Surgery of chronic pancreatitis: Chronicle of confusion and despair

The evolution of surgery for pancreatitic disease has been arduous owing to the technical difficulties of addressing the organ and the lack of understanding the mechanisms of the disease processes involving it. In particular, the tardy advance of surgery in the management of chronic pancreatitis exemplifies these problems. Because no specific target has been identified, mechanical intervention has for the most part reflected intuitive or creative attempts to address perceived pathologic issues such as sphincter disease, calculi, and fibrotic masses. The past and present remain a confusion of etiologies and diagnoses. Treatment remains for the most part a dramatically disappointing scenario, and both patients and their physicians are frustrated. Although the remarkable technologic progress exhibited by the odyssey of operative strategy from simple drainage, to ductal drainage, to the complex refinements of extensive resection is a testimonial to surgical skill and determination, it has been nullified to a large extent by the inability to address the initiating factors of the disease or alter those that engender progress of the pathology. It is not unreasonable to recognize that we are facing an enigmatic disease process generically classified as “chronic pancreatitis” for want of any more specific terminology. In the light of our current knowledge and experience, intervention should probably be modest in the extreme and limited to centers and individuals with expertise or who are involved in specific studies to determine the precise criteria and techniques necessary for optimum intervention. It is important that when charting such a course future surgeons involved in the management of chronic pancreatitis have an understanding of the historical evolution of the subject. As Theodor Billroth, the greatest of the surgical innovators remarked: “An awareness of the past is necessary to comprehend the present, and without it no consideration of the future is possible.”