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Surgery for chronic pancreatitis

Katherine Morgan, MD, FACS
Section Editor
Stanley W Ashley, MD
Deputy Editor
Wenliang Chen, MD, PhD


Chronic pancreatitis (CP) is a benign, inflammatory disorder of the pancreas resulting in fibrotic replacement of the pancreatic parenchyma. The clinical presentation of CP is marked by severe, refractory abdominal pain. CP often leads to progressive endocrine failure (type 3c diabetes mellitus [1]) and exocrine failure (malabsorption with attendant nutritional compromise) of the pancreas.

Clinical management of CP is challenging, given incomplete understanding of disease pathogenesis and the complexities of pain control. Initial management of CP entails risk factor modification with alcohol abstinence and tobacco cessation, treatment of pain (ideally) with supportive behavioral therapy, and nutritional optimization with pancreatic enzyme replacement. Patients who continue to have debilitating pain despite best medical management are candidates for therapeutic intervention.

We discuss the indications, techniques, and outcomes of surgery for chronic pancreatitis in this topic. Nonsurgical treatments of chronic pancreatitis and surgical treatments of other pancreatic diseases are discussed in other topics. (See "Treatment of chronic pancreatitis" and "Surgical resection of lesions of the head of the pancreas" and "Surgical resection of lesions of the body and tail of the pancreas" and "Total pancreatectomy".)


For patients with chronic pancreatitis (CP) who require therapeutic intervention, endoscopic approaches are usually undertaken before surgery, owing to the perception that less invasive procedures should be attempted first. The optimal timing of surgery for patients who fail endoscopic interventions, however, is debated.

A 2015 Cochrane review suggested that for CP, surgery is superior to endoscopy in achieving lasting pain relief, and that early surgical intervention may help preserve pancreatic function [2]. Included in the Cochrane review are two randomized trials that compared endoscopic with surgical treatment of CP:

