Treatment Selection for Painful Chronic Pancreatitis

A review of studies comparing the Beger and Frey procedures for duodenum-preserving pancreatic head resection found that both operations produced similar rates of exocrine pancreatic insufficiency — and nearly every other outcome — in patients with painful chronic pancreatitis.

Researchers from London combed several databases to find 5 papers that reported results of different resection procedures. A total of 323 pancreatitis patients underwent some sort of surgery. Of those, 138 underwent the Beger procedure, 99 underwent the original Frey procedure, 32 underwent a minimal Frey procedure, 25 underwent a modified Frey procedure and 29 underwent a Berne’s modification.

All of the procedures appeared similarly effective in managing pain associated with chronic pancreatitis and similarly likely to produce significant problems such as exocrine pancreatic insufficiency. Indeed, the authors of the new study performed a meta-analysis of the 2 papers that directly compared the Beger and Frey procedures and found no significant differences in any outcome.

Post-operative pain levels were virtually identical (relative difference [RD], 0.06; 95% confidence interval [CI], -0.21 to 0.09), as was mortality (RD, 0.01; 95% CI, −0.03 to 0.05), morbidity (RD, 0.12; 95% CI, −0.00 to 0.24), exocrine insufficiency (RD, 0.04; 95% CI, −0.10 to 0.18) and endocrine insufficiency (RD, −0.14; 95% CI, −0.28 to 0.01).

“All procedures are equally effective for the management of pain for chronic pancreatitis,” the authors of the review wrote in HPB. The choice of procedure should be determined by other factors including the presence of secondary complications of pancreatitis and intra-operative findings.”

The purpose of both procedures is to provide an organ-sparing alternative to pancreaticoduodenectomy, but neither procedure tends to spare pancreatic function. A randomized trial undertaken in Germany and published less than 2 years ago in the Journal of the American College of Surgeons reported endocrine insufficiency in 87% of 38 patients who underwent the Beger procedure and 86% of 36 patients who underwent the Frey procedure (p = 0.953). Exocrine pancreatic insufficiency, moreover, was developed in 77% of the Beger patients and 83% of the Frey patients (p = 0.655) during a lengthy follow-up period.

That analysis also found that mortality rates 16 years after surgery were 39% among Beger patients and 34% among Frey patients while postoperative survivals averaged 13.0 ± 1.1 years and 13.3 ± 0.9 years, respectively (p = 0.660).

“Duodenum-preserving resections of the pancreatic head offered good and permanent pain relief and substantially increased quality of life in chronic pancreatitis,” the German investigators wrote. “Overall, a 16-year long-term follow-up found comparable outcomes for the Beger and Frey procedures.”

The Beger procedure excavates the pancreatic head but preserves the duodenum and a layer of pancreatic tissue. The reconstruction is performed by 2 anastomoses with a jejunal loop to drain what remains of the pancreas and to cover and drain the defect in the pancreatic head. The technically difficult procedure has become common in Europe but not in the US.

The less demanding Frey procedure combines partial resection of the head of the pancreas with lateral pancreatico-jejunostomy for drainage. This hybrid procedure improves the overall pancreatic ductal drainage by decompressing both the duct of Santorini and ducts in the uncinate process. It also removes the pancreatic head that is thought to be the epicenter of pancreatitis pain and allows for removal of calculi.