Key Words: bile duct obstruction, biliary drainage, obstructive jaundice, endoscopic drainage

Transcription

1 HPB, 2007; 9: PRESIDENTIAL ADDRESS Stent versus surgery DIRK J. GOUMA Abstract Following the introduction of percutaneous and endoscopic biliary drainage there has been an ongoing debate about the indications and outcomes of endoscopic versus surgical drainage in a variety of bilio-pancreatic disorders. The evidencebased literature concerning four different areas of pancreatobiliary diseases have been reviewed. Preoperative endoscopic biliary drainage in patients with obstructive jaundice should not be used routinely but only in selected patients. For patients with biliary leakage and bile duct strictures after a laparoscopic cholecystectomy, endoscopic stent therapy might be first choice and surgery should be used for failures of endoscopic treatment. Surgery is the treatment of choice after transection of the bile duct (the major bile duct injuries). The majority of patients with obstructive jaundice due to advanced pancreatic cancer will undergo endoscopic drainage but for relatively fit patients with a prognosis of more than 6 months, surgical drainage or even palliative resection might be considered. For patients with persistent pain due to chronic pancreatitis surgical drainage combined with limited pancreatic head resection might be first choice for pain relief. Most importantly, the management of patients with these pancreatobiliary diseases should be performed by a multidisciplinary HPB approach and teamwork consisting of gastroenterologists, radiologists and surgeons. Key Words: bile duct obstruction, biliary drainage, obstructive jaundice, endoscopic drainage Introduction Following the introduction of percutaneous and endoscopic drainage techniques for the biliary tract and more recently the pancreatic duct there has been an ongoing debate worldwide regarding the indications for endoscopic/percutaneous versus surgical drainage in a variety of bilio-pancreatic disorders. Traditionally the AMC in Amsterdam had a very active Department of Gastroenterology under the leadership of Professor Guido Tytgat and Professor Kees Huibregtse and excellent interventional radiology under Professor Han Laméris, and therefore both minimally invasive techniques and surgery were used with good cooperation during the past decades. This presidential lecture is an opportunity to review the evidence-based literature concerning these different drainage approaches for several HPB disorders such as:. obstructive jaundice and the role of preoperative biliary drainage;. endoscopic and surgical management of biliary stricture and bile duct injury;. endoscopic versus surgical palliative treatment of pancreatic carcinoma; and finally,. the use of both drainage procedures in patients with chronic pancreatitis. We should realize that the implementation of these findings in daily HPB practice is mainly dependent on the local expertise of the different partners in the multidisciplinary HPB approach. Obstructive jaundice and preoperative biliary drainage Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor as well as a proximal bile duct tumor (Klatskin tumor) is associated with a higher risk of postoperative complications than in non-jaundiced patients. The increased risk of surgery in jaundiced patients had already been recognized in 1935 by Allen O. Whipple, who proposed a two-stage procedure for surgery in deeply jaundiced patients [1]. After the introduction of percutaneous and endoscopic drainage, Correspondence: Prof. dr. Dirk J. Gouma, MD, Department of Surgery, Academic Medical Center, PO Box 22660, 1100 DD Amsterdam, The Netherlands. Tel: Fax: d.j.gouma@amc.nl Presidential lecture: EHPBA, Verona 69 June (Received 1 October 2007; accepted 4 October 2007) ISSN X print/issn online # 2007 Taylor & Francis DOI: /

2 Table I. The potential benefits and adverse effects of preoperative biliary drainage in patients with obstructive jaundice.. Potential benefit: Decreases bilirubin level/improves liver function Improves nutritional status/immune function Reduces endotoxaemia and TNF/IL-6 release Treatment of biliary infection (cholangitis) Assessment of intraductal extent of tumor (proximal bile duct carcinoma). Adverse effects: Cholangitis (prolongs hospital stay) Morbidity of drainage procedure Secondary infection (postoperative) leading to postoperative sepsis and leakage Stent versus surgery 409 ERCP/PTC and subsequent drainage was included in the routine diagnostic work-up in several countries [24]. Internal biliary drainage has been shown to improve liver function and