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Literature review current through: Nov 2017. | This topic last updated: Sep 25, 2017.
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  1. Rickels MR, Bellin M, Toledo FG, et al. Detection, evaluation and treatment of diabetes mellitus in chronic pancreatitis: recommendations from PancreasFest 2012. Pancreatology 2013; 13:336.
  2. Ahmed Ali U, Pahlplatz JM, Nealon WH, et al. Endoscopic or surgical intervention for painful obstructive chronic pancreatitis. Cochrane Database Syst Rev 2015; :CD007884.
  3. Díte P, Ruzicka M, Zboril V, Novotný I. A prospective, randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis. Endoscopy 2003; 35:553.
  4. Cahen DL, Gouma DJ, Nio Y, et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med 2007; 356:676.
  5. Cahen DL, Gouma DJ, Laramée P, et al. Long-term outcomes of endoscopic vs surgical drainage of the pancreatic duct in patients with chronic pancreatitis. Gastroenterology 2011; 141:1690.
  6. van der Gaag NA, van Gulik TM, Busch OR, et al. Functional and medical outcomes after tailored surgery for pain due to chronic pancreatitis. Ann Surg 2012; 255:763.
  7. Ammann RW, Muellhaupt B. The natural history of pain in alcoholic chronic pancreatitis. Gastroenterology 1999; 116:1132.
  8. Ammann RW, Akovbiantz A, Largiader F, Schueler G. Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology 1984; 86:820.
  9. Layer P, Yamamoto H, Kalthoff L, et al. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology 1994; 107:1481.
  10. PUESTOW CB, GILLESBY WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. AMA Arch Surg 1958; 76:898.
  11. Nealon WH, Matin S. Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis. Ann Surg 2001; 233:793.
  12. Tantia O, Jindal MK, Khanna S, Sen B. Laparoscopic lateral pancreaticojejunostomy: our experience of 17 cases. Surg Endosc 2004; 18:1054.
  13. Eid GM, Entabi F, Watson AR, et al. Robotic-assisted laparoscopic side-to-side lateral pancreaticojejunostomy. J Gastrointest Surg 2011; 15:1243.
  14. Greenlee HB, Prinz RA, Aranha GV. Long-term results of side-to-side pancreaticojejunostomy. World J Surg 1990; 14:70.
  15. Sato T, Miyashita E, Yamauchi H, Matsuno S. The role of surgical treatment for chronic pancreatitis. Ann Surg 1986; 203:266.
  16. Bradley EL 3rd. Long-term results of pancreatojejunostomy in patients with chronic pancreatitis. Am J Surg 1987; 153:207.
  17. Holmberg JT, Isaksson G, Ihse I. Long term results of pancreaticojejunostomy in chronic pancreatitis. Surg Gynecol Obstet 1985; 160:339.
  18. Sarles JC, Nacchiero M, Garani F, Salasc B. Surgical treatment of chronic pancreatitis. Report of 134 cases treated by resection or drainage. Am J Surg 1982; 144:317.
  19. Adams DB, Ford MC, Anderson MC. Outcome after lateral pancreaticojejunostomy for chronic pancreatitis. Ann Surg 1994; 219:481.
  20. Schnelldorfer T, Lewin DN, Adams DB. Operative management of chronic pancreatitis: longterm results in 372 patients. J Am Coll Surg 2007; 204:1039.
  21. 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 modified puestow procedure. Ann Surg 1993; 217:458.
  22. Rios GA, Adams DB, Yeoh KG, et al. Outcome of lateral pancreaticojejunostomy in the management of chronic pancreatitis with nondilated pancreatic ducts. J Gastrointest Surg 1998; 2:223.
  23. Rios GA, Adams DB. Does intraoperative electrohydraulic lithotripsy improve outcome in the surgical management of chronic pancreatitis? Am Surg 2001; 67:533.
  24. Frey CF, Smith GJ. Description and rationale of a new operation for chronic pancreatitis. Pancreas 1987; 2:701.
  25. Frey CF, Amikura K. Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg 1994; 220:492.
  26. Keck T, Wellner UF, Riediger H, et al. Long-term outcome after 92 duodenum-preserving pancreatic head resections for chronic pancreatitis: comparison of Beger and Frey procedures. J Gastrointest Surg 2010; 14:549.
  27. Negi S, Singh A, Chaudhary A. Pain relief after Frey's procedure for chronic pancreatitis. Br J Surg 2010; 97:1087.
  28. Pessaux P, Kianmanesh R, Regimbeau JM, et al. Frey procedure in the treatment of chronic pancreatitis: short-term results. Pancreas 2006; 33:354.
  29. Gestic MA, Callejas-Neto F, Chaim EA, et al. Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience. HPB (Oxford) 2011; 13:263.
  30. 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.
  31. Klempa I, Spatny M, Menzel J, et al. [Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple's operation]. Chirurg 1995; 66:350.
  32. Büchler MW, Friess H, Müller MW, et al. Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg 1995; 169:65.
  33. Farkas G, Leindler L, Daróczi M, Farkas G Jr. Prospective randomised comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy. Langenbecks Arch Surg 2006; 391:338.
  34. Izbicki JR, Bloechle C, Knoefel WT, et al. Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial. Ann Surg 1995; 221:350.
  35. Izbicki JR, Bloechle C, Broering DC, et al. Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg 1998; 228:771.
  36. Gurusamy KS, Lusuku C, Halkias C, Davidson BR. Duodenum-preserving pancreatic resection versus pancreaticoduodenectomy for chronic pancreatitis. Cochrane Database Syst Rev 2016; 2:CD011521.
  37. Diener MK, Hüttner FJ, Kieser M, et al. Partial pancreatoduodenectomy versus duodenum-preserving pancreatic head resection in chronic pancreatitis: the multicentre, randomised, controlled, double-blind ChroPac trial. Lancet 2017; 390:1027.
  38. WHIPPLE AO. Radical surgery for certain cases of pancreatic fibrosis associated with calcareous deposits. Ann Surg 1946; 124:991.
  39. Sakorafas GH, Farnell MB, Nagorney DM, et al. Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients. Arch Surg 2000; 135:517.
  40. Jimenez RE, Fernandez-Del Castillo C, Rattner DW, Warshaw AL. Pylorus-preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003; 27:1211.
