Longitudinal Pancreaticojejunostomy (Puestow Procedure) 

Updated: Feb 28, 2018
Author: Vikram Kate, MBBS, MS, PhD, FRCS, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS; Chief Editor: Kurt E Roberts, MD 

Overview

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]

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.[16]

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.[17]

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.[18]

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.[19]

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.[20] Examples of hybrid procedures include the following:

  • Frey procedure, [21]  which combines resection and drainage
  • Beger procedure [22]

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.[23] 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.[24]

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.[25]

Laparoscopic approaches to LPJ have been described.[26, 27, 28]  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. Robot-assisted techniques have been described as well.[14, 29]

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%.[30]  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%.

 

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.

Preprocedural Planning

The goals of preoperative assessment before longitudinal (lateral) pancreaticojejunostomy (LPJ) include the following[16] :

  • 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.[31]  Doppler ultrasonography yields additional information concerning the status of portal vein and splenic venous systems and the presence of portal hypertension.[32]

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.[33]

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.[34]

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.[35]

However, differentiation between pancreatic cancer and focal mass-forming chronic pancreatitis, which is a well-known risk factor for pancreatic ductal adenocarcinoma, remains difficult.[31]  Advances in CT, such as targeted triple-phase contrast-enhanced imaging of the pancreas, have improved this differentiation. CT can be used to confidently detect severe and advanced chronic pancreatitis.[35]

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 the 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.[35]

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.

The Cambridge classification was developed in 1983, which combined CT and ERCP to grade changes of chronic pancreatitis.[36]

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 increasingly being used 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.[37]

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 a shorter operating time.[38]

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.[39]

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 providing fixed retraction of the costal angles.

Monitoring & Follow-up

Endocrine function must be monitored postoperatively. 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.[40, 41]

 

Technique

Longitudinal Pancreaticojejunostomy

Preparation for surgery

Standard preoperative medications given before longitudinal (lateral) pancreaticojejunostomy (LPJ) may include proton pump inhibitors (PPIs) and a mild anxiolytic the day before the procedure.

Preoperative administration of a broad-spectrum antibiotic with adequate coverage against gram-negative enteric organisms is recommended. Commonly, prophylaxis takes the form of a third-generation cephalosporin (eg, cefotaxime or ceftazidime) administered at the time of induction. Another dose can be given if the operation is prolonged. Patients with other risk factors or comorbidities may be given a complete 1-week course of antibiotics. Several groups now proceed with major pancreatic surgery without the routine use of postoperative antibiotics.

Some surgeons prefer bowel preparation to fully decompress the colon, but this is not a universal practice.

Analgesics are used in most patients prior to LPJ. Pancreatic enzyme supplements (ie, pancrelipase) may be required for pain relief and steatorrhea control. Some patients may need opioids for pain control, potentially leading to opioid dependence. Some reports have suggested that the response to surgery in patients who have received opioids may be inferior to the response in those who have not received opioids.[42, 43]

Incision and exploration

The abdomen is entered via either a bilateral subcostal (chevron) incision or a midline incision. A chevron incision allows better exposure of the pancreatic tail in patients whose pancreas has more of a vertical orientation. A midline incision may be preferred in lean and thin individuals with a narrow costal angle.

Initial exploration should confirm chronic pancreatitis and rule out malignancy. The pancreas of a patient with chronic pancreatitis should have a firm fibrotic feel, which should be evident throughout the gland. In addition, in some cases, parenchymal calcification is obvious or pancreatic calculi are palpable in the dilated duct.

Any localized hard areas or masses palpated in the pancreas that are suspicious for malignancy should be immediately evaluated with fine-needle aspiration cytology (FNAC). An incisional biopsy is appropriate if the lesion is located away from the pancreatic duct. Suspicious lesions on the surface of the gland or infiltrating along the root of the mesentery should also be sampled with biopsy. The mesenteric, peritoneal, and hepatic surfaces should be meticulously visualized; any suspicious lesions should be sent for frozen section.[40]

A wide Kocher maneuver is performed by means of sharp dissection or diathermy. The purpose of this maneuver is to lift up the duodenum and pancreas from their retroperitoneal attachments and to obtain a proper feel of the head and uncinate process.

Exposure of anterior surface of pancreas

After thorough exploration, the entire anterior surface of the pancreas is completely exposed.

With care taken to spare the gastroepiploic vessels, the lesser sac is opened with ligation and division of the gastrocolic omentum. The ultrasonic scalpel or LigaSure may aid in this step. The gastrocolic ligament is divided as far to the left as possible (almost reaching the hilum of the spleen) in order to completely expose the tail of the pancreas. The transverse colon and the hepatic and splenic flexures are fully mobilized and retracted inferiorly.

