Role of original and modified Frey's procedures in chronic pancreatitis

Table 1 Clinical characteristics of patients

Characteristic	O Frey(n = 44)	M Frey(n = 36)	P value
Age (yr)	46 ± 12.5	48 ± 8.4	0.560
Sex			0.130
Male	35	33
Female	9	3
Etiology			0.720
Alcohol	22	21
Nicotine	7	4
Idiopathic	15	11
Pain severity index	3.84 ± 1.14	2.92 ± 1.47	0.020
Exocrine insufficiency	3	0	0.580
Endocrine insufficiency	14	17	0.450
Morphologic characters
Stone of calcification	39	29	0.360
Large cavities (> 10 mm)	7	11	0.120
Gland enlargement (> 2 × normal)	7	9	0.310
Severe organ complications
Obstruction of ductus choledochus	0	2	0.200
Ascites	0	0
Weight loss	13	9	0.650
M-ANNHEIM severity index			0.060
A	1	4
B	29	17
C	12	15
D	2	0
E	0	0
Indication for surgery
Intractable pain	38	28	0.315
Recurrent episodes	2	2
Bile duct stenosis	0	2
Risk of malignancy	4	4
Follow-up time (mo)	50.3 ± 17.3	48.7 ± 15.6	0.670

M Frey: Modified Frey’s procedure; O Frey: Original Frey’s procedure.

Table 2 Short-term results of two types of Frey’s procedures

	O Frey	M Frey	P value
Operating time (min)	230 ± 79	258 ± 65	0.095
Blood loss (mL)	111 ± 79	98 ± 89	0.492
Morbidity
Pancreatic fistula, B and C	0	2	0.199
Postoperative hemorrhage	1	1	1
Pulmonary infection	2	1	1
Abdominal infection	4	4	1
Mortality	0	0	\
Postoperative hospital stay (d)	8.3 ± 3.1	8.6 ± 4.7	0.698

M Frey: Modified Frey’s procedure; O Frey: Original Frey’s procedure.

Table 3 Postoperative risk factors and condition of pancreatic function

Postoperative condition	O Frey(n = 44)	M Frey(n = 36)	P value
Alcohol abuse	3	4	0.387
Nicotine abuse	5	2	0.307
New-onset exocrine insufficiency	8	7	0.886
Worsen exocrine insufficiency	1	1	1.000
New-onset endocrine insufficiency	2	3	0.404
Worsen endocrine insufficiency	5	3	0.475

M Frey: Modified Frey’s procedure; O Frey: Original Frey’s procedure.

Table 4 Postoperative pain relief after two types of Frey’s procedures

History of surgery	Pain symptom	O Frey	M Frey	P value
< 5 yr	Positive	11	17	0.032
	Negative	22	11
> 5 yr	Positive	6	5	0.551
	Negative	5	3

Pain symptom positive: According to the M-ANNHEIM scoring system, the total score of “patient report of pain” and “pain control” is ≥ 3 points; Pain symptom negative: According to the M-ANNHEIM scoring system, the total score of “patient report of pain” and “pain control” is < 3 points. M Frey: Modified Frey’s procedure; O Frey: Original Frey’s procedure.

Table 5 QoL after two types of Frey’s procedures

Follow-up results of QoL assessment	O Frey	M Frey	P value
Functional scales
Physical	95	91	0.113
Role	95	93	0.322
Cognitive	87	83	0.241
Emotional	69	58	0.047
Social	66	53	0.052
Global QoL	62	53	0.115
Symptom scales
Fatigue	28	39	0.028
Nausea and vomiting	0	0
Pain	18	28	0.153
Dyspnea	0	0
Sleep disturbance	4	1	0.294
Appetite loss	30	37	0.297
Constipation	3	1	0.683
Diarrhea	21	26	0.445
Financial impact	32	42	0.120

M Frey: Modified Frey’s procedure; O Frey: Original Frey’s procedure; QoL: Quality of life.