nutritional status, to reduce systemic endotoxaemia and cytokine release, and subsequently to improve immune response in multiple experimental models [59] (Table I). A number of non-randomized studies on internal drainage reported a reduced mortality and morbidity. However, other clinical studies and small randomized trials could not confirm the positive effect of preoperative biliary drainage (PBD) on outcome [1012]. Some studies even reported a deleterious effect, partly due to complications associated with the drainage procedure [4,13,14]. We found that around 90% of patients with obstructive jaundice in The Netherlands currently undergo preoperative drainage. In the light of the ongoing controversy regarding preoperative drainage, a meta-analysis of randomized clinical trials and comparative studies was performed [15]. No difference in mortality could be detected between the two strategies, but the overall complication rate in patients who underwent preoperative drainage was significantly higher compared with direct surgical treatment, 57% and 42%, respectively. Unfortunately, most of these studies have methodological flaws. A few studies used external (percutaneous) drainage only (no restoration enterohepatic cycle), different tumors and levels of obstruction (Klatskin tumors and pancreatic tumors) were included, there was a wide range of drainage period (from 10 to 32 days), and different types of operation were compared (bypass vs resection). Therefore, a prospective randomized trial addressing the effects of PBD on patients with obstructive jaundice due to distal obstruction is currently being performed as a multicentre study in The Netherlands [16]. The study design and protocol have been published and 210 patients should be included. An independent safety committee recently analysed the data after inclusion of 105 patients (50%). The treatment in both arms pylorus-preserving pancreaticoduodenectomy (PPPD) (71% vs 64%) and bypass (30% vs 33%) was not different. Mortality and complications rate in both groups did not lead to early closure of the trial and we are awaiting the final results. The outcome of this study will probably have consequences for the time interval for diagnostic work-up, the waiting time for surgery and referral pattern. The strategy for proximal lesions is even more difficult. Most authors agree that at least extended liver resection should not be performed in severely jaundiced patients and they need drainage of the remnant lobe. The percutaneous or endoscopic approach to these patients is still a matter of local expertise and might be an important subject for a trial for the future, because there are no data to compare both techniques. Endoscopic and surgical management of biliary stricture and bile duct injury Bile duct injury (BDI) after laparoscopic cholecystectomy remains a major problem in current surgical practice. BDI is associated with poor survival, increased morbidity, and impaired quality of life [17,18]. Timing of treatment and treatment strategy in terms of a surgical reconstruction versus endoscopic and percutaneous drainage and dilatation procedures are still subject to debate [19,20]. Management is of course partly dependent on the type of injury [21]. According to the Amsterdam classification, type A and B lesions (leakage of cystic duct and leakage of the bile duct) will primarily be treated by endoscopy. Type D lesions (transection of the bile duct) nearly always need surgical reconstruction [19,2224]. Controversy still exists as to the management of type C lesions (strictures) [2025]. Due to the nature of the lesions, the unpredictable diagnostic work-up and initial management in regional hospitals and variable referral pattern, as well as different types of injury, a randomized study might not be expected. In a prospective cohort study 500 patients referred to our centre were analysed in terms of internal referral pattern and final treatment [26]. The referral pattern of BDI patients from the initial hospital to the tertiary center is summarized in Figure 1. The initial referral rate to the Departments of Gastroenterology, Surgery and Radiology was 66%, 29% and 5%, respectively. The referral rate within the tertiary centre, between different departments, ranged from 7% (from gastroenterology to radiology) to 40% (from radiology to surgery). In all, 160 patients (32%) underwent a definitive surgical treatment, whereas endoscopy was the definitive treatment in 264 patients (53%) and a radiologic intervention in 58 patients (12%). Eighteen patients (4%) did not receive additional interventional treatment after referral.

