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The Management of Chronic Pancreatitis

INTRODUCTION Most patients with chronic pancreatitis seek medical care because of the pain that is commonly associated with the disease. This chapter reviews briefly the diagnosis, medical management, and endoscopic treatment of pain in these patients. A more detailed discussion of the surgical management and the operations for pain relief is provided, including the Peustow, Frey, and Beger procedures and pancreaticoduodenectomy. DEFINITION AND TYPES OF CHRONIC PANCREATITIS Chronic pancreatitis is characterized by progressive inflammatory changes in the pancreas that result in permanent structural damage. The inflammation is usually associated with epigastric abdominal pain, which is the most common presenting symptom. Nevertheless 5% to 10% of patients remain pain-free. The structural damage can result in impairment of endocrine and exocrine function. Patients may develop type I diabetes mellitus and fat malabsorption. Chronic pancreatitis contrasts with acute pancreatitis, which is an acute inflammatory response to pancreatic injury that often does not progress and is usually reversible. The two conditions may overlap, and patients with chronic pancreatitis can have intermittent episodes of acute inflammation. However the histopathologic features of the gland with chronic pancreatitis (acinar and islet atrophy, and chronic inflammation with fibrosis) do not return to normal when the episodes resolve. Less commonly, repeated episodes of acute pancreatitis can lead to chronic pancreatitis when they cause structural damage in the pancreas, such as ductal strictures or disruptions, or pseudocysts. Due to the chronic inflammation, patients with chronic pancreatitis are at risk for pancreatic cancer. It has been shown that oncogenic KRAS mutations coupled with inflammation can lead to malignant transformation. Approximately 4% of patients with chronic pancreatitis develop pancreatic cancer in their lifetime. Chronic pancreatitis has many causes. Alcohol abuse is the most common cause, particularly in the Western world, where it is the cause of 60% of cases. Caustic environmental insults also have been implicated. Certain anatomic changes that obstruct the pancreatic ducts also may lead to chronic pancreatitis. These include ductal strictures and disruptions, pseudocysts, stones, periampullary tumors, pancreas divisum, or mechanical and structural changes of the pancreatic duct sphincter. Chronic pancreatitis due to ductal obstruction is less likely to be associated with ductal calcification, which is more common in alcoholic chronic pancreatitis. There are a number of genetic causes of chronic pancreatitis. These include mutations in the cystic fibrosis transmembrane receptor (CFTR), trypsin inhibitor (SPINK1), and trypsin-1 gene (PRSS-1). Many less common causes complete the list. Autoimmune pancreatitis occurs in a small number of patients. It is usually associated with elevated serum levels of IgG4. Active flares can be relieved with systemic steroids. However, chronic and progressive inflammation can lead to the development of chronic pancreatitis. Tropical pancreatitis, another unusual cause, is rare in the Western world. Unfortunately, the exact cause of the disease often cannot be determined, and patients are diagnosed with “idiopathic” chronic pancreatitis in up to 30% of cases. DIAGNOSIS AND SEVERITY CLASSIFICATION The diagnosis of chronic pancreatitis can be difficult because other conditions may produce similar symptoms. If one is suspicious of the diagnosis, it is important to send these patients to a medical professional with experience in the management of pancreatic diseases. With disease progression, most patients experience abdominal pain; exocrine and endocrine dysfunction usually occur later. The pain is multifactorial; this may be due in part to increased intraductal and parenchymal pressure of the pancreas, which leads to ischemia of the gland. An increase in the number and sensitivity of intrapancreatic pain sensors also occurs. Exocrine function usually declines before endocrine function, but clinical evidence of insufficiency may not become evident for many years after the histopathologic changes begin. When exocrine function is impaired significantly, patients may no longer have elevations of pancreatic enzymes in the serum during episodes of acute inflammation. Many imaging tests can be used to diagnose and “stage” chronic pancreatitis. On abdominal plain films, intraductal calcifications can be seen in 30% to 50% of patients. These are pathognomonic for the disease and are thought to be due to increased protein concentration in the pancreatic juice, which leads to concretions and proteinaceous plugs that eventually calcify (Figure 1). Computed tomographic (CT) scan or magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) are commonly used and are quite accurate for diagnosis. In most cases, there is characteristic beading of the main pancreatic duct with side branch ectasia (Figure 2) or ductal dilation. Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive test that is now only occasionally used for diagnostic purposes. More often, it has a therapeutic role to manage ductal stones and strictures. The Cambridge Classification System (Table 1) was based on ERCP findings and used to divide patients into three categories according to the extent of the ductal changes. These correlate with pancreatic functional impairment. The categories include Cambridge I: equivocal; Cambridge II: mild to moderate; and Cambridge III: considerable changes (Figure 3). This classification can still be used today based on the ductal features evident from noninvasive imaging. Endoscopic ultrasound (EUS) is the highest-resolution test to visualize the pancreatic parenchyma and ducts, and it has been used to detect some of the earliest changes of chronic pancreatitis. EUS in the setting of more advanced chronic pancreatitis is used to obtain pancreatic tissue (fine needle aspiration) to differentiate chronic pancreatitis and pancreatic cancer. Cancer should always be excluded first in patients about to undergo endoscopic or surgical therapy. MEDICAL MANAGEMENT Patients with chronic pancreatitis are best managed at specialized centers because they often require experts from multiple disciplines such as radiology, gastroenterology, and surgery to coordinate their care. In addition to pain control, a prime objective of patient management is to minimize the insults to the pancreas, which may slow the progressive inflammatory changes. Alcoholic patients with chronic pancreatitis should be strongly encouraged to stop all alcohol intake. While cigarette smoking has not been implicated as a cause of chronic pancreatitis, it can accelerate the disease. Smokers should be advised to stop smoking. Oral pancreatic enzymes that inhibit cholecystokinin (CCK) release have been used to decrease the frequency of acute attacks of inflammation, but their efficacy is doubted by most.

