Pain relief after Frey's procedure for chronic pancreatitis

An update on improving long-term outcomes for patients with chronic pancreatitis post-surgery

INTRODUCTION

Chronic pancreatitis is a common inflammatory disease that severely impairs patients' quality of life, mainly due to abdominal pain which is the most frequent symptom. Current guidelines suggest medical therapy as the first line intervention based on a stepwise use of analgesics (i.e. NSAIDs followed by weak opioids and later by strong oppioids), which is rarely effective in improving pain and often leads to opioid addiction. Interventional procedures are therefore frequently needed. Endoscopic therapy is suggested as the second line of intervention, aiming at decompressing the main pancreatic duct via structure dilatation and ductal stone removal. Endoscopic therapy is usually effective in reducing pain in the short term, but its effects frequently decrease with time and multiple procedures are often required. Surgery is usually reserved as a last resource when medical and endoscopic therapy have failed. Pancreatic surgery is burdened with non negligible morbidity and mortality but is effective in reducing pain and improving quality of life in chronic pancratitis with long lasting effects.

AREAS COVERED

Surgical treatment of chronic pancreatitis is based on resection of inflammatory head mass or decompression of the ductal system, alone or in combination, which can be performed using different techniques. In this paper we reviewed the current evidence on the long-term outcomes of this type of surgery in terms of pain relief, quality of life, exocrine end endocrine function, and long-term mortality.

EXPERT OPINION

Quality of current evidence on this field is on average poor; a consensus to define clinically significant outcomes is needed in order to correctly design prospective studies that will enable gastroenterologists to understand which patients, and when, will benefit most from surgery and should therefore be referred to surgeons.

Predictors of 90-day morbidity and mortality after Frey procedure for chronic pancreatitis

BACKGROUND

The literature on predictors for postoperative complications after Frey procedure (FP) is sparse. The aim of this study is to report our experience with 90-day complications of FP and predictors for complications.

METHODS

All patients with chronic pancreatitis (CP), who underwent a FP between August 2007 and July 2021, were retrospectively reviewed. Univariate and multivariate analysis were used to identify predictors of 90-day morbidity and mortality.

RESULTS

Of the total 270 patients, 84 (31%) patients developed at least one postoperative complication. Major complications occurred in 32 (12%) patients. Most common complication was wound infection and it was significantly more common in stented patients (p = 0.017). Pancreatic fistula and post pancreatectomy hemorrhage (PPH) developed in 7.4% of patients. Thirteen patients (4.8%) required early re-operation and the most common cause of re-exploration was PPH. 90-day mortality was 1% (n = 3) and all 3 patients required re-exploration for PPH. Median postoperative hospital stay was 9 (5-51) days. Perioperative blood transfusions was the only independent predictor of postoperative complications after FP.

CONCLUSIONS

Frey procedure is an acceptable treatment modality with low rates of mortality and reasonable perioperative morbidities. Minimizing blood transfusions may further improve 90-day outcomes.

Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study

INTRODUCTION

Optimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision.

METHODS

A prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed.

RESULTS

Of 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea.

CONCLUSIONS

After MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

Evaluating Outcomes and Misuse in Opioid-Dependent Chronic Pancreatitis Using a State-Mandated Monitoring System

INTRODUCTION

Patients with chronic pancreatitis (CP) often require opioids for pain control. The goal of our study was to characterize opioid use in patients with CP in a real-life practice using a state-mandated online monitoring program and to assess outcomes compared to CP patients without opioid dependency.

METHODS

CP patients seen in our Pancreas Center from 2016 to 2021 were divided into two groups-with and without chronic opioid use. Details of opioids and other controlled prescriptions were obtained by review of the Massachusetts Prescription Awareness Tool (MassPat).

RESULTS

Of the 442 CP outpatients, 216 used chronic opioids. Patients with opioid use had significantly more recurrent acute pancreatitis (76.6% vs. 52.7%), concurrent alcohol use (11.2% vs. 5.8%), tobacco use (37.8% vs. 19.7%), anxiety (22.4% vs. 16.6%), depression (43.5% vs. 23.5%) and daily pain (59.8% vs. 24.8%) (p < 0.001). They also concurrently used more benzodiazepines (43.7% vs. 12.4%), gabapentinoids (66.4% vs. 31.1%) and medical marijuana (14.9% vs. 4.19%) (p < 0.001). They had more celiac plexus blocks (22.0% vs. 6.67%), surgery (18.3% vs. 8.89%) and more hospitalizations for CP flares (3.6 vs. 1.0 visits) (p < 0.001). Less than 13% patients received opioids by means of ED visits; 81.7% patients received their prescriptions from one facility and 75% received them at regular intervals.

CONCLUSION

Opioid-dependent CP patients exhibit polypharmacy and have worse outcomes with higher resource utilization. The state-monitoring program ensures that the majority of patients receive opioids from a single facility, thereby minimizing misuse.

Complications of chronic pancreatitis prior to and following surgical treatment: A proposal for classification

BACKGROUND

Chronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification.

AIM

The aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up.

METHODS

After institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP.

RESULTS

We distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency.

CONCLUSION

The proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.

