Frey procedure in pediatric chronic calcific pancreatitis: a single-centre case series

Abstract

Chronic pancreatitis in children is an uncommon but debilitating disorder characterized by recurrent abdominal pain, pancreatic ductal abnormalities, calcification, and progressive loss of pancreatic function. Although medical and endoscopic therapies are useful in selected patients, persistent pain, recurrent pancreatitis, ductal obstruction, pancreatic calculi, and impaired quality of life may necessitate surgical intervention. The Frey procedure, combining pancreatic head coring with longitudinal pancreaticojejunostomy, provides pancreatic ductal decompression while preserving pancreatic tissue and function. Published pediatric experience remains limited. The aim of the study is to describe the clinical presentation, indications, operative findings, technical challenges, postoperative complications, and follow-up outcomes of children with chronic pancreatitis managed with the Frey procedure. A single-centre retrospective case series of six pediatric patients with chronic pancreatitis who underwent surgical management with the Frey procedure. Clinical records were reviewed for age, etiology, previous endoscopic interventions, imaging findings, indications for surgery, operative findings, postoperative complications, pain, quality of life, and follow-up outcomes. Particular attention was given to pancreatic duct morphology and technical challenges encountered during surgery. The patients ranged from 6 years 4 months to 13 years of age. Etiologies included idiopathic disease and pancreas divisum. Several patients had chronic calcific pancreatitis with pancreatic ductal calculi and ductal dilatation. Recurrent pancreatic-type abdominal pain was the principal indication for surgery, and some patients had previously undergone ERCP and pancreatic duct stenting. Imaging demonstrated pancreatic atrophy, calcification, ductal dilatation, pancreatic calculi, and pseudocyst formation in individual cases. One child had a non-dilated pancreatic duct measuring less than 2 mm with splenic vein thrombosis and left-sided portal hypertension, creating a major technical challenge. Postoperative complications included pancreatic fistula in one patient and transient blood-stained drain output in another. One patient developed a lower common bile duct stricture with jaundice three years after surgery, which was managed with PTBD following failed ERCP. At six years of follow-up, this patient remained asymptomatic. Follow-up in the other patients demonstrated improvement in pain and quality of life. The Frey procedure appears to be a feasible organ-preserving surgical option for carefully selected children with chronic pancreatitis and debilitating pain, particularly those with calcific disease, ductal obstruction, pancreatic calculi, or failure of endoscopic management. The series also highlights the technical challenges encountered in young children with an atrophic or minimally dilated pancreatic duct and associated portal hypertension. Larger multicentre studies with standardized assessment of pain, pancreatic function, quality of life, and long-term outcomes are required.