Background: Current guidelines provide recommendations for morphology-based surgery in patients with symptomatic chronic pancreatitis (CP). International studies evaluating the use and impact of these guidelines across Europe are lacking.Methods: Post-hoc analysis in the prospective multicenter international ESCOPA study, including patients undergoing surgery for CP in 22 centers in 13 countries (June 2021 - November 2022), with a 6-month follow-up. Patients were stratified into morphological subtypes: ‘isolated dilated main pancreatic duct (MPD)’, ‘isolated enlarged pancreatic head (PH)’, ‘combined dilated MPD and enlarged PH’, and ‘small duct disease’. Treatment was based on the European HaPanEU and International IAP-APA-JPS-EPC guidelines. Primary outcomes were 90-day major morbidity, mortality, and pain relief at 6 months. Practice variation was assessed, including a case-based survey.Results: Overall, 207 patients underwent surgery for symptomatic CP with 1.4% 90-day mortality and 72.6% pain relief. Per morphological subtype, the type of surgery varied widely: mostly duodenum-preserving pancreatic head resections (DPPHR) for ‘combined dilated MPD and enlarged PH’ (22/47, 46.8%, p=0.016); and mostly formal pancreatectomy for both ‘isolated dilated MPD’ (31/96, 63.3%, p=0.040) and ‘small duct disease’ (33/50, 66.0%, p=0.004). Guideline-concordant surgery (n=124, 66%) was not associated with major morbidity (concordant 12.9% vs discordant 18.8%, p=0.387), 90-day mortality (1.6% vs 1.6%, p>0.999), and pain relief (75.3% vs 66.7%, p=0.468). Guideline-based drainage/parenchyma preserving surgery was not associated with lower major morbidity (9.2% vs 18.9%, p=0.177) and mortality (0 vs 1.9%, p=0.449) vs formal pancreatectomy. The survey confirmed variability in the use of surgery per morphological subtype which may be related to conflicting recommendations (n=4) and the unclear role for formal pancreatectomy (e.g. pancreatoduodenectomy) and V-shaped pancreatectomy in current guidelines.Conclusion: The next generation of unified guidelines for surgery in symptomatic chronic pancreatitis should resolve the current conflicting recommendations and address the role of formal pancreatectomy and V-shaped pancreatectomy.