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Original Investigation | Association of VA Surgeons

The Frey Procedure for Chronic Pancreatitis Secondary to Pancreas Divisum

Sam G. Pappas, MD1,2; Charles H. C. Pilgrim, MD, PhD1; Rebecca Keim, MD1,3; Rachel Harris, MD1; Stuart Wilson, MD1; Kiran Turaga, MD1; Susan Tsai, MD1; Kulwinder Dua, MD4,5; Abdul Khan, MD4,5; Young Oh, MD4,5; T. Clark Gamblin, MD1; Kathleen Christians, MD1
[+] Author Affiliations
1Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
2Division of Surgical Oncology, Department of Surgery, Loyola University Medical Center, Chicago, Illinois
3Department of Surgery, St Peter’s Hospital, Albany, New York
4Division of Gastroenterology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
5Division of Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
JAMA Surg. 2013;148(11):1057-1062. doi:10.1001/jamasurg.2013.3728.
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Importance  Pancreas divisum is an uncommon congenital anomaly that may result in chronic pancreatitis (chronic pancreatitis secondary to pancreas divisum [CPPD]) and intractable pain. We evaluated the role of the Frey procedure in the management of patients with pain related to CPPD as compared with patients with chronic pancreatitis secondary to alcohol (CPA) or idiopathic causes (ICP).

Objective  To review our experience with the Frey procedure for the management of chronic pancreatitis related to pancreas divisum.

Design  This was a 2-year institutional retrospective of patients undergoing the Frey procedure for chronic pancreatitis related–pain from April 2008 to June 2010.

Setting  Academic tertiary care referral center.

Participants  A consecutive sample of 14 patients undergoing the Frey procedure for chronic pancreatitis and disease-related intractable pain. We sought to examine the utility of the Frey procedure in patients with CPPD as compared with CPA and ICP.

Intervention  The Frey procedure.

Main Outcomes and Measures  Perioperative outcomes and postoperative narcotic requirement were compared among patient groups.

Results  Fourteen patients underwent the Frey procedure. The etiology of the disease was pancreas divisum in 6 patients, alcohol in 5, and idiopathic in 3. The most common indication for surgery was intractable pain, and all patients had undergone endoscopic retrograde cholangiopancreatography for attempted relief in the past. There were no statistically significant differences in median operative time (263 minutes), intraoperative blood loss (425 mL), median length of stay (9.5 days), or rate of morbidity (21%) between the 3 etiologies. Two-thirds of patients required less or no opioid at follow-up, although follow-up was significantly longer for CPPD and ICP than CPA (median, 249, 259, and 42 days, respectively; P < .02).

Conclusions and Relevance  In this series, outcomes for patients with CPPD treated with the Frey procedure were equivalent to those treated for CPA. Patients with pancreas divisum and a dilated pancreatic duct may be ideally suited for this surgical strategy. The potential advantage of this approach over minor duct sphincteroplasty and lateral pancreaticojejunostomy is the removal of the fibrotic tissue of the head of the pancreas, thought to be the epicenter of pain in this condition. The benefits over resection alone include a more extensive ductal drainage procedure.

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