Fibrous adhesions between the posterior wall of the stomach and the anterior surface of the pancreas are taken down with cautery or sharp dissection. Injury to the blood vessels and vagus nerves along the lesser curvature that may be contained within dense adhesions should be avoided.

Additional time spent at this stage clearing the anterior surface of the pancreas will facilitate suture placement during the subsequent anastomosis. It is desirable to achieve complete separation of the pancreas from the stomach so that the latter can be retracted up completely for placement of the sutures during the longitudinal pancreaticojejunal anastomosis.[11, 12, 40]

Special attention should be paid to identifying the superior mesenteric vein (SMV) within the fibrosed adhesions and avoiding avulsion of the branches of this vessel. Following the path of the middle colic vein helps pinpoint the location of the SMV. Anterior pancreaticoduodenal and gastroepiploic veins may be suture-ligated and divided if necessary for full exposure of the gland head. Once the pancreatic head is freed, it should be palpated for stones and masses; any suspicious lesions should be biopsied and sent for frozen section.[40]

Identification and opening of pancreatic duct

After the pancreas has been adequately exposed, the pancreatic duct is identified by the following methods.

Within the middle-to-distal portion of the body of the gland, the dilated duct can be palpated as a soft and compressible area in a firm pancreas. This can be confirmed by aspiration with a 20-gauge needle yielding clear pancreatic juice. If needed, pancreatography can be performed with gentle injection of 2-5 mL of radiopaque contrast and fluoroscopic imaging. Usually, preoperative imaging will have provided sufficient anatomic information, and pancreatography will not be needed.

If stones are palpable, the pancreatic parenchyma is cut on the duct in the area of the stone to gain access to the duct. The stones are then retrieved from the open duct (see the image below).

Pancreatic calculi being retrieved from dilated pa Pancreatic calculi being retrieved from dilated pancreatic duct.

If the duct is difficult to locate, intraoperative ultrasonography may be helpful.

When these approaches are not available, a vertical incision into the parenchyma at the level of the midbody to the left of the SMV can be made and deepened until the duct is entered. The opening in the duct is extended by incising the overlying parenchyma with diathermy. A right-angle forceps or malleable metallic probe can be used in the duct to identify its course within the gland. The duct should be incised as far as possible to ensure full decompression.[11, 12, 39, 40]

To the left, the duct should be incised to within 1 cm of the tip of the pancreas tail. Patients with large dilated pancreatic ducts may have numerous calculi (see the image below).

Pancreatic calculi. Pancreatic calculi.

Decompression of the head is more complex and more critical.[40] Inadequate drainage here can account for failure and the need for reoperation. The gland is often bulky in this region, and the course of the duct as it travels posterior and inferior to the right of the SMV into the uncinate process can complicate adequate decompression.

The duct opening on the main and accessory ducts should be carried to within 1 cm of the ampulla of Vater and the medial wall of the duodenum. It may be necessary to place a catheter into the common bile duct (CBD) via the cystic duct or a choledochotomy to help identify the CBD as it courses through the pancreatic head to reduce its risk of injury.[12, 40]

Modifications for bulky pancreatic head

If adequate drainage is not possible with ductotomy alone, local resection or “coring out” of the pancreatic head, as described by Frey, can be considered. This debulks the bulky tissue of the pancreas head, helps in removing any stones, and provides drainage to the ducts in the head and uncinate process.

With the pancreas held with the left hand by the surgeon, standing to the right of the patient, the anterior capsule of the gland and the underlying pancreatic tissue to the level of the main pancreatic duct can be removed by using the cautery. Approximately 5 mm of parenchyma should be left intact for suture placement. Having the left hand of the surgeon hold the gland also helps in controlling bleeding.[40]

Resected or cored-out pancreatic parenchyma should preferably be sent for frozen section to rule out occult carcinoma. All ductal calculi and concretions that can be safely removed should be removed. Concretions of calcium carbonate can extend into the parenchyma and must be firmly extracted. Pancreatic bleeding can be controlled with cauterization, suture ligation, or application of topical hemostatic agents.[23]

The Frey procedure is an appropriate, safe, and effective technique for the management of patients with chronic pancreatitis in the absence of neoplasia.[44] The potential advantage of this “head coring” approach over LPJ is with the removal of the fibrotic tissue of the head, which is theorized to be the primary source of pain in this condition.[45]

Creation of Roux limb of jejunum

A 50-cm Roux-en-Y limb is constructed after the jejunum is divided 20-30 cm distal to the ligament of Treitz. A stapler can be used. If there is any concern about the security of the stapled end of jejunum, the staple line can be reinforced with a layer of nonabsorbable sutures. The Roux-en-Y limb is passed retrocolically through a mesenteric window between the right and middle colic vessels. An enterotomy is made along the antimesenteric border of the jejunal loop. Because the intestine will stretch, the enterotomy should be slightly shorter than the length of the duct incision.