Frey procedure for chronic pancreatitis: A narrative review

Chronic pancreatitis is (CP) is a progressive inflammatory disease of the pancreas associated with disabling abdominal pain and gradual deterioration of exocrine and endocrine function. Up to 50% of patients with CP may require surgery during the course of the disease. The main indication for surgery is intractable abdominal pain not amenable to medical and endoscopic therapy. The type of surgery depends on pancreatic ductal diameter and associated parenchymal pathology like inflammatory head mass. Frey procedure (FP) is an effective method for control of pain in patients with enlarged pancreatic head. FP can be performed with a very low mortality and an acceptable morbidity. Compared with pancreaticoduodenectomy (PD), FP has favourable outcomes in terms of operation time, blood loss, morbidity, post-operative hospital stay, intensive care unit stay, and quality of life. FP has shorter operation time and lower morbidity in comparison to Beger procedure. But, long-term pain control and exocrine and endocrine dysfunctions are comparable between PD, Beger and FP. FP is technically easier than PD and Beger procedure. FP is thus a widely acceptable procedure for CP with enlarged pancreatic head in absence of a neoplasia.

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Frey procedure for chronic pancreatitis is associated with acceptable perioperative.

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morbidity and a low mortality.

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It provides excellent pain control.

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It is an effective procedure for chronic pancreatitis with enlarged pancreatic head.

Pain patterns in chronic pancreatitis and chronic primary pain

BACKGROUND

Abdominal pain is the most distressing symptom of chronic pancreatitis (CP), and current treatments show limited benefit. Pain phenotypes may be more useful than diagnostic categories when planning treatments, and the presence or absence of constant pain in CP may be a useful prognostic indicator.

AIMS

This cross-sectional study examined dimensions of pain in CP, compared pain in CP with chronic primary pain (CPP), and assessed whether constant pain in CP is associated with poorer outcomes.

METHODS

Patients with CP (N = 91) and CPP (N = 127) completed the Comprehensive Pancreatitis Assessment Tool. Differences in clinical characteristics and pain dimensions were assessed between a) CP and CPP and b) CP patients with constant versus intermittent pain. Latent class regression analysis was performed (N = 192) to group participants based on pain dimensions and clinical characteristics.

RESULTS

Compared to CPP, CP patients had higher quality of life (p < 0.001), lower pain severity (p < 0.001), and were more likely to use strong opioids (p < 0.001). Within CP, constant pain was associated with a stronger response to pain triggers (p < 0.05), greater pain spread (p < 0.01), greater pain severity, more features of central sensitization, greater pain catastrophising, and lower quality of life compared to intermittent pain (all p values ≤ 0.001). Latent class regression analysis identified three groups, that mapped onto the following patient groups 1) combined CPP and CP-constant, 2) majority CPP, and 3) majority CP-intermittent.

CONCLUSIONS

Within CP, constant pain may represent a pain phenotype that corresponds with poorer outcomes. CP patients with constant pain show similarities to some patients with CPP, potentially indicating shared mechanisms.

A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management

An inflammatory process involving the pancreas, known as pancreatitis, can be categorized as either acute or chronic and may present in one of many ways. The clinical manifestations of acute pancreatitis are generally limited to epigastric or right upper quadrant pain, while manifestations of chronic pancreatitis are broader and may include abdominal pain in tandem with signs and symptoms of pancreatic endocrine and exocrine insufficiency. An understanding of the initial insult, proper classification, and prognosis are all factors that are of paramount importance as it pertains to managing patients who are afflicted with this disease. Our review delves into the depths of pancreatitis by exploring the embryology and anatomy of the pancreas, the pathophysiology and etiology of acute and chronic pancreatitis, and the medical and surgical management of acute and chronic pancreatitis.

ALCOHOLIC VS. NON-ALCOHOLIC CHRONIC PANCREATITIS: SURGEONS' PERSPECTIVE FROM A TERTIARY CENTRE IN INDIA

Background:

Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients.

Aim:

To evaluate clinical features, surgical outcome and quality of life between these two groups of patients.

Method:

All patients with chronic pancreatitis who underwent surgery were prospectively reviewed.

Results:

From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group.

Conclusion:

Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

Reporting of longitudinal pancreatojejunostomy with partial pancreatic head resection (the Frey procedure) for chronic pancreatitis: A systematic review

BACKGROUND

Longitudinal pancreatojejunostomy with partial pancreatic head resection (the Frey procedure) is accepted for surgical treatment of painful chronic pancreatitis. However, conduct and reporting are not standardized and thus, making comparisons difficult. This study assesses the reporting standards of this procedure.

DATA SOURCES

A systematic literature review was performed between January 1987 and January 2020. The keyword and Medical Subject Heading "chronic pancreatitis" was used together with the individual operation term "Frey pancreatojejunostomy". Reports were included if they provided original information on conduct and outcome. Thirty-three papers providing information on 1205 patients constituted the study population. Risk of bias in included reports was assessed.

RESULTS

Etiology of chronic pancreatitis (alcohol) was reported in 26 of 28 (93%) studies, duration of symptoms prior to surgery in 19 (58%) studies and pre-operative opiate use in 12 (36%) studies. In terms of morphology, pancreatic duct diameter was reported in 17 (52%) studies and diameter of the pancreatic head in 13 (39%) studies. In terms of technique, three (9%) studies reported weight of excised parenchyma. There were 9 (0.7%) procedure-related deaths. Post-operative follow-up ranged from 6 to 82.5 months. No studies reported post-operative portal hypertension.

