Hepatobiliary Pancreat Dis Int，Vol 6，No 2 • April 15，2007 • www.hbpdint.com • 121 Author Affiliations: Department of Hepatobiliary and Pancreatic Surgery, Royal London Hospital, UK (Gourgiotis S); Upper GI and General Surgery, Leighton Hospital, Mid Cheshire NHS Trust, UK (Germanos S); Department of Surgical Sciences, Gemelli University Hospital, Catholic University of the Sacred Heart School of Medicine, Rome, Italy (Ridolfini MP) Corresponding Author: Stavros Gourgiotis, MD, PhD, 41 Zakinthinou Street, Papagou, 15669, Athens, Greece (Tel: 00302106525802; Fax: 00302106525802; Email: drsgourgiotis@tiscali.co.uk) © 2007, Hepatobiliary Pancreat Dis Int. All rights reserved. BACKGROUND: Treatment of chronic pancreatitis (CP) is a challenging condition for surgeons. During the last decades, increasing knowledge about pathophysiology of CP, improved results of major pancreatic resections, and integration of sophisticated diagnostic methods in clinical practice have resulted in significant changes in surgery for CP. DATA SOURCES: To detail the indications for CP surgery, the surgical procedures, and outcome, a Pubmed database search was performed. The abstracts of searched articles about surgical management of CP were reviewed. The articles could be identified and further scrutinized. Further references were extracted by cross-referencing. RESULTS: Main indications of CP for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The goal of surgical treatment is to improve the quality of life of patients. The surgical approach to CP should be individualized according to pancreatic anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. The approach usually involves pancreatic duct drainage and resection including longitudinal pancreatojejunostomy, pancreatoduodenectomy (Whipple's procedure), pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum- preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Non-pancreatic and endoscopic management of pain has also been advocated. CONCLUSIONS: Surgical procedures provide long-term pain relief, a good postoperative quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low early and late mortality and morbidity. In addition to available results from randomized controlled trials, new studies are needed to determine which procedure is the most effective for the management of patients with CP. (Hepatobiliary Pancreat Dis Int 2007; 6: 121-133) KEY WORDS: chronic pancreatitis; surgery; pain; malignancy; pancreatic function Introduction C hronic pancreatitis (CP), a chronic inflam- matory disease of the pancreas, is often associated with complications that may require surgical intervention. [1-3] The incidence of CP is approximately 5-10 cases per 100 000 population [4, 5] and has nearly quadrupled in the past 30 years, although this likely represents increased recognition due to a broader definition and improvement in pancreatic imaging (with consequent inclusion of earlier-stage patients) rather than a true increase in occurrence. Because of our limited understanding of disease pathogenesis, the unpredictability of the clinical course in a given individual and controversies in both diagnostic criteria and therapeutic options, management of patients with CP remains a difficult and challenging problem. The vast majority of them is managed conservatively and never requires operative intervention, [6] although about 20% of patients require frequent opioid analgesia. In general, patients are referred for surgery late in the course of disease, which means that the pathologic process can at most be halted or stabilized but not reversed. The usual technical complexities of pancreatic surgery are made even more imposing by the presence of inflammation in the pancreas and peripancreatic areas, which can obscure anatomic landmarks and planes. The choice of surgical procedure is rarely straightforward and other factors including disease location, prior Surgical management of chronic pancreatitis Stavros Gourgiotis, Stylianos Germanos and Marco Pericoli Ridolfini London, UK Review Article