Table 6 Impact of M-ANNHEIM severity index on pain relief after two types of Frey’s procedures

History of surgery	Surgery	Pain symptom	M-ANNHEIM severity		P value
			A, B	C-E
< 5 yr	O Frey	Positive	7	4	0.794
		Negative	15	7
	M Frey	Positive	11	6	0.591
		Negative	6	5
> 5 yr	O Frey	Positive	4	2	0.576
		Negative	4	1
	M Frey	Positive	2	3	0.500
		Negative	2	1

Pain symptom positive: According to the M-ANNHEIM scoring system, the total score of “patient report of pain” and “pain control” is ≥ 3 points; Pain symptom negative: According to the M-ANNHEIM scoring system, the total score of “patient report of pain” and “pain control” is < 3 points. M Frey: Modified Frey’s procedure; O Frey: Original Frey’s procedure.

Table 7 M-ANNHEIM scoring system for the grading of clinical features of chronic pancreatitis

Clinical features		Points
Patient report of pain
No pain without therapy	(patient reports requiring no pain medication)	0
Recurrent acute pancreatitis	(patient reports freedom from pain between attacks of acute pancreatitis)	1
No pain with therapy	(patient reports freedom from pain with pain medication or endoscopic intervention)	2
Intermittent pain	(patient reports intermittent pain-free episodes, either with or without therapy; possibly additional attacks of acute pancreatitis)	3
Continuous pain	(patient reports absence of pain-free episodes, either with or without therapy; possibly additional attacks of acute pancreatitis)	4
Pain control1
No medication		0
Use of non-opioid drugs or use of mild opioids (WHO step 1 or 2)		1
Use of potent opioids (WHO step 3) or endoscopic intervention		2
Surgical intervention12
Pancreatic surgical intervention for any reason		4
Exocrine insufficiency3
Absence of exocrine insufficiency		0
Presence of mild, moderate, or unproven exocrine insufficiency not requiring enzyme supplementation (including patient reports of intermittent diarrhea)		1
Presence of proven exocrine insufficiency (according to exocrine function tests) or presence of marked exocrine insufficiency defined as steatorrhea (> 7 g fac/24 h), normalized or markedly reduced by enzyme supplementation		2
Endocrine insufficiency
Absence of diabetes mellitus		0
Presence of diabetes mellitus		4
Morphologic status on pancreatic imaging (according to the Cambridge classification)
Normal		0
Equivocal		1
Mild		2
Moderate		3
Marked		4
Severe organ complication2 (not included in the Cambridge classification)
Absence of complications		0
Presence of possibly reversible complication4		2
Presence of irreversible complications4		4

¹The classification of pancreatic pain according to the severity index is done by combining the observed pain patterns together with their treatment interventions. For example, potent opioids (2 points) resulting in intermittent occurrence of abdominal pain (3 points) is 5 points on the severity index;

²Any surgical intervention and any severe complication are included in the calculation of the severity index starting from their first occurrence and continuing during the later course of the disease. Thus, if a patient has two different severe complications, both must be included separately in the calculation of the severity index;

³As tests for pancreatic exocrine function are relatively insensitive for detecting mild or moderate exocrine insufficiency, the presence of intermittent diarrhea and a typical description of the stool, suggestive of chronic pancreatitis, given by the patient (e.g., while, bulky, voluminous, with undigested food present), together with normal test results of exocrine function, are consequently classified as partial pancreatic exocrine insufficiency (1 point);

⁴Reversible severe complications: development of ascites, bleeding, pseudoaneurysm, obstruction or stricture of the ductus choledochus, pancreatic fistula, duodenal stenosis. Irreversible severe complications: portal or splenic vein thrombosis with or without portal hypertension, pancreatic cancer.

Table 8 M-ANNHEIM severity index of chronic pancreatitis

Severity index	Severity level	Point range
M-ANNHEIM A	Minor	0-5
M-ANNHEIM B	Increased	6-10
M-ANNHEIM C	Advanced	11-15
M-ANNHEIM D	Marked	16-20
M-ANNHEIM E	Exacerbated	> 20

M-ANNHEIM scoring system points are added together, and the sum is used to categorize a patient’s disease according to the M-ANNHEIM severity index.