  41. Russell RC, Theis BA. Pancreatoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003; 27:1203.
  42. Vickers SM, Chan C, Heslin MJ, et al. The role of pancreaticoduodenectomy in the treatment of severe chronic pancreatitis. Am Surg 1999; 65:1108.
  43. Traverso LW, Longmire WP Jr. Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet 1978; 146:959.
  44. Tran KT, Smeenk HG, van Eijck CH, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg 2004; 240:738.
  45. Seiler CA, Wagner M, Bachmann T, et al. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. Br J Surg 2005; 92:547.
  46. Iqbal N, Lovegrove RE, Tilney HS, et al. A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: a meta-analysis of 2822 patients. Eur J Surg Oncol 2008; 34:1237.
  47. Ohtsuka T, Yamaguchi K, Ohuchida J, et al. Comparison of quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection. Hepatogastroenterology 2003; 50:846.
  48. Beger HG, Krautzberger W, Bittner R, et al. Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery 1985; 97:467.
  49. Palanivelu C, Rajan PS, Rangarajan M, et al. Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. J Hepatobiliary Pancreat Surg 2009; 16:731.
  50. Kendrick ML, Cusati D. Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch Surg 2010; 145:19.
  51. Asbun HJ, Stauffer JA. Laparoscopic vs open pancreaticoduodenectomy: overall outcomes and severity of complications using the Accordion Severity Grading System. J Am Coll Surg 2012; 215:810.
  52. Zureikat AH, Moser AJ, Boone BA, et al. 250 robotic pancreatic resections: safety and feasibility. Ann Surg 2013; 258:554.
  53. Zureikat AH, Postlewait LM, Liu Y, et al. A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy. Ann Surg 2016; 264:640.
  54. Beger HG, Schlosser W, Friess HM, Büchler MW. Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26-year experience. Ann Surg 1999; 230:512.
  55. Beger HG, Büchler M, Bittner RR, et al. Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results. Ann Surg 1989; 209:273.
  56. Büchler MW, Friess H, Bittner R, et al. Duodenum-preserving pancreatic head resection: Long-term results. J Gastrointest Surg 1997; 1:13.
  57. Eliason EL, Welty RF. Pancreatic Calculi. Ann Surg 1948; 127:150.
  58. Riediger H, Adam U, Fischer E, et al. Long-term outcome after resection for chronic pancreatitis in 224 patients. J Gastrointest Surg 2007; 11:949.
  59. Hutchins RR, Hart RS, Pacifico M, et al. Long-term results of distal pancreatectomy for chronic pancreatitis in 90 patients. Ann Surg 2002; 236:612.
  60. Schoenberg MH, Schlosser W, Rück W, Beger HG. Distal pancreatectomy in chronic pancreatitis. Dig Surg 1999; 16:130.
  61. Sakorafas GH, Sarr MG, Rowland CM, Farnell MB. Postobstructive chronic pancreatitis: results with distal resection. Arch Surg 2001; 136:643.
  62. Schnelldorfer T, Mauldin PD, Lewin DN, Adams DB. Distal pancreatectomy for chronic pancreatitis: risk factors for postoperative pancreatic fistula. J Gastrointest Surg 2007; 11:991.
  63. Diener MK, Seiler CM, Rossion I, et al. Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial. Lancet 2011; 377:1514.
  64. Gagner M, Pomp A, Herrera MF. Early experience with laparoscopic resections of islet cell tumors. Surgery 1996; 120:1051.
  65. Kooby DA, Gillespie T, Bentrem D, et al. Left-sided pancreatectomy: a multicenter comparison of laparoscopic and open approaches. Ann Surg 2008; 248:438.
  66. Venkat R, Edil BH, Schulick RD, et al. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg 2012; 255:1048.
  67. Gruessner RW, Sutherland DE, Dunn DL, et al. Transplant options for patients undergoing total pancreatectomy for chronic pancreatitis. J Am Coll Surg 2004; 198:559.
  68. Dresler CM, Fortner JG, McDermott K, Bajorunas DR. Metabolic consequences of (regional) total pancreatectomy. Ann Surg 1991; 214:131.
  69. Rickels MR, Schutta MH, Markmann JF, et al. {beta}-Cell function following human islet transplantation for type 1 diabetes. Diabetes 2005; 54:100.
  70. Sutherland DE, Matas AJ, Najarian JS. Pancreatic islet cell transplantation. Surg Clin North Am 1978; 58:365.
  71. Morgan K, Owczarski SM, Borckardt J, et al. Pain control and quality of life after pancreatectomy with islet autotransplantation for chronic pancreatitis. J Gastrointest Surg 2012; 16:129.
  72. Sutherland DE, Radosevich DM, Bellin MD, et al. Total pancreatectomy and islet autotransplantation for chronic pancreatitis. J Am Coll Surg 2012; 214:409.
  73. Argo JL, Contreras JL, Wesley MM, Christein JD. Pancreatic resection with islet cell autotransplant for the treatment of severe chronic pancreatitis. Am Surg 2008; 74:530.
  74. Rodriguez Rilo HL, Ahmad SA, D'Alessio D, et al. Total pancreatectomy and autologous islet cell transplantation as a means to treat severe chronic pancreatitis. J Gastrointest Surg 2003; 7:978.
  75. Robertson RP, Lanz KJ, Sutherland DE, Kendall DM. Prevention of diabetes for up to 13 years by autoislet transplantation after pancreatectomy for chronic pancreatitis. Diabetes 2001; 50:47.
  76. Chinnakotla S, Bellin MD, Schwarzenberg SJ, et al. Total pancreatectomy and islet autotransplantation in children for chronic pancreatitis: indication, surgical techniques, postoperative management, and long-term outcomes. Ann Surg 2014; 260:56.
  77. Leppard WM, Shary TM, Adams DB, Morgan KA. Choledochoduodenostomy: is it really so bad? J Gastrointest Surg 2011; 15:754.
  78. Taylor SM, Adams DB, Anderson MC. Duodenal stricture: a complication of chronic fibrocalcific pancreatitis. South Med J 1991; 84:338.
  79. Nealon WH, Walser E. Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis. Ann Surg 2003; 237:614.
  80. Adams DB, Mauterer DJ, Vujic IJ, Anderson MC. Preoperative control of splenic artery inflow in patients with splenic venous occlusion. South Med J 1990; 83:1021.
  81. Adams DB, Davis BR, Anderson MC. Colonic complications of pancreatitis. Am Surg 1994; 60:44.