Longitudinal Pancreaticojejunostomy (Puestow Procedure) Periprocedural Care

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

Patient Education and Consent

Patients need to be informed about the alarm symptoms of malignancy. They should also be made aware of the worsening exocrine/endocrine functions that may develop after drainage procedures for chronic pancreatitis.

All patients with alcohol-related chronic pancreatitis need to abstain from alcohol postoperatively; persistent alcoholism has been shown to be associated with recurrence of pain and worsening of pancreatic function.

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Preprocedural Evaluation

The goals of preoperative assessment before longitudinal (lateral) pancreaticojejunostomy (LPJ) include the following [13] :

  • Confirmation of the diagnosis
  • Identification of existing endocrine or exocrine insufficiency
  • Exclusion of other causes of pain
  • Assessment of fitness for surgery

History and physical examination

A meticulous history can provide insight into the etiology of chronic pancreatitis, particularly when the cause is alcoholic or biliary. A history of analgesic use is also sought.

A physical examination helps in the assessment of recent inflammation (tenderness in abdomen) or the presence of palpable masses (pseudocysts).

Workup

Routine hematologic and biochemical investigations, radiography of the chest, and electrocardiography (ECG) are used to assess anesthetic fitness. These are also helpful for the diagnosis and assessment of the severity of disease and associated complications.

Ultrasonography can be used for assessment (eg, evaluation of intraductal or parenchymal calcifications, duct diameter, associated pseudocyst, biliary dilatation) and is very useful for planning treatment. Patients with a duct diameter greater than 5 mm are generally considered suitable for LPJ.

Transabdominal ultrasonography yields a low sensitivity for early disease and is more operator-dependent than computed tomography (CT) is. [27]  Doppler ultrasonography yields additional information concerning the status of portal vein and splenic venous systems and the presence of portal hypertension. [28]

Endoscopic ultrasonography (EUS) is well suited for assessment of the pancreas, owing to its high resolution and the proximity of the transducer to the pancreas, avoiding air in the gut. Evaluation of chronic pancreatitis was an early target for EUS, initially just for diagnosis but later also for therapeutic purposes. EUS is particularly useful for differentiating between an inflammatory head mass and malignancy. EUS-guided fine-needle aspiration biopsy (FNAB) is especially helpful for this purpose. [29]

Ca 19-9 is a tumor marker that can be useful when malignancy is a preoperative suspicion. However, it may not be specific for cancer and can be elevated even in patients with chronic pancreatitis. [30]

Contrast-enhanced CT provides objective information and much more precise information about the regional distribution/involvement of the gland, depicting the dimensions of the uncinate, the main pancreatic duct, and the distribution of the glandular calcifications. Contrast-enhanced CT can also objectively reveal pseudocysts, venous thrombosis, complications related to pancreatitis (eg, duodenal or biliary stenosis), and evidence of malignancy. [31]

However, differentiation between pancreatic cancer and focal mass-forming chronic pancreatitis, which is a well-known risk factor for pancreatic ductal adenocarcinoma, remains difficult. [27] Advancements in CT, such as targeted triple-phase contrast-enhanced imaging of the pancreas, has improved this differentiation. CT can be used to confidently detect severe and advanced chronic pancreatitis. [31]

Endoscopic retrograde cholangiopancreatography (ERCP) may be necessary in patients with chronic pancreatitis in specific situations. These include chronic pancreatitis without any ductal dilatation, a dominant stricture in the head of pancreas with upstream dilatation, choledocholithiasis, or associated biliary dilatation. With the increasing use and availability of ERCP, many patients are given a trial of endoscopic management for pain control.

When associated interventions are expected, ERCP offers unique diagnostic and therapeutic possibilities, such as brush biopsy, sphincterotomy, removal of common bile duct stones (see the video below), and biliary or pancreatic stent placement. ERCP is useful for examining pancreatic ductal changes, diagnosing chronic pancreatitis, and determining the origin of pseudocysts and the location of strictures in neoplasms, the former of which communicate with the main pancreatic duct in 50% of cases. [31]

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.

The Cambridge classification was developed in 1983, which combined CT and ERCP to grade changes of chronic pancreatitis. [32]

Magnetic resonance imaging (MRI) techniques are highly versatile and are emerging as the imaging modalities of choice for pancreatic diseases. Magnetic resonance cholangiopancreatography (MRCP) is being used increasingly in the evaluation of chronic pancreatitis. It does not expose the patient to radiation, unlike CT, and it provides an objective assessment of the pancreatic duct anatomy without the morbidity associated with ERCP. Visualization of the second-order pancreatic duct is a specific limitation of MRCP; direct injection of dye by ERCP offers better resolution. [33]

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Equipment

Standard surgical diathermy is desirable.

Availability of an ultrasonic scalpel and a LigaSure may help in expediting certain steps of the procedure, such as exposing the anterior aspect of the pancreas and dividing the gastrocolic omentum. In addition, Chaudhary et al reported that an ultrasonic scalpel facilitated head coring in the Frey procedure, with less blood loss and operating time. [34]

Intestinal staplers facilitate and expedite creation of the Roux jejunal limb.

Availability of a fluoroscope in the operating room may be beneficial if intraoperative pancreatography or cholangiography is necessary. [35]

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Patient Preparation

General anesthesia is required for LPJ.

Patients undergoing LPJ are placed in the supine position. Good subcostal retraction is needed, and mechanical retractors (eg, Thompson retractors) can aid in giving fixed retraction of the costal angles.

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Monitoring & Follow-up

Endocrine function must be monitored. Good diabetic control requires frequent monitoring of blood sugars and adjusting of dosages of insulin and/or oral hypoglycemic agents. Diabetes may develop after resectional procedures. However, this is less likely with drainage procedures such as LPJ.

Exocrine function may also have to be monitored. Some patients may need enzyme supplements even after undergoing surgery for chronic pancreatitis.

Some patients who have undergone LPJ may experience recurrent or persistent pain; investigations may reveal that these patients have a strictured LPJ. In such cases, reanastomosis may be necessary. A subset of patients may require an additional resectional procedure, such as the Frey or Beger procedure. [36, 37]

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