Free ABSITE Sample Questions

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First Free ABSITE Sample Question

A 55-year-old man with a history of chronic pancreatitis presents for evaluation of surgical treatment options. MRCP demonstrates a large inflammatory mass in the head of the pancreas with no evidence of distal ductal dilatation. Endoscopic ultrasonography with fine-needle aspiration does not demonstrate any evidence of malignancy. Which of the following procedures is correctly matched to its description and is the most appropriate treatment option?

• A) Puestow procedure; distal pancreatectomy
• B) Frey procedure; longitudinal pancreaticojejunostomy
• C) Whipple procedure; distal pancreatectomy
• D) Bern procedure; coring out of the pancreatic head plus longitudinal pancreaticojejunostomy with a Roux-en-Y pancreaticojejunostomy
• E) Beger procedure; resection of pancreatic head with a Roux-en-Y jejunal loop as side-to-end and side-to-side pancreaticojejunostomy

The Answer and Explanation

The correct answer is: E

The Beger procedure is a duodenum-preserving pancreatic head resection procedure. The pancreatic head is dissected to the level of the portal vein, and cored out, leaving behind a thin rim of pancreatic tissue abutting the duodenum. This is then reconstructed with 2 anastomoses using a Roux-en-Y jejunal loop to the pancreatic tail remnant (end-to-side) and to the excavated pancreatic head (side-to-side). This is typically reserved for patients with a large inflammatory mass in the head of the pancreas with no evidence of distal ductal dilatation. The lack of distal ductal dilatation is key in selecting the Beger procedure over other surgical approaches, as this makes the end-to-side pancreaticojejunostomy the most appropriate anastomosis.

The diagram below illustrates a Beger procedure:

Incorrect Answer Explanations

Answer A: The Puestow procedure (illustrated below) is a longitudinal pancreaticojejunostomy (not a distal pancreatectomy). This is typically reserved for chronic pancreatitis with dilatation of the pancreatic duct (≥ 7 mm). The Puestow procedure has an 80% rate of immediate pain relief, with about 60% of patients achieving long-term pain relief.

Answer B: The Frey procedure (illustrated below) involves coring out the head of the pancreas with a longitudinal dissection of the pancreatic duct toward the tail. The reconstruction is subsequently performed with a Roux-en-Y pancreaticojejunostomy. This is typically reserved for smaller inflammatory masses of the head of the pancreas and dilated pancreatic ducts. Again, the distal duct dilatation of ≥ 7 mm is key in the selection of any procedure that includes a longitudinal pancreaticojejunostomy (ie, Puestow or Frey procedure).

Answer C: The Whipple procedure, or pancreaticoduodenectomy (illustrated below), entails resection of the pancreatic head, duodenum, and distal one-third of the stomach. Reconstruction requires a gastrojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy. The Whipple procedure is typically reserved for neoplasms of the head of the pancreas. In the setting of chronic pancreatitis, pancreaticoduodenectomy is rarely required unless malignancy cannot be excluded.

Answer D: The Bern procedure (illustrated below) is a modification of the Beger procedure that does not involve resection of the pancreatic head. In contrast to the Beger procedure, the pancreas is not transected at the level of the portal vein, which may be advantageous in the setting of extensive inflammation. Reconstruction only requires a single anastomosis with a Roux-en-Y jejunal loop to the pancreas. There is no significant difference in outcomes between the Beger and Bern procedures.

Bottom Line

The Beger procedure is a duodenum-preserving pancreatic head resection procedure, which is reconstructed with 2 anastomoses using a Roux-en-Y jejunal loop to the pancreatic tail remnant (end-to-side) and to the excavated pancreatic head (side-to-side). This is typically reserved for patients with a large inflammatory mass in the head of the pancreas with no evidence of distal ductal dilatation.

TrueLearn Insight

The choice of surgical approach in a patient with chronic pancreatitis is largely dependent on 2 key factors: 1) distal ductal dilatation ≥ 7 mm. 2) pancreatic head involvement (ie, by mass or significant inflammation/fibrosis). Though it is more nuanced, one may simplify the selection process as follows:

• For dilated duct with head involvement – choose the Frey procedure
• For a normal or small duct with head involvement – choose the Beger or Bern procedures
• For a dilated duct without head involvement – choose the Puestow procedure

For more information, see:

Dudeja V, Christein JD, Jensen EH, and Vickers SM. Chapter 55: Exocrine Pancreas. In: Townsend C, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Elsevier; 2017:1520-1555.

Hartwig W, Koliogiannis D, Werner J. Chapter 58: Management of chronic pancreatitis: conservative, endoscopic, and surgical. In: Jarnagin WR, Allen PJ, Chapman WC, et al, eds. Blumgart’s Surgery of the Liver, Biliary Tract, and Pancreas. 6th ed. Elsevier; 2017:927-937.e3.

Strobel O, Büchler MW, Werner J. Surgical therapy of chronic pancreatitis: indications, techniques and results. Int J Surg. 2009;7(4):305-12.

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