Surgery of chronic pancreatitis

Abstract
Surgery of chronic pancreatitis
Charles F. Frey, M.D. a , Dana K. Andersen, M.D. b, *
a University of California Davis, Rescue, CA, USA
b Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224, USA
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 inflammation, 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 fibrocalcific 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 inflammation, and
the manifestations of exocrine and endocrine insufficiency.
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: 1-410-550-
0154.
E-mail address: dander54@jhmi.edu
The American Journal of Surgery 194 (Suppl to October 2007) S53–S60
0002-9610/00/$ – see front matter © 2007 Excerpta Medica Inc. All rights reserved.
doi:10.1016/j.amjsurg.2007.05.026
increased ductal pressure is thought to be a cause for pain in
chronic obstructive pancreatitis [3], the role of chronic inflammation
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 benefit 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 efficacious: 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

S54 C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53–S60
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 inflammation or ductal
hypertension, all 3 procedures remove the source of
chronic inflammatory changes and provide drainage for
the distal ductal system. Other frequent complications of
chronic pancreatitis resulting from fibrosis and obstruction,
such as pseudocysts and common bile duct and
duodenal obstruction, can usually be managed by modifications
of these 3 procedures. Occasionally, a patient
with chronic inflammatory changes localized to the body
or tail of the gland will benefit 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 Gillesby’s 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 [11–13]. 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 first 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 insufficient to prevent exocrine
and endocrine insufficiency post operatively, and the resulting
“brittle” diabetes was particularly difficult 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 inflammatory 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 confirmed pancreatico-duodenectomy
to be an effective means of managing pain and the complications
of chronic pancreatitis [21–26]. 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 benefits associated with retention of the pylorus
[23,28], but these benefits have never been well substantiated,
and some studies have shown no significant nutritional
differences between the 2 procedures [29,30]. Most studies
have documented an improved quality of life after the PPPD
[31–34], 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
definition of a leak [35–37]. Although pancreatic anastomotic
leaks are less likely to occur in chronic pancreatitis
because of the firmer consistency of the gland, the main duct
can be 2 to 3 mm or less in a gland with diffuse sclerosis,
and difficulties 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) S53–S60
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 fibrin 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
S55
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].

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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 [53–56]. 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 Beger’s duodenal-preserving pancreatic
head resection (DPPHR), first 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 insufficiency 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 flow 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 al’s 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 (LR-
LPJ) was described by Frey and Smith [69] (Fig. 4). The
operation combined features of Child’s 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 3½ years, the results of 50 cases
were reported [70]. Pain was relieved in 80% of the patients
and exocrine and endocrine insufficiency 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 uninflammed 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 significant 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) S53–S60
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 inflammation. 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 inflammation
of the ductal mucosa in the body and tail, consistent with recurrent
inflammation due to chronic pancreatitis. Reprinted with permission [71].
vein. In the event of portal hypertension and associated
inflammatory changes, this may be technically difficult,
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
S57
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 difficult 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 confirmed 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) S53–S60
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 significant differences between the
groups with regard to global quality of life, pain scores, late
mortality, and exocrine or endocrine insufficiency. 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 significant differences in outcomes
or pain relief between DPPHR and LR-LPJ [68]. Finally,
level 2 data support the efficacy of both DPPHR and LR-
LPJ 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 inflammation make division
of the neck of the pancreas difficult, 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.
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