REOPERATIONS AFTER FREY PROCEDURE FOR CHRONIC PANCREATITIS

Abstract

Background and Aims: Frey procedure is coring out of the pancreatic head associated with longitudinal pancreaticojejunostomy which is easier to perform and less invasive to the patients with chronic pancreatitis. However, long time follow up may reveal localized inflammation may relapse and in some cases reoperation is required. The clinical background and appropriate reoperative procedure will be discussed. Patients and Methods: Frey procedure is performed in our department for the patients with chronic calcifying pancreatitis who has dilated main pancreatic duct since 1992. The coring out of the pancreatic head is not as radical as the original method but sufficient enough to drain the complicated ductal system. The main pancreatic duct is incised as far as possible toward the tail. All stone in the main duct was removed while the stones incarcerated into the branches were not removed. Patients were supplemented with digestive enzymes and insulin if required. Annual inquiries were sent to the patients to assess the quality of life and drinking status. Results: Out of 50 patients who underwent Frey procedure from 1992 to 2005, two patients had early complications (4.0%). One had perforation of gastric ulcer and cured conservatively, while the other had intraductal hemorrhage which required interventional angiography and subsequent operative hemostasis. Five cases (10.0%) required reoperations during the follow up period. The most common cause of reoperation was relapsing abscess or cyst formation at the splenic hilum in four cases, three of whom underwent resection of undrained pancreatic tail at 11 to 18 months after Frey procedure. The blind end of the jejunal loop for longitudinal pancreaticojejunostomy was reused to cover the stump of the pancreas. Another patient underwent cystojejunostomy for the pseudocyst at the pancreatic tail. Another cause of reoperation was relapsing cholangitis in a patient with marked dilatation of the common bile duct before Frey procedure. This patient underwent choledochoduodenostomy after 20 months from the Frey procedure. All late reoperative cases were alcoholic and could not stop drinking. Rest of the cases is doing well though more than half of them are still drinking. Discussion: Long time outcome of Frey procedure is sufficient enough to improve the quality of life of the patients with chronic pancreatitis. Pseudocyst at the splenic hilum is the most frequent cause of late-onset relapse and can be the cause of reoperation. Resection of the pancreatic tail with jejunal coverage was performed successfully at the reoperation. Cessation of drinking is critical to prevent the relapse of localized inflammation. Additional pancreatic tail resection with Frey procedure may be suggested if stones are impacted in the very distal tail branches. Conclusion: Frey procedure has good long-term outcome if the drainage of the branches are sufficient. Reoperation should be performed if the patient cannot stop drinking and has relapsing inflammation. Resection of the undrained pancreatic tail is useful at the reoperation in order to preserve the pancreatic parenchyma.