CONCLUSIONS

There is substantial heterogeneity between studies in reporting of clinical baseline, morphology of the diseased pancreas, operative detail and outcome after longitudinal pancreatojejunostomy with partial pancreatic head resection. This critically compromises the comparison between centers and between surgeons. Structured reporting is necessary for clinicians to assess choice of procedure and for patients to make informed choices when seeking treatment for painful chronic pancreatitis.

Swedish national guidelines for chronic pancreatitis

Chronic pancreatitis (CP) should be suspected in the case of recurrent upper abdominal pain of unknown origin and/or clinical signs of exocrine pancreatic insufficiency (EPI). Alcohol is the most common etiological factor associated with CP, others being smoking, male gender, and hereditary forms. CP is often associated with recurrent episodes of acute exacerbations.As of today, there is no accepted clinical definition of CP. However, irreversible morphological changes within the pancreas often occur, including dilatation of the main and branch pancreatic ducts, calcifications in ducts and parenchyma, parenchymal atrophy, and development of pseudocysts, though less so in the early phase of CP.

Short- and long-term outcome of Frey procedure for chronic pancreatitis in adults

OBJECTIVE

To report our experience with Frey procedure (FP) for chronic pancreatitis (CP) in adults.

METHODS

Adult patients with CP, who underwent a FP between August 2007 and July 2018, were retrospectively reviewed.

RESULTS

Of the total 138 patients, 95 (69%) were male. The median age at operation was 36.5 years. The median pain-surgery interval was 48 months. Alcohol abuse was identified in 64 (46%) patients. The major indication for surgery was disabling pain (94%). There was no postoperative mortality. Postoperative complications developed in 43 (31%) patients. Median postoperative hospital stay was 9 days. Over a median follow-up of 65 months, 84% of patients had complete pain relief. Continuous pain and high preoperative Izbicki pain score were associated with incomplete pain control. New-onset diabetes and exocrine insufficiency developed in 31% and 27% of patients respectively. Longer duration of disease and previous pancreatic surgery were associated with the development of new-onset diabetes after the FP.

CONCLUSIONS

Frey procedure is safe with an acceptable perioperative complications and good long-term pain control.

Patient and Disease Characteristics Associate With Sensory Testing Results in Chronic Pancreatitis

BACKGROUND

Abdominal pain is the most common symptom in chronic pancreatitis (CP) and has an extensive impact on patients' lives. Quantitative sensory testing (QST) provides information on sensitivity to pain and mechanisms that can help quantify pain and guide treatment. The aims of this study were (1) to explore sensitivity to pain in patients with CP using QST and (2) to associate patient and disease characteristics with QST results.

METHODS

Ninety-one patients with painful CP and 28 healthy control participants completed a QST paradigm using static tests (muscle pressure stimulation and electrical skin stimulations) to unravel segmental and widespread hyperalgesia as a consequence of visceral pain. A dynamic conditioned pain modulation (CPM) paradigm was used as a proxy of pain modulation from the brainstem to inhibit incoming nociceptive barrage, and questionnaires were used to gather information on pain experience and quality of life.

RESULTS

Patients had impaired CPM compared with controls (18.0±29.3% vs. 30.9±29.3%, P=0.04) and were hypersensitive to pressure stimulation, specifically in the pancreatic (Th10) dermatome (P<0.001). The capacity of CPM was associated with clinical pain intensity (P=0.01) and (in the univariate analysis only) the use of opioids was associated with hyperalgesia to pressure stimulation (P<0.05).

CONCLUSIONS

Sensitivity to pain in CP patients can be characterized by a simple bedside QST. Severe clinical pain in CP was associated with reduced CPM function and should be targeted in management.

Short- and long-term outcome of surgery for chronic pancreatitis in children: a single surgeon experience

OBJECTIVE

The aim of this study was to report on the short-and long-term outcomes of surgery for chronic pancreatitis (CP) in children.

METHODS

All the children, who underwent surgery for CP between August 2007 and July 2019 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed.

RESULTS

Of the total 54 patients, 33 (61%) were girls. The median age at operation was 16.5 years. The median duration between onset of pain and surgery was 36 months. 26% of patients were referred after failure of endotherapy. The most common indication for surgery was pain (94%). Surgery performed included modified Puestow (n = 26), Frey (n = 25), and Izbicki procedures. Twelve postoperative complications developed in ten (18.5%) patients. Most common complication was wound infection. Pancreatic leak developed in four (7.4%) patients (type A = 3, type B = 1). Median postoperative hospital stay was 8 days. There was no in-hospital mortality. Over a median follow-up of 48 months, 83% of patients had complete pain control. Weight gain was achieved in 77% of patients. New-onset diabetes and exocrine insufficiency developed in 4 and 14% of patients, respectively.

CONCLUSIONS

Surgery is safe with fairly acceptable perioperative complications and good long-term pain control.

Assessment of functional outcome of patients undergoing surgery for chronic pancreatitis: A prospective study

Backgrounds/Aims

This study was done with the aim of assessing impact of surgery for chronic pancreatitis on exocrine and endocrine functions, quality of life and pain relief of patients.

