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Diagrams for Surgical Procedures of Chronic Pancreatitis

The selection of the operative procedure often depends on the surgeon's expertise and individual preference. There is some criteria that usually favor one type of surgery over another. When the pancreatic duct in the body or tail is dilated beyond 6 mm, the Puestow procedure is usually the most effective surgery . When disease occurs predominantly in the head, Frey's procedure is used. When there is a focal mass in the head without significant duct dilation, the Whipple procedure is most frequently used. Increasingly, Beger's procedure, which preserves the duodenum, is used as an alternative.

1-Whipple Procedure:
The most common pancreatic resection surgery is the Whipple procedure, which is performed for chronic pancreatitis with ductal strictures or amorphous inflammatory mass in the head for which distinction from cancer cannot be made preoperatively. However, many specialist pancreatic surgeons no longer consider this to be the most appropriate surgery for chronic pancreatitis.
Diagram of pylorus-preserving Whipple procedure. Classic Whipple procedure is shown in inset: It entails radical dissection of pancreatic head, adjacent nodes, right half of omentum, gall bladder, common bile duct, and most or all of duodenum followed by gastrojejunostomy/duodenojejunostomy (green arrow), pancreaticojejunostomy (blue arrow), and hepaticojejunostomy (red arrow). (Courtesy of the Office of Visual Media, Indiana University)

2-Beger's Procedure :
Beger's procedure is a less radical surgery with resection of the pancreatic head and preservation of the duodenum . After Beger's surgery, pain relief is seen in up to 85% of patients at 5-year follow-up , but the postoperative morbidity rate is 20%. A randomized study comparing Beger's and Whipple procedures showed similar results at 6 months except for better pain tolerance and glucose control in those treated with Beger's surgery.
Diagram of Beger's procedure. Pancreatic body and most of head have been resected. Sleeve of pancreas is left with duodenum to preserve blood supply for latter. This procedure is technically harder to perform than Whipple procedure. Note pancreaticojejunostomy (red arrows) at two sites of Roux limb (green arrow).

3-Puestow Procedure :
The Puestow procedure is a side-to-side longitudinal pancreaticojejunostomy that drains the pancreatic duct directly into a loop of jejunum . This procedure is best performed if the main pancreatic duct is significantly dilated, usually wider than 6 mm.
Diagram of Puestow procedure. Pancreas is filleted to expose main duct from neck to tail and ductal calculi are removed. Roux loop is anastomosed to "capsule" of pancreas with direct drainage of main and secondary pancreatic ducts into jejunum over 8- to 10-cm segment. Loop (arrows) lies anterior to pancreas.

4-Frey's Procedure :
Frey's procedure is a recently popularized procedure that combines partial resection of the pancreatic head with a longitudinal jejunostomy . The morbidity rate of Frey's procedure is approximately 9-22% , well below that of the Whipple procedure performed for chronic pancreatitis, for which the complication rate is 30-40% . Frey's procedure is contraindicated in the presence of duodenal or biliary stricture.
Diagram of pancreas after Frey's procedure. Head of pancreas is cored out (blue arrow) and pancreaticojejunostomy is created via Roux loop (green arrows). Procedure is best performed in patients with duct dilation of head and body.

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