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MOG 340508

REVIEW

CURRENT
OPINION Surgical treatment of pain in chronic pancreatitis
Mariya E. Skube and Greg J. Beilman

Purpose of review
Patients suffering from chronic pancreatitis often require surgical intervention to treat their disease. This
review discusses surgical options as well as reviews current trends and research in the operative
management of chronic pancreatitis.
Recent findings
Relevant current topics in the field include the appropriate timing of surgery as well as the relative benefits
of various procedures, particularly duodenum-preserving pancreatic head resection versus
pancreaticoduodenectomy. Multiple studies have found that surgery earlier in the disease course results in
improved outcomes. Furthermore, the recent literature reports similar outcomes of duodenum-preserving
pancreatic head resection when compared with pancreaticoduodenectomy.
Summary
It is important for treating clinicians to be well versed on the interplay of medical, endoscopic, and surgical
strategies to carefully tailor a patient’s treatment plan. Each patient warrants careful consideration and an
individualized approach in collaboration with multidisciplinary colleagues.
Keywords
chronic pancreatitis, pancreatectomy, surgical decision-making

INTRODUCTION recent publications and debates within the field, the

For 40–75% of chronic pancreatitis patients, the emphasis of the following discussion will be the
pain and related sequalae of their disease ultimately timing of surgery with particular consideration of
lands them in the operating room [1,2]. The timing the interplay of endoscopic and surgical approaches,
of operative intervention and the surgical procedure the evaluation of duodenum-preserving pancreatic
of choice are carefully determined by individual head resection (DPPHR), and the splanchotomy
patient factors such as underlying cause, duration approach to pain management.
of disease, and ductal morphology. This article will
provide a brief overview of the surgical options for
TIMING OF SURGERY IN A MINIMALLY
management of pain in chronic pancreatitis as well
INVASIVE ERA
as discuss the current salient topics in the field.
A crucial aspect of surgical success in the treatment
of chronic pancreatitis is the careful selection of the
SURGICAL MANAGEMENT OPTIONS appropriate timing of surgical intervention. In
Traditionally, the arsenal of surgical techniques for 2012, the Dutch Pancreatitis Study Group reported
treating chronic pancreatitis has included options for on pain relief after surgery for chronic pancreatitis
&
both drainage and resection [1,3,4 ]. A description of [6]. They found that 3 years or less of pain (P ¼ 0.03),
the most relevant procedures is provided in Table 1. absence of preoperative narcotic use (P ¼ 0.006),
Although each patient case merits an individualized and five or less endoscopic procedures (P ¼ 0.05)
approach, there are some basic guidelines to the were independent predictors of postoperative pain
appropriate surgical approach for chronic pancreati-
tis patients. Figure 1 provides a simple guide to surgi-
cal decision-making for these patients [5]. Department of Surgery, University of Minnesota, Minneapolis, Minnesota,
USA
Correspondence to Greg J. Beilman, MD, Department of Surgery,
MANAGEMENT TRENDS AND NEW University of Minnesota, 420 Delaware St SE, MMC 195, Minneapolis,
LITERATURE MN 55445, USA. Tel: +1 612 626 6122; e-mail: [email protected]
In the past few years, the work in the field has a Curr Opin Gastroenterol 2018, 34:000–000
number of recurring themes. Reflecting the trends of DOI:10.1097/MOG.0000000000000460

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MOG 340508

Pancreas

months was the cutoff threshold (area under the

KEY POINTS curve 0.66) for their series of 66 patients in having
 Pursuing operative intervention early in the disease successful pain relief.
process results in improved outcomes. Advances in the field of endoscopic manage-
ment present further challenges in determining
 In recent studies, duodenum-preserving pancreatic head the best timing of surgery. Often, endoscopy can
resection has been performed as well as
relieve pain and associated symptoms for many
pancreaticoduodenectomy in regards to
patient outcomes. patients and provide a less invasive treatment
option. These capabilities also present an additional
 Each patient with chronic pancreatitis warrants careful challenge in determining the ideal timing to pro-
consideration and an individualized approach in ceed with a surgical approach. As the aforemen-
collaboration with multidisciplinary colleagues.
tioned studies reveal, earlier surgical intervention
may actually improve rates of postoperative pain
relief. Furthermore, multiple studies have revealed
relief. Of note, total pancreatectomy patients were that increasing numbers of endoscopic intervention
not included. These findings challenged the theory and/or stent placement predict less pain relief post-
of exhausting medical management prior to opera- operatively [6,8]. For example, in a review of 581
tive intervention and suggested early surgical expo- total pancreatectomy patients by Chinnakotla et al.,
sure may be advantageous. Following this report, multivariate analysis indicated that a previous stent
Yang et al. published a single institution’s experi- placement [P ¼ 0.055, odds ratio (OR) 1.93], greater
ence with the surgical treatment of pain associated than two stents (P ¼ 0.020, OR 2.73), and prior
with chronic pancreatitis to assess optimal timing sphincterotomy (P ¼ 0.020, OR 1.76) were associated
of surgery [7]. Their research revealed that duration with narcotic use at 1 year after surgical intervention
of chronic pancreatitis prior to operating of 26.5 [8].