Methods

35 patients of chronic pancreatitis who underwent surgery were included. Exocrine function assessed with fecal fat globule estimation and endocrine function assessed with glycated haemoglobin (HbA1C), fasting plasma glucose (FPG), Insulin and C-peptide levels. Percentage (%) beta cell function by homeostatic model assessment (HOMA) was determined using web-based calculator. Quality of life (QOL) and pain assessment was done using Short form survey (SF-36) questionnaire and Izbicki scores respectively. Follow up done till 3 months following surgery.

Results

Endocrine insufficiency was noted in 13 (37%) patients in the postoperative period compared to 17 (49%) patients preoperatively (p=0.74). Exocrine insufficiency was detected in 11 (32%) patients postoperatively compared to 8 (23%) patients preoperatively, with denovo insufficiency noted in 3 (8%) patients (p<0.05). The mean Izbicki score at 3 months postoperatively was remarkably lower compared to preoperative score (29.3±14.3 vs. 60.6±12.06; p<0.05). QOL at 3 months following surgery for chronic pancreatitis was significantly better than preoperative QOL (50.24±22.16 vs. 69.48±20.81; p<0.05).

Conclusions

Significant pain relief and improvement in quality of life among patients of chronic pancreatitis following surgery. However, worsening of exocrine function with only clinical improvement of endocrine function was also noted.

International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.

METHODS

An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

Association of multiple patient and disease characteristics with the presence and type of pain in chronic pancreatitis

BACKGROUND AND AIM

Pain is the primary symptom of chronic pancreatitis (CP) and associates with a number of patient and disease characteristics. However, the complex interrelations of these parameters are incompletely understood, and pain treatment remains unsatisfactory in a large proportion of patients. The aim of this study is to investigate multiple pain risk factors in a large population of CP patients, with a special emphasis on patients' patterns of smoking and alcohol use.

METHODS

This was a multicenter, cross-sectional study including 1384 patients with CP. Patient demographics and disease characteristics, as well as current patterns of smoking and alcohol use, were compared for patients with pain (n = 801) versus without pain (n = 583). Multivariate logistic regression models were performed to assess the variables associated with the presence and type of pain (constant vs intermittent pain).

RESULTS

The mean age of participants was 52.1 ± 14.6 years, and 914 (66%) were men. Active smoking (odds ratio 1.6 [95% confidence interval 1.1-2.2], P = 0.005) and alcohol consumption (odds ratio 1.8 [95% confidence interval 1.1-3.0], P = 0.03) were independently associated with the presence of pain. In addition, patients' age at diagnosis, pancreatic duct pathology, and the presence of pseudocysts, duodenal stenosis, and exocrine pancreatic insufficiency were confirmed as pain risk factors (all P ≤ 0.01). Constant pain, as opposed to intermittent pain, was more frequently reported by smokers (P = 0.03), while alcohol consumption was associated with intermittent pain (P = 0.006).

CONCLUSION

Multiple patient and disease characteristics, including patterns of smoking and alcohol consumption, associate with the presence and type of pain in patients with CP.

Geographical variance in reporting of elective surgery for chronic pancreatitis

The selection of optimum surgical procedure from the range of reported operations for chronic pancreatitis (CP) can be difficult. The aim of this study is to explore geographical variation in reporting of elective surgery for CP. A systematic search of the literature was performed using the Scopus database for reports of five selected procedures for CP: duodenum-preserving pancreatic head resection, total pancreatectomy with islet autotransplantation (TPIAT), Frey pancreaticojejunostomy, thoracoscopic splanchnotomy and the Izbicki V-shaped resection. The keyword and MESH heading 'chronic pancreatitis' was used. Overall, 144 papers met inclusion criteria and were utilized for data extraction. There were 33 reports of duodenum-preserving pancreatic head resection. Twenty-one (64%) were from Germany. There were 60 reports of TPIAT, 53 (88%) from the USA. There are only two reports of TPIAT from outwith the USA and UK. The 34 reports of the Frey pancreaticojejunostomy originate from 12 countries. There were 20 reports of thoracoscopic splanchnotomy originating from nine countries. All three reports of the Izbicki 'V' procedure are from Germany. There is geographical variation in reporting of surgery for CP. There is a need for greater standardization in the selection and reporting of surgery for patients with painful CP.

Effect of Frey's procedure on islet cell function in patients with chronic calcific pancreatitis

BACKGROUND

Frey's procedure involves both drainage and resection of the pancreas in subjects with chronic calcific pancreatitis (CCP). The procedure may affect the pancreatic endocrine function after surgery. The present study was to evaluate the effect of Frey's procedure on both beta and alpha cell function in CCP patients.

METHODS

Thirty CCP patients who underwent Frey's procedure were included. According to the glycemic status, patients were divided into the diabetes mellitus (DM), prediabetes, and normal glucose tolerance (NGT) groups. Islet cell function was assessed before and 3 months after surgery.

RESULTS

At baseline, there was a significant difference in beta cell function among the three groups [NGT group 1.71 (1.64-2.07) vs prediabetes group1.50 (0.83-1.61) vs DM group 0.33 (0.12-0.55), P < 0.0001], but the insulin resistance was not different among them. Post glucose hyperglucagonemia representing alpha-cell dysfunction during oral glucose tolerance test was present in all of them, but showed no significant difference [NGT group 0.15 (0.06-0.31) vs prediabetes group 0.32 (0.05-0.70) vs DM group 0.07 (0.02-0.18), P = 0.20]. Frey's procedure did not change beta cell function and insulin resistance. However, alpha-cell dysfunction deteriorated after surgery [0.10 (0.03-0.27) vs 0.33 (0.09-0.68), P = 0.004].

