The American Journal of Surgery 194 (Suppl to October 2007) S53S60

Surgery of chronic pancreatitis

Charles F. Frey, M.D.a, Dana K. Andersen, M.D.b,*
b a University of California Davis, Rescue, CA, USA Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224, USA

Abstract Chronic pancreatitis is a progressive disease of multiple etiologies. Surgery is frequently indicated for relief of debilitating pain as well as to address other complications, and three operations have proven effective. The pancreatico-duodenectomy (Whipple) procedure results in excellent long-term pain relief, but is associated with a low mortality rate and a persistent risk of early and late complications. The duodenum-preserving pancreatic head resection (DPPHR) introduced by Beger et al, and the local resection of the pancreatic head with longitudinal pancreatico-jejunostomy (LR-LPJ) devised by Frey, achieve the same high rate of pain relief long term but are associated with lower rates of perioperative complications and a decreased incidence of diabetes long term. All 3 operations address the head of the pancreas as the nidus of persistent inammation, and all 3 achieve success with both dilated and nondilated duct disease. The LR-LPJ has a lower risk of perioperative problems and may be easier to perform. 2007 Excerpta Medica Inc. All rights reserved.
Keywords: Chronic pancreatitis; Duodenum-preserving pancreatic head resection; Beger procedure; Local resection of the pancreatic head with longitudinal pancreatico-jejunostomy; Frey procedure; Whipple procedure

Chronic pancreatitis is a progressive, debilitating disease of multiple etiologies. Although alcohol abuse accounts for the majority of cases in North American and some European series, biliary stone disease, tropical brocalcic pancreatitis, post ERCP and post-traumatic pancreatitis, congenital or hereditary pancreatitis, ductal anomalies such as pancreas divisum, and idiopathic causes also have been reported. Symptoms include chronic relapsing pain, obstruction of adjacent structures due to peri-pancreatic inammation, and the manifestations of exocrine and endocrine insufciency. Although chronic pain is the most common indication for surgical treatment, complications of chronic pancreatitis such as pseudocyst formation, strictures of pancreatic and biliary ductal systems, and suspected neoplasm also result in surgery. For a complete review of the causes, manifestations, and treatment approaches to chronic pancreatitis, see Fisher et al [1]. Until recently, surgery was considered the last resort after medical management of chronic pancreatitis had failed. Lankisch et al reported that pain may decrease or disappear over a period of several years, although this is accompanied by worsening exocrine and endocrine dysfunction, narcotic addiction, and disability [2]. Although
* Corresponding author. Tel.: 1-410-550-2821; fax: 1-410-5500154. E-mail address: dander54@jhmi.edu

increased ductal pressure is thought to be a cause for pain in chronic obstructive pancreatitis [3], the role of chronic inammation and progressive perineural disease is also held as a cause of pain [4]. Nealon and Matin analyzed the various pain syndromes associated with chronic pancreatitis and proposed a method to predict the responses to various surgical approaches [5]. Pain that is found in association with pancreatic ductal hypertension is most readily relieved by surgical drainage, and a trial of endoscopic decompression may predict those patients who will benet from surgical decompression. In a prospective randomized trial, Nealon and Thompson found that decompression of an obstructed pancreatic duct prevents or delays the progression of disease [6], so that surgical intervention is now dictated by the anatomy of the disease and the need to restore patients to full activity. The Evolution of Surgical Treatment Three operative approaches to relieve the pain and address the major complications of chronic pancreatitis have proven to be efcacious: pancreatico-duodenectomy (Whipple procedure), duodenal-preserving pancreatic head resection (DPPHR or Beger procedure), and local resection of the pancreatic head with extended longitudinal pancreatico-jejunostomy (LR-LPJ or Frey procedure). Each procedure addresses disease in the proximal pancreas by removing all or part of the head of the

0002-9610/00/$ see front matter 2007 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.05.026

S54

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60

pancreas, so that the ducts of Santorini and Wirsung are excised, and the uncinate duct is excised or decompressed. Therefore, whether the cause of pain in chronic pancreatitis is due to perineural inammation or ductal hypertension, all 3 procedures remove the source of chronic inammatory changes and provide drainage for the distal ductal system. Other frequent complications of chronic pancreatitis resulting from brosis and obstruction, such as pseudocysts and common bile duct and duodenal obstruction, can usually be managed by modications of these 3 procedures. Occasionally, a patient with chronic inammatory changes localized to the body or tail of the gland will benet from distal pancreatectomy alone. A variety of surgical procedures advocated in the past have lost favor because of serious drawbacks associated with their use. In 1947, Cattell described a Roux-en-Y, side-to-end, pancreatico-jejunostomy as effective palliation for obstructive pancreatopathy secondary to malignancy [7], and in 1954, Duval described the caudal, end-to-end, pancreatico -jejunostomy as a drainage procedure for chronic pancreatitis [8]. These efforts at duct drainage failed as a result of recurrent or progressive segmental stenosis of the pancreatic duct, which was described by Puestow and Gillesby as a chain-of-lakes appearance of the duct [9]. They reported good results with a longitudinal decompression of the body and tail of the pancreas into a Roux limb of jejunum. Four of Puestow and Gillesbys 21 initial cases were constructed as side-to-side anastomoses, and 2 years later, in 1960, Partington and Rochell described in detail the side-to-side longitudinal pancreatico-jejunostomy that became known as the Puestow procedure [10]. Although this procedure became the standard drainage procedure for close to 30 years, it was evident that not all patients with chronic pancreatitis had dilated ductal disease. Moreover, despite early postoperative pain relief observed in 80% of patients, recurrent pain developed within 3 to 5 years in up to 30% of patients after the Puestow procedure [1113]. The recurrence of pain was often attributed to persistent or recurrent disease in the head of the pancreas [14] (Fig. 1). Whipple described the proximal pancreatico-duodenectomy (and total pancreatectomy) for the treatment of chronic pancreatitis in 1946 [15], but early experience demonstrated that this was a daunting approach in that era. The 95% distal pancreatectomy (Child procedure) was described in 1965 [16] as an alternative to total or proximal pancreatectomy, and as an approach that would spare the duodenum and biliary tree from resection. The rst duodenal-preserving head resection was effective in achieving long lasting pain relief in 80% of patients studied after an average follow-up of 6 years [17] but was abandoned due to the metabolic consequences of the operation. It became apparent that the remnant of pancreatic tissue left along the inner aspect of the duodenum was insufcient to prevent exocrine and endocrine insufciency post operatively, and the resulting brittle diabetes was particularly difcult to manage in some patients. Gall et al reported that in a series of more than 100 total pancreatectomies performed for chronic pancreatitis, half of all the late deaths were due to fatal hypoglycemia [18]. Most recently, total pancreatectomy has been

Fig. 1. Head-of-pancreas mass after Puestow procedure. The computed tomographic appearance of an inammatory mass occupying the head of the pancreas, which developed 2 years after Puestow-type decompression of the body and tail of the pancreas. Reprinted with permission [1].

combined with islet autotransplantation to afford both a high likelihood of pain relief, as well as improved metabolic control [19,20]. However, the still limited availability of this technique prevents its widespread adoption. Proximal Pancreatico-Duodenectomy Many reports have conrmed pancreatico-duodenectomy to be an effective means of managing pain and the complications of chronic pancreatitis [2126]. In the 3 largest modern (circa 2000) series of the treatment of chronic pancreatitis by the Whipple procedure, pain relief 4 to 6 years after operation ranged from 71% to 89% of patients [24 26]. However, in spite of the long history and extensive experience with the operation, pancreatico-duodenectomy remains a work in progress due to many technical issues. While the mortality rate of the operation has been reduced to less than 5% in high-volume centers, the morbidity stubbornly remains at about 40% [24 27]. The introduction of the pylorus-preserving pancreatico-duodenectomy (PPPD) in chronic pancreatitis by Traverso and Longmire [28] was enthusiastically received because of presumed nutritional and physiologic benets associated with retention of the pylorus [23,28], but these benets have never been well substantiated, and some studies have shown no signicant nutritional differences between the 2 procedures [29,30]. Most studies have documented an improved quality of life after the PPPD [3134], but others support the use of the standard technique [21,22,29]. Pancreatic anastomotic leak is a major cause of prolonged hospital stay and intra-abdominal infection. The incidence in series that include both malignancy and chronic pancreatitis varies from 6% to 28%, and is dependent on the denition of a leak [3537]. Although pancreatic anastomotic leaks are less likely to occur in chronic pancreatitis because of the rmer consistency of the gland, the main duct can be 2 to 3 mm or less in a gland with diffuse sclerosis, and difculties with the anastomosis can occur. A variety of techniques have been employed, and the duct-to-mucosa

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60

S55

Fig. 2. Duodenum-preserving pancreatic head resection (DPPHR) or Beger procedure. The neck of the pancreas is transected, and most of the head and uncinate process is excised, leaving a rim of pancreatic tissue and the exposed intra-pancreatic portion of the distal common bile duct. Reprinted with permission from Bell RH. Atlas of pancreatic surgery. In: Bell RH, Rikkers LF, Mulholland MW, editors. Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven; 1996:1014.

