Question

A 50 year old patient presents with a 2 year history of recurrent abdominal pain radiating to the back, relieved only by parenteral analgesics. This time the pain is severe and radiating to the back. The appropriate treatment procedure is?

• A. Vagotomy with gastroduodenostomy
• B. Vagotomy with antrectomy
• C. Whipple procedure
• D. Longitudinal pancreaticojejunostomy

Hint:

Chronic pancreatitis with a dilated duct needs a drainage operation, not a resection.

Answer 1

The Correct Option is D

Step 1: Identify the diagnosis. Chronic, recurrent epigastric pain radiating to the back over years, severe enough to need parenteral analgesics, is the classic presentation of chronic pancreatitis.
Step 2: Determine the surgical principle. When chronic pancreatitis is associated with a dilated main pancreatic duct, the surgical aim is ductal drainage (decompression) to relieve pain.
Step 3: Choose the correct procedure. A longitudinal (lateral) pancreaticojejunostomy, the Puestow / Partington-Rochelle procedure, opens the dilated duct along its length and anastomoses it to a jejunal loop, draining the duct and relieving pain while preserving pancreatic tissue.
Step 4: Eliminate the other options. Vagotomy with gastroduodenostomy and vagotomy with antrectomy are operations for peptic ulcer disease, not chronic pancreatitis. The Whipple procedure (pancreaticoduodenectomy) is a major resection reserved for head masses or suspected malignancy, not for drainage of a dilated duct in benign chronic pancreatitis.
Step 5: Conclusion. Longitudinal pancreaticojejunostomy is the appropriate procedure.