Pancreatic head resections with preservation of the duodenum: Techniques and long-term outcome

Chronic pancreatitis is a benign, inflammatory process of the pancreas that leads to permanent damage of the gland and loss of functional parenchyma. The evolution of the disease is usually progressive and associated with development of exocrine and endocrine pancreatic insufficiency with a higher risk of developing a pancreatic cancer. Alcohol abuse is the most frequent aetiology in Western industrialized countries. The predominant symptom of chronic pancreatitis is pain and it is often difficult to control with analgesics. Other symptoms are diabetes mellitus, steatorrhea and weight loss. The diagnosis of chronic pancreatitis is usually made on a medical history, but retrograde endoscopic pancreaticography (ERCP) and an abdominal contrast-enhanced CT scan are still the gold standards for the diagnosis and staging. However, the conventional MRI combined with MR angiography and MR cholangio-pancreaticography (MRCP) is a very challenging alternative. Indications for surgery are severe abdominal pain with pancreatic head enlargement, common bile duct stenosis, intestinal obstruction, compression of retropancreatic vessels or suspicion of malignancy. The duodenum-preserving pancreatic head resection (DPPHR) is an organ preserving operation, which was developed to replace the Whipple procedures (classical or pylorus-preserving) in patients with chronic pancreatitis. It eliminates chronic pancreatitis related complications and leads to pain relief. In this procedure, the pancreatic head is resectioned subtotally under preservation of the body and tail of the pancreas, of the stomach, the duodenum, and the extrahepatic bile duct. In a serie of 298 patients, hospital mortality was 1% and the most frequent perioperative complication was bleeding in 5.7% of the patients. Pancreatic fistulas occurred in 2.7% of the patients and the total reoperation rate was 5.7%. After an average follow-up of 6 years, almost 90% were free of pain or with minimal signs of disease. 63% of the patients were professionally active. Late mortality was 8.9%. The duodenum-preserving pancreatic head resection in chronic pancreatitis is a safe and effective operation procedure providing long-term pain relief in treating chronic pancreatitis-related complications. Therefore this organ-preserving procedure should be considered first in chronic pancreatitis.