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Surgery is performed for chronic pancreatitis (CP) when more conservative therapies have been exhausted. The goal of surgery is to relieve intractable pain and preserve pancreatic function to the greatest extent possible. In general, outcomes from the various surgical procedures used are inconsistent.

Surgical intervention is considered for a select group of patients including those who:

• Require continuous use of narcotics to control pain or are at risk for addiction
• Are unable to maintain steady employment due to severe pain
• Are unable to maintain a healthy body weight
• Are severely impacted by severe pain in their quality of life and activities of daily living

The objective of surgery is to resect (remove) as little tissue as possible in order to achieve improvement of symptoms, particularly disabling pain or flare-ups of pancreatitis. The specific surgical procedure chosen for any individual patient depends on several factors, including:

• Severity of the pain
• Levels of exocrine/endocrine dysfunction
• Extent of pancreatic disease
• Ductal anatomy
• Presence of complications, such as stones or pseudocysts
• Overall medical condition of the patient

Surgery may also be performed in the presence of:

• Obstruction
• Hemorrhage
• Suspected tumor

Approximately 50% of patients with chronic pancreatitis undergo surgery at some point to either treat complications or to manage pain. Surgery does not stop exocrine or endocrine loss of function. Results of surgery indicate that 60-70% of patients find relief from surgery but after 5 years the benefits begin to diminish.

There are two types of surgical procedures that are considered for chronic pancreatitis:

• Pancreatic resection
• Total pancreatectomy (surgical removal of the pancreas) with islet autotransplantation

Pancreatic Resection

Pancreatic resection is performed with some of the following goals in mind:

• Pain relief
• Pancreatic drainage
• Maximizing any pancreatic function that can be salvaged

Pancreatic resection may be accomplished by a variety of different surgical techniques including:

• Puestow procedure - This is also called a lateral pancreaticojejunostomy in which the pancreatic duct is connected to the small intestines so that pancreatic juices drain directly into the intestines. It is an effective drainage procedure for patients with significant dilatation of the pancreatic duct. This technique is successful in achieving pain relief in up to 80% of patients over the short-term. Pancreatic function is not affected and the procedure is associated with low morbidity and mortality.

• Frey procedure - The Puestow procedure is combined with removing part of the pancreatic head to improve pancreatic duct drainage. This procedure may be performed if there is damage or inflammation to the pancreatic head. It is technically less challenging than the Whipple procedure (see below) and is associated with:

  • low morbidity and mortality
  • high rate of sustained pain relief
  • high rate of return to productivity and quality of life

• _Beger procedure _- Most of the pancreatic head is removed while sparing the duodenum, stomach, and bile duct. This procedure may be performed to treat an enlarged pancreatic head. This procedure is more commonly done in Europe but is gaining favor in the U.S.

• _Whipple procedure (pancreatoduodenectomy) _ - This procedure involves surgery of the head of the pancreas. With the Whipple procedure, the head of the pancreas along with the small bowel embracing the head, the gall bladder, and part of the bile duct and stomach are removed en-block (as one unit). The remaining part of the pancreas is connected to the small intestine. Pain relief is achieved in 60-80% of patients for several years after surgery. The mortality rate from this procedure is less than 5%, however, it is associated with complications such as chronic gastrointestinal complications and diabetes in up to 30% of patients who undergo this procedure. The Whipple procedure is effective for patients with various symptoms including: