Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Longitudinal Pancreaticojejunostomy (Puestow Procedure)

  • Author: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Jan 25, 2016
 

Background

Chronic pancreatitis is characterized by progressive pancreatic fibrosis and loss of endocrine and exocrine function. The most common symptom of chronic pancreatitis is pain, which can be severe and intractable in some patients. Although it is itself benign, chronic pancreatitis can significantly affect quality of life and can cause significant distress with its attendant complications.[1]

The initial treatment for pain in most cases is nonoperative, consisting of enzyme replacement, control of diabetes with insulin, and administration of oral analgesics.

Surgical intervention is required in patients with intractable pain that is resistant to conventional nonsurgical therapy, in patients with associated or suspected malignancy, and in patients who have developed complications such as biliary or duodenal obstruction, pancreatic fistulae, pancreatic ascites/pleural effusion, pseudocysts, or hemosuccus pancreaticus.[2]

The etiology of pain in chronic pancreatitis is unclear. It often precedes any loss of endocrine or exocrine function and any radiographically demonstrable changes in the pancreas. Some evidence has suggested that perineural inflammation may be the cause of pain. A dilated pancreatic duct, secondary to obstruction, may cause increased intraductal pressures, resulting in pain.[3]

The primary aim of therapy is the achievement of primary pain relief and an improvement in quality of life. This could be achieved by surgery, endotherapy, or other treatment modalities.[4]

Historical perspective of surgical management

Gould successfully removed calculi from Wirsung duct in 1898.[5]

Moynihan in 1902[6] and subsequently Mayo-Robson in 1908[7] reported that timely removal of calculi from the pancreatic duct prevented atrophy of the pancreas and relieved pain.

Coffey first performed distal pancreatectomy with pancreaticoenterostomy in dogs. He suggested that this procedure may be beneficial in various conditions.[8]

Link reported the first pancreatic duct drainage operation for chronic pancreatitis as early as 1911. In this procedure, a catheter was placed in the pancreatic duct to drain the pancreatic juice through the skin, providing pain relief and restoring the patient’s normal weight.[9]

Two procedures were developed in the 1950s. Duval reported on distal pancreatectomy, splenectomy, and pancreaticojejunostomy in 1954.[10] In this procedure, an end-to-end distal pancreaticojejunostomy was performed, and the pancreatic duct was decompressed in a retrograde manner. The disadvantage of this procedure was that, if the ductal system contained strictures, the entire duct would not be decompressed.

In 1958, Puestow and Gillesby introduced the lateral (longitudinal) pancreaticojejunostomy (LPJ), which consists of a longitudinal incision of the pancreatic duct and implantation of the tail of the gland into the Roux-en-Y limb of the jejunum following splenectomy and distal pancreatectomy.[11] Although this procedure decompressed a greater length of pancreatic duct and was useful in patients with strictures in the main pancreatic duct, it involved splenectomy and distal pancreatectomy and did not satisfactorily decompress the pancreatic head and the uncinate ducts.

In 1963, Partington and Rochelle modified the Puestow-Gillesby pancreaticojejunostomy by creating an anastomosis between a longitudinally incised anterior surface of the pancreas and duct with a longitudinally incised Roux-en-Y jejunal loop.[12] This modification did not require distal pancreatectomy, splenectomy, or mobilization of the pancreas from its retroperitoneal attachments. Anastomosis to the opened anterior surface of the pancreas and duct allowed decompression of the pancreatic duct from the head to the tail of the pancreas.

Next

Indications

Surgical intervention is required in patients with the following:

  • Intractable pain resistant to conventional nonsurgical therapy
  • Patients with associated or suspected malignancy
  • Patients who have developed complications such as biliary or duodenal obstruction, pancreatic fistulae, pancreatic ascites/pleural effusion, pseudocysts, or hemosuccus pancreaticus

A particular indication for LPJ is chronic pancreatitis associated with main pancreatic duct dilatation exclusively without an inflammatory mass in the head of the pancreas.[13]

Sudo et al, in their single-center experience with LPJ in patients with chronic pancreatitis, reported that the percentage of pain-free patients after surgery was 91%, and further acute exacerbation was prevented in 95%. They concluded that LPJ is safe, feasible, and effective for managing chronic pancreatitis and that it prevents further exacerbations and maintains appropriate pancreatic endocrine and exocrine function.[14]

Similarly, Laje et al reported good results with LPJ in children for pain control and prevention of further damage to the pancreas in patients with obstructive chronic pancreatitis.[15]

Previous
Next

Contraindications

Absolute contraindications for LPJ include coagulopathy and an inability to undergo general anesthesia. Relative contraindications include the presence of malignancy, small-duct disease, and extrahepatic portal venous obstruction (owing to the risk of associated hemorrhage).

In patients with small-duct disease (duct size <5 mm), classic LPJ may not be feasible. Izbicki et al described a procedure in which a V-shaped wedge of tissue from the pancreas is removed and the jejunostomy is performed to the margins of the wedge defect in the pancreas instead of the duct.[16]

Previous
Next

Technical Considerations

Anatomy

The pancreas is prismoid in shape and appears triangular in cut section with superior, inferior, and anterior borders as well as anterosuperior, anteroinferior, and posterior surfaces.

The head of the pancreas lies in the duodenal C loop in front of the inferior vena cava (IVC) and the left renal vein. The uncinate process is an extension of the lower (inferior) half of the head toward the left; it is of varying size and is wedged between the superior mesenteric vessels (the vein on the right and the artery on the left) in front and the aorta behind.

For more information about the relevant anatomy, see Pancreas Anatomy.

Procedural planning

Operative procedures to relieve the pain associated with chronic pancreatitis can be performed for drainage or resection. The two approaches are based on the differing pathophysiologic theories of the etiology of pain in this disease. Those who advocate resection favor removing the portion of pancreas with affected neural tissue, whereas advocates of drainage procedures suggest that decompressing the affected ductal system would relieve pain.

Resectional procedures include the following:

  • Pancreaticoduodenectomy
  • Total pancreatectomy
  • Distal pancreatectomy
  • Duodenum-preserving pancreatic head resection (DPPHR; Beger procedure)

Decompressive procedures include the following:

  • LPJ or modified Puestow procedure
  • Pancreaticogastrostomy and sphincterotomy/sphincteroplasty (less common)

Hybrid procedures combine limited resection with decompression, providing the long-term pain relief usually associated with resectional procedures, as well as the low morbidity and mortality typical of decompression.[17] Examples of hybrid procedures include the following:

  • Frey procedure, [18, 19]  which combines resection and drainage
  • Beger procedure [20]

Endoscopic methods by which the pancreatic duct can be stented can also offer decompression in selected cases.

The surgical decompressive procedure most commonly performed is LPJ—that is, the Partington-Rochelle modification of the Puestow procedure.[21] Decompression surgery is generally recommended in patients with refractory pain and an obstructed, dilated main pancreatic duct with no inflammatory mass or calcifications in the head of the pancreas.[22]

In patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass, the modified Puestow procedure is the procedure of choice, in that it is technically simple to perform with a minimum of morbidity and mortality, preserving pancreatic endocrine and exocrine function.[23]

Laparoscopic approaches to LPJ have been described.[24, 25]  Studies have found that laparoscopic LPJ is a safe, effective, and feasible technique in patients with chronic pancreatitis in the presence of a significantly dilated pancreatic duct with calculi and that it yields a favorable outcome. 

Complication prevention

Attention to surgical detail can prevent most, if not all, complications.

Bleeding from the pancreas is the most common intraoperative complication. Meticulous attention in controlling bleeding is needed. Bleeding can be controlled by means of either suture ligation with fine polypropylene or bipolar diathermy. Hemostatic sutures placed into the pancreatic parenchyma during the exposure of the duct of the pancreatic head limits bleeding from the vessels in this area. An ultrasonic scalpel or LigaSure (Covidien; Minneapolis, MN) can also be used to cut the parenchyma and to open the duct so that bleeding is limited and satisfactorily controlled.