CONCLUSIONS

Although Frey's procedure does not affect the beta cell function and insulin resistance in CCP patients, the alpha-cell dysfunction deteriorates after surgery.

Total Pancreatectomy With Islet Autotransplantation for Acute Recurrent and Chronic Pancreatitis

PURPOSE OF REVIEW

The first total pancreatectomy and islet autotransplantation (TP-IAT) was performed for chronic pancreatitis in 1977 with the goal to ameliorate the pain and simultaneously preserve islet function. We reviewed the recent medical literature regarding indications, patient suitability, current outcomes, and challenges in TP-IAT.

RECENT FINDINGS

Current indications for TP-IAT include intractable pain secondary to chronic pancreatitis (CP) or acute recurrent pancreatitis (ARP) with failed medical and endoscopic/surgical management. Independent studies have shown that TP-IAT is associated with elimination or significant improvement in pain control and partial or full islet graft function in the majority of patients. In single-center cost analyses, TP-IAT has been suggested to be more cost-effective than medical management of chronic pancreatitis. While initially introduced as a surgical option for adults with long-standing chronic pancreatitis, TP-IAT is now often utilized in children with chronic pancreatitis and in children and adults with intractable acute recurrent pancreatitis. The surgical procedure has evolved over time with some centers offering minimally invasive operative options, although the open approach remains the standard. Despite many advances in TP-IAT, there is a need for further research and development in disease diagnosis, patient selection, optimization of surgical technique, islet isolation and quality assessment, postoperative patient management, and establishment of uniform metrics for data collection and multicenter studies. TP-IAT is an option for patients with otherwise intractable acute recurrent or chronic pancreatitis which presents potential for pain relief and improved quality of life, often with partial or complete diabetes remission.

Risk factors for pain after Frey's procedure in chronic pancreatitis

Pancreatic pain is the most frequent symptom of chronic pancreatitis (CP) and is difficult to treat. This retrospective study aimed to determine the risk factors for pain in CP.From January 2009 and March 2014, 75 consecutive patients with CP who underwent Frey's procedure were reviewed for this study. According to Izbicki pain scores, these patients were divided into 2 groups: (1) pain (Izbicki pain score of >10 after a decrease of >50%) and (2) pain-free (Izbicki pain score of ≤10). Demographic data, medical history, postoperative variables, and follow-up evaluations of the patients were documented.The postoperative pain score (11.8) was significantly lower than the preoperative score (51.8) after a median follow-up of 4.2 years. Alcoholism (odds ratio [OR] 7.767, P = .002) and preoperative analgesic medication use (OR 4.113, P = .030) were independent risk factors for pain.Frey's procedure is an effective operation for pain relief in patients with CP. Alcoholism and preoperative analgesic medication use were 2 factors for failure to achieve complete pain relief.

Total pancreatectomy for recurrent acute and chronic pancreatitis: a critical review of patient selection criteria

PURPOSE OF REVIEW

Critical review of the indications for total pancreatectomy and highlight limitations in current diagnostic criteria for chronic pancreatitis.

RECENT FINDINGS

The diagnosis of noncalcific chronic pancreatitis remains controversial because of an overreliance on nonspecific imaging and laboratories findings. Endoscopic ultrasound, s-magnetic resonance cholangiopancreatography, and/or endoscopic pancreatic function testing are often used to diagnose noncalcific chronic pancreatitis despite the fact that there is no gold standard for this condition. Abdominal pain is not specific for chronic pancreatitis and is more likely to be encountered in patients with functional gastrointestinal disorders based on the high incidence of these conditions. The duration of pain and opioid analgesic use results in central sensitization that adversely affects pain outcomes after total pancreatectomy. An alcoholic cause is associated with poorer pain outcomes after total pancreatectomy.

SUMMARY

The lack of a gold standard for noncalcific chronic pancreatitis limits the diagnostic accuracy of imaging and laboratory tests. The pain of chronic pancreatitis is nonspecific and is affected by duration, preoperative opioid use, and cause. These factors will need to be considered in the development of future selection criteria for this morbid surgery.

Operative management of chronic pancreatitis: A review

BACKGROUND

Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach.

RESULTS

There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients.

DISCUSSION

Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.

The impact of surgical strategies on outcomes for pediatric chronic pancreatitis

PURPOSE

To review our institutional experience in the surgical treatment of pediatric chronic pancreatitis (CP) and evaluate predictors of long-term pain relief.

METHODS

Outcomes of patients ≤21 years surgically treated for CP in a single institution from 1995 to 2014 were evaluated.

RESULTS

Twenty patients underwent surgery for CP at a median of 16.6 years (IQR 10.7-20.6 years). The most common etiology was pancreas divisum (n = 7; 35%). Therapeutic endoscopy was the first-line treatment in 17 cases (85%). Surgical procedures included: longitudinal pancreaticojejunostomy (n = 4, 20%), pancreatectomy (n = 9, 45%), total pancreatectomy with islet autotransplantation (n = 2; 10%), sphincteroplasty (n = 2, 10%) and pseudocyst drainage (n = 3, 15%). At a median follow-up of 5.3 years (IQR 4.2-5.3), twelve patients (63.2%) were pain free and five (26.3%) were insulin dependent. In univariate analysis, previous surgical procedure or >5 endoscopic treatments were associated with a lower likelihood of pain relief (OR 0.06; 95% CI 0.006-0.57; OR 0.07; 95%, CI 0.01-0.89). However, these associations were not present in multivariate analysis.

