Surgical management of chronic pancreatitis: current concepts and future perspectives.

Initial management of chronic pancreatitis is always conservative. All forms of nonsurgical intervention should be exhausted before surgery. Main indications for surgery in chronic pancreatitis are intractable pain, suspicion of malignancy, and complications from adjacent organs. Preoperative evaluation should include an evaluation of the severity of pain, interference of quality of life, and presence of chemical dependency and imaging examinations to determine the primary site of disease, presence of pancreatic ductal dilatation, and associated peripancreatic complications. The surgical treatment approach involves proximal or distal resection (depending on the main location of the disease) for small-duct disease and lateral pancreaticojejunal drainage for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey and thoracoscopic transthoracic splanchnicectomy await good confirmatory, independent trials to confirm their efficiency in the surgical management of chronic pancreatitis. The V-shaped excision of ventral pancreas in association with a lateral pancreatojejunostomy is also an interesting alternative in the management of small-duct disease that is also under investigation. In recent years, a clear trend in favor of resectional procedures (including the newer nonanatomic pancreatic resections) has been observed.