In chronic pancreatitis (CP) a benign inflammatory process in the pancreas results in progressive structural changes with replacement of functional exocrine and endocrine parenchyma by a fibrotic and inflammatory tissue. The consequences are diabetes mellitus, exocrine insufficiency, and severe recurrent upper abdominal pain, often resulting in a significant reduction of the quality of life. In addition, the inflammatory process or the formation of pseudocysts can cause local complications such as obstruction of the pancreatic duct, bile duct, duodenum, as well as the portal vein. In most patients with CP the trigger of the disease is an inflammatory mass of the pancreatic head, and surgical resection provides good short and long-term results including pain relieve and improvement in the quality of life in patients with CP. Despite adequate surgical resection, exocrine and endocrine insufficiency may progress. In contrast, ductal drainage operations have limited effects and poor long-term outcomes.

While the partial pancreatoduodenectomy (Kausch-Whipple procedure), in its classical or pylorus-preserving variant, has been the procedure of choice for pancreatic head resection in CP for many years, the duodenum-preserving pancreatic head resections (DPPHR) and its variants (Beger procedure, Frey procedure, Bern procedure) represent less invasive, organ-sparing techniques with better perioperative, better short-term, and at least equally good long-term results. The present chapter describes the different types of DPPHR in detail and elucidates the individual advantages and disadvantages.

A thorough medical history and physical examination is pivotal for the diagnosis and adequate therapy of patients with CP. In the medical history, evaluation of etiologic factors (especially alcohol) and of pancreatic pain is crucial to select patients for the different therapeutic options as discussed below.

Besides routine parameters, laboratory data should include cholestasis parameters, and tumor markers for pancreatic adenocarcinoma. In order to adequately inform patients about the course of their disease and possible consequences of surgery (e.g., need of insulin), the endocrine and exocrine function have to be evaluated. Exocrine function test is often provided by gastroenterologists but not required for surgical decision-making, except for patients with uncertain diagnosis due to atypical clinical presentation.

For tailored therapy and especially for planning of surgical therapy, imaging studies play a central role in the diagnostic workup of patients with CP. Most of the patients with CP first consult general practitioners and gastroenterologists. For the general practitioner abdominal ultrasound is an effective screening method, which may help to establish the diagnosis in patients with a thickened pancreas or head mass, a dilated duct, or pseudocysts. Gastroenterologists frequently use endoscopic ultrasound, which is more sensitive and specific than transabdominal ultrasound. Many patients undergo multiple endoscopic retrograde cholangiopancreatographies (ERCP) for diagnosis and therapeutic intervention. The gold standard of imaging for diagnosing CP and for the design of surgical therapy is cross section imaging by contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). The superiority of CT or MRI is still a matter of debate but either imaging study is adequate if performed with sufficient quality. If a patient presents without ERCP, the MRI offers the additional possibility to evaluate the ductal system by MR cholangiopancreatography. Only ERCP or MRCP allows for evaluation according to the Cambridge-classification, which is at present still the only broadly accepted classification-system. However, an ERCP or MRCP is not mandatory, and if surgery is indicated should be omitted because of the risk of pancreatitis and secondary infections. The advantage of CT is the better visualization of parenchymal calcifications. In fact, it is a difficult task to diagnose cancer in a chronically inflamed pancreatic head. Thus, as indicated by a recent review the indication for surgery for a pancreatic mass should not be based on preoperative tissue diagnosis because of frequent false negative results due to sampling problems. We believe that patients with cancer as differential diagnosis should undergo surgical exploration and resection.

Since ethanol abuse is the most common cause of chronic pancreatitis in the Western world, active alcoholism needs to be ruled out before a surgical procedure is performed.

Most of the patients with chronic pancreatitis who are transferred to a surgeon have been treated for intractable pain for many years before and are often dependent on their pain medication. Thus, close perioperative and postoperative follow-up and an individualized pain management must be available.

If a pancreatic malignancy is suspected, a partial pancreatoduodenectomy (PD) should be performed and DPPHR should be omitted, since the DPPHR are not oncologic operations since lymphnodes and adjacent organs are not resected.

Patients are positioned on the back in a straight position; the right arm extended (90 degrees) in the shoulder to allow access to the right arm.

A midline laparotomy is performed in most patients, while in adipose patients a transverse incision is preferred by us. After a systematic exploration of the abdomen and after a malignancy (liver metastasis, peritoneal carcinosis) has been ruled out, the pancreas is explored by opening the lesser sac through the gastrocolic ligament and by the Kocher maneuver. Due to the chronic inflammation and especially in case of portal hypertension, these steps might be more difficult than in pancreatic cancer cases. To get access to the complete pancreatic head, the gastroepiploic vessels need to be divided and the right colon flexure should be mobilized into the lower abdomen.

In contrast to an oncologic lymph node dissection, the hepatoduodenal ligament does not need to be dissected and the anatomical structures do not need to be explored. The gallbladder is removed in the typical fashion.