Table 1. Operative approaches to chronic pancreatitis

Disease feature (s) of

Procedure Category ideal candidate Technique Notes

Longitudinal Drainage Dilation of the main Pancreatic duct is opened along the Modification of the original Puestow
pancreatico- pancreatic duct length of the anterior surface of the procedure that had the additional
jejunostomy pancreas features of distal pancreatectomy
Roux limb of jejenum is anastomosed and splenectomy
to the open duct
Duodenum- Drainage Disease localized in the Pancreatic neck is transected, and the Berne modification to this procedure
preserving Resection pancreatic head, diseased pancreatic head is resected involves coring out the diseased
pancreatic head duodenum, and/or leaving a cuff of pancreatic disease pancreatic head and draining the
resection (Beger) common bile duct along the duodenum main pancreatic duct without
Roux limb of jejunum is than pancreatic transection
anastomosed as bridge between the
pancreatic remnant on the duodenal
wall and the distal pancreas
Frey Drainage Main pancreatic duct Resection of the pancreatic head while In contrast to the DPPHR the
Resection dilation and disease of leaving residual pancreas on the pancreatic neck is not transected
the head of the pancreas duodenum Modifications exist involving varied
Main pancreatic duct is opened and a degrees of pancreatic head
lateral pancreaticojejunostomy is resection
performed
Partial Resection Intraductal papillary Pancreatico-duodenectomy Pancreaticoduodenectomy may be
pancreatectomy mucinous neoplasm, Distal pancreatectomy performed with or without pylorus
suspected malignancy preservation
Total Resection Intractable disease, May be performed with or without
pancreatectomy hereditary pancreatitis, islet autotransplantationa
small duct or minimal
change pancreatitis
&
Sources: Data from [1,3,4 ].
a
See article on Total Pancreatectomy with Islet Auto Transplant in this issue.

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Surgical treatment of pain in chronic pancreatitis Skube and Beilman

multidisciplinary committee comprised clinicians

from surgery, gastroenterology, endocrinology, psy-
chology, and pain backgrounds discuss cases weekly
to determine the ideal approach.

DUODENUM-PRESERVING PANCREATIC
HEAD RESECTION
Not only does determining surgical timing pose
challenges for the clinician but also selecting the
appropriate surgical procedure can present an addi-
tional hurdle in the management of chronic pan-
&
creatitis patients [14 ]. One area of particular
interest has been weighing the relative benefits of
partial pancreaticoduodenectomy compared with
DPPHR. To this end, a number of recent publications
&
have investigated the role of DPPHR [3,15 ,16,17].
FIGURE 1. Guide to surgical decision-making for the
The European ChroPac randomized controlled trial
management of chronic pancreatitis. These are general compared quality of life at 2 years postoperatively
guidelines only. Every patient warrants a tailored approach for patients randomized to pancreaticoduodenec-
&