Pancreaticojejunal anastomosis

The pancreaticojejunal anastomosis is performed with various techniques, depending on the size of the duct and the thickness of the parenchyma. Some surgeons use a single-layer continuous anastomosis. A two-layer anastomosis is also popular with some surgeons.[21]  Nonabsorbable suture (eg, polypropylene) or slowly absorbable materials (eg, polydioxanone [PDS]) can be used for anastomosis.

The laid-open pancreatic duct is anastomosed to the enterotomy in a side-to-side fashion, and the anastomosis is started at the pancreatic tail, which is the more difficult area to suture (see the image below).

Pancreatic duct laid open adjacent to opened Roux Pancreatic duct laid open adjacent to opened Roux loop of jejunum for starting longitudinal pancreaticojejunostomy anastomosis.

The anastomosis proceeds along the superior and inferior borders by taking full-thickness bites of jejunum and pancreatic capsule until it is completed at the head of the pancreas (see the image below).

Modified Puestow (longitudinal pancreaticojejunost Modified Puestow (longitudinal pancreaticojejunostomy [LPJ]) anastomosis completed.

The pancreatic stitch may include a small portion of the transected parenchymal edge. Sewing directly to the mucosa of the pancreatic duct need not be attempted, though it may be performed where the parenchyma often becomes thin. Sutures placed deep into the gland in an attempt to reach the ductal mucosa may occlude secondary duct branches and may lead to a postoperative leak of pancreatic fluid or limit pancreatic decompression.[12, 40]

Intestinal continuity is reestablished by means of an end-to-side stapled or sutured jejunojejunostomy (see the image below).

Roux loop completed by doing end-to-side jejunojej Roux loop completed by doing end-to-side jejunojejunostomy (handsewn).

The mesenteric and mesocolic windows are closed to prevent internal herniation (see the image below).

Mesocolic window being closed to prevent internal Mesocolic window being closed to prevent internal herniation.

Cholecystectomy may be performed during LPJ.[40] A feeding jejunostomy may be necessary if the patient is malnourished or if an unusually long period of bowel recovery is anticipated. Placing drains may be preferable, especially if leakage of bile or pancreatic secretions is a concern. They may be placed near the anastomosis, anteriorly and exiting through the flanks. Closed suction drains may be used instead.

Management of associated problems

Many patients undergoing LPJ have complications of chronic pancreatitis that may necessitate operative intervention, such as pseudocysts, biliary obstruction, or duodenal obstruction.

Pseudocyst

Pseudocysts can cause pain and therefore divert attention from the underlying chronic pancreatitis, resulting in incomplete treatment. As many as 40% of patients with chronic pancreatitis have pseudocysts, which should be managed with drainage or aspiration at the time of pancreatic duct decompression.[46]

Combined drainage with the pancreatic duct is a safe and effective treatment of the pseudocyst. Intrapancreatic pseudocyst drainage can be performed by extending the pancreatic ductal incision into the pseudocyst and incorporating it into the Roux limb of the jejunum. Draining a pseudocyst not in continuity with the pancreas can be performed by anastomosing the free end of the jejunal limb to the dependent portion of the cyst.

An alternative to drainage into the jejunum is aspiration. For easily accessible small cysts, aspiration combined with duct drainage can be effective. Nealon et al proposed the concept of a fistula between the main pancreatic duct and the pseudocyst.[47] With decompression of the pseudocyst into the jejunum, pancreatic fluid flows into the bowel instead of the pseudocyst. Aspiration allows immediate decompression, and LPJ provides prolonged drainage so that the pseudocyst does not recur. Potential advantages of aspiration include decreased dissection and operating time.[46, 48]

Biliary obstruction

As many as 30% of patients with chronic pancreatitis undergoing pancreatic duct drainage develop biliary obstruction or stricture. Whereas some patients may be asymptomatic, others have progressive jaundice or even life-threatening cholangitis.