3 410 D.J. Gouma Department to which BDI patients are referred Surgery n = % Gastroenterology n =329 66% Radiology n =25 5% (22.6%) (15.1%) (18.8%) (7.0 %) (40.0%) Internal referral rates (62.3%) (74.2%) (60.0%) Surgery n = % Gastroenterology n = % Radiology n =58 12% Department that performed the definitive treatment for BDI Figure 1. Referral pattern of BDI patients within the AMC (adapted from Surgery 2007, 42). The hospital mortality was 0.4% (n2), and after a mean follow-up period of years, 42 patients had died (8.4%), a relatively low mortality compared with the study from Flum et al. [17]. In 10 of 42 patients who died, death was related to the biliary injury. Endoscopic stent therapy as a final treatment was performed in 93 patients with persistent leakage of the bile duct (including leakage of the cystic duct, n67) and 110 patients underwent stenting for a bile duct stricture [27]. The overall long-term success rate (mean follow-up 4.5 years) was 95% for patients with bile leakage and 74% for patients with strictures. The mean duration of stents in situ was 2 months and 11.5 months, respectively (Table II). Independent predictors for outcome were injuries classified as Bismuth III and IV type, endoscopic stenting before referral and the number of stents inserted at the first procedure. We concluded that endoscopic stenting is the treatment of first choice for these lesions. Surgery is indicated after failure (6 months) of stenting. As mentioned, surgical reconstruction by a hepaticojejunostomy has to be performed for nearly all type D lesions as well as failures of endoscopic management. Recently the long-term outcome of 151 patients (mean follow-up 5.3 years) who underwent reconstruction by a hepaticojejunostomy was analysed [28]. The in-hospital mortality was zero, surgical complications were found in 29 patients (19%) and 14 patients (3%) developed a stricture at the anastomosis after a mean follow-up period of 4.5 years. In summary, reconstructive surgery has excellent short-term as well as long-term outcome for patients with major BDI (transection of the bile duct). Endoscopic stenting is the primary treatment for patients with bile leakage and strictures; surgery is still indicated after failure of endoscopy. Stenting versus bypass or resection as palliative treatment of pancreatic carcinoma Unfortunately the majority of patients with pancreatic carcinoma will have palliative treatment and the three most important symptoms that should be treated in advanced pancreatic and periampullary cancer are obstructive jaundice, duodenal obstruction and pain. Biliary drainage can be achieved nonsurgically by placement of a biliary stent (endoscopically or percutaneously) or surgically by performing a biliary bypass. The success rate for short-term relief of biliary obstruction is comparable for both surgical and non-surgical drainage procedures and varies Table II. Endoscopic stent therapy in bile duct injury patients with biliary leakage and bile duct stricture. Bile duct leakage Bile duct stricture Parameter n93 % n110 % Number of stent changes, median (range) 1 (05) 4 (012) Mean duration of stents in situ, months (9SD) 2 (1.8) 11.5 (9.4) Number of patients with a stent-related complication Referred for surgery Subsequent stenting for recurrence of stenosis Mortality related to BDI Successful endoscopic stenting

4 between 90 and 100%. Randomized studies (relatively older studies performed between 1988 and 1994) comparing surgical biliary drainage and endoscopic drainage showed that surgical treatment is associated with higher early morbidity, a longer hospital stay and higher mortality, but long-term results are better. Endoscopic treatment is associated with more long-term complications such as cholangitis, clotting of stents and gastic outlet obstruction [2933]. In a more recent randomized study Nieveen et al. compared a Wallstent versus a surgical bypass (hepaticojejunostomy and gastroenterotomy) in patients with pathology proven metastasis after a diagnostic laparoscopy [34]. Survival and hospital-free survival were longer after surgery compared with stenting (192 days vs 116 days, respectively), but this was a selected group of relatively fit patients. The new development of duodenal stenting for gastric outlet obstruction might change the indication for bypass surgery [35]. Currently palliative resection is also performed in a selected group of patients with limited liver or peritoneal metastasis, and a recent study showed a mean survival of 15 months and acceptable morbidity and mortality [36]. These encouraging results of palliative