Fig. 3. Reconstruction of the DPPHR or Beger procedure. An end-to-end pancreatico-jejunostomy to the body of the pancreas, and an end-to-side pancreatico-jejunostomy to the same Roux-en-Y limb of jejunum is constructed. A separate chole-dochojejunostomy can be fashioned if needed, or the exposed intra-pancreatic common bile duct can be incorporated into the proximal anastomosis. Reprinted with permission from Bell RH. Atlas of pancreatic surgery. In: Bell RH, Rikkers LF, Mulholland MW, editors. Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven; 1996:1014 5.

anastomosis leak rate has been reported to be as low as .9% [38], considerably less than the 12% leak rate observed with the invagination anastomosis [39]. Prospective, randomized trials of the use of octreotide administered postoperatively to prevent leak have both supported [40] and refuted [39,41] its value, and the use of brin glue appears ineffective to prevent leak [42,43]. Pancreatico-gastrostomy has been advocated as safer and easier to perform than the pancreatico-jejunostomy anastomosis [44]. Randomized, controlled trials are contradictory

as to whether the leak rate or the operating time differs between these techniques [45,46], and Jang et al found no functional differences between the 2 anastomoses in patients with pancreatic cancer 1 year after pancreatico-duodenectomy [47]. The use of either internalized or externalized pancreatic duct stents to ensure patency of the anastomosis has been advocated, but complications have been reported, including migration and alterations of the pancreatic duct anatomy when stents are left for months or longer [48,49].

S56

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60

Life-threatening postoperative complications that occur rarely include the development of necrotizing pancreatitis in the remaining pancreas, which may require completion pancreatectomy, and intraluminal bleeding from a pancreatic artery or from erosion by the gastroduodenal artery into the Roux limb. Such complications are more commonly associated with operation performed for neoplasms. Long-term complications of the panceatico-duodenectomy include stricturing of the anastomoses with loss of exocrine and endocrine function in the remaining pancreas [50 52]; the late incidence of both exocrine and endocrine dysfunction is about 50%. Delayed gastric emptying has been reported as an early postoperative complication, which usually resolves spontaneously, or as a late complication associated with a retro-colic, as opposed to an ante-colic, gastro-jejunostomy [5356]. The incidence of delayed gastric emptying has been reported to be higher in patients in whom the pylorus was preserved than with the standard operation or duodenal-preserving head resection [57 63]. The Duodenum-Preserving Pancreatic Head Resection of Hans Beger The genius of Hans Begers duodenal-preserving pancreatic head resection (DPPHR), rst reported in 1980 [64], and what distinguished it from the 95% distal pancreatectomy, was that the pancreatic resection was limited to the head of the gland with preservation of the body and tail of the pancreas (Figs. 2 and 3). Experience with the operation has been extensive and pain relief of 80% to 85% has been well maintained for 5 years or more [65]. Exocrine and endocrine insufciency after DPPHR progresses as a function of the underlying chronic pancreatitis and its course appears minimally altered by the operation [65,66]. The incidence of new diabetes after DPPHR ranges from 8% to 21%, and some patients show an improvement in glucose metabolism after the procedure [65]. This appears to be due to preservation of insulin and pancreatic polypeptide secretion postoperatively [52]. Key steps in the performance of the DPPHR include identifying and preserving the posterior branch of the gastroduodenal artery, which provides blood ow to the duodenum, intrapancreatic common bile duct, and pancreaticoduodenal groove. The neck of the pancreas overlying the portal and superior mesenteric vein is divided, and all but a small amount of pancreatic tissue along the inner aspect of the duodenum is resected. The common bile duct is decompressed, if necessary, either by choledocho-pancreatostomy to the rim of surrounding pancreas, or by choledocho-jejunostomy to the Roux limb of jejunum that is used to form the pancreatico-jejunostomy with the pancreatic body and tail. Reconstruction consists of an end-to-end pancreaticojejunostomy to the distal pancreas, and end-to-side pancreatico-jejunostomy to the remnant of pancreatic tissue on the inner aspect of the duodenum. The body and tail of the pancreas can be drained with a longitudinal pancreatico-jejunostomy if the main duct in the body and tail of the pancreas is obstructed. Beger decompresses the common duct in about 50% of his patients and employs the longitudinal pancreaticojejunostomy in 10% to 15% [65].