In patients with symptomatic biliary obstruction with CBD dilatation, jaundice, or cholangitis, it is imperative that the biliary tree be drained at the time of the pancreaticojejunostomy. Either a hepaticodochojejunostomy or a choledochoduodenostomy can be performed for drainage. However, in asymptomatic patients with only elevated alkaline phosphatase levels, management is debatable; most groups perform only a pancreatic drainage procedure.[49]

Duodenal obstruction

Duodenal obstruction can occur in as many as 15% of patients with chronic pancreatitis undergoing pancreatic duct decompression. Obstruction may result from inflammation alone and may be reversible and resolve without surgery. Persistent fibrotic obstruction may necessitate operative therapy.

When LPJ is performed, lysis of adhesions or drainage of a concomitant pseudocyst near the duodenum may relieve the duodenal obstruction. If bypass is required, a side-to-side gastrojejunostomy proximal to the jejunojejunostomy can be constructed. Pancreaticoduodenectomy or simultaneous bypass with pancreaticojejunostomy, gastrojejunostomy, and choledochoduodenostomy is appropriate for patients with chronic pancreatitis and obstruction of the CBD and duodenum.[46, 49]

Extrahepatic portal hypertension may complicate LPJ because of the collaterals, increasing blood loss and morbidity. Resectional procedures are known to cause more reversal of the portal hypertension than drainage procedures do. Meticulous hemostasis is necessary to minimize blood loss and to decrease operating time and morbidity.[50]

Postoperative Care

Nasogastric decompression is continued postoperatively until bowel function resumes. Oral intake is resumed as after any major abdominal procedure.

Postoperative analgesic usage must be tailored to the individual patient. Analgesic requirements may be high in patients with chronic pancreatitis, in that some may have developed a tolerance to opioids.

The role of octreotide in the postoperative period is controversial; the enzyme secretion in patients with chronic pancreatitis is expected to be minimal as compared with that in other patients who undergo pancreatic surgery where exocrine function is unaltered.

Complications

Intraoperative

Bleeding is the most common intraoperative complication.

Injury to the intrapancreatic portion of the bile duct is rare during LPJ; it is more common during Frey and Beger procedures. In such a situation, one option is to splay open the inadvertently opened duct with interrupted absorbable sutures into the pancreaticojejunal anastomosis. Draining the biliary tree (hepaticojejunostomy) with the same Roux loop is another option when the bile duct is inadvertently opened during LPJ.[51]

Postoperative

Early

Bleeding may occur in the immediate postoperative period after LPJ. It may be intraluminal (bleeding into the lumen of the jejunum) or extraluminal (bleeding from the drains). Conservative management of bleeding when the patient is hemodynamically stable is an option; when supported with blood and blood products, the bleeding may abate without further measures.

Heavy bleeding or bleeding that results in hemodynamic instability should prompt consideration of angiography and embolization for control. Reexploration and suture ligation of bleeding vessels may be needed if angiography is unable to reveal the site of bleeding or the bleeding cannot be otherwise controlled. In some cases, it is necessary to take down the anastomosis to control intraluminal bleeding.[52]

Intra-abdominal abscess formation after LPJ may be related to anastomotic leakage from the pancreaticojejunostomy. Leak rates after pancreaticojejunostomy performed for chronic pancreatitis are lower than those for pancreaticojejunostomy after a Whipple procedure for malignancy; the pancreatic parenchyma in patients with chronic pancreatitis is firm and holds sutures well, in contrast to a soft gland, which may be found in the absence of chronic pancreatitis.[53]

A leaking anastomosis may be managed conservatively if it is a controlled leak with adequate drainage by operatively placed drain tubes or percutaneous drains. The controlled drainage forms a pancreatic fistula, which will close with conservative management in most cases.

Jejunojejunostomy leakage is rare.

Late

Pain relief, freedom from narcotics, and return to normal activities are expected after LPJ. Pain relief is reported in as many as 85% cases. However, as many as 30% of patients report recurrent pain after drainage procedures. Recurrent pain may be more common in patients who had a preoperative dependence on narcotic analgesics.[54, 42]

Biliary obstruction can occur after LPJ but is less common than after Frey and Beger procedures. Malignancy must be ruled out when the patient presents with biliary obstruction after LPJ. If biliary tree strictures are found to be benign after investigations, they can be managed with endoscopic stenting or biliary bypass.

Strictured pancreaticojejunostomy is possible.

As many as 4% of patients with chronic pancreatitis develop pancreatic carcinoma within 20 years of being diagnosed. A proper preoperative evaluation and thorough exