A 58-year-old man with a 20-year history of chronic pancreatitis presents with epigastric pain, steatorrhea, and weight loss. Imaging shows a dilated pancreatic duct with multiple strictures and calcifications. He has failed conservative management. Which surgical procedure would provide the best long-term pain relief and preserve maximum pancreatic parenchyma?

Explanation

## Surgical Management of Chronic Pancreatitis **Lateral pancreaticojejunostomy (Puestow procedure)** is the gold standard for pain relief in chronic pancreatitis with a dilated pancreatic duct (>7 mm) and ductal obstruction. ### Key Point: - **Indications for Puestow**: Dilated main pancreatic duct, strictures, calcifications, failed medical therapy - **Mechanism**: Creates a wide anastomosis between the opened pancreatic duct and jejunum, decompressing the gland - **Advantage**: Preserves maximum pancreatic parenchyma, avoiding endocrine and exocrine insufficiency - **Success rate**: 70–80% pain relief at 5 years ### Why Other Options Are Inferior: - **Whipple**: Reserved for malignancy or uncorrectable duodenal obstruction; destroys significant pancreatic tissue - **Distal pancreatectomy**: Causes diabetes and malabsorption; reserved for distal duct obstruction or tail pathology - **Total pancreatectomy with islet autotransplantation**: Experimental; reserved for failed previous surgery or severe intractable pain; high morbidity ### Clinical Pearl: The **modified Puestow (Partington-Rochelle)** procedure (opening the duct without sphincteroplasty) is equally effective and technically simpler.