Complications of the DPPHR procedure include the risk of ischemia of the duodenum due to inadequate perfusion of the posterior branch of the gastroduodenal artery, the risk of leak from either of the 2 pancreatico-jejunal anatomoses, and the risks of delayed gastric emptying, ileus, and intraabdominal problems similar to the Whipple procedure. In a prospective study in which 40 patients were randomized to either DPPHR or the pylorus-preserving Whipple procedure, Buchler et al reported that postoperative morbidity (15% to 20%) and length of stay (13 to 14 days) were similar [67]. Aspelund et als retrospective study of DPPHR, LR-LPJ, and Whipple procedures performed consecutively at Yale revealed a major complication rate after Whipple procedures of 40%, compared to 25% after the DPPHR, with the rates of leak being 10% and 25%, respectively [68]. Local Resection of the Head of the Pancreas with Longitudinal Pancreatico-Jejeunostomy In 1987 the local resection of the head of the pancreas combined with longitudinal pancreatico-jejunostomy (LRLPJ) was described by Frey and Smith [69] (Fig. 4). The operation combined features of Childs 95% distal pancreatectomy in the head of the pancreas (with whom Frey worked while at the University of Michigan) and the longitudinal pancreatico-jejunostomy of Puestow. In 1994, after an average follow-up of 3 years, the results of 50 cases were reported [70]. Pain was relieved in 80% of the patients and exocrine and endocrine insufciency followed the natural history of chronic pancreatitis and did not seem to be affected by the operation. The operation was designed to remove most of the head of the pancreas (the so-called pacemaker of the disease) while preserving the body and tail of the pancreas, the stomach, and duodenum to minimize morbidity. Although drainage of the main pancreatic duct in the body and tail of the gland is usually performed because of the presence of post-stenotic dilatation and ductal stones, it may not be an essential part of the procedure if the main duct in the body and tail is open and uninammed throughout its length. This coring of the pancreatic head with preservation of the posterior capsule is the essential feature of the LR-LPJ operation. It can be performed safely using the ultrasonic dissector and aspirator [71] (Fig. 5), or with a combination of suture plication and cautery. As with the DPPHR, it is important to recognize and preserve the intrapancreatic common bile duct. The DPPHR described by Beger has similarities to the LR-LPJ. Both are directed primarily at the disease in the head of the pancreas and both preserve gastrointestinal continuity. Not surprisingly, the results of both operations in terms of pain relief and quality of life appear to be similar. These 2 operations also have signicant differences. The posterior capsule of the pancreas is preserved in the LR-LPJ, which allows the excavated head (and dorsal duct) to be drained into a single, side-to-side pancreatico-jejunostomy. The DPPHR does not preserve the posterior capsule, which mandates 2 anastomoses. The Beger operation requires that the pancreas be divided at its neck overlying the superior mesenteric and portal

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60

S57

Fig. 4. Local resection of the pancreatic head with longitudinal pancreatico-jejunostomy (LR-LPJ) or Frey procedure. The extended longitudinal Roux-en-Y pancreatico-jejunostomy with excavation of the pancreatic head provides complete decompression of the distal ductal system as well as removal of the nidus of chronic inammation. Reprinted with permission from Bell RH. Atlas of pancreatic surgery. In: Bell RH, Rikkers LF, Mulholland MW, editorss. Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven; 1996:1024.

Fig. 5. Operative photograph of a completed excavation of the pancreatic head using the ultrasonic aspirator and dissector. Note the complete removal of the proximal ductal systems with preservation of the posterior pancreatic capsule. The longitudinal pancreatotemy reveals chronic inammation of the ductal mucosa in the body and tail, consistent with recurrent inammation due to chronic pancreatitis. Reprinted with permission [71].

vein. In the event of portal hypertension and associated inammatory changes, this may be technically difcult, but is avoided in the LR-LPJ. Comparisons of the Three Operative Procedures: Pancreatico-Duodenectomy, DPPHR, and LR-LPJ There has been considerable interest particularly in European centers to apply evidence-based methods to the

study of the 3 operations currently advocated for the treatment of chronic pancreatitis. Reports of results of a single operative procedure from a single institution are difcult to compare with those of another operative procedure from another institution, as patient selection, patient populations, measurements of pain and quality of life may vary, as do the methods and details of follow-up. The best studies, or level 1 data by the Strength of Recommendation Taxonomy (SORT), are prospective, randomized controlled trials comparing 2 or more operations from a single or multi-institutional study. Retrospective, cohort-based studies are regarded as level 2 data by the SORT criteria. To date, 5 published level 1 studies have examined various comparisons between these 3 operations, and 1 level 2 study has examined all 3 procedures at a single institution. In the level 1 study of 43 patients by Klempa et al [72], DPPHR patients had a shorter hospital stay, greater weight gain, less postoperative diabetes, and exocrine dysfunction than PPPD over a 3- to 5-year follow-up. Pain control was similar between the 2 procedures. This was conrmed in a level 1 study of 40 patients by Buchler et al [67] in which DPPHR patients reported better pain relief, glucose tolerance, and weight gain; however, the follow-up averaged less than 1 year. In a level 1 study of 61 patients randomized to PPPD or LR-LPJ, Izbicki et al [73] found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality of life scores (71% vs 43%, respectively). Both operations were equally effective in controlling pain over a

S58

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60 [4] Bockman DE, Buchler MW. Pain mechanisms. In: Beger HG, Warshaw AL, Buchler MW, et al, editors. The Pancreas. London, UK: Blackwell-Science; 1998:698 702. [5] Nealon WH, Matin S. Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. Ann Surg 2001; 233:793 800. [6] Nealon WH, Thompson JC. Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modied Puestow procedure. Ann Surg 1993;217:458 64. [7] Cattell RB. Anastomosis of the duct of Wirsung in palliative operation for carcinoma of the head of the pancreas. Surg Clin North Am 1947;27:63753. [8] Duval MK Jr. Caudal pancreatico-jejunostomy for chronic relapsing pancreatitis. Ann Surg 1954;140:775 81. [9] Puestow CB, Gillesby WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. Arch Surg 1958;76:898 904. [10] Partington PF, Rochelle REL. Modied Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 1960;152: 1037 44. [11] Bradley EL. Long term results of pancreaticojejunostomy in patients with chronic pancreatitis. Am J Surg 1987;153:20713. [12] Mannell A, Adson MA, McIlrath DC, et al. Surgical management of chronic pancreatitis: long term results in 141 patients. Br J Surg 1988;75:46772. [13] Taylor RH, Bagley FH, Braasch JW, et al. Ductal drainage or resection for chronic pancreatitis. Am J Surg 1981;141:28 33. [14] Beger HG, Buchler M, Ditschnuneit H. Malfertheiner. Berlin, Germany: Springer-Verlag; 1990:418. [15] Whipple AO. Radical surgery for certain cases of pancreatic brosis associated with calcareous deposits. Ann Surg 1946;124:9911006. [16] Fry WJ, Child CG. Ninety-ve percent distal pancreatectomy for chronic pancreatitis. Ann Surg 1965;162:5439. [17] Frey CF, Child CG, Fry WJ. Pancreatectomy for chronic pancreatitis. Ann Surg 1976;184:40314. [18] Gall FP, Muhe E, Gebhardt C. Results of partial and total pancreatectomy in 117 patients with chronic pancreatitis. World J Surg 1981;5:269 75. [19] Robertson RP, Lanz KJ, Sutherland DER. Prevention of diabetes for up to 13 years by autoislet transplantation after pancreatectomy for chronic pancreatitis. Diabetes 2001;50:4750. [20] Rodriquez Rilo HL, Ahmad SA, DAlessio D, et al. Total pancreatectomy and autologous islet cell transplantation as a means to treat severe chronic pancreatitis. J Gastrointest Surg 2003;7:978 89. [21] Sakorafas G, Sarr MG. Changing trends in operations for chronic pancreatitis: a 22 year experience. Eur J Surg 2000;166:6337. [22] Schmidt CM, Powell ES, Yiannoutsos CT, et al. Pancreaticoduodenectomy: a 20year experience in 516 Patients. Arch Surg 2004;139: 718 25. [23] Vickers SM, Chan C, Heslin MJ, et al. The role of pancreaticoduodenectomy in the treatment of severe pancreatitis. Am Surg 1999;65: 1108 11. [24] Jiminez RE, Fernandez-Del Castillo C, Rattner DW, et al. Pylorus preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003;27:1211 6. [25] Russell RC, Theis BA. Pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003;27:120310. [26] Sakorafas GH, Farnell MB, Nagorney DM. Pancreatico-duodenectomy for chronic pancreatitis. Long term results in 1105 patients. Arch Surg 2000;135:51723. [27] Huang JJ, Yeo CJ, Sohn TA, et al. Quality of life and outcomes after pancreaticoduodenectomy. Ann Surg 2000;231:890 7. [28] Traverso LW, Longmire WP. Preservation of the pylorus during pancreaticoduodenectomy. Surg Gynecol Obstet 1978;146:959 62. [29] Balcon JH 4th, Rattner DW, Warshaw AL, et al. Ten year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001; 136:391 8. [30] Mcleod RS, Taylor BR, OConnor BI, et al. Quality of life, nutritional status, and gastrointestinal hormone prole following the Whipple procedure. Am J Surg 1995;169:179 85. [31] Traverso LW. The pylorus preserving Whipple procedure for the treatment of chronic pancreatitis. Swiss Surg 2000;6:259 63.

2-year follow-up. More recently, a level 1 study by Farkas et al [74] examined 40 patients randomized to PPPD or what was described as an organ-preserving pancreatic head resection (OPPHR), which appears essentially identical to the Frey procedure. The authors found that OPPHR was associated with a shorter operating time, less postoperative morbidity, shorter hospital stay, and better quality of life than PPPD, and the degree of pain relief was equal over a 1- to 3-year follow-up. In 1995, Izbicki and colleagues began a level 1 study of 42 patients randomized to receive DPPHR or LR-LPJ [75]. The study was continued and updated in 1997 [76] to include 74 patients. In 2005 the long-term results of these 74 patients with an average follow-up of 8.5 years was reported [77]. There were no signicant differences between the groups with regard to global quality of life, pain scores, late mortality, and exocrine or endocrine insufciency. These results were echoed in the level 2 study by Aspelund et al, which demonstrated fewer complications with both the DPPHR and LR-LPJ procedures compared to pancreaticoduodenectomy, and a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no signicant differences in outcomes or pain relief between DPPHR and LR-LPJ [68]. Finally, level 2 data support the efcacy of both DPPHR and LRLPJ in patients with dilated as well as nondilated ducts [78,79]. Comments The operative procedures that provide the least postoperative morbidity and mortality and the best quality of life in patients who require pain relief due to chronic pancreatitis are the DPPHR of Beger and the LR-LPJ of Frey. The Frey procedure may be easier to perform, particularly in situations when portal hypertension and inammation make division of the neck of the pancreas difcult, and it has a lower incidence of pancreatic leak. However, long-term results of these 2 operations are virtually identical. Both the Beger and Frey operations are improvements over the standard or PPPD in terms of operative morbidity and mortality, length of hospital stay, weight gain, nutrition and quality of life. Therefore PPPD should be reserved for those patients in whom there is suspicion for the presence of carcinoma. Pain relief after pancreatico-duodenectomy, DPPHR, or LR-LPJ is similarly good, although the risk of new diabetes is less with both the Beger and Frey procedures. Acknowledgment The authors are indebted to Louisa L. Petrosillo and Robyn Hinke for assistance with the manuscript. References
[1] Fisher WE, Andersen DK, Bell RH Jr, et al, Pancreas. In: Brunicardi FC, Andersen DK, Billiar TR, et al, editors. Schwartzs Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1240 74 (also available at: http://www.accesssurgery.com/content.aspx?aid16220). [2] Lankisch PG, Lohr-Happe A, Otto J, et al. Natural course in chronic pancreatitis: pain, exocrine and endocrine pancreatic insufciency and prognosis of the disease. Digestion 1993;54:148 57. [3] Bradley EL III. Pancreatic duct pressure in chronic pancreatitis. Am J Surg 1982;144:313 6.

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60 [32] Hartel M, Tempia-Callera AA, Wente MN, et al. Evidence-based surgery in chronic pancreatitis. Langenbecks Arch Surg 2003;388: 1329. [33] Slavin J, Ghaneh P, Sutton R, et al. Pylorus-preserving KauschWhipple resection: the successor of the classical Kausch-Whipple in chronic pancreatitis. Ann Ital Chir 2000;71:57 64. [34] Ohtsuka T, Yamaguchi K, Ohuchida J, et al. Comparison of quality of life after pylorus-preserving pancreticodenectomy and Whipple resection. Hepatogastroenterology 2003;50:846 50. [35] Ohwada S, Ogawa T, Kawate S, et al. Results of duct to mucosa pancreaticojejunostomy for pancreaticoduodenectomy Billroth I type reconstruction in 100 consecutive patients. J Am Coll Surg 2001;193: 29 35. [36] Hsu JT, Yeh CN, Hwang TL, et al. Outcome of pancreaticoduodenectomy for chronic pancreatitis. J Formosa Med Assoc 2005;104: 8115. [37] Yang YM, Tian XD, Zhuang Y, et al. Risk factors of pancreatic leakage after pancreaticoduodenectomy. World J Gastroenerol 2005; 11:2456 61. [38] Shyr YM, Chen TH, Su CH, et al. Non-stented pancreaticogastrostomy for 111 patients undergoing pylorus-preserving pancreaticoduodenectomy. Hepatogatroenterology 2005;52:2537. [39] Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic ocreotide decrease the rates of pancreatic stula and other complications after pancreaticoduodenectomy? Results of a prospective randomized placebo-controlled trial. Ann Surg 2000;232:419 29. [40] Buchler MW, Friess H, Klempa I, et al. Role of octreotide in the prevention of post-operative complications following pancreatic resection. Am J Surg 1992;163;12531. [41] Shan YS, Sy ED, Tsai ML, et al. Effects of somatostatin prophylaxis after pylorus preserving pancreatico-duodenectomy: increased delayed gastric emptying and reduced plasma motilin. World J Surg 2005;29:1319 24. [42] Lillemoe KD, Cameron JL, Kim MP, et al. Does brin glue sealant decrease the rate of Pancreatic stula after pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2004;8:766 72. [43] Adam U, Makowiec F, Riediger H, et al. [Pancreatic leakage after pancreas resection. An analysis of 345 operated patients.] Chirug 2002;73:466 73. [44] Standop J, Overhaus M, Schaefer N, et al. Pancreatogastrostomy after pancreatoduodenectomy: a safe, feasible reconstruction method? World J Surg 2005;29:50512. [45] Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreaticojejunostomy following pancreaticoduodenectomy: results of a comparative study. Ann Surg 2005;242:76771. [46] Duffas JP, Suc B, Msika S, et al. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Amer J Surg 2005;189:720 9. [47] Jang JY, Kim SW, Park SJ, et al. Comparison of the functional outcome after pylorus-preserving pancreatoduodenectomy: pancreatogastrostomy and pancreatojejunostomy. World J Surg 2002;26: 366 71. [48] Ammori BJ, White CM. Proximal migration of transanastomotic pancreatic stents following pancreaticoduodenectomy and pancreatic jejunostomy. Int J Pancreatol 1999;25:2115. [49] Schnelldorfer T, Lewin DN, Adams DB. Do preoperative pancreatic stents increase operative morbidity for chronic pancreatitis? Hepatogastroenterology 2005;66:1878 82. [50] Telford GL, Mason GR. Improved technique for pancreaticojejunostomy after pancreaticoduodenectomy. Am J Surg 1981;142:386 7. [51] Amano H, Takada T, Ammori BJ, et al. Pancreatic duct patency after pancreaticogastrostomy: long-term follow-up study. Hepatogastroenterology 1998;45:23827. [52] Slezak LA, Andersen DK. Pancreatic resection. Effects on glucose metabolism. World J Surg 2001;25:452 60. [53] Tani M, Terasawa H, Kawai M, et al. Improvement of delayed gastric emptying in pylorus-preserving pancreaticoduodenectomy: results of a prospective, randomized, controlled trial. Ann Surg 2006;243:316 20. [54] Butler TJ, Vair DB, Colohan S, et al. Multivariate analysis of technical variables in pancreaticoduodenectomy: the effect of Pylorus preservation and retro-mesenteric jejunal position on early outcome. Can J Surg 2004;47:3337.

S59

[55] Park YC, Kim SW, Jang JY, et al. Factors inuencing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. J Am Coll Surg 2003;196:859 65. [56] Kurosaki I, Hatakeyama K. Clinical and surgical factors inuencing delayed gastric emptying after pyloric-preserving pancreaticoduodenectomy. Hepatogastroenterology 2005;52:143 8. [57] Fischer CP, Hong JC. Method of pyloric reconstruction and impact upon delayed gastric emptying and hospital stay after pyloruspreserving pancreaticoduodenectomy. J Gastrointest Surg 2006;10: 2159. [58] Muller MW, Friess H, Beger HG, et al. Gastric emptying following pylorus-preserving Whipple and duodenum-preserving pancreatic head resection in patients with chronic pancreatitis. Amer J Surg 1997;173:257 63. [59] Shan YS, Tsai ML, Chiu NT, et al. Reconsideration of delayed gastric emptying in pancreaticoduodenectomy. World J Surg 2005; 29:8739. [60] Takahata S, Ohtsuka T, Nabae T, et al. Comparison of recovery of gastric phase III motility and gastric juice output after different types of gastrointestinal reconstruction following pylorus-preserving pancreatoduodenectomy. J Gastroenterol 2002;37:596 603. [61] Shan YS, Hsieh YH, Sy ED, et al. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. J Formosa Med Assoc 2004;103:76772. [62] Strommer L, Raty S, Hennig R, et al. Delayed gastric emptying and intestinal hormones following pancreatoduodenectomy. Pancreatology 2005;5:537 44. [63] Riediger H, Makowiec F, Schareck WD, et al. Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications. J Gastroenterol Surg 2003;7:758 65. [64] Beger HG, Witte C, Krautzberger W, et al. Experience with duodenum-sparing pancreas head resection in chronic pancreatitis. Chirurg 1980;51:3037. [65] Beger HG, Schlosser W, Freiss HM, et al. Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26 year experience. Ann Surg 1999; 230:5129. [66] Malka D, Hammel P, Sauvanet A, et al. Risk factors for diabetes mellitus in chronic pancreatitis. Gastroenterology 2000;119: 1324 32. [67] Buechler M, Friess H, Mueller MW, et al. Randomized trial of duodenum preserving pancreatic head resection versus pylorus preserving Whipple in chronic pancreatitis. Am J Surg 1995;169:65. [68] Apelund G, Topazian MD, Lee JH, et al. Improved outcomes for benign disease with limited pancreatic head resection. J Gastrointest Surg 2005;9:400 9. [69] Frey CF, Smith GJ. Description and rationale of a new operation for chronic pancreatitis. Pancreas 1987;2:7017. [70] Frey CF, Amikura K. Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Arch Surg 1994;220:492 507. [71] Andersen DK, Topazian MD. Excavation of the pancreatic head: a variation on the theme of duodenum-preserving pancreatic head resection. Arch Surg 2004;139:3759. [72] Klempa I, Spatny M, Menzel J, et al. Pankreasfunktion und Kebensqualitat nach Pankreaskopfresektion bei der chronischen Pankreatitis. Chirurg 1995;66:350 9. [73] Izbicki JR, Bloechle C, Broering DC, et al. Extended drainage versus resection in surgery for chronic pancreatitis prospective randomized trail comparing the longitudinal pancreatico-jejunostomy combined with local pancreatic head excision with pylorus preserving pancreaticoduodenectomy. Ann Surg 1998;228:7719. [74] Farkas G, Leindler L, Daroczi M, et al. Prospective randomized comparison of organpreserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy. Langenbecks Arch Surg 2006;391:338 42. [75] Izbicki JR, Bloechle C, Knoefel WT, et al. Duodenum preserving head resections of the head of the pancreas in chronic pancreatitis: a prospective randomized trial. Ann Surg 1995;221:350 8.

S60

C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60 [78] Ramesh H, Jacob G, Lekha V, et al. Ductal drainage with head coring in chronic pancreatitis with small-duct disease. J Hepatobiliary Pancreat Surg 2003;10;366 72. [79] Shrikhande SV, Kleef J, Friess H, et al. Management of pain in small duct chronic pancreatitis. J Gastrointest Surg 2006;10: 22733.

[76] Izbicki JR, Bloechle C, Knoefel WT, et al. Drainage versus resection in surgical therapy of chronic pancreatitis of the head of the pancreas: a randomized study. Chirurg 1997;68:369 77. [77] Strate T, Taherpour Z, Bloechle C, et al. Long term follow-up of a randomized trial comparing the Beger and Frey procedures for patients suffering from chronic pancreatitis. Ann Surg 2005;241:591 8.