Hybrid procedures
In the early 1970s, it was observed that many patients with chronic pancreatitis had an inflammatory mass in the head of the pancreas. The three principal ductal systems (Wirsung duct, Santorini duct, and uncinate process duct) adjoin in the head of pancreas, that may represent the “core”in which the disease begins. Therefore, hybrid approaches that associate partial pancreatic head resection with drainage of the main pancreatic duct were proposed.
In 1972 Beger introduced the duodenum-preserving pancreatic head resection. By subtotal resection of the pancreatic head and by preserving the body and tail of the pancreas, pylorus, duodenum, and extra-pancreatic bile ducts, this operation preserves the normal anatomy of the upper gut and the normal passage of food. The intention of this operation is to treat only the enlarged pancreatic head. Reconstruction involves an end-to-side pancreaticojejunostomy and a side-to-side pancreaticojejunostomy. If necessary, the body and the tail can be drained via a longitudinal pancreaticojejunostomy. Immediate relieve of pain has been reported in 80% of patients.
Combining the surgical principles of drainage and organ-preserving resection, Frey introduced in 1987 a modification of the duodenum-preserving pancreatic head resection, the longitudinal pancreatojejunostomy with local pancreatic head resection. Key steps in the performance of the Frey procedure include preservation of the pancreatic neck as well as the capsule of the posterior pancreatic head. The ducts of Wirsung and Santorini are excised, and the excavation is created in continuity with the longitudinal dochotomy of the dorsal duct. The locally excised head of the pancreas is covered with the opened Roux-en-Y limb of jejunum in continuity with the opened main pancreatic duct in the body and tail of the pancreas. Results are similar to those of the Beger procedure.
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