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Invited Critique |

Six of One, Half a Dozen of the Other Comment on “Surgical Treatment Strategies in Chronic Pancreatitis

Thomas J. Howard, MD
Arch Surg. 2012;147(10):969. doi:10.1001/2013.jamasurg.182.
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Yin and colleagues1 have done a great service to surgical pancreatologists by gathering 15 published studies (5 randomized and 10 nonrandomized) comparing duodenal-preserving pancreatic head resections (DPPHR; Beger and Frey operations) with standard resections (pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy) in patients with pain and chronic pancreatitis. They applied a sophisticated statistical meta-analysis using the defined protocols for the Preferred Items for Systematic Reviews and Meta-Analyses and the Meta-analysis of Observational Studies in Epidemiology. In pooling the Beger and Frey operations as DPPHR, the data clearly show that short- and long-term global quality of life were significantly better than the standard resections. This outcome is the primary objective in any intervention for chronic pancreatitis. Subgroup analysis, however, reveals the Beger operation achieves significantly better postoperative pain relief with perioperative morbidity similar to the standard resections, whereas the Frey operation has significantly lower perioperative morbidity but similar postoperative pain relief as the standard resection techniques. So which DPPHR operation does one use? The answer depends on the patient's anatomy and your surgical skill set. The Beger operation is technically more challenging, requiring transection of the pancreatic neck, a 90° rotation of the pancreatic head with subtotal pancreatic head resection, and 2 separate pancreaticojejunostomies (end-to-side and side-to-side), accounting for the equivalence of its perioperative morbidity with the standard resections. In contrast, the Frey operation does not require gland transection or rotation and the reconstruction is via a single long lateral pancreaticojejunostomy—improving postoperative morbidity but making adequate decompression of the uncinate process (the proverbial “pacemaker” of the disease) much more problematic, hence the pain relief profile similar to standard resections. As in much of surgery, honest skill assessment and intraoperative judgment are essential to improving the long-term global quality of life in our patients.

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