Frey procedure may yield better outcomes in chronic pancreatitis

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1. For patients with chronic pancreatitis, the Frey pancreatic resection yielded better physical status, appetite and body weight outcomes compared to pylorus-preserving pancreatoduodenectmy (PPPD). 

2. Post-PPPD, patients had a shorter survival and died at a younger age compared to patients who underwent the Frey procedure. 

Evidence Rating Level: 1 (Excellent)       

Study Rundown: Patients with chronic pancreatitis experience chronic pain and have life spans that are 10-20 years shorter than expected. After initial conservative medical treatment, persistent pain is an indication for surgical intervention. This study examined long-term mortality, pancreatic function and quality of life in patients randomized to undergo PPPD or the Frey procedure. Length of survival as well as some quality of life and symptom outcomes were significantly better following the Frey procedure. That said, the majority of patient-reported measures were similar between the two procedures. The Frey group had 66% smokers while 80% of PPPD patients smoked – a substantial difference that likely contributed to prolonged survival in the Frey group. Additionally, 20% of patients either died from diseases unrelated to chronic pancreatitis such as lung cancer or had unclear causes of death. This study is the first RCT to directly compare these two procedures and boasts long follow-up times as well as excellent patient retention (only 1 patient dropped out). A limitation of this study is small sample size, which precluded statistical analysis of multiple factors including smoking history and cause of death.

Click to read the study in Annals of Surgery

Relevant Reading: Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy

In-Depth [randomized control trial]: This study enrolled 60 patients with pancreatitis-induced recurrent intractable pain to receive either PPPD or the Frey procedure. In short, PPPD is a Whipple procedure modified to preserve the pylorus. The Frey operation preserves a portion of the pancreas and attaches the exposed pancreatic duct to a loop of jejunum. Patients were initially followed closely and then reassessed at a median of 15 years after the procedure by clinicians blinded to their procedure assignment.

Almost half of the patients died during follow up. Mean survival was significantly better after the Frey procedure compared to PPPD (14.5 vs. 11.3 years p=0.037), and at time of death patients who underwent the Frey procedure were older than those who received PPPD (56 vs. 53 years old). Both groups had similar analgesic intake requirements and similar levels of pain 15 years after the procedure. On the symptom scale, Frey group patients were more likely to have better outcomes with regard to their appetite and body weight. In terms of quality of life, physical status was much better for patients who underwent the Frey surgery, compared to those who underwent PPPD (100 vs. 60 on 0-100 scale, p=0.011), but other metrics of QOL were not significantly different. Pancreatic exocrine and endocrine function was similarly comparable between the two groups.

By Asya Ofshteyn and Chaz Carrier

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