Major Pancreatic Resection

Indications for major pancreatic resection in chronic pancreatitis include intractable pain, mechanical complications, and suspicion for malignancy. Unique technical aspects of pancreatoduodenectomy with or without pylorus preservation in the setting of chronic pancreatitis are discussed, including issues of arterial vascular anomalies, portal–mesenteric–splenic venous thrombosis with collateralization, and strategies to address chronic inflammation with resultant fibrosis in operative conduct. Short-term outcomes following pancreatoduodenectomy for chronic pancreatitis demonstrate perioperative mortality of 0–3% and morbidity of 18–51%. Pain relief is maintained in over 70% of patients at greater than 3 years of surgical follow-up. The long-term efficacy of pancreatoduodenectomy for chronic pancreatitis was recently evaluated at 15 years of surgical follow-up with durable pain relief demonstrated by 65% of patients requiring no analgesic medications and improved quality of life. Pancreatic endocrine insufficiency occurs in up to 67% of patients requiring dietary modification, oral hypoglycemic medications, or insulin at 15 years of follow-up. Pancreatic exocrine insufficiency at 15 years of follow-up is present in 57% of patients. Long-term survival following pancreatoduodenectomy for chronic pancreatitis is consistently lower than age-matched population controls at 5, 10, 15, and up to 25 years.