TABLE 1:╇ Cambridge classification of image severity for chronic pancreatitis Cambridge class Main pancreatic duct Abnormal side branches Normal Normal 0 Equivocal Normal <3 Mild Normal >3 Moderate Abnormal >3 Marked Abnormal* >3

  • Main pancreatic duct (MPD) terminates prematurely (abrupt, tapering,

irregular), multiple MPD strictures, MPD dilated >10╯mm, ductal filling defects (stones), intrapancreatic or extrapancreatic “cavities” are observed, or contiguous organ involvement (stenoses of common bile duct or duodenum, arterial venous fistula). Modified from Axon ATR, Classen M, Cotton PB, et╯al: Pancreatography in chronic pancreatitis: international definitions, Gut 25:1107–1112, 1984.

Proponents also believe that they will slow the progression of disease and improve chronic pain and acute exacerbations. We are skeptical. Of course, pancreatic enzyme supplements should be administered to patients with fat malabsorption manifested as diarrhea and steatorrhea. They should receive at least 30,000╯IU of lipase with each meal and also be given medications to reduce gastric acid secretion, which can denature the non-enteric-coated enzymes and eliminate their activity. Most patients with chronic pancreatitis require analgesics for pain relief. Nonopioid medications should be used whenever possible. Referral to a pain specialist may be of value. ENDOTHERAPY By the time a patient has been referred for a surgical evaluation, most have been evaluated by a gastroenterologist, and many with strictures and dilated ducts have undergone some form of endoscopic intervention designed to relieve their pain. This usually takes the form of stricture dilation with or without stone removal, followed by the placement of a pancreatic duct stent. While strictures often can be dilated and stented effectively with endoscopic techniques, clearing the duct of stones is more challenging. Problems include difficulty with access to the stones because of stricture(s), adherence of the stone to the duct wall, and large size of the stone that precludes its removal. Fragmentation of the stone with endoscopic or extracorporal shock wave lithotripsy has been used with some success. The extracorporal approach is more frequently used in Europe compared to the United States. Multiple procedures may be required before a satisfactory result is obtained; often complete clearance is not possible. Pain relief after endoscopic treatment is more likely in patients who have pancreatic duct strictures without stones. Stricture resolution may occur in one third of cases, and two thirds of patients experience improvement of pain. Most failures are due to recurrence of stricture after stents are removed, and there has been an unfortunate tendency for such patients to be managed with stents over long periods of time. Instead, such patients should be strongly considered for surgery. The results are worse for patients with pancreatic duct stones. In most series, at least one half of patients progress to surgery. Cahen and colleagues (Cahen D, et╯al., 2011) (Figure 4) recently reported in a randomized trial with 5-year follow-up that chronic pancreatitis patients with a dilated pancreatic duct who went straight to surgery had less hospitalizations and repeat procedures and better long-term pain relief. Based on these results, those authors recommend that surgical therapy should be strongly considered at the outset and endotherapy reserved for those with multiple comorbidities who cannot tolerate the operation. We agree. SURGICAL TREATMENT Pain is the most common indication for surgery, but other reasons include biliary or duodenal obstruction or concern for cancer, usually in the head of the pancreas. Here we consider surgery for pain relief. Consideration of surgery requires an assessment of the significance of the pain for the individual patient, which is highly subjective; a determination of the type of surgical procedure that might be appropriate; and an evaluation of the ability of the patient to deal with any long-term morbidity that the operation itself might produce (e.g., diabetes or exocrine insufficiency). In general, an operation may be indicated in patients whose pain interferes with the quality of their lives. For example, the attacks of pain may require frequent hospitalizations that interfere with school or employment. The patient may be unable to function productively because of the depression that often accompanies the chronic pain state. Nutrition may be impaired because oral intake is limited by the pain that eating produces. The patient may be addicted to narcotics. The etiology of pain is not well understood, but it is probably multifactorial. Two pathogenic theories direct different surgical treatments. The first hypothesis relates the pain in chronic pancreatitis to the high pressure within the pancreatic ducts and the pancreatic parenchyma, which results in a compartment syndrome and gland ischemia. This is the rationale for drainage procedures in patients with dilated main pancreatic ducts. The second hypothesis relates the pain to the release of neurotransmitters in an “inflammatory mass” most often situated in the pancreatic head. This is the rationale for resections of the pancreatic head. Most discussions about the choice of operation are centered on performing a resection versus a drainage procedure, or a combination of the two, and are influenced by the diameter of the main pancreatic duct and the size of the head of the pancreas. Normal duct diameters are 4╯mm in the head, 3╯mm in the body, and 2╯mm in the tail of the pancreas. A pancreatic duct diameter greater than 7╯mm in the body of the pancreas suggests that a pancreatic duct drainage procedure (lateral pancreaticojejunostomy or Puestow procedure) would likely relieve pain. Indeed, prompt pain relief occurs in 80% to 85% of such patients, and endocrine and exocrine function are usually spared because no pancreatic parenchyma is removed. But because pain may recur in up to 50% of cases within 5 years, this operation is not ideal. If the pancreatic head exceeds 4╯cm in its anterior-posterior diameter, some form of head resection should be considered. Most commonly, either a standard Whipple resection (pancreaticoduodenectomy) or its pylorus-preserving variant is done, which provides permanent pain relief in 85% to 90% of patients. However, because exocrine and endocrine insufficiencies occur in approximately 50% of cases, there may be reluctance to do the operation in certain patients who are judged to be incapable of managing these problems. A total pancreatectomy is sometimes considered, often in patients in whom multiple previous lesser operations have been done without pain relief. Of course, this guarantees endocrine and exocrine insufficiency, and the resulting diabetes may be brittle and difficult to manage. For this reason, this operation has been done only rarely. With improvements in the results of auto islet transplantation, this may be a more attractive alternative in the future. If the duct and the head of the pancreas are both enlarged, often the best choice is an operation that combines drainage of the dilated duct along with a more limited resection of the pancreatic head and preservation of