CONCLUSION

In children with CP, the step-up practice including a limited trial of endoscopic interventions followed by surgery tailored to anatomical abnormalities and gene mutation status is effective in ensuring long-term pain relief and preserving pancreatic function.

Chronic Pancreatitis: A Review

This is to incorporate the recent trends in chronic pancreatitis. Extensive literature search was done from Pubmed and Ovid SP. Full text articles and abstracts related to chronic pancreatitis were reviewed and the article was prepared. Chronic pancreatitis is evolving fast on its etiology and treatment areas. The main etiological factors are pointing towards genetic, alcohol, and smoking. Autoimmune has also been added as a cause. Endoscopic ultra sound (EUS) becoming the standard diagnostic procedure. Surgery is becoming the treatment of choice for pain and mechanical complications and not the endotherapy in the long-term follow-up. The numbers of surgeries are getting narrowed down. The two etiological groups of chronic pancreatitis namely alcohol + smoking and genetic getting clearer, where the later group present at an early age. Endoscopic ultrasound and imaging with secretin is diagnostic of chronic pancreatitis before the structural changes. Endotherapy is found to be inferior to surgery in long-term pain relief. Diagnostic criteria for autoimmune pancreatitis are established. Pancreaticogenic diabetes (Type3c) and its problem associated with fat malabsorption are being understood.

Quality of Life after Frey's Procedure in Patients with Chronic Pancreatitis

INTRODUCTION

Chronic pancreatitis is a debilitating disease, associated with excruciating abdominal pain, exocrine and endocrine pancreatic insufficiency. Different types of surgical techniques have been described for the management of complications of this disease. The most common procedure which has been adopted for improving the quality of life of the patients with chronic pancreatitis is Frey's Procedure. It is an organ preserving procedure in which the main pancreatic duct is drained by lateral pancreatico-jejunostomy along with coring of the head of the pancreas.

AIM

In this study, we have assessed the outcome of Frey's procedure in terms of quality of life in patients with chronic pancreatitis.

MATERIALS AND METHODS

This was a prospective observational study done at a tertiary care center in West Bengal, India. The study period was from 2010 to 2014. All the patients who have undergone Frey's Procedure during the study duration and with the postoperative histopathology of chronic pancreatitis were included in this study. The preoperative and postoperative pain and quality of life assessment was done using VAS score (0-100) and EORTC QLQ-C30 (Version 3) respectively. The statistical analysis was performed with the help of Epi Info (TM) 3.5.3.

RESULTS

A total of 35 patients with chronic pancreatitis underwent Frey's procedure during the study period. The mean age (mean ± s.e) of the 33 patients included in the study was 38.48±5.55 years with a range of 29-49 years. The mean preoperative Physical Functional Domain (PFD), Physical Domain (PD), Emotional Domain (ED), Social Domain (SD) and general health raw score with standard errors were 32.06±0.40, 37.86±0.36, 15.18±0.32, 8.63±0.31 and 4.48±0.26 respectively. ANOVA showed that there was significant differences in PFD, PD, ED, SD and GH values during different time period of follow up (p<0.0001) and as per Critical Difference the postoperative values of PFD, PD, ED and SD decreased while postoperative value of GH increased significantly in different months compared to the preoperative values.

CONCLUSION

We conclude that Frey's procedure is a low risk surgery, which significantly improves the quality of life of the patients with chronic pancreatitis in all the domains and can be recommended as a surgical therapy for such patients.

Surgical Management of Chronic Pancreatitis

Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.

Pancreatic pain

PURPOSE OF REVIEW

Pain is the most common symptom of chronic pancreatitis, with a profound socioeconomic impact. Historical management paradigms failed, as they did not adequately address the fundamental underlying mechanisms. The present article describes the neurobiology of pain and sensitization in this condition, in an effort to explain prior failings and provide future directions for managing pain in chronic pancreatitis.

RECENT FINDINGS

A number of recent advances have been made in understanding the neurobiology of pain for this condition. This has been coupled with clinical advances in assessing sensitization to pain in these patients, which has been shown to predict response to medical and surgical therapy.

SUMMARY

Pain in chronic pancreatitis is complex. Addressing the mechanical and morphological findings in chronic pancreatitis without addressing the underlying neurobiological mechanisms is destined to fail. New advances in our understanding of the neurobiology of pain in chronic pancreatitis helps to explain prior failings and provides future direction for managing pain in patients afflicted by this disease.

Frey procedure for chronic pancreatitis: Evidence-based assessment of short- and long-term results in comparison to pancreatoduodenectomy and Beger procedure: A meta-analysis

BACKGROUND AND OBJECTIVE

Patients with chronic pancreatitis often require surgical treatment. The aim of this study was to evaluate the published evidence for Frey procedure in patients with chronic pancreatitis.

METHODS

Literature search was undertaken to identify eligible studies until February 2015. Using meta-analytical techniques, Frey procedure was compared with pancreatoduodenectomy or Beger procedure, and the short- and long-term outcomes were analysed.

