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 means of surgery, endotherapy, or other treatment modalities. [4]
Historical perspective of surgical management
Gould successfully removed calculi from the 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.
Management goals
The two primary goals in treating chronic pancreatitis are long-term pain relief and improved quality of life, which can now be achieved with advances in surgical technique in the form of laparoscopic or robotic lateral pancreaticojejunostomy. [13] Kirks et al, in a study comparing the clinical and cost outcomes of robot-assisted laparoscopic (RAL) LPJ with those of open LPJ for chronic pancreatitis, found that RAL LPJ shortened hospitalization and reduced medication costs, though overall hospitalization costs were equivalent. [14]
In children, LPJ is one of the surgical options for the managment of chronic pancreatitis, apart from resectional surgery. [15] To date, however, it has not been as frequently performed in children as in adults. [16]
Indications
Surgical intervention is required in patients with the following:
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Intractable pain resistant to conventional nonsurgical therapy
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Patients with associated or suspected malignancy
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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. [17]
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. [18]
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. [19]
Yang et al reported that a Puestow procedure can be combined with esophageal cancer resection in patients who have esophageal cancer with underlying chronic pancreatitis. [20] They performed the two procedures in the same sitting and found the outcomes to be acceptable.
A modified Puestow procedure can be considered in children with chronic pancreatitis due to anular (annular) pancreas and duodenal duplication, as described by Alatas et al in a case report of an 18-year-old woman with with recurrent acute-on-chronic pancreatitis. [21] Initially, resection of the duodenal duplication was performed; however, the patient developed recurrent abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed dilatation of the peripheral pancreatic duct and stenosis and malformation of both the ducts due to multiple stones. Accordingly, a modified Puestow procedure was performed.
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. [22]
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:
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Pancreaticoduodenectomy
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Total pancreatectomy
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Distal pancreatectomy
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Duodenum-preserving pancreatic head resection (DPPHR; Beger procedure)
Decompressive procedures include the following:
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LPJ or modified Puestow procedure
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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. [23] Examples of hybrid procedures include the following:
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. [26] 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. [27]
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. [28]
Laparoscopic approaches to LPJ have been described. [29, 30, 31] 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. Arora et al reported a series of three children with chronic pancreatitis who were managed with the laparoscopic Puestow procedure. [16] The mean operating time was 126 minutes, with minimal blood loss (25 mL). The mean hospital stay was 6.5 days.
Robot-assisted techniques have been described as well. [14, 32]
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 meticulous technique, perioperative and postoperative octreotide (100/200 g subcutaneously q8hr for 1 week) could be useful in prevention of this complication.
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%. [33] 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%.
In a large series of 524 patients with chronic pancreatitis reported by Napolitano et al, the 30-day mortality for LPJ was found to be 1.2%. [34] At least one major complication occurred in 19.1% of patients, including death (1.2%), major organ dysfunction (8.2%), pulmonary embolism (1.3%), and surgical-site infection (13.0%). The risk factors for complications were diabetes, chronic obstructive pulmonary disease (COPD), and multiple transfusions. Limiting transfusions and optimizing preoperative pulmonary status were recommended to improve 30-day outcomes.
A systematic review on laparoscopic LPJ found that the procedure was commonly performed with four trocars, that the conversion rate was low (5%), that bleeding was minimal, and that morbidity was 11%. [35] No mortality was reported. The mean hospital stay was reduced to 5.6 days, with overall good results for pain control (90%) at 2-year follow-up. It was concluded that laparoscopic LPJ was safe, feasible, and effective in patients with chronic pancreatitis.
A retrospective review of 116 patients with chronic pancreatitis reported that 83.1% had pain relief after a modified Puestow procedure. [36]
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Pancreatic calculi being retrieved from dilated pancreatic duct.
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Pancreatic calculi.
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Pancreatic duct laid open adjacent to opened Roux loop of jejunum for starting longitudinal pancreaticojejunostomy anastomosis.
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Modified Puestow (longitudinal pancreaticojejunostomy [LPJ]) anastomosis completed.
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Roux loop completed by doing end-to-side jejunojejunostomy (handsewn).
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Mesocolic window being closed to prevent internal herniation.
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This video, captured via endoscopic retrograde cholangiopancreatography, shows insertion of biliary extraction balloon over guide wire. Sweeps of common bile duct are made with extraction balloon to remove stones, sludge, and debris from common bile duct. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