the duodenum, in an effort to minimize the risk of endocrine and exocrine insufficiency. Two procedures are available to achieve these goals: the so-called Beger procedure and the Frey operation. Randomized trials comparing the two procedures have shown equivalent permanent pain relief in 85% to 90% of patients and no endocrine or exocrine insufficiency precipitated by the surgery. SURGICAL DRAINAGE AND RESECTION TECHNIQUES Pancreaticoduodenectomy (Whipple Operation) The Whipple operation (pancreaticoduodenectomy, pylorus-preserving pancreaticoduodenectomy) (Figure 5) is done most commonly for malignant or premalignant lesions in the head of the pancreas, but the technique for resection in patients with chronic pancreatitis is identical. However, in this latter group, repeated episodes of inflammation are common, so adherence of the peripancreatic tissues to various tributaries of the portal vein is frequent, and there may be some element of portal venous hypertension from venous compression in the head of the pancreas. Thus, operative blood loss is on average a bit higher than when the operation is being done for malignant disease. Pancreatic fistulae are uncommon because of the firm nature of the pancreas. In patients with chronic pancreatitis, a pancreaticoduodenectomy should always be done if there is also concern for the presence of cancer in the head of the pancreas, which may be difficult to diagnose with certainty in this setting. Otherwise, if the presence of cancer is not a concern, the choice for a Whipple resection is usually made on the basis of individual surgeon preference and consideration of the factors already discussed. Lateral Pancreaticojejunostomy (Puestow Procedure) The Puestow procedure is a lateral pancreaticojejunostomy between the main pancreatic duct and a Roux-en-Y limb of jejunum (Figure 6). The lesser sac is entered and the pancreas is exposed. The duodenum and head of the pancreas are mobilized (Kocher maneuver), and the gastroduodenal artery is ligated as it courses on the head of the pancreas at the point where it emerges from under the duodenum. The pancreatic duct is located by inserting a needle through the parenchyma on the anterior surface of the gland. The duct is then opened longitudinally by incising through the parenchyma. The duct must be opened over a long distance that begins in the head (even closer to the duodenum than shown in Figure 6) and through the entire length of the body and into the tail. Stones and concretions are removed from the duct lumen, and a retrocolic roux limb of jejunum is then anastomosed to the pancreatic duct in one or two layers. Although we routinely leave a closed suction drain along the anastomosis, fistulas are rare because the firm parenchyma holds sutures well. Duodenum-Preserving Pancreatic Head Resection (Beger Procedure) In Germany in 1972, Hans Beger performed a duodenum-preserving pancreatic head resection, or DPPHR, in patients with an inflammatory mass in the head of the pancreas. Many of these patients also had an enlarged pancreatic duct (Figure 7). The operation removes the inflammatory mass but maintains the viability of the duodenum and intrapancreatic common bile duct by preserving the posterior branch of the gastroduodenal artery. The neck of the pancreas is divided, and all but a small amount of pancreatic tissue along the medial aspect of the duodenum is removed. Reconstruction consists of an end-to-end pancreaticojejunostomy to the distal pancreas and pancreaticojejunostomy to the remnant of pancreatic tissue on the inner aspect of the duodenum. If the pancreatic duct is also dilated, it is longitudinally opened and a pancreaticojejunostomy is done to the body/tail portion of the pancreas. Local Resection of the Head of the Pancreas With Lateral Pancreaticojejunostomy (Frey Procedure) Charles Frey described a local resection of the head of the pancreas with lateral pancreaticojejunostomy in 1985. This is similar to the DPPHR, and it combines the pancreatic head resection with a duct drainage procedure, while preserving duodenal continuity (Figures 8 and 9). This operation is also indicated in patients with an enlarged inflammatory mass in the pancreatic head, and it preserves endocrine and exocrine function. The operation differs from the DPPHR in that the neck of the pancreas is not transected. Thus, inflammatory adherence to the superior mesenteric and portal veins, which may result in troublesome bleeding during the Beger operation, is not a problem. For that reason, many surgeons prefer it. The Frey procedure is more frequently performed in the United States, while the Beger procedure is more commonly done in Europe. Which Operation? The majority of published studies on the outcomes of the surgical management of painful chronic pancreatitis are retrospective. Moreover, the patients who were analyzed were operated on at different stages of their disease, and often for more than a single indication. Thus, only limited guidance is available from those data. Only a few general guidelines that are derived from better studies are currently available. A meta-analysis of four randomized controlled trials comparing limited resections (Beger or Frey) to pancreaticoduodenectomy revealed that the drainage operations combined with duodenal-preserving limited head resections resulted in greater pain relief with lower perioperative morbidity (Figure 10) compared to the Whipple operation. Moreover, they were associated with lower rates of both early and late development of endocrine and exocrine dysfunction (Table 2). The choice between a Beger or Frey operation should depend on the individual preference and experience of the surgeon. However, if there is suspicion of the presence of a pancreatic cancer, any limited form of resection is contraindicated, and a pancreaticoduodenectomy should be done. Finally, the data from Cahen and colleagues (Cahen D, et╯al., 2011) (see Figure 4) suggest that early operations to surgically drain a dilated duct are probably better than prolonged efforts at endoscopic manipulations, stone extractions, and dilation of pancreatic duct strictures. SUMMARY CP is a debilitating condition for many patients. They are best treated in high-volume centers with a multidisciplinary team of experts who are specialized in pancreatic diseases. At the time of diagnosis, all patients should be encouraged to stop the insulting substance in cases of acquired disease. The timing of intervention is not well established, but there is consensus that patients with a firm diagnosis of chronic pancreatitis and ductal obstruction with a dilated duct need to have ductal drainage. Early intervention may delay the progression of disease and development of endocrine and exocrine insufficiency. Endoscopic therapy with stone extraction and stent placement is an option for some prior to surgery, but many patients eventually need definitive surgical duct decompression. There are many factors that are considered when deciding the surgical treatment. The most prominent are the presence of an enlarged pancreatic head and dilated pancreatic duct. A limited resection with duodenal preservation and ductal drainage may be the best option for patients who have both findings.

