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8 Chronic Pancreatitis: Resection
creatitis: the multicentre, randomised, controlled, double-blind ChroPac trial. Lancet.
2017;390(10099):1027–37. https://doi.org/10.1016/S0140- 6736(17)31960- 8.
3. Siegel JB, Mukherjee R, Lancaster WP, Morgan KA.Distal pancreatectomy for pancreatitis in
the Modern Era. J Surg Res. 2022;275:29–34. https://doi.org/10.1016/j.jss.2022.01.016. Epub
2022 Feb 23
4. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer.
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23622135; PMCID: PMC3662544
5. Rieder B, Krampulz D, Adolf J, Pfeiffer A.Endoscopic pancreatic sphincterotomy and stent-
ing for preoperative prophylaxis of pancreatic stula after distal pancreatectomy. Gastrointest
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6. Nathan JD, Yang Y, Eaton A, Witkowski P, etal. Surgical approach and short-term outcomes
in adults and children undergoing total pancreatectomy with islet autotransplantation: a report
from the prospective observational study of TPIAT.Pancreatology. 2022;22(1):1–8. https://doi.
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7. Bassi C, Marchegiani G, Dervenis C, Sarr M, etal., International Study Group on Pancreatic
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139
Chapter 9
Combined Procedures (Open Vs. MIS)
JörgKleeff, JohannesKlose, andUlrichRonellentsch
Introduction
Given that the concept and pathogenesis of chronic pancreatitis had been poorly
dened until the 1950s, surgical options were mostly limited to symptomatic measures [1]. Procedures to resolve cholestasis in the early twentieth century were all
limited to extrapancreatic structures and included cholecystostomy, cholecystoenterostomy, and bilioenteric anastomosis. Although it was known that drainage and
stone removal from the pancreatic duct led to pain relief, only in 1954 Zollinger and
Duval introduce the rst combined drainage and resection procedure, which
included distal pancreatectomy with splenectomy and distal pancreatojejunostomy
for internal drainage [2, 3]. However, such retrograde internal drainage usually provided little pain relief. Over time, the notion that the “pacemaker of pain” in chronic
pancreatitis is most often located in the pancreatic head emerged [4]. While mere
drainage operations came into clinical practice in the late 1950s and pancreatoduodenectomy was the established treatment for pancreatic head malignancies, in 1972
the rst duodenum-preserving resection of the head of the pancreas was performed
by Beger [5]. The aim of the procedure was to remove the pacemaker of pain, providing effective pancreatic drainage and removing cholestasis while at the same
time preserving pancreatic tissue to the most possible extent. This concept has been
further developed in technical and anatomical modications to the procedure.
Nowadays, combined resection and drainage procedures form an important cornerstone in the surgical treatment of chronic pancreatitis.
J. Kleeff (*) · J. Klose · U. Ronellentsch
Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle (Saale),
Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
e-mail: joerg.kleeff@uk-halle.de; johannes.klose@uk-halle.de;
ulrich.ronellentsch@uk-halle.de
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_9
141© The Author(s), under exclusive license to Springer Nature
142
J. Kleeff et al.
Indications forCombined Resection andDrainage Surgery
forChronic Pancreatitis andChoice ofOne Procedure Vs.
theOther
Rationale forSurgery inChronic Pancreatitis
The aim of surgery in patients with chronic pancreatitis is multi-faceted. Most
importantly, relief from pain, which often severely disables patients in their daily
activities, must be achieved. This can lead to a signicant improvement in patients’
quality of life. Secondly, preservation or restoration of gastrointestinal function,
which comprises the integrity of the stomach and duodenum, the exocrine pancreas
function as well as the biliary excretion into the intestinal tract, should be attained.
Left-sided portal hypertension resulting from compression of the portal vein and the
conuence of the superior mesenteric and the splenic vein should be resolved.
Lastly, preservation of the pancreatic endocrine function is important. Keeping
these goals in mind, the ideal surgical approach for chronic pancreatitis should both
remove the “pacemaker of pain” [4], which is predominantly located in the pancreatic head and only rarely in the tail, and provide drainage of a pre-stenotic dilated
pancreatic and/or biliary duct. Combined resection and drainage procedures are
used to achieve these aims. In contrast to pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy, they limit the resection of pancreatic tissue to the
diseased parts and maintain the maximal possible amount of healthy pancreatic tissue and the distal stomach and duodenum. At the same time, they provide effective
drainage of the dilated pancreatic and/or biliary duct to the small intestine.