to care with multidisciplinary input. tomy and DPPHR groups at 18 hospitals [15 ].
One hundred and 25 patients were randomized to
each group with slightly lower numbers included in
Nonetheless, endoscopy plays an important role final analysis (pancreaticoduodenectomy n ¼ 111,
in the management of chronic pancreatitis. For DPPHR n ¼ 115). There was not a difference in
many patients, endoscopy provides significant pain reported quality of life (P ¼ 0.284) at the designated
relief and promising disease management. Jafri et al. time point. Secondarily, rates of adverse events were
compiled a meta-analysis of 16 studies investigating similar between the two groups. The DPPHR group
the efficacy of endotherapy in relieving chronic however did have an increased rate of readmissions
&&
pancreatitis pain [9 ]. Although immediate pain during the follow-up period (27 versus 11%,
relief was reported as high [88%, 95% confidence P ¼ 0.002).
interval (CI) 81–94%], this down trended to 67% Apart from this report on the ChroPac trial,
(95% CI 58–76%) at long-term follow-up (mean of there was also a recent Cochrane reviewing assessing
47 months). The complication rate was 8%. Patients pancreaticoduodenectomy versus DPPHR [16].
with intraductal stones in the pancreatic ahead as Analysis of five eligible trials revealed no difference
well as main duct strictures are frequently ideal in mortality, adverse events, or quality of life; how-
endoscopic candidates [10]. Endoscopic maneuvers ever, all the trials were single institution studies and
are also often employed in patients with features were noted to have low or very low quality of evi-
consistent with both recurrent acute pancreatitis dence. The length of hospital stay however was
and chronic pancreatitis [11]. lower in the DPPHR patients by 1–5 days. Further
Although the literature is admittedly sparse, delineating the distinct duodenum-preserving pan-
when compared head to head, surgery currently creatic head resection strategies, Zhao et al. con-
has the long-term advantage over endoscopy. A ducted a systematic review and meta-analysis of
Cochrane review of three randomized controlled the DPPHR versus pancreaticoduodenectomy as
trials comparing endoscopic and surgical manage- well as Beger versus pancreaticoduodenectomy, Frey
ment found that surgical patients had greater and versus pancreaticoduodenectomy, and Beger versus
more durable pain relief. At long-term follow-up (5 Frey [18]. DPPHR was found to have a lower opera-
years), the risk ratio of pain relief was 1.56 (95% CI tive time (P < 0.00001), less blood transfusions
1.18–2.05) in the surgical patients with comparable (P ¼ 0.02), and a shorter length of stay (P ¼ 0.0002)
rates of morbidity and mortality [12]. The true chal- compared with pancreaticoduodenectomy. They
lenge is early recognition of patients with disease also found short-term morbidity to be lower in
characteristics not amenable to endoscopic therapy the DPPHR group (P ¼ 0.0007). Pain relief and qual-
alone, and rigorous clinical trials to provide clearer ity-of-life outcomes were similar among the groups.
&
guidance are needed [13 ]. In order to reconcile the Differences in exocrine insufficiency existed more
advantages of endoscopic therapy with the benefit frequently in the pancreaticoduodenectomy group
of early surgery, at the authors’’ institution a in the studies with shorter follow-up (<60 months);

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Pancreas

however, this did not persist at greater than pancreatic pain relief and minimal complications
60 months of follow-up. Endocrine outcomes were using this minimally invasive approach to pain
similar. control [29,30]. The durability of this procedure
Investigating variations within the DPPHR pro- and comparison with alternate modalities is yet to
cedure itself, Klaiber et al. reported a 10-year follow- be clearly elucidated. What this procedure does
up of a randomized controlled trial comparing the represent however is that a definite solution for
original DPPHR (Beger procedure) to the Berne mod- treating the pain of chronic pancreatitis remains
ification [3]. Sixty-two percent (n ¼ 40) of the origi- elusive, and the field continues to evolve to produce
nal cohort had follow-up data available. There were optimal outcomes for patients.
no long-term differences in the quality-of-life
parameters, and both groups reported improved
quality of life. Functional outcomes, including daily CONCLUSION
pain and reoperation among other parameters, were Chronic pancreatitis is a challenging disease that
also comparable. As the original Beger procedure is produces great suffering for the patient and perplex-
more technically challenging, these results suggest ing management decisions for the clinician. It is
that the Berne modification presents an equally important for treating clinicians to be well versed on
effective alternative. the interplay of medical, endoscopic, and surgical
In summary, the recent literature still indicates strategies to carefully tailor a patient’s treatment
mixed results in regards to the optimal surgical plan. Although the timing and technique of surgical
intervention, and additional surgical trials are war- intervention must be carefully weighed, there is
&
ranted [14 ]. The recent studies do suggest that for mounting evidence that pursuing surgery in the
surgical candidates with disease of the pancreatic first few years of disease for the appropriate candi-
head, procedures such as DPPHR and Frey result in dates provides durable pain relief and improved
similar outcomes to pancreaticoduodenectomy and quality of life in chronic pancreatitis patients.
thus may be preferable in order to salvage the duo-
denum and its key structural and enteroendocrine
&
functions [3,15 ,16,19,20]. Furthermore, there is a Acknowledgements
large body of evidence to support the role of total None.
pancreatectomy with islet autotransplantation
(TPIAT) in chronic pancreatitis patients with small Financial support and sponsorship
duct or minimal change disease and intractable M.E.S. is supported by grant numbers NIH/NIDDK
pain, and the experience is also growing in patients T32DK108733.
with recurrent acute and hereditary pancreatitis,
including in the pediatric population [8,21–
& &
25,26 ,27 ]. As surgeons who treat chronic pancrea- Conflicts of interest
titis are well aware, each patient warrants careful The authors do not have any conflicts of interest or
consideration and an individualized approach in disclosures to report.
collaboration with multidisciplinary colleagues.
REFERENCES AND RECOMMENDED
SPLANCHNOTOMY READING
Papers of particular interest, published within the annual period of review, have
Seeking surgical relief from pancreatic pain has not been highlighted as:
& of special interest
been isolated to intra-abdominal procedures. A few && of outstanding interest

recent reports detail experience with splanchnot-

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