Indications for endoscopic or surgical treatment of chronic pancreatitis

In patients suffering from chronic pancreatitis, pain as the predominant symptom remains a therapeutic challenge which often cannot be tackled conservatively. Since pancreatic duct obstruction - frequently within the pancreatic head - is an important etiological factor, treatment in these cases aims at decompressing the duct either endoscopically or surgically. Endoscopic drainage includes sphincterotomy, dilation of strictures, removal of stones, and insertion of a stent; it has a success rate of 30-100%. Surgical treatment may be accomplished by drainage or resection procedures. Drainage procedures (such as the longitudinal opening of the pancreatic duct followed by a pancreaticojejunostomy) can be performed with a low rate of postoperative complications (6-30%) and mortality (0-2%), and can achieve long-term pain relief in 65-85% of the cases. Furthermore, there are a variety of resection procedures such as pancreaticoduodenenectomy (Whipple procedure), pylorus-preserving pancreaticoduodenenectomy, different types of the duodenum-preserving pancreatic head resection (i.e. Beger, Frey, or Büchler procedures), segmentectomy, and V-shaped excision of the pancreatic duct. However, the surgical procedure of choice is controversially discussed. While it has been shown that parenchyma-preserving surgery is superior to more extensive resections, it remains unclear which of the modifications of the parenchyma-sparing procedures is suited best for which case. Recently, two randomized controlled trials have demonstrated that surgical treatment is superior to endotherapy in long-term pain reduction, physical health score results, and the number of reinterventions. Thus, in patients with chronic pancreatitis refractory to conservative medical treatment, surgery rather than endotherapy is the standard of care. Parenchyma-preserving resections should preferably be performed because they ensure lower morbidity and mortality, preserve endocrine function, and improve quality of life.