delayed by DPPHR (Muller MW Br J Surg 2008). Nevertheless, at 14 year follow up there remained a trend towards better endocrine function, while there was significant benefit in terms of appetite, subjective feeling of well being and mean period of employment after surgery for patients undergoing DPPHR(Muller MW Br J Surg 2008). Thus, while short term results favour DPPHR over PPPD in CP, long term results appear equivalent and probably reflect the natural course of the disease.

Only 2 randomized trials have compared different DPPHR procedures, with 1 trial undergoing long term follow up (table 2). The first trial compared the Beger and Frey procedures with no significant differences being found in the short term apart from a benefit for the Frey operation in terms of morbidity. After a median of 8.5 years, all variables had comparable outcomes while almost all patients were noted to be exocrine insufficient (Izbicki JR Ann Surg 1995; Strate T Ann Surg 2005). The second study compared the Beger and Berne procedures, suggesting a benefit for the Berne operation in terms of operation time and hospital stay. Results were analysed on intention to treat basis however, including 8 out of 32 (Beger procedure) and 6 out of 33 (Berne procedure) patients who had their operations altered for technical reasons. When patients were analysed per protocol ie only those who underwent their assigned procedure, only the difference in operating times remained significant.

More extensive pancreatic resections such as total or near total distal pancreatectomy offer only short term relief and are associated with significant mortality and morbidity, often as a result of markedly reduced pancreatic function. They have largely been abandoned with their main role being as salvage procedures for complications relating to previous surgical interventions (including anastamotic leakage, pancreatic fistula and intractable pain following previous adequate resection or drainage surgery).
