**2. Indications of surgery**

The most accepted surgical indications are as follows [23]:


insufficiency. The most important pathologic finding in CP is the replacement of normal pancreatic tissue for irreversible fibrosis [2–6]. The CP incidence is between 2 and 200 per 100,000 persons and shows an increasing trend year by year. Historically, excess alcohol consumption plays the leading cause role in Western countries, accounting for 60% of CP cases, although tobacco consumption, usually joined to alcohol consumption, plays the most important role

On the basis of the histopathological changes in the pancreas, CP can be classified into three types: (1) chronic obstructive pancreatitis, (2) chronic calcifying pancreatitis (the most common type of CP, which includes alcoholic CP) and (3) chronic inflammatory pancreatitis, including CP resulting from chronic inflammation of the biliary tract and stenosis induced

In principle, patients with CP need medical treatment for long periods of time or indefinitely, as long as the medical treatment relieves symptoms and patients do not develop any complication requiring surgery. Disabling pain, analgesic treatment refractory or cause opiate dependence, is the most frequent symptom sets the surgical indication. However, other wellestablished surgical prescriptions are the complications of adjacent organs such as bile duct or duodenum stenosis, associated pseudocysts with ductal anomalies, pancreatic fistulas, ascites, gastrointestinal bleeding from oesophageal varices secondary to segmental thrombosis of the splenic vein and portal hypertension or inability to differentiate whether a pancreatic

Furthermore, several authors suggest the superiority of surgical therapy over endoscopic therapy for chronic pancreatitis and pancreatic duct obstruction. However, many papers have been published on the possibilities offered by interventional endoscopy nevertheless the endoscopic therapy only reach a rate of 32% in pain relief, the worse result than any surgery

The two main objectives in CP treatment are pain relief and complications management. An optimum treatment must provide social and occupational rehabilitation as well as no pain recurrence. The problem is that there is neither an exact or validated measure of pain control nor randomised clinical studies comparing surgery with conservative treatment to help establish the indication of surgery [10]. It is usually recommended to consider surgery when the patient needs major opioids for more than 3 months and in case of treatment side effects or

in pancreas cell injury [7].

56 Challenges in Pancreatic Pathology

by scar formation [8, 9].

procedure [14–20].

lack of obvious benefit [21–24].

**2. Indications of surgery**

**1.** Refractory abdominal pain

**2.** Local complications:

The most accepted surgical indications are as follows [23]:

mass is really a focal CP or a neoplasia [10–13].


Patients with pancreatic duct dilation require surgical drainage, which achieves pain relief in 70–80% of the cases [10]. Decompression (drainage), resection and neuroablation are the most commonly used surgical treatment options of CP [25–27]. If the pancreatic involvement involved the head or the tail of pancreas or if the Wirsung is dilated, a pancreatic resection of the head or the tail or a pancreatojejunostomy is required. Chronic inflammation in the head of pancreas leads to main bile duct stricture in 60%, to duodenal stricture in 36% and to portal hypertension in 17% of the patients. Surgical indication in this group of patients is evident; however, when the whole pancreas is damaged or the Wirsung duct is not dilated, the surgical indication is not so clear [28].

Derivative surgical procedures as the techniques described by Puestow, Gillesby or its modification, Partington-Rochelle, are the best options [29, 30]. The Wirsung duct should have enough diameters (6–8 mm) to perform a pancreatojejunal anastomosis. If the diameter is smaller, a longitudinal V resection of the anterior pancreas can be performed, followed by a pancreatojejunal anastomosis, as Izbiki published [31–34]. The main advantages of drainage procedures are their low morbidity and mortality rates, although up to 20–30% of the patients do not benefit of the surgical drainage and have persistent pain. We should select this group of patients and offer them a different treatment [31].

Resection is indicated when there is an important involvement of the pancreas head, a bile duct or duodenum obstruction and for those patients with suspicion of carcinoma or when a malignant tumour diagnosis cannot be discarded [35]. Resective surgical procedures are the techniques of Whipple, Traverso-Longmire, Frey (resective-derivative) and Beger (resectivederivative) [11–13, 26, 27, 35–37]. Beger and Frey procedures are both complex techniques with no differences in terms of pain relief and exocrine function preservation. The main drawback for these last techniques is the risk of tumour dissemination during surgery, as they are incomplete resection procedures and the risk of an underlying carcinoma is around 10% of the patients. Literature reports show a great variation in morbidity and mortality for each technique.

The surgeon should know every surgical procedure and its indications and be also familiarised with all of them. The surgical procedure should also be individualised to the patient and his stage of disease.
