Chronic Pancreatitis — Surgical Management

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?

A 52-year-old man with a 15-year history of alcohol-induced chronic pancreatitis presents with severe, intractable epigastric pain radiating to the back, unresponsive to medical management for 6 months. On examination, he is cachectic (BMI 18) with mild jaundice. Abdominal ultrasound shows a dilated pancreatic duct (8 mm) with multiple intraductal stones and a normal common bile duct. Fecal elastase is 180 µg/g (normal >500). Endoscopic therapy has been attempted twice without sustained relief. What is the most appropriate surgical intervention?

A 48-year-old woman with alcohol-induced chronic pancreatitis presents with recurrent episodes of acute-on-chronic pancreatitis, severe pain, and a 10 cm pseudocyst in the pancreatic body compressing the stomach. Endoscopic ultrasound-guided cyst drainage was attempted 3 weeks ago but the cyst has re-accumulated. She has no history of diabetes. On imaging, the pancreatic duct is 5 mm (normal), and there is no evidence of malignancy. What is the most appropriate surgical management?

A 48-year-old woman with chronic pancreatitis secondary to idiopathic ductal stricture presents with intractable pain despite 8 weeks of optimized medical therapy (pancreatic enzyme supplements, fat-soluble vitamins, analgesics). CT shows a 4 mm pancreatic duct with severe parenchymal atrophy affecting the body and tail. The head is spared. Endoscopic therapy is contraindicated due to altered anatomy from prior gastric surgery. Laboratory tests show fasting glucose 198 mg/dL and 72-hour fecal fat 18 g/day. What is the most appropriate surgical intervention?

A 52-year-old man with a 15-year history of alcohol use presents with chronic epigastric pain radiating to the back, unresponsive to medical management for the past 6 months. He has lost 8 kg over 3 months and reports steatorrhea. Imaging shows a dilated pancreatic duct (8 mm) with multiple stones and a 3 cm pseudocyst in the pancreatic head. Serum amylase and lipase are normal. His fasting blood glucose is 156 mg/dL. Endoscopic therapy has been attempted twice without success. What is the most appropriate surgical intervention?