Another potential complication is pancreatic fistula due to anastomostic leakage. In addition to a meticulous technique, perioperative and postoperative octreotide (100/200 g subcutaneously q8hr for 1 week) could be useful in prevention of this complication.

Previous
Next

Outcomes

In a retrospective study of 64 patients who underwent LPJ for chronic pancreatitis at a single center in Japan, Sudo et al reported a mortality of 0% and a postoperative morbidity of 33%.[26]  Pain was relieved in 91% of patients after surgery, and further acute exacerbation was prevented in 95%. Subsequent surgery for pancreatitis-related complications was necessary in 7%.

Previous
 
 
Contributor Information and Disclosures
Author

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Coauthor(s)

Ranjit Hari Vijayahari, MBBS, MS, MCh Assistant Professor, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, India

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

The authors would like to express their thanks to Dr. C.P. Lakshmi, Assistant Professor, Department of Medical Gastroenterology, JIPMER, Pondicherry, India, for her valuable assistance in the preparation of this manuscript. She was of immense help in the drafting of the manuscript with attention and care.

The authors would also like to acknowledge the assistance of the Residents of department of Surgery Unit 4, JIPMER, Pondicherry for helping in taking the photographs for the cases.

Medscape Reference thanks Dawn Sears, MD, Associate Professor of Internal Medicine, Division of Gastroenterology and Hepatology, Scott and White Memorial Hospital; and Dan C Cohen, MD, Fellow in Gastroenterology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine, for assistance with the video contribution to this article.

References
  1. Lankisch PG, Löhr-Happe A, Otto J, Creutzfeldt W. Natural course in chronic pancreatitis. Pain, exocrine and endocrine pancreatic insufficiency and prognosis of the disease. Digestion. 1993. 54(3):148-55. [Medline].

  2. O'Neil SJ, Aranha GV. Lateral pancreaticojejunostomy for chronic pancreatitis. World J Surg. 2003. 27(11):1196-202. [Medline].

  3. Braganza JM. A framework for the aetiogenesis of chronic pancreatitis. Digestion. 1998. 59 Suppl 4:1-12. [Medline].

  4. Bachmann K, Izbicki JR, Yekebas EF. Chronic pancreatitis: modern surgical management. Langenbecks Arch Surg. 2011. 396(2):139-49. [Medline].

  5. Gould AP. Pancreatic calculi: transaction of the clinical Society of London. Lancet. 1898. 2:1532.

  6. Moynihan SG. Pancreatic calculus. Lancet. 1902. 355.

  7. Mayo-Robson AW. The pathology and surgery of certain diseases of the pancreas. Lancet. 1904:773.

  8. Coffey RC. Pancreaticoenterostomy and pancreatectomy: a preliminary report. Ann. Surg. 1908. 50:1238-64.

  9. Link G. Treatment of chronic pancreatitis by pancreostomy, new operation. Ann. Surg. 1911. 53:768-82.

  10. DUVAL MK Jr. Caudal pancreatico-jejunostomy for chronic relapsing pancreatitis. Ann Surg. 1954 Dec. 140(6):775-85. [Medline]. [Full Text].

  11. PUESTOW CB, GILLESBY WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. AMA Arch Surg. 1958 Jun. 76(6):898-907. [Medline].

  12. Partington PF, Rochelle RE. Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann. Surg. 1963. 152:1037-43.

  13. H.G. Beger. The Pancreas: An Integrated textbook of Basic Science, Medicine and Surgery. 2nd Edn. 2008. 537-60.

  14. Sudo T, Murakami Y, Uemura K, et al. Short- and long-term results of lateral pancreaticojejunostomy for chronic pancreatitis: a retrospective Japanese single-center study. J Hepatobiliary Pancreat Sci. 2013 Oct 23. [Medline].

  15. Laje P, Adzick NS. Modified Puestow procedure for the management of chronic pancreatitis in children. J Pediatr Surg. 2013 Nov. 48(11):2271-5. [Medline].

  16. Izbicki JR, Bloechle C, Broering DC, Kuechler T, Broelsch CE. Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure. Ann Surg. 1998 Feb. 227(2):213-9. [Medline].

  17. Andersen DK, Frey CF. The evolution of the surgical treatment of chronic pancreatitis. Ann Surg. 2010. 251(1):18-32. [Medline].

  18. Ho HS, Frey CF. The Frey procedure: local resection of pancreatic head combined with lateral pancreaticojejunostomy. Arch Surg. 2001. 136(12):1353-8. [Medline].

  19. Ho HS, Frey CF. The Frey procedure: combined local resection of the head of the pancreas with longitudinal pancreaticojejunostomy. Operat Tech Gen Surg. 2002. 153.

  20. Beger HG, Witte C, Krautzberger W, Bittner R. Erfahrung mit einer das Duodenum erhaltenden Pankreaskopfresektion bei chronischer Pankreatitis. Chirurg. 1980. 51:303-7.

  21. O'Neil SJ, Aranha GV. Lateral pancreaticojejunostomy for chronic pancreatitis. World J Surg. 2003. 27(11):1196-202. [Medline].

  22. Ceppa EP, Pappas TN. Modified puestow lateral pancreaticojejunostomy. J Gastrointest Surg. 2009 May. 13(5):1004-8. [Medline].

  23. Isaji S. Has the Partington procedure for chronic pancreatitis become a thing of the past? A review of the evidence. J Hepatobiliary Pancreat Sci. 2010 Nov. 17(6):763-9. [Medline].

  24. Sahoo MR, Kumar A. Laparoscopic longitudinal pancreaticojejunostomy using cystoscope and endoscopic basket for clearance of head and tail stones. Surg Endosc. 2014 Aug. 28 (8):2499-503. [Medline].

  25. Khaled YS, Ammori BJ. Laparoscopic lateral pancreaticojejunostomy and laparoscopic Berne modification of Beger procedure for the treatment of chronic pancreatitis: the first UK experience. Surg Laparosc Endosc Percutan Tech. 2014 Oct. 24 (5):e178-82. [Medline].

  26. Sudo T, Murakami Y, Uemura K, Hashimoto Y, Kondo N, Nakagawa N, et al. Short- and long-term results of lateral pancreaticojejunostomy for chronic pancreatitis: a retrospective Japanese single-center study. J Hepatobiliary Pancreat Sci. 2014 Jun. 21 (6):426-32. [Medline].

  27. Munoz JED. Chronic pancreatitis. Munoz JED. Clinical Pancreatology for Practicing Gastroenterologists and Surgeons. Malden: Blackwell; 2006. 180-253.

  28. Warshaw AL, Jin GL, Ottinger LW. Recognition and clinical implications of mesenteric and portal vein obstruction in chronic pancreatitis. Arch Surg. 1987 Apr. 122(4):410-5. [Medline].

  29. Seicean A. Endoscopic ultrasound in chronic pancreatitis: where are we now?. World J Gastroenterol. 2010 Sep 14. 16(34):4253-63. [Medline].

  30. Buxbaum JL, Eloubeidi MA. Molecular and clinical markers of pancreas cancer. JOP. 2010. 11(6):536-44. [Medline].

  31. Remer EM, Baker ME. Imaging of chronic pancreatitis. Radiol Clin North Am. 2002 Dec. 40(6):1229-42, v. [Medline].

  32. Banks PA. Classification and diagnosis of chronic pancreatitis. J Gastroenterol. 2007. 42 Suppl 17:148-51. [Medline].

  33. Choueiri NE, Balci NC, Alkaade S, Burton FR. Advanced imaging of chronic pancreatitis. Curr Gastroenterol Rep. 2010 Apr. 12(2):114-20. [Medline].

  34. Chaudhary A, Negi S, Bhojwani R. Frey's procedure using the harmonic scalpel. Surg Today. 2005. 35(3):263-4. [Medline].

  35. Prinz RA, Edwards MR, Quiros RM. Roux-en-Y lateral pancreatojejunostomy for chronic pancreatitis. Fisher JE, Bland KI. Mastery of Surgery. 5th Edn. Philadelphia: PA: Lippincott, William & Wilkins; 2007. Vol II: 1244-52.

