Nationwide Outcome of Tailored Surgery for Symptomatic Chronic Pancreatitis based on Pancreatic Morphology: Validation of the International guidelines

Objective: To determine the nationwide use and outcome of tailored surgical treatment for symptomatic chronic pancreatitis (CP) as advised by recent guidelines. Background: Randomized trials have shown that surgery is superior to endoscopy in patients with symptomatic CP, although endoscopy remains popular. Recent guidelines advice to "tailor surgery"is based on pancreatic morphology, meaning that the least extensive procedure should be selected based on pancreatic morphology. However, nationwide and multicenter studies on tailored surgery for symptomatic CP are lacking. Methods: Nationwide multicenter retrospective analysis of consecutive patients undergoing surgical treatment for symptomatic CP in all 7 Dutch university medical centers (2010-2020). Outcomes included volume trend, major complications, 90-day mortality, postoperative opioid use, and clinically relevant pain relief. Surgical treatment was tailored based on the size of the main pancreatic duct and pancreatic head (eg, surgical drainage for a dilated pancreatic duct and normal size pancreatic head). Results: Overall, 381 patients underwent surgery for CP: 127 surgical drainage procedures (33%; mostly extended lateral pancreaticojejunostomy), 129 duodenum-preserving pancreatic head resections (34%, mostly Frey), and 125 formal pancreatic resections (33%, mostly distal pancreatectomy). The annual surgical volume increased slightly (Pearson r=0.744). Mortality (90-d) occurred in 6 patients (2%) and was nonsignificantly lower after surgical drainage (0%, 3%, 2%; P=0.139). Major complications (12%, 24%, 26%; P=0.012), postoperative pancreatic fistula grade B/C (0%, 3%, 22%; P=0.038), surgical reintervention (4%, 16%, 12%; P=0.006), and endocrine insufficiency (14%, 21%, 43%; P<0.001) occurred less often after surgical drainage. After a median follow-up of 11 months (interquartile range: 3-23), good rates of clinically relevant pain relief (83%, 69%, 80%; P=0.082) were observed and 81% of opioid users had stopped using (83%, 78%, and 84%; P=0.496). Conclusions: The use of surgery for symptomatic CP increased over the study period. Drainage procedures were associated with the best safety profile and excellent functional outcome, highlighting the importance of tailoring surgery based on pancreatic morphology.