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

The clinical thread here is a middle-aged patient with years of relapsing upper abdominal pain that bores through to the back and is so intense it only yields to injectable painkillers, which is the textbook profile of chronic pancreatitis. The surgical decision then hinges on the goal of treatment: in chronic pancreatitis with a dilated main pancreatic duct, the strategy is to decompress and drain that duct rather than resect the gland. The operation that accomplishes drainage is the longitudinal (lateral) pancreaticojejunostomy, also called the Puestow or Partington-Rochelle procedure, in which the duct is filleted open along its length and joined to a Roux loop of jejunum, relieving the obstructive pain while sparing functioning pancreatic parenchyma. The remaining choices do not fit. Vagotomy combined with either gastroduodenostomy or antrectomy are classic acid-reducing operations for peptic ulcer disease and have no role in pancreatic ductal pain. The Whipple resection is an extensive operation indicated for head-of-pancreas masses or malignancy, which is overtreatment for a simple drainage problem. Hence the drainage operation is correct.\[\boxed{\text{Longitudinal pancreaticojejunostomy}}\]