Pancreaticogastrostomy: the preferred operation for pain relief in chronic pancreatitis

A Comparative Study Between Longitudinal Pancreacticojejunostomy v/s Lateral Pancreaticogastrostomy as a Drainage Procedure for Pain Relief in Chronic Pancreatitis Done in a Tertiary Referral Centre of Eastern India

Chronic pancreatitis (CP) is a chronic inflammation of pancreas that leads to progressive fibrosis of pancreatic parenchyma. Commonest indication of surgery in chronic pancreatitis is intractable pain. Choice of procedure depends upon the main pancreatic duct (MPD) morphology. Decompression is useful in dilated and obstructed ducts. Traditional form of decompression is construction of a pancreatico-jejunal anastomosis (LPJ). Another method to achieve ductal decompression is by a pancreaticogastrostomy (LPG) and this study will try to evaluate its effectiveness against pancreaticojejunostomy. To compare the effectiveness of LPG and LPJ in relieving intractable abdominal pain in patients with CP and their respective post-operative complications. This prospective study was done over a period of 4 years from Jan 2007 to Dec 2010 at IPGME & R (SSKM), a tertiary hospital of eastern India. Patients with diagnosis of CP with or without duct calculi and MPD diameter ≥7 mm with intractable pain were included. 70 patients were randomly allocated for LPJ and LPG operation by lottery method. Study tools were questionnaires, blood and radiological investigations and standard instruments for open surgery. The patients were prospectively analyzed for duration of surgery and hospital stay, operative/postoperative complications and assessment of postoperative pain relief. Pain relief was assessed as complete (no analgesic requirement), satisfactory (tolerable pain with normal daily activities) and unsatisfactory (hospitalization, narcotics or hampered daily activities). 1. Operative time was shorter in LPG than LPJ (Median 85 vs. 110 min). 2. Incidence of ileus was lesser in LPG group (p = .054). Other complications were comparable in both groups. 3. LPG was associated with shorter duration of hospital stay (Mean 6 vs. 8 days). 4. Pain relief was comparable in LPG and LPJ. LPG is a good alternative to LPJ for CP.

Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis

OBJECTIVE

Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the commonly preferred methods of anastomosis after pancreaticoduodenectomy (PD). The ideal choice of anastomosis remains a matter of debate.

DATA SOURCES

Articles published until end of March 2006 comparing PJ and PG after PD were searched.

STUDY SELECTION

Two reviewers independently assessed quality and eligibility of the studies and extracted data for further analysis. Meta-analysis was performed with a random-effects model by using weighted odds ratios.

DATA EXTRACTION AND SYNTHESIS

Sixteen articles were included; meta-analysis of 3 randomized controlled trials (RCT) revealed no significant difference between PJ and PG regarding overall postoperative complications, pancreatic fistula, intra-abdominal fluid collection, or mortality. On the contrary, analysis of 13 nonrandomized observational clinical studies (OCSs) showed significant results in favor of PG for the outcome parameters with a reduction of pancreatic fistula and mortality in favor of PG.

CONCLUSIONS

All OCSs reported superiority of PG over PJ, most likely influenced by publication bias. In contrast, all RCTs failed to show advantage of a particular technique, suggesting that both PJ and PG provide equally good results. This meta-analysis yet again highlights the singular importance of performing well-designed RCTs and the role of evidence-based medicine in guiding modern surgical practice.

Is any surgical procedure ideal for chronic pancreatitis?

Chronic pancreatitis continues to be a major therapeutic challenge for all pancreatic surgeons. This article is written with a purpose to review various surgical procedures developed from time to time for the relief of pain in these patients. Since no single procedure can be labeled as "ideal" because of the problems of the inability to address the whole pathology at the initial procedure, failure or recurrence of the pain; most of the pancreatic and practicing surgeons may benefit from knowledge of the various procedures being performed, even though the personal experience of the surgeon most of the time ultimately dictates the final choice of the procedure for the patient.

Endoscopic management of pancreatic fistula after pancreatic and other abdominal surgery

Post-operative pancreatic fistulae represent a challenge for all the actors in gastroenterology: for surgeons, because they want to prevent and treat conservatively this complication since re-operation is associated with high morbidity and mortality rates; for radiologists, because they have to provide the best staging and informations without any additional risk; and for endoscopists, because endoluminal treatment is emerging as a safe and effective procedure provided it is performed in highly experienced tertiary centres in the setting of a multidisciplinary approach. Herein, we review the definitions, the causes, the staging and the possible options to prevent or treat post-operative pancreatic fistulae. Special attention is paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Practical problems and issues are clearly outlined as well as the need for future improvements in staging and management of the patients having such complications.

Ultrasound-guided endoscopic surgery

Ten years' development of sectorial linear endoscopic ultrasound (EUS) has allowed us to perform guided biopsies of lymph nodes, mediastinal masses and pancreatic tumours. Furthermore, biopsy guided by EUS has been the first step in the development of interventional EUS. This development, in turn, has been made possible by the appearance of the interventional echoendoscope with a large working channel. EUS-guided biopsy obtains the best results for lymph nodes, anastomotic relapses and extrinsicz compression as well as for pancreatic tumours. Results in the literature show a global sensitivity of the technique that varies between 76 and 91%, a specificity of 84-100% and an accuracy of 78-94%. Using alcohol injection of the plexus nerves, the coeliac block guided by EUS is a simple technique. It will replace percutaneous access under US or CT scan guidance. Data from the literature show a significant reduction in pain of the order of 85-90% of cases-results that would have been good for percutaneous techniques. The technique of cystoenterostomy guided by EUS allows more accurate drainage of the cysts with a lower risk of perforation and haemorrhage. With regard to haemorrhage it should be emphasized that colour Doppler and power Doppler assessment of the punctures rules out the risk of vascular perforation during puncture but the risk of haemorrhage due to decompression of a vascular lesion in the vicinity of the cyst remains. The new ultrasound echoendoscope EG 38X, with a large working channel (3.8 mm), is now available. This system allows more effective drainage and also enables the placement of cystodigestive stents.

Comparison of local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (frey procedure) and duodenum-preserving resection of the pancreatic head (beger procedure)

The etiology of pain in chronic pancreatitis may be ductal hypertension, increased parenchymal pressure, or neural damage. It is difficult to assess the severity of pain in this patient population, a problem made more challenging by the frequency of narcotic dependency. Therapeutic interventions developed to relieve the pain of chronic pancreatitis include denervation of the pancreas, decompression of the main duct of the pancreas, resection of part or all of the diseased pancreas, and reduction of pancreatic secretion. Operative intervention for patients with chronic pain is indicated when severe pain, complications of pain, or potential malignancy are present. The operations that consistently provide long-lasting pain relief all have in common resection of all or a portion of the head of the pancreas. Adverse effects on exocrine and endocrine function, nutrition, and quality of life are related to the amount of pancreas resected. The ideal procedure should be easy to perform, have a low morbidity and mortality rate, provide long-lasting pain relief, and not augment endocrine and exocrine insufficiency. No single operation fulfills this ideal. The local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) proposed by Frey and the duodenum-preserving resection of the head of the pancreas (DPHR) proposed by Beger are discussed. The conceptualization, development, and technique of LR-LPJ are discussed, and comparisons of patient outcomes are made with the outcomes of other procedures for chronic pancreatitis.

EUS-guided pancreaticogastrostomy

BACKGROUND

The pain of chronic pancreatitis can be caused by pancreatic ductal hypertension, and endoscopic drainage of the main pancreatic duct can provide relief. When transpapillary access to a dilated portion of the main duct cannot be obtained, conventional endoscopic drainage is not possible. The use of interventional EUS to perform a pancreaticogastrostomy in such cases is described.

METHODS

Four patients presented with pain and a dilated main pancreatic duct proximal to a complete obstruction. EUS was used to access the dilated duct and create a pancreaticogastrostomy. Patency of the latter was maintained by placement of a pancreaticogastric stent.

OBSERVATIONS

EUS-guided pancreaticogastrostomy was performed without major complication. Three of 4 patients had satisfactory relief of pain at a median follow-up of 1 year.

CONCLUSION

EUS-guided pancreaticogastrostomy may be a promising new technique for pancreatic drainage and pain relief when conventional transpapillary access to the pancreatic duct is not possible.

Upper jejunal motility after pancreatoduodenectomy according to the type of anastomosis, pancreaticojejunal or pancreaticogastric

BACKGROUND

The goal of this study was to compare upper jejunal motor patterns after Billroth II pancreatoduodenectomy according to the type of pancreatic anastomosis (pancreaticojejunostomy [PJA] or pancreaticogastrostomy [PGA]) and the presence or absence of postoperative symptoms.

STUDY DESIGN

Manometric recordings during fasting and after a 750-kcal meal were performed in the afferent limb in 12 patients (7 PJA, 5 PGA) and in the efferent limb in 15 other patients (7 PJA, 8 PGA) with a postoperative delay of 15+/-6 days and 3.9+/-2.2 months respectively. Patient data were compared to those of 20 healthy controls.

RESULTS

During fasting, the 2 main abnormal findings were a higher incidence (p < 0.05) and a slower migration velocity (p < 0.01) of incomplete phase III by comparison with that recorded in controls. No difference for phase III was observed between the 2 surgical procedures regardless of recording site. Trimebutine, 100 mg intravenously, induced a phase III in 89% (24 of 27) of the patients. Delay of motor response varied from 5 to 10 minutes without difference between the recording site; it was less than 2 minutes in 100% of controls. Trimebutine-induced phase III showed similar propagation abnormalities to the spontaneous phase III. Duration of the fed pattern (p < 0.001) and motor index (p < 0.001) were significantly lower than in controls after the meal, in both limbs, whatever the type of anastomosis. Differences between the 2 surgical procedures were a slower migration velocity of phase III (p < 0.01) and a lower postmeal motor index (p < 0.05) in the efferent limb after PJA than after PGA. Nine of 27 patients were symptomatic. In these 9 patients, mean phase III migration velocity was slower (p < 0.001), and mean area under the postprandial curve was higher (p < 0.01) than in asymptomatic patients. Propagated clusters of contractions were only found in symptomatic patients and in the afferent limb.

CONCLUSIONS

Pancreatoduodenectomy is associated with significant motor disturbances, mainly slower phase III and a reduced fed pattern, in the upper jejunum, at least during the first 3 postoperative months. Few motor differences were observed between PGA and PJA pancreatic anastomosis. A lesser occurrence of postsurgical motor anomalies does not appear to be an argument for preferring PGA to PJA.

Results of pancreatogastrostomy after pancreatoduodenectomy in 160 consecutive patients

BACKGROUND

The advantages of pancreatogastrostomy over pancreatojejunostomy after pancreaticoduodenectomy are still debated. This study analyses the results of pancreatogastrostomy to identify factors that could influence immediate outcome.

METHODS

During a 10-year period, 160 consecutive patients underwent a pancreatogastrostomy. There were 109 men (68 per cent) and 51 women (32 per cent) with a mean(s.d.) age of 59(10) (range 22-82) years; 27 patients were older than 70 years. The following parameters were assessed: mortality rate, morbidity, reasons for reoperation, length of hospital stay, duration of nasogastric tube and drainage.

RESULTS

Hospital mortality rate was 3 per cent; overall morbidity rate was 30 per cent. The reoperation rate was 12 per cent, mainly because of bleeding at the pancreatic margin. Delayed gastric emptying occurred in 36 patients. The overall rate of pancreatic fistula was 2.5 per cent. Age, sex, indications for pancreatoduodenectomy, and the texture of the pancreatic remnant did not influence the occurrence of pancreatic fistula or delayed gastric emptying.

CONCLUSION

This study confirmed that pancreatogastrostomy is a safe procedure with low mortality and morbidity rates.

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis

OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts.

PATIENT MATERIAL

The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification.

ASSESSMENT

Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily.

RESULTS

Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively.

CONCLUSIONS

The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis

OPERATION: Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts.

PATIENT MATERIAL

The operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification.

ASSESSMENT

Pain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate--Vicodin weekly daily; and major--meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily.

RESULTS

Pain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 11% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively.

CONCLUSIONS

The LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force.

Surgery in tropical pancreatitis: analysis of risk factors

Over a 7-year period, 91 patients with tropical pancreatitis underwent operation for intractable pain. Univariate and multivariate analyses were performed to identify factors correlating with mortality, major complications, poor pain relief and associated malignancy. Patients with benign disease (group 1, n = 72) had longer survival than those with superimposed malignancy (group 2, n = 19). Pain relief was better in group 1 (59 patients compared with none, P less than 0.01). Age above 40 years, short duration of symptoms, mass lesions on ultrasonography and main pancreatic duct obstruction on endoscopic retrograde pancreatography were associated with a high risk of cancer. After reoperation major complications (four of ten) or death (three of ten) occurred more commonly than after primary procedures (seven of 81, P = 0.019 and five of 81, P less than 0.05, respectively). Poor pain relief in group 1 patients was more common after incomplete clearance of main duct stones (four of 13 versus three of 53, P less than 0.01) and after short length ductotomy (three of eight versus four of 58, P less than 0.01). Tropical pancreatitis has a high association with pancreatic adenocarcinoma. Wide ductotomy, stone clearance and drainage gave good symptomatic results in patients with benign disease. Overall results were poor in patients with cancer.

Cancer of the pancreas. Pylorus-preserving resection of the pancreas

Pylorus-preserving pancreaticoduodenectomy represents an important advance in the history of pancreatic surgery. The operation can be performed with a low operative mortality and morbidity, is technically easier than the standard Whipple resection, and it minimizes the long-term physiological disturbance to the patient. Clinical and experimental evidence has substantiated the view that preservation of the pylorus reduces the incidence of marginal anastomotic ulceration following pancreatectomy. Although gastric emptying may be prolonged transiently in the immediate postoperative period, this complication is easily managed, and is hardly a frequent long-term problem. PPPD is associated with a lower incidence of enterogastric reflux, dumping and diarrhoea than the classical Whipple operation, and patients who have had PPPD are more likely to regain their preoperative and preillness weight. Initial concerns about the use of PPPD in malignant disease have not been borne out, and should now be considered for curative or palliative resections of lesions in the periampullary region including the head of the pancreas. Present data suggest that PPPD does not compromise the long-term survival in patients with periampullary cancers. There is little doubt that the excellent results reported with this procedure as with other forms of major pancreatic surgery, are not simply related to improvements in surgical technique but to establishment of specialist pancreatic surgery.

Pancreatic tissue fluid pressure during drainage operations for chronic pancreatitis

Pancreatic tissue fluid pressure was measured in 10 patients undergoing drainage operations for painful chronic pancreatitis. The pressure was measured by the needle technique in the three anatomic regions of the pancreas before and at different stages of the drainage procedure, and the results were compared with preoperative endoscopic retrograde cholangiopancreatography (ERCP) morphology. The preoperatively elevated pressure decreased in all patients but one, to normal or slightly elevated values. The median pressure decrease was 50% (range, 0-90%; p = 0.01). The drainage anastomosis (a pancreaticogastrostomy) was made in the body of the pancreas, but the pressure decrease in this region was not significantly different from that in the head and tail. The pressure decrease was independent of findings during ERCP (stone, total duct obstruction, or major ductal stenosis). In conclusion, the results showed a decrease in pancreatic tissue fluid pressure during drainage operations for pain in chronic pancreatitis. Regional pressure decrease were apparently unrelated to ERCP findings.

Pylorus preserving pancreatoduodenectomy: an overview

Pylorus preserving pancreatoduodenectomy (PPPD) was reintroduced 12 years ago. Since that time, over 400 patients have undergone PPPD with approximately 41 per cent having chronic pancreatitis and 54 per cent having pancreatic and other periampullary malignancies. Reported 5-year survivals in this latter group have been comparable to those achieved by the classic Whipple procedure. The postoperative mortality rate in 339 reported patients has been 3.8 per cent. Postoperative morbidity, including delayed gastric emptying, has been similar to that of the classic Whipple operation. However, PPPD has been associated with fewer late problems with dumping, diarrhoea, delayed gastric emptying (8.6 per cent), and marginal ulceration (3.6 per cent). Moreover, most patients undergoing PPPD have been able to return to their preoperative and preillness weight. The additional advantage of decreased operative time makes PPPD an attractive alternative to the classic pancreatoduodenectomy.

Comparison of regional pancreatic tissue fluid pressure and endoscopic retrograde pancreatographic morphology in chronic pancreatitis

The relation between pancreatic tissue fluid pressure measured by the needle method and pancreatic duct morphology was studied in 16 patients with chronic pancreatitis. After preoperative endoscopic retrograde pancreatography (ERP) the patients were submitted to a drainage operation. The predrainage pressures were higher in the tail of the pancreas (29 mm Hg; range, 16-37 mm Hg) than in the head (18 mm Hg; range, 2-30 mm Hg; p = 0.02). The regional pressure differences were significantly greater in four patients who had previously undergone pancreatic surgery than in the 12 patients without previous surgery. A stone, total obstruction, or major stenosis in the pancreatic duct at ERP was related to a downstream pressure gradient significantly higher than found in a non-obstructed pancreatic main duct, but the relation was not uniform. Generally, there was no significant relation between pancreatic duct diameter and pressure, but in each individual patient, the regional pressure tended to be highest in the region with the largest duct diameter. In conclusion, the study shows considerable regional pressure differences in chronic pancreatitis and indicates that the intraoperative pressure measurements give important information supplementary to ERP about the pathologic process in patients with chronic pancreatitis.

Pancreatogastrostomy in experimental acute necrotizing pancreatitis

Experimental acute necrotizing pancreatitis was induced retrogradely in dogs with sunflower oil injected intraductally. Then, a zipper was sutured into the abdominal wound. From the first postoperative day, three different treatments were started: first group: only conservative therapy was used; second group: removal of necrotized tissue and single peritoneal lavage were applied; and third group: the necrotic part of the pancreas was marsupialized into the stomach. Through the systematic opening of the zipper, the abdominal cavity could easily be explored and the temporal course of disease could be observed in all animals. During this regular procedure, the amylase concentration and the amount of peritoneal exudate were determined. The blood amylase and glucose levels were also measured. On the first postoperative day, the amylase level and the amount of peritoneal exudate were high in all groups. The dogs of the pancreatogastrostomized group showed a dramatic decrease of the exudate and the most advantageous temporal course of the blood amylase level. The survival rate similarly was advantageous in the pancreatogastrostomized group.

Chronic pancreatitis: results of operations for relief of pain

Pancreaticojejunostomy is the method of choice for surgical treatment of pain in chronic pancreatitis in the case of ductal dilation. The operative risk is small and all remaining glandular tissue preserved. At 5 years postoperatively, about two-thirds of the patients still experience pain relief. In the absence of dilated ducts, the surgical options are somewhat more controversial. Parenchyma-saving alternatives such as nerve-cutting procedures have not met expectations. Instead, percutaneous blockage of the celiac plexus using alcohol and phenol have been more commonly used for short-term pain relief. The relatively great number of different resective procedures probably reflects the dissatisfaction with the effect of each one of them. Neither left resection nor total pancreatectomy is, today, an attractive alternative due to the relatively high mortality and morbidity (short- and long-term) risks, especially when evaluated against the backdrop of the limited pain reduction in many patients. The Whipple procedure is still the best alternative, although it should be used with critical selection by both the patient and the surgeon. As for the new operations presented during the 1980's, it is too early to foresee their possible future role. We feel, however, that we still have to await the operation which fulfills the criteria of an ideal operation for pain in chronic pancreatitis.

Observations and surgical management of tropical pancreatitis in Kerala and southern India

This article describes the surgery of tropical pancreatitis as practiced in a region of high incidence, based on the experience at 2 centers: the Department of Surgical Gastroenterology and Proctology, Government General Hospital, Madras, Tamilnadu (a tertiary-care referral unit) where 52 patients were diagnosed and 40 were operated on between 1982 and 1987; and the Department of Gastroenterology, Deva Matha Hospital, Koothattukulam (a specialized center located in the main endemic area of Kerala), where 116 patients were diagnosed and 33 operated on between 1983 and 1988. The latter series is described in detail with emphasis on the preoperative imaging, operative findings, surgical procedures, complications, and results of surgery. The experience of other centers in southern India is summarized and discussed. The disease is obviously different from chronic pancreatitis in the West. Special problems of tropical pancreatitis, particularly the management of diabetes and the association of pancreatic carcinoma at a young age, are discussed.

Observations and surgical management of chronic pancreatitis in the British Isles: a review of the twentieth century

Chronic pancreatitis was a recognized clinical entity in the British Isles at the beginning of the twentieth century, but until little more than 30 years ago, it was considered to be a rare condition and received scant attention from British surgeons. During the second half of the twentieth century, the incidence of the disease in the British Isles has increased significantly and alcohol abuse has become, by far, the most important etiological factor. Per capita consumption of alcohol in the British Isles has increased very markedly in the past 30 years and alcohol abuse is becoming a major social problem, but, although chronic pancreatitis is more common now than it was 30 years ago, the increase in its incidence is a good deal less than might be expected. British surgeons are agreed that intractable pain is the cardinal indication for surgical intervention in chronic pancreatitis and success depends on selection of the operative procedure most appropriate to the pathological state of the pancreas and, in particular, of its ductal system. In recent years, British surgeons in highly specialized units have become more radical in their approach to the treatment of chronic pancreatitis with total pancreatectomy in selected patients currently being advised more frequently than in previous decades.