resection might also be due to a selection bias. A well conducted controlled trial of the role of palliative resection is still not available. In summary, endoscopic treatment will still be indicated in the majority of patients; however, surgical palliation with a bypass procedure or even with a palliative resection might be preferred in a selected group of relatively fit patients. Endoscopic and surgical drainage in chronic pancreatitis Management of pain in chronic pancreatitis, particularly chronic pain, that is insufficiently relieved by medication (requiring opiates) remains a therapeutic dilemma. In patients with ductal obstruction, as well as an inflammatory mass of 4 cm, a combined resection and drainage procedure is generally accepted [37,38]. In patients with obstruction and a stricture/stones in the pancreatic duct but without an inflammatory mass in the pancreatic head, endoscopic and surgical drainage have both been used frequently [39]. Reviewing the endoscopic treatment and summarizing the results from the literature from 11 studies with more than 30 patients (n 2319), stenting is associated with 74% complete or partial pain relief (mean follow-up 40 months) and 11% proceeded to surgery. Surgical drainage by lateral pancreaticojejunostomy summarizing 16 studies with more than 20 patients (n 889) is associated with 80% complete or partial Stent versus surgery 411 pain relief, after a mean follow-up period of 63 months, with a mortality of 1.1%. Recently we conducted a randomized trial comparing endoscopic and surgical drainage with respect to the outcome of pain relief, morbidity, quality of life and pancreatic function. This study showed that patients who underwent surgery, as compared with those who were treated endoscopically, had lower Izbicki pain scores (25 vs 51, p B0.001) and better physical health summary scores on the Medical Outcomes Study 36-Item Short-Form General Health Survey questionnaire (p 0.003). At the end of follow-up, complete or partial pain relief was achieved in 32% of patients assigned to endoscopic drainage as compared with 75% of patients assigned to surgical drainage (p 0.007). Patients receiving endoscopic treatment required more procedures than did patients in the surgery group [40]. The benefits of surgery were demonstrated by more rapid, effective and sustained pain relief (Figure 2). Even with more aggressive endoscopic management patients will suffer pain during the relatively long treatment period, as shown in our study. This study led to comments about the surgical and endoscopic treatment. We should realize that surgical treatment was limited to drainage of the duct and not the pancreatic head area and the uncinate process. Indeed four randomized studies comparing different and more extended drainage procedures with limited resection or standard PPPD showed further improved results after more extended treatment up to pain relief between 94% and 100% [4144] (Table III). However, during the trial we were limited to drainage by pancreaticojejunostomy instead of the more commonly used Frey procedure that we are using routinely after closing the trial. This study was also led to comments about the drawbacks of the endoscopic treatment in the trial, such as the relatively short period of endoscopic stenting [45]. Figure 2. Endoscopic versus surgical PD duct drainage: mean Izbicki pain score during follow-up. (Adapted from NEJM, 2007; 356)

5 412 D.J. Gouma Table III. Prospective randomized studies comparing surgical drainage and resection techniques for patients with chronic pancreatitis. Authors Year No. of patients Surgical procedures Follow-up (months) Results Klempa et al. [42] HR vs PD 3666 HR: pain relief 100% (vs 70%), better pancreatic function. Equal mortality and morbidity Büchler et al. [43] HR vs PPPD 6 HR: pain relief 94% (vs 67%), better pancreatic function, morbidity 15% (vs 20%) Izbicki et al. [44] Frey vs PPPD 24 Frey: pain relief 94% (vs 95%), in-hospital complications 19% (vs 53%) Strate et al. [41] Frey vs HR 104 Equal pain relief and pancreatic function HR, pancreatic head resection (Beger); (PP)PD (pylorus-preserving) pancreaticoduodenectomy. Fortunately M. Delhaye and J. Devière, who also performed the lithotripsy in our patients (n 16) recently published another randomized trial [46]. An even less invasive treatment protocol than ours (ESWL only) showed that ESWL was superior in terms of symptom relief and costs to prolonged and aggressive stenting combined with ESWL. They concluded that adding endoscopy and stenting on top of ESWL adds to the costs of care without improving outcome. In