Procedures
Two combined resection-drainage operations are commonly used while one is
rarely employed contemporarily. In addition, there are several modications or
combinations of these techniques.
The duodenum-preserving pancreatic head resection (DPPHR), also named
Beger procedure after the German surgeon who rst performed it in the 1970s and
reported the rst large case series in 1980 [5], includes a division of the pancreas at
the level of the mesenteric-portal axis, which can release compression of the portal
vein and thereby revert left-sided portal hypertension. The proximal pancreas is
divided along the concave side of the descending part of the duodenum, preserving
a layer of pancreatic tissue as well as the common bile duct and the papilla (Fig.9.1).
The intrapancreatic segment of the common bile duct is dissected along its anterior
wall, which often leads to its decompression. The procedure results in removal of
the pancreatic head and uncinate process while preserving a few millimeters wide
remnant of the pancreatic head towards the duodenal wall. Subsequently, an
9 Combined Procedures (Open Vs. MIS)
Fig. 9.1 Duodenumpreserving pancreatic head
resection (DPPHR).
Division of the proximal
pancreas along the concave
side of the descending part
of the duodenum,
preserving a layer of
pancreatic tissue as well as
the common bile duct and
the papilla. (From [28])
143
anastomosis of the divided pancreatic duct at the body, and optionally of the common bile duct to a small bowel loop, is performed as Roux-en-Y reconstruction.
The Frey procedure, named after the American surgeon who rst described it in
1987 [6], can be regarded as a combination of DPPHR and the Partington-Rochelle
operation. The extent of resection at the pancreatic head is smaller than in DPPHR
since a posterior layer of pancreatic tissue is preserved. The pancreas is thus not
transected at the level of the mesenteric-portal axis, which facilitates the operation
especially in the presence of massive inammatory adhesions. However, a possible
left-sided portal hypertension cannot be resolved. It uses a long side-to-side pancreaticojejunostomy with Roux-en-Y reconstruction to drain the pancreatic duct
(Fig.9.2).
The Duval operation dates back to the 1950s, when it was rst described independently by Duval and Zollinger [2, 3]. It involves drainage of the pancreatic duct
towards its distal end by resecting the pancreatic tail and performing an anastomosis
between the pancreatic remnant and a small intestinal loop. The procedure resects
the “pacemaker of pain” only in the rare cases where it is located in the tail, and thus
does not often lead to sustainable pain relief. This is the reason why it has been
largely abandoned.
The Hamburg modication was described in 1998 by Izbicki etal. [7]. It represents a modication of the Frey procedure and involves a larger extent of pancreatic
144
Fig. 9.2 Frey procedure.
Construction of a retrocolic
long side-to-side
pancreaticojejunostomy to
drain the pancreatic duct.
(From [28])
J. Kleeff et al.
Fig. 9.3 Hamburg modication. A larger extent of pancreatic head including the uncinate process
is resected, while division of the pancreas at the level of the mesenteric-portal axis is avoided. After
pancreatic duct decompression, a long side-to-side pancreaticojejunostomy with Roux-en-Y
reconstruction is performed. (From [29])
head resection reaching also into the uncinate process. It avoids division of the
pancreas at the level of the mesenteric-portal axis in order to reduce the risk of vessel injury. The pancreatic duct is further decompressed by a V-shaped excision of
the anterior pancreatic wall, and a long side-to-side pancreaticojejunostomy with
Roux-en-Y reconstruction is performed (Fig.9.3).
9 Combined Procedures (Open Vs. MIS)
145
The Berne modication was described in 2001 by Gloor etal. and combines the
Frey procedure with DPPHR [8]. It also avoids division of the pancreas at the level
of the mesenteric-portal axis. Division is instead performed further towards the duodenum so that the anterior surface of the common bile duct is still completely dissected. Reconstruction is done similarly to DPPHR with pancreaticojejunostomy
and a Roux limb (Fig.9.4).
