The Puestow procedure, also known as a longitudinal pancreaticojejunostomy, is a drainage operation in which a side-to-side anastomosis is made between a longitudinal pancreatic ductotomy and a Roux-en-Y limb of the jejunum [1]. The Puestow procedure is used in patients with diffuse ductal dilation (>7 mm) and confers little benefit to patients with nondilated ducts [2, 3]. With regard to endocrine function, 27–29% of patients will develop new-onset diabetes mellitus postoperatively [4, 5]. One common criticism of the Puestow procedure is that pain relief is suboptimal, with 15–20% of patients having no immediate pain relief and an additional 20% develop recurrence of pain years after the procedure [6]. Small cohort studies have suggested that 7–21% [4, 7] of patients will eventually require a salvage excisional procedure due to progressive parenchymal disease and pain.

The Beger procedure is commonly referred to as duodenum-preserving pancreatic head resection. In this operation, the pancreas is transected at the level of the portal vein, and the head is removed while preserving the bile duct. The distal pancreatic remnant is then drained into a Roux limb of the jejunum. The Beger operation is indicated in head-predominant pancreatic disease, such as pancreatitis secondary to inflammatory masses or obstructive ductal neoplasia [8]. The primary advantage over a classic Whipple pancreaticoduodenectomy is that both the endocrine and mechanical properties of the duodenum implicated in gastric emptying are preserved. In a long-term follow-up study of 388 patients by Beger et al., greater than 90% had pain relief, and about 11% were found to have improvement in their endocrine function; 21% developed diabetes following the procedure [9].

The Frey procedure combines localized pancreatic head resection with a longitudinal pancreaticojejunostomy; it is essentially a hybrid operation that incorporates aspects of both the Puestow and Beger procedures. It is therefore ideal in patients with significant disease of the pancreatic head that also extends into the ductal system. A major advantage of the Frey procedure is that it enables surgeons to perform a complete decompression of the ductal system with particular attention to the duct of Santorini and the duct to the uncinate; these may otherwise be incompletely decompressed during a traditional Puestow procedure. In addition, the Frey procedure incurs lower operative risk compared to the Beger head resection, because the pancreas is not transected above the portal vein, but instead the posterior capsule of the pancreas is left intact [10]. Numerous studies have concluded that the degree of pain relief is comparable to that seen with the Beger procedure, with some degree of relief in >90% of patients [11–13].

Distal pancreatectomy is less commonly employed for the treatment of chronic pancreatitis, but may be indicated in cases of body- or tail-predominant disease. The border of resection is patient specific, but typically about 50% of the total pancreatic volume is removed. Due to the shared splenic vasculature, the pancreatic tail is removed with the spleen en bloc. Pain relief is less robust compared with alternate surgical methods, with only 60–88% of patients having improvement in their pain [14, 15]. Additionally, given the relatively large parenchymal resection associated with distal pancreatectomy and the increased islet cell density in the tail relative to the head [16], development of diabetes is of particular concern in distal pancreatectomy patients; Hutchins et al. found that 46% of their cohort developed diabetes mellitus postoperatively [15].

Though drastic, total pancreatectomy is indicated for the treatment of chronic pancreatitis in patients with diffuse, non-focal disease that would not be responsive to a partial resection procedure. This is often a last resort operation reserved for the most severe cases of pancreatitis, given that in excising the entire pancreas, both endocrine and exocrine function are permanently compromised. A “completion” total pancreatectomy may also be performed as a salvage operation in patients who continue to have pain following partial resections. Recently, there has been considerable interest in the application of autologous islet cell transplantation following total pancreatectomy to reduce the burden of surgical diabetes. With islet autotransplant, approximately one-third of total pancreatectomy patients are insulin-free following the procedure. For more information on islet cell transplantation, see Chap. 17.

Pertinent factors in selecting the optimal drainage or resection procedure for this patient include his:

With these considerations, the Puestow procedure is a reasonable intervention. First, it will effectively relieve his ductal obstruction by allowing the removal and passage of stones. Second, it incurs a relatively low risk of compromising his endocrine function given the minimal parenchymal resection. Third, because he has minimal pain at baseline, the durability of pain relief associated with the Puestow is of less concern. Lastly, the Puestow procedure will reduce the risk of injury to the replaced hepatic artery present in the head of his pancreas.