RESULTS

Twenty-three studies comprising a total of 800 patients were reviewed. The postoperative morbidity and mortality were 23.2% and 0.4% respectively. The percentage of postoperative pain-relief patients was 89.4%. New onset of diabetes and exocrine insufficiency was present in 17.3% and 30.7% of patients, respectively. Compared with pancreatoduodenectomy, Frey procedure had favorable outcomes in terms of operation time, blood transfusion, overall morbidity, length of hospital and intensive care unit stay, pancreatic function and quality of life. Compared with Beger procedure, Frey procedure had shorter operation time and lower morbidity.

CONCLUSIONS

Frey procedure is a safe and effective surgical procedure for chronic pancreatitis with dilated duct in the absence of neoplasia.

Systematic review of early surgery for chronic pancreatitis: impact on pain, pancreatic function, and re-intervention

BACKGROUND

Surgical intervention has traditionally been reserved as the last management option for pain in chronic pancreatitis. Recently, there has been a call for surgery to be offered earlier in the disease process. The objectives of this review were to evaluate the effect of early surgery on postoperative pain, pancreatic function, and re-intervention rates in chronic pancreatitis.

METHODS

A systematic literature search through EMBASE, Cochrane Review, and PubMed from January 1950 to January 2014 was conducted. Citations found in relevant papers are hand-searched. Data which could be pooled were analyzed using Revman (v5.2). Risk of bias analysis was conducted.

RESULTS

Of the 2,886 potentially eligible studies identified, 11 studies met the inclusion criteria. There was large heterogeneity in the study designs, and studies were conducted over a lengthy time span. Seven studies examined pain, three studies examined pancreatic function, and three studies examined rates of re-intervention. Meta-analysis of the three studies with comparative raw data regarding complete pain relief showed that early surgery was associated with an increased likelihood of complete postoperative pain relief (RR = 1.67, 95% CI 1.09-2.56, p = 0.02). Early surgery was also associated with reduced risk of pancreatic insufficiency and low re-intervention rates.

CONCLUSIONS

Data from this study supports considering early surgery for pain management in patients with chronic pancreatitis, with the potential of a reduced risk of pancreatic insufficiency and the need for further intervention. Further prospective randomized studies are warranted comparing early surgery against conservative step-up approaches.

Chronic pancreatitis: A surgical disease? Role of the Frey procedure

Although medical treatment and endoscopic interventions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Although pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complication and pancreatic exocrine or/and endocrine dysfunction rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to analyze its outcome. Because of its hybrid nature, combining both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical procedure performed for chronic pancreatitis.

Influence of bile duct obstruction on the results of Frey's procedure for chronic pancreatitis

OBJECTIVES

To evaluate the influence of a biliary obstruction (BO) requiring biliary bypass on both short and long-term outcomes of patients undergoing Frey's procedure for chronic pancreatitis (CP).

METHODS

From 1999 to 2010, 33 consecutive patients underwent Frey's procedure for CP in two centers. Seventeen (54%) patients underwent biliary bypass to treat an associated BO. Characteristics and outcomes of these patients were compared to those of 16 others without BO.

RESULTS

Patients with BO had more severe disease including lower BMI and larger pancreatic head (4 cm vs. 6 cm, p = 0.021). The operative mortality was nil. Patients with BO experienced more overall postoperative complications (71% vs. 31%, p = 0.024) but similar major complication rates (18% vs. 6%, p = 0.316) compared to those without BO. After a median follow-up of 51 (1-96) months, 91% of the patients experienced either partial or complete relief of their symptoms and 36% exhibited deterioration of their endocrine function. Multivariate analysis revealed preoperative BO to be associated with long-term impairment of endocrine function (OR: 43.249; 95% CI 2.221-84.277; p = 0.013).

CONCLUSION

In patients undergoing Frey's procedure for CP, associated BO can be safely managed using biliary bypass. However, the severity of CP in these patients is responsible for a higher risk of long-term endocrine insufficiency.

Preoperative opioid use and the outcome of thoracoscopic splanchnicectomy in chronic pancreatitis: a systematic review

BACKGROUND

Thoracoscopic splanchnicectomy (TS) is a minimally invasive intervention to relieve pain in patients with chronic pancreatitis (CP) with equivocal results. Preoperative opioid use seems to impair TS outcome but this has not been investigated in a systematic matter.

METHODS

We searched PubMed, EMBASE, and The Cochrane Library for studies on the outcome of TS in CP patients. Studies with ≥5 patients and a follow-up of ≥12 months were included. Success was defined as the proportion of patients free of opioids or who had a reduction of ≥4 points on a pain scale. The effect of opioid use on the success rate of TS was analyzed by uni- and multivariate regression.

RESULTS

Sixteen studies with 484 patients were included in our review. The mean (±SD) age of the patients was 44 ± 4.3 years and 66 % were male. Median follow-up period was 21 months (IQR 14-35). Median preoperative opioid use was 85 % (IQR 54-100 %). After TS, a median of 49 % (IQR 22-75 %) of patients were free of opioids at end of follow-up. The median success rate was 62 % (IQR 48-86 %). Mean success rate in studies in which ≤50 % of the patients used opioids preoperatively was 81 % (SD ± 21) compared to 60 % (SD ± 15) for other studies (p = 0.049). Higher age, male gender, and lower rates of preoperative opioid use were associated with a higher success rate (p = 0.003, 0.047, and 0.017, respectively). Multivariate regression, including age, gender, preoperative opioid use, and duration of follow-up, identified age and preoperative opioid use as independent predictors of success after TS (both p = 0.002).