TABLE 2:╇ Meta-analyses comparing DPPHR versus PD, including sensitivity analyses Outcome Comparison Effect size, RR/WMD (95% CI: P: I2) Pain relief DPPHR vs PD RR 1.08 (0.88-1.33; 0.46; 43%) Morbidity DPPHR vs PD RR 0.54 (0.20-1.46; 0.22; 77.6%) Blood replacement DPPHR vs PD WMD-1.28 (–2.32 to –0.25; 0.02; 88.7%) Frey vs ppPD*,† WMD-2.09 (–2.30 to –1.87; 0.01; 0%) Operation time DPPHR vs PD WMD-53.03 (–134.96 to 28.89; 0.20; 99.2%) Frey vs ppPD*,† WMD-112.45 (–164.07 to –60.84; 0.01; 88.6%) Pancreatic fistula DPPHR vs PD RR 0.39 (0.08-1.97; 0.26; 0%) Delayed gastric emptying DPPHR vs PD RR 0.23 (0.05-1.11; 0.07; 32%) Frey vs ppPD*,† RR 0.06 (0.01-0.46; 0.01; 0%) Hospital stay DPPHR vs PD WMD-4.32 (–6.46 to –2.00; 0.01; 60.7%) Exclusion of Buchler et╯al.‡ WMD-5.26 (–6.67 to –3.86; 0.01; 0%) Exocrine insufficiency DPPHR vs PD RR 0.20 (0.06-0.66; 0.01; 57.7%) Endocrine insufficiency DPPHR vs PD RR 0.49 (0.22-1.09; 0.08; 0%) Weight gain DPPHR vs PD RR 1.93 (1.33-2.81; 0.01; 46.1%) Occupational rehabilitation DPPHR vs PD RR 1.36 (1.07-1.71; 0.01; 0%) Quality of life DPPHR vs PD WMD-25.07 (18.83-31.31; 0.01; 57.1%) P values of 0.01 include all data of <0.01. CI, 95% confidence interval; DPPHR, duodenum-preserving pancreatic head resection; I2, degree of statistical heterogeneity (0%-25% moderate, 26%-50% average, 51%-100% high statistical heterogeneity); PD, pancreaticoduodenectomy; ppPD, pylorus-preserving Whipple procedure; RR, relative risk; WMD, weighted mean difference.

