Long-term follow-up in small duct chronic pancreatitis: A plea for extended drainage by "V-shaped excision" of the anterior aspect of the pancreas.

The heterogeneity of patient population and of symptoms as well as poor understanding of the pathophysiology in patients with CP are obstacles in the effectiveness of patient treatment. The symptom triad of chronic pancreatitis includes exocrine and endocrine pancreatic insufficiency and, representing the most important surgical indication, recurrent episodes of pain, which brings patients to their physicians and causes addiction to analgesics. In the past, 2 major reasons have been addressed advocating conservative treatment. The “historical” “burn-out” theory, advocating that pain will eventually subside as a consequence of the self-limiting pathophysiology of pancreatitis-related pain,1 has been challenged by more recent series, which report persistence of pain for more than 10 years.2 The second, emphasizing high morbidity and mortality rates associated with pancreatic operations, has become more or less obsolete as a result of significant progress in surgical and interventional techniques, especially in high-volume pancreatic centers. Therefore, conservative “watchful waiting” is nowadays hardly acceptable, especially if pancreatic pain has a morphologic basis. Therapeutic options in conservative, interventional (endosonography-guided celiac plexus blockade), and surgical treatment of CP (including thoracoscopic splanchnicectomy) are mainly addressing pain relief. Based on the various hypotheses of pain origin in CP,3,4 (ductal) drainage and resection have become the 2 major principles for surgical treatment. Both options are combined in the principle of duodenum-preserving pancreatic head resection and its various modifications.5–8 Apart from morphologic changes involving the glandular parenchyma, 2 anatomic variants of chronic pancreatitis can be distinguished with regard to the diameter of the main pancreatic duct, which is normally 4 to 5 mm.9 The large duct form, defined as main ductal diameter of >7 mm,10 has been considered the classic domain of drainage procedures.11–13 This so-called “large-duct chronic pancreatitis” is the typical feature of ductal irregularities presented by patients suffering from chronic pancreatitis (CP). Although conclusive, the argumentation that ductal dilatation causes ductal hypertension, hereby leading to pain, lacks evidence. An extremely rare form of CP has been termed small duct pancreatitis, defined as main ductal diameter of ≤3 mm.9 This condition has been regarded as the domain of resectional procedures of various extents.14–19 Even total pancreatectomy as ultima ratio has been suggested. The therapeutic algorithm from the American Gastroenterological Association (AGA) in 1998, does not consider the option of draining procedures for these patients.20 To maintain as much pancreatic tissue as possible and to lower the risk of postoperative exocrine and endocrine pancreatic dysfunction, our group devised, in a previous study, a surgical technique of an organ-sparing operation, which consisted in a longitudinal V-shaped excision of the anterior aspect of the pancreas.21 Based now on more than 10 years of follow-up, here we report on long-term results regarding pain relief, improvement of quality of life, as well as exocrine and endocrine pancreatic functions in patients with SDP.