Indications
The indication for a combined resection and drainage procedure is the removal of an
assumed “pacemaker of pain,” usually located in the pancreatic head, with the
expectation that a mere drainage operation cannot relieve the symptoms because
compression of the pancreatic and bile duct would persist. Obstruction of the common bile duct or the pancreatic duct resulting in duct stones or pseudocysts, or of
the portal vein resulting in left-sided portal hypertension can also constitute an indication for surgery, even in the absence of severe pain. Several meta-analyses showed
that the long-term outcomes of surgery are superior to those of endoscopic treatment with regard to pain relief [9]. Given their lower invasiveness and risk of complications, endoscopic treatments are often the rst treatment step. Usually, the
indication for the operation is seen when repetitive endoscopic treatments fail to
have a benecial effect. The operation should not be delayed for too long, as pain
can become chronic and refractory to therapy [10, 11]. Several studies showed that
an operation early after rst diagnosis leads to much stronger pain relief, and that a
high number of endoscopic procedures as well as opioid use are associated with
Fig. 9.4 Berne modication. In this combination of the Frey procedure with DPPHR, the pancreatic division is performed further towards the duodenum with the anterior surface of the common
bile duct being completely dissected. (From [29])
146
worse pain relief [12, 13]. Endoscopic and isolated drainage procedures bear the
risk that a malignant tumor is not detected and not removed. The risk of developing
pancreatic cancer is markedly increased in patients with chronic pancreatitis. It
reaches 4.6% at 5years after and 14.0% at 25years after rst diagnosis of chronic
pancreatitis. It is assumed that this risk can be reduced by 90% with a combined
drainage and resection procedure [10, 11, 14]. However, lower estimates of cancer
risk in chronic pancreatitis patients have lately been reported, and the risk reduction
achieved by surgery has been disputed.
J. Kleeff et al.
Contraindications
There are several relative and absolute contraindications towards combined resection and drainage procedures in chronic pancreatitis. A very limited physical status
and severe comorbidities can represent contraindications against any larger abdominal surgery including combined resection and drainage procedures. Common
comorbidities in patients with chronic pancreatitis are persistent alcohol abuse,
often with liver cirrhosis, and addiction to opioids. Careful multidisciplinary assessment by the surgeon, the anesthesiologist, and other disciplines (e.g., gastroenterologists, cardiologists) is required to assess the operative risk. A pronounced lack of
expected postoperative compliance, especially if exocrine or endocrine dysfunction
is to be expected, is a relative contraindication to surgery. Finally, severe portal
hypertension, often occurring due to complete occlusion of the superior mesenteric,
splenic, or portal vein, with enlarged venous collaterals around the pancreas constitute a prohibitive risk of intraoperative hemorrhage or of destruction of portal
venous drainage and subsequent hemorrhagic intestinal infarction. In such cases,
complete pancreatic head resection is contraindicated, limiting the choice of feasible procedures. If malignancy is suspected based on imaging features or high Ca
19–9 serum levels without concomitant cholestasis, or even histologically conrmed, a combined resection and drainage procedure is not indicated. Rather, an
oncological resection, usually pancreatoduodenectomy or total pancreatectomy,
with systematic lymphadenectomy, must be performed.
Choice ofProcedure
First, the choice between a mere resection procedure and a potentially parenchymasparing combined drainage and resection procedure should be made. A metaanalysis of randomized controlled trials published in 2016 showed no relevant
differences between pancreatoduodenectomy and DPPHR in terms of morbidity
and mortality, but a shorter hospital stay following DPPHR [15]. The available evidence was insufcient to allow for a comparison of postoperative pain relief. Results
of the hitherto largest multicentric study, the ChroPac trial, were published in 2017
9 Combined Procedures (Open Vs. MIS)
147
[16]. The trial showed no difference in its primary endpoint, quality of life 24months
after surgery, or in the secondary endpoints such as postoperative complications,
length of hospital stay, and endocrine function, between the two procedures. Based
on this evidence, no clear recommendation for either pancreatoduodenectomy on
the one hand or parenchyma-sparing combined drainage and resection procedure on
the other hand can be made [10, 11]. Although this recommendation is based only
on expert consensus, DPPHR and modications are to be favored over pancreatoduodenectomy in patients with severe portal hypertension and portal venous drainage via collaterals (Fig. 9.5) given the high risk of intraoperative bleeding and
postoperative hemorrhagic intestinal infarction [10].