  36. R.A.Prinz. Pancreatic duct drainage procedures. Beger HG, Saiki Matsuno, John L Cameron. Diseases of the Pancreas-Current Surgical Therapy. 2008. 389-98.

  37. Schnelldorfer T, Lewin DN, Adams DB. Reoperative surgery for chronic pancreatitis: is it safe?. World J Surg. 2006 Jul. 30(7):1321-8. [Medline].

  38. Schnelldorfer T, Lewin DN, Adams DB. Operative management of chronic pancreatitis: longterm results in 372 patients. J Am Coll Surg. 2007 May. 204(5):1039-45; discussion 1045-7. [Medline].

  39. Terrace JD, Paterson HM, Garden OJ, Parks RW, Madhavan KK. Results of decompression surgery for pain in chronic pancreatitis. HPB (Oxford). 2007. 9(4):308-11. [Medline].

  40. Roch AM, Brachet D, Lermite E, Pessaux P, Arnaud JP. Frey procedure in patients with chronic pancreatitis: short and long-term outcome from a prospective study. J Gastrointest Surg. 2012 Jul. 16(7):1362-9. [Medline].

  41. Pappas SG, Pilgrim CH, Keim R, et al. The Frey procedure for chronic pancreatitis secondary to pancreas divisum. JAMA Surg. 2013 Nov. 148(11):1057-62. [Medline].

  42. Usatoff V, Brancatisano R, Williamson RC. Operative treatment of pseudocysts in patients with chronic pancreatitis. Br J Surg. 2000 Nov. 87(11):1494-9. [Medline].

  43. Nealon WH, Walser E. Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis. Ann Surg. 2003 May. 237(5):614-20; discussion 620-2. [Medline]. [Full Text].

  44. Munn JS, Aranha GV, Greenlee HB, Prinz RA. Simultaneous treatment of chronic pancreatitis and pancreatic pseudocyst. Arch Surg. 1987 Jun. 122(6):662-7. [Medline].

  45. Vijungco JD, Prinz RA. Management of biliary and duodenal complications of chronic pancreatitis. World J Surg. 2003 Nov. 27(11):1258-70. [Medline].

  46. Izbicki JR, Yekebas EF, Strate T, Eisenberger CF, Hosch SB, Steffani K, et al. Extrahepatic portal hypertension in chronic pancreatitis: an old problem revisited. Ann Surg. 2002 Jul. 236(1):82-9. [Medline]. [Full Text].

  47. D'Cruz K, Angamuthu N, Anand J. Inadvertent choledochotomy during Frey's procedure: management options. Indian J Gastroenterol. 2003 Nov-Dec. 22(6):226-7. [Medline].

  48. Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007 Jul. 142(1):20-5. [Medline].

  49. Kalady MF, Broome AH, Meyers WC, Pappas TN. Immediate and long-term outcomes after lateral pancreaticojejunostomy for chronic pancreatitis. Am Surg. 2001 May. 67(5):478-83. [Medline].

  50. Greenlee HB, Prinz RA, Aranha GV. Long-term results of side-to-side pancreaticojejunostomy. World J Surg. 1990 Jan-Feb. 14(1):70-6. [Medline].

  51. Lowenfels AB, Maisonneuve P, Cavallini G, Ammann RW, Lankisch PG, Andersen JR, et al. Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med. 1993 May 20. 328(20):1433-7. [Medline].

 
Previous
Next
 
Pancreatic calculi being retrieved from the dilated pancreatic duct.
Pancreatic calculi.
Pancreatic duct laid open adjacent to the loop of opened Roux loop of jejunum for starting the longitudinal pancreaticojejunostomy anastomosis.
Modified Puestow (longitudinal pancreaticojejunostomy [LPJ]) anastomosis completed.
Roux loop completed by doing end-to-side jejunojejunostomy (handsewn).
Mesocolic window being closed to prevent internal herniation.
This video, captured via endoscopic retrograde cholangiopancreatography, shows the insertion of a biliary extraction balloon over the guidewire. Sweeps of the common bile duct are made with the extraction balloon to remove stones, sludge, and debris from the common bile duct. Video courtesy of Dawn Sears, MD, and Dan C. Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.