CONCLUSION

Preoperative opioid use is associated with a worse outcome after TS in CP patients. To optimize outcome, use of TS may be considered at an earlier stage in the treatment of patients with CP before prolonged opioid therapy.

Prospective evaluation of pain control and quality of life in patients with chronic pancreatitis following bilateral thoracoscopic splanchnicectomy

Background

Abdominal pain in chronic pancreatitis (CP) is the most common symptom with a highly unfavorable impact on the quality of life. It has been shown that bilateral thoracoscopic splanchnicectomy (BTS) may produce marked pain relief for the majority of patients. The aim of this study was to evaluate the effectiveness of BTS in pain control and quality-of-life improvement in patients with a severe form of CP.

Methods

Between April 2000 and April 2009, a total of 30 patients qualified for BTS due to CP-related pain. Their age ranged from 28 to 60 years. A 12-month follow-up period was planned for all the patients enrolled. To evaluate effectiveness of BTS, an 11-point Numeric Rating Scale (NRS) and the Quality of Life Questionnaire C-30 (QLQ-C30) in its basic form, developed by European Organization for Research and Treatment of Cancer, were used. An NRS value between 0 and 3 was considered a positive postoperative pain control result.

Results

The bilateral splanchnicectomy procedure was performed successfully in 27 of 30 qualified patients. A positive effect based on decreased pain (p < 0.05) at 12 months was achieved in 24 patients (80 %). The initial change in quality of life was not significant but it gradually improved with time (preop vs. 12 months QLQ-C30 score, p < 0.001).

Conclusions

This study showed that BTS is safe and efficacious for pain alleviation in patients with severe CP. It may significantly increase the chances of a long-lasting, life-changing improvement in the quality of life.

Functional and medical outcomes after tailored surgery for pain due to chronic pancreatitis

OBJECTIVE

We measured a comprehensive set of outcome measures after different surgical procedures for painful chronic pancreatitis (CP) at long-term follow-up.

BACKGROUND

Pain caused by CP can be alleviated through operative intervention with type of procedure depending on anatomical abnormalities. Outcome measures include functional (pain relief, quality of life [QoL]), medical (endo- and exocrine function), and clinical (reoperation) results reported by patient.

METHODS

A cross-sectional cohort of 223 consecutive patients who underwent surgical drainage, head resection, or left-sided pancreas resection, depending on anatomical abnormalities, was analyzed. Participating patients were reassessed during a prospectively scheduled outpatient clinic visit.

RESULTS

At follow-up, 44 patients had died; 146 of 179 living patients consented to participate in the study. After 63 months (range: 14-268), 68% reported no or little pain, 19% reported intermediate pain, and 12% reported severe pain. Preoperative daily opioid use (OR: 3.04; 95% confidence interval [CI]: 1.09-8.49) and high numbers of preceding endoscopic procedures (OR [odds ratio]: 3.89; 95% CI: 1.01-14.9) were associated with persistent severe pain. Compared with the general population, physical more than mental QoL remained impaired (P < 0.05). At follow-up, endocrine insufficiency was present in 57% of patients and exocrine insufficiency was present in 77%. Independently, a head resection and a reoperation for any cause were moderately associated with new-onset diabetes (P < 0.1). Compared with patients who underwent left-sided resection, the risk of developing exocrine insufficiency after surgery was higher after drainage or head resection. After 20 months (interquartile range: 10-51) after surgery, 26 (12%) of 223 patients underwent 1 or more elective reoperations.

CONCLUSIONS

Operative intervention for painful CP, tailored to anatomical abnormalities, results in excellent to fair long-term pain relief, but approximately 10% of patients do not respond. QoL scores remained slightly compromised. High preoperative pain levels, suggested through daily opioid use and high numbers of endoscopic procedures, are associated with less favorable outcome.

Tratamento cirúrgico da pancreatite crônica com a técnica de F rey: panorama atual

INTRODUÇÃO: A pancreatite crônica é desordem inflamatória progressiva caracterizada pela destruição irreversível do parênquima pancreático, podendo estar associada à dor crônica incapacitante e perda permanente da função endócrina e exócrina. A principal indicação cirúrgica é a dor abdominal intratável e a escolha da melhor técnica a ser empregada permanece um desafio. A técnica descrita por Frey conseguiu combinar a eficácia no controle da dor das operações de ressecção com as baixas taxas de mortalidade e morbidade das derivativas. OBJETIVO: Comparar e discutir os resultados do tratamento cirúrgico da pancreatite crônica com a técnica de Frey. MÉTODOS: Revisão bibliográfica de 276 artigos científicos disponíveis no Medline/Pubmed e no banco de dados de teses nacionais com os descritores pancreatite crônica, tratamento cirúrgico e cirurgia de Frey. Foram selecionados os 30 artigos de maior importância e que relataram maior experiência com esta opção cirúrgica. CONCLUSÕES: A técnica de Frey demonstra ser opção de alta efetividade no controle da dor abdominal secundária à pancreatite crônica no longo prazo naqueles pacientes com dor abdominal incapacitante e aumento volumétrico da cabeça pancreática, com menores taxas de morbidade e mortalidade. Os estudos demonstraram pequena interferência da técnica na deterioração das funções endócrina e exócrina.