If a specic combined drainage and resection procedure is decided for, the choice
which of the different procedures is most appropriate for a given patient is not easy
and only partially supported by high-level evidence regarding selected clinical outcomes. The Duval procedure is only indicated in the rare cases in which the “pacemaker of pain” is suspected to be located in the pancreatic tail. A recently published
network meta-analysis of the eleven hitherto conducted randomized controlled trials, which all showed at least one domain with a high risk of bias, aimed at comparing the different operations for chronic pancreatitis with the pacemaker supposedly
located in the pancreatic head, i.e., pancreatoduodenectomy, DPPHR, the Berne
modication, and the Frey procedure [17]. For none of the operations, a statistically
signicant advantage over another one was found for the outcomes pain relief, quality of life, pancreatic function, morbidity, and mortality. Probability ranking showed
that for short-term pain relief, PPPD had the highest probability of being ranked
rst followed by the Berne, Frey, and DPPHR procedures, while for long- term pain
relief the Berne modication was ranked rst. For quality of life, the Frey operation
had the highest probability of being ranked rst. Both for exocrine and endocrine
pancreatic function, the Berne and Frey procedures were ranked rst. For postoperative morbidity and long-term mortality, the Berne modication had the highest
probability of being ranked most benecial followed by the Frey procedure, DPPHR,
Fig. 9.5 Axial CT image
of a patient with chronic
pancreatitis, occlusion of
the portal vein, and
consecutive severe portal
hypertension with portal
venous drainage via
retropancreatic collaterals
(red arrow)
148
and PPPD.Another network meta-analysis including eight randomized controlled
trials with 597 patients, all judged to have moderate to high risk of bias, ranked
DPPHR best for pain relief and the Frey procedure best for quality of life and exocrine pancreatic function [18].
In summary, the available evidence cannot convincingly show that one single
procedure is superior to the others with regard to the wide spectrum of clinical outcomes. Therefore, the indication for surgery and the choice of procedure requires an
individualized approach, which is tailored to the morphological disease stage,
comorbidities and overall physical status of the given patient. In particular, portal or
superior mesenteric vein compression or occlusion and the presence of portal
venous collaterals may constitute a contraindication against pancreatic head resection and thus against PPPD and DPPHR, leaving the choice between the Frey procedure and the Berne modication. In turn, as explained above, PPPD is mandatory
if malignancy is suspected.
J. Kleeff et al.
Pre-op andPreparation Pearls
Preoperative Workup
A thorough preoperative workup is key for a correct indication for surgery, for the
best choice of the procedure, and for a good postoperative outcome. It should
include the following items:
• Conrmed diagnosis of chronic pancreatitis, excluding non-pancreatic pain to
the largest possible extent
• Treatment of the respective cause of pancreatitis
– Alcohol cessation in alcoholic pancreatitis
– Tobacco cessation since smoking is a known risk factor for chronic pancreati-
tis and accelerates disease progression
– Cholecystectomy and removal of common bile duct stones in biliary
pancreatitis
– Immunosuppressive treatment in autoimmune pancreatitis
– Cessation of causative drug in drug-induced pancreatitis
• Evaluation of pain (pain diary, visual analogue pain scale)
• Employment/work history
• Evaluation of quality of life with a validated instrument, for example, the EORTC
QLQ-C30 and QLQ-PAN26 modules [19]
• Clinical evaluation:
– Height and weight, body mass index
– Jaundice
– Ascites
– Other clinical signs of liver failure
9 Combined Procedures (Open Vs. MIS)
149
• Evaluation of exocrine (steatorrhea, fecal elastase measurements) and endocrine
(glucose prole, HbA1c and C-peptide measurements, insulin dosage) pancreatic function
• Laboratory tests:
– Complete blood count
– Liver function tests (transaminases, albumin, cholinesterase)
– Cholestasis indicators (direct and indirect bilirubin, alkaline phosphatase,
gamma-glutamyl transferase)
– Coagulation tests (INR, partial thrombin time)
– Electrolytes
– Kidney function tests
– IgG4
• Triphasic CT with a specic focus on:
– Pancreatic masses
– Calcications
– Involvement of adjacent organs
– Portal, superior mesenteric, and splenic vein patency
– (Left-sided) portal hypertension with collaterals
– Gallstones, common bile duct stones
• MRT/MRCP, endosonography to evaluate the biliary and pancreatic ducts
(optional)
• Endosonography-guided biopsy if a mass/malignancy is suspected
Preparation forSurgery
Longer term and immediate preparation for the procedure should comprise:
• Ensuring sufcient postoperative compliance regarding the causative agent
(alcohol abstinence, continuation of medical treatment)
• Smoking cessation
• Prehabilitation including improvement of nutritional status according to nutrition guidelines, if needed using enteral or parenteral supplementary nutrition,
and physical activity
• Preparation of a sufcient number of blood group matched units of packed red
blood cells
• Perioperative prophylactic antibiotic prophylaxis (“single shot”) according to
local standards