  • Farkas G, Leindler L, Daroczi M et al: Prospective randomized comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy.

Langenbecks Arch Surg 391:338-342, 2006. †Izbicki JR, Bloechle C, Broering DC, et al: Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunsotomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg 228:771-779, 1998. ‡Buchler MW, Friess H, Muller MW, et al: Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg 169:65-69, 1995. From Diener MK, Rahbari NN, Fischer L, et╯al: Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis, Ann Surg 247:950–961, 2008.

S u g g e s t e d R e a d i n g s Cahen DL, Gouma DJ, Laramee P, et al: Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis, Gastroenterology 141:1690–1695, 2011. Diener MK, Rahbari NN, Fischer L, et al: Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis, Ann Surg 247:950–961, 2008. Frulloni L, Falconi M, Gabbrielli A, et al: Italian consensus guidelines for chronic pancreatitis, Dig Liver Dis 42(Suppl 6):S381–S406, 2010. Steer ML, Waxman I, Freedman S: Chronic pancreatitis, N Engl J Med 332:1482–1490, 1995.

Figure 1: CT scan of a patient with chronic pancreatitis.

Cross-sectional imaging without intravenous contrast of the body and tail of the pancreas reveals numerous calcifications within the

pancreatic ductal system (red arrow).

Figure 2: Abdominal MRI in a patient with chronic pancreatitis. T2

weighted images of an abdominal MRI with gadolinium contrast in a patient with chronic pancreatitis. The red arrow points to the pancreatic duct in the body/tail of the pancreas, which is moderately

dilated and tortuous, both radiographic signs of chronic pancreatitis.

Figure 3: ERCP images in patients with Cambridge III chronic pancreatitis. A, Red arrow reveals a long

pancreatic duct stricture with upstream ductal irregularity (blue arrow). B, Long pancreatic duct stricture

(red arrow) with an upstream ductal disruption. The patient in (B) presented with pancreatic ascites.

Figure 4: Randomized trial of

endoscopic versus surgical therapy for patients with chronic pancreatitis and main pancreatic duct dilation. Ninety-five percent of patients who underwent surgical drainage did not require further treatment. In contrast, only 32% who had endoscopic therapy did not require further treatment. These results suggest that surgical therapy may be a more appropriate initial therapy. (From Cahen DL, Gouma DJ, Laramee P: Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis, Gastroenterology 141:1690–1695,


Figure 5: After pylorus-preserving

pancreaticoduodenectomy (PPPD), reconstruction of the pancreatic duct and bile duct are in a retrocolic fashion. The pancreaticojejunostomy can be made in a side-to-side fashion if a chain-of-lakes ductal pattern exists in the pancreatic remnant. The end-to-side duodenojejunostomy is in an antecolic position to isolate the duodenal anastomosis from the pancreatic anastomosis and minimize delayed gastric emptying if the pancreatic anastomosis should leak. (From Traverso LW: The surgical management of chronic pancreatitis: the Whipple procedure. In Cameron JL, editor: Advances in

surgery, vol 32, St Louis, 1999, Mosby, p 33.)

Figure 6: The Puestow procedure (lateral pancreaticojejunostomy)

is depicted. Note the end of the limb is positioned toward the tail of the pancreas. If the Puestow procedure fails to relieve pain in long-term follow-up and a head resection is required, this position of the jejunal limb allows for the preservation of the pancreatic anastomosis and also allows addition of the biliary connection to the jejunal limb. (Reprinted from Pancreaticojejunostomy [Puestow] for chronic pancreatitis. In Scott-Conner CEH, editor: Chassin’s operative strategy in general surgery: an expositive atlas, ed 3, New York, 2002, Springer-

Verlag. With kind permission of Springer Science+Business Media.)

Figure 7: The Beger technique (duodenum-preserving pancreatic

head resection) on the left is compared to the Frey procedure (LR-LPR, subtotal ventral head or local head resection combined with a lateral pancreaticojejunostomy). (Reprinted from Köninger J, Seiler CM, Sauerland S, et╯al: Duodenum-preserving head resection: a randomized controlled trial comparing the original Beger procedure with the Berne

modification, Surgery 143:490–498, 2008.)

Figure 8: A, Tissue removed from the head of the

pancreas, including the duct of Santorini. Note that we do not try to remove this tissue as a single specimen as shown here, but rather in piecemeal fashion, taking slices outward from the opened duct of Wirsung and duct to the uncinate process. This technique allows us to assess the extent of resection by placing the thumb of the left hand within the head of the pancreas and with the fingers behind the Kocherized head. SMA, Superior mesenteric artery; SMV, superior mesenteric vein. B, Completed local resection of the head of the pancreas and decompressed main duct in the body and tail of the pancreas. It is unnecessary to ligate the pancreatic duct stump (Wirsung), shown at the bottom of the cavity created by the coring. The common duct is shown traversing the posterior head within the pancreatic parenchyma. The intrapancreatic location of the common duct is most frequently associated with clinical and biochemical evidence of biliary obstruction. When performing the local resection in such patients, it is best to place a metal Bakes dilator in the common duct so its position can be identified and injury prevented while freeing up the bile duct from obstructing scar tissue. (From Frey CF, Reber HA: Local resection of the head of the pancreas with pancreaticojejunostomy, J Gastrointest Surg 9(6):863–868,


Figure 9: A, The two-layer anastomosis approximates the opened jejunum to the circumference of the locally resected head

and to the decompressed main duct in the body and tail of the pancreas. The inner layer is accomplished with running 3-0 or 4-0 absorbable sutures (e.g., PDS). Note: This layer approximates the capsule of the pancreas (not the wall of the duct) to the jejunum. The outer layer consists of 3-0 or 4-0 interrupted nonabsorbable sutures. B, Cross-sectional view of the completed two-layer anastomosis between the opened jejunum and the decompressed main duct in the body of the pancreas. (From Frey CF, Reber HA:

Local resection of the head of the pancreas with pancreaticojejunostomy, J Gastrointest Surg 9(6):863–868, 2005.)

Figure 10: Meta-analysis of

complete pain relief. Combined analysis of four randomized clinical trials suggests there is no significant difference in pain relief between pancreaticoduodenectomy and limited resection (Frey or Beger). (Extracted from Diener MK, Rahbari NN, Fischer L, et╯al: Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis,

Ann Surg 247:950–961, 2008.)

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