the light of the results from that study the criticism of our trial should be reconsidered [45]. We therefore conclude that surgery in patients with advanced symptomatic chronic pancreatitis is more effective than endoscopic treatment. Pain relief is immediate and consistent. Combined surgical drainage with limited pancreatic head resection might further improve results in the near future. Conclusions Summarizing the role of endosopic versus surgical drainage in four different areas of pancreatobiliary disorders it can be concluded that preoperative endoscopic intervention (preoperative biliary drainage) in patients with obstructive jaundice should not be used routinely but only in selected patients. For patients with biliary leakage and bile duct strictures after a laparoscopic cholecystectomy endoscopic stent therapy might be first choice and surgery should be used for failures and is the treatment of choice after transection of the bile duct (the major bile duct injuries). The majority of patients with obstructive jaundice due to advanced pancreatic cancer will undergo endoscopic drainage, but for relatively fit patients with a prognosis of more than 6 months survival, surgical drainage or even palliative resection might be considered. For patients with persistent pain due to chronic pancreatitis, surgical drainage combined with limited pancreatic head resection might be the first choice for pain relief. Most importantly, management of patients with these bilio-pancreatic disorders should be performed by a multidisciplinary HPB approach and teamwork consisting of gastroenterologist, radiologists and surgeons. Acknowledgements and disclosures There are no disclosures. References [1] Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of Vater. Ann Surg 1935;/102:/ [2] Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut 2005;54(Suppl 5):v116. [3] Gouma DJ, Nieveen van Dijkum EJ, Obertop H. The standard diagnostic work-up and surgical treatment of pancreatic head tumours. Eur J Surg Oncol 1999;/25:/ [4] Povoski SP, Karpeh MS Jr, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreatico-duodenectomy. Ann Surg 1999;/230:/ [5] Gouma DJ, Coelho JC, Fisher JD, Schlegel JF, Li YF, Moody FG. Endotoxemia after relief of biliary obstruction by internal and external drainage in rats. Am J Surg 1986;/151:/4769. [6] Roughneen PT, Gouma DJ, Kulkarni AD, Fanslow WF, Rowlands BJ. Impaired specific cell-mediated immunity in experimental biliary obstruction and its reversibility by internal biliary drainage. J Surg Res 1986;/41:/ [7] Gouma DJ, Roughneen PT, Kumar S, Moody FG, Rowlands BJ. Changes in nutritional status associated with obstructive jaundice and biliary drainage in rats. Am J Clin Nutr 1986;/44:/ [8] Gouma DJ, Coelho JC, Schlegel JF, Li YF, Moody FG. The effect of preoperative internal and external biliary drainage on mortality of jaundiced rats. Arch Surg 1987;/122: /7314. [9] Bemelmans MH, Gouma DJ, Greve JW, Buurman WA. Effect of antitumour necrosis factor treatment on circulating tumour necrosis factor levels and mortality after surgery in jaundiced mice. Br J Surg 1993;/80:/ [10] McPherson GA, Benjamin IS, Hodgson HJ, Bowley NB, Allison DJ, Blumgart LH. Pre-operative percutaneous transhepatic biliary drainage: the results of a controlled trial. Br J Surg 1984;/71:/3715. [11] Pitt HA, Gomes AS, Lois JF, Mann LL, Deutsch LS, Longmire WP Jr. Does preoperative percutaneous biliary drainage reduce operative risk or increase hospital cost? Ann Surg 1985;/201:/ [12] Hatfield AR, Tobias R, Terblanche J, Girdwood AH, Fataar S, Harries-Jones R, et al. Preoperative external biliary drainage in obstructive jaundice. A prospective controlled clinical trial. Lancet 1982;/2:/8969.

6 [13] Sohn TA, Yeo CJ, Cameron JL, Pitt HA, Lillemoe KD. Do preoperative biliary stents increase postpancreaticoduodenectomy complications? J Gastrointest Surg 2000;/4: / [14] Sewnath ME, Birjmohun RS, Rauws EA, Huibregtse K, Obertop H, Gouma DJ. The effect of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy. J Am Coll Surg 2001;/192:/ [15] Sewnath ME, Karsten TM, Prins MH, Rauws EJ, Obertop H, Gouma DJ. A meta-analysis on the efficacy of preoperative biliary drainage for tumors causing obstructive jaundice. Ann Surg 2002;/236:/1727. [16] Van der Gaag NA, de Castro SM, Rauws EA, Bruno MJ, van Eijck CH, Kuipers EJ, et al. Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial). BMC Surg 2007;/7:/3. [17] Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA 2003;/290:/ [18] Boerma D, Rauws EA, Keulemans YC, Bergman JJ, Obertop H, Huibregtse K, et al. Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis. Ann Surg 2001;/234:/7507. [19] Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;/180:/ [20] Rauws EA, Gouma DJ. Endoscopic and surgical management of bile duct injury after laparoscopic cholecystectomy. Best Pract Res Clin Gastroenterol 2004; /18:/ [21] Bergman JJ, van den Brink GR, Rauws EA, de Wit L, Obertop H, Huibregtse K, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996;/38:/1417. [22] Sicklick JK, Camp MS, Lillemoe KD, Melton GB, Yeo CJ, Campbell KA, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 2005;/241:/ [23] Strasberg SM, Picus DD, Drebin JA. Results of a new strategy for reconstruction of biliary injuries having an isolated rightsided component. J Gastrointest Surg 2001;/5:/ [24] Thomson BN, Parks RW, Madhavan KK, Wigmore SJ, Garden OJ. Early specialist repair of biliary injury. Br J Surg 2006;/93:/ [25] Costamagna G, Pandolfi M, Mutignani M, Spada C, Perri V. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001;/54:/1628. [26] de Reuver PR, Rauws EA, Bruno MJ, Lameris JS, Busch OR, van Gulik TM, et al. Survival in bile duct injury patients after laparoscopic cholecystectomy: a multidisciplinary approach of gastroenterologists, radiologists, and surgeons. Surgery 2007;/ 142:/19. [27] de Reuver RP, Rauws E, Vermeulen M, Dijkgraaf M, Gouma D, Bruno M. Endoscopic treatment of post-surgical bile duct injuries: long term outcome and predictors of success. Gut 2007;/56:/ [28] de Reuver PR, Grossmann I, Busch OR, Obertop H, van Gulik TM, Gouma DJ. Referral pattern and timing of repair are risk factors for complications after reconstructive surgery for bile duct injury. Ann Surg 2007;/245:/ [29] Bornmann PC, Harries-Jones EP, Tobias R, Van Stiegmann G, Terblanche J. Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for incurable carcinoma of head of pancreas. Lancet 1986;/1:/6971. [30] Shepherd HA, Royle G, Ross AP, Diba A, Arthur M, Colin- Jones D. Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distal common bile duct: a randomized trial. Br J Surg 1988;/75:/ Stent versus surgery 413 [31] Andersen JR, Sorensen SM, Kruse A, Rokkjaer M, Matzen P. Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 1989; /30:/ [32] Smith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB. Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994;/344:/ [33] Telford JJ, Carr-Locke DL, Baron TH, Tringali A, Parsons WG, Gabbrielli A, et al. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcome from a multicenter study. Gastrointest Endosc 2004; /60:/ [34] Nieveen van Dijkum EJ, Romijn MG, Terwee CB, de Wit LT, van der Meulen JH, Lameris HS, et al. Laparoscopic staging and subsequent palliation in patients with peripancreatic carcinoma. Ann Surg 2003;/237:/6673. [35] Taylor MC, McLeod RS, Langer B. Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a meta-analysis. Liver Transpl 2000;/6:/3028. [36] Shrikhande SV, Kleeff J, Reiser C, Weitz J, Hinz U, Esposito I, et al. Pancreatic resection for M1 pancreatic ductal adenocarcinoma. Ann Surg Oncol 2007;/14:/ [37] Ho HS, Frey CF. The Frey procedure: local resection of pancreatic head combined with lateral pancreaticojejunostomy. Arch Surg 2001;/136:/ [38] Beger HG, Kunz R, Poch B. The Beger procedure duodenum-preserving pancreatic head resection. J Gastrointest Surg 2004;/8:/ [39] Dite P, Ruzicka M, Zboril V, Novotny I. A prospective, randomized trial comparing endoscopic and surgical therapy for chronic pancreatitis. Endoscopy 2003;/35:/5538. [40] Cahen DL, Gouma DJ, Nio Y, Rauws EA, Boermeester MA, Busch OR, et al. Endoscopic versus surgical drainage of the pancreatic duct in chronic pancreatitis. N Engl J Med 2007;/ 356:/ [41] Strate T, Taherpour Z, Bloechle C, Mann O, Bruhn JP, Schneider C, et al. Long-term follow-up of a randomized trial comparing the Beger and Frey procedures for patients suffering from chronic pancreatitis. Ann Surg 2005;/241:/ [42] Klempa I, Spatny M, Menzel J, Baca I, Nustede R, Stockmann F, et al. [Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple s operation]. Chirurg 1995; /66:/3509. [43] Büchler MW, Friess H, Muller MW, Wheatley AM, Beger HG. Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg 1995;/169:/659. [44] Izbicki JR, Bloechle C, Broering DC, Knoefel WT, Kuechler T, Broelsch CE. 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. Ann Surg 1998;/228:/7719. [45] Endoscopic versus surgical treatment for chronic pancreatitis. Correspondence. N Engl J Med 2007;356: [46] Dumonceau JM, Costamagna G, Tringali A, Vahedi K, Delhaye M, Hittelet A, et al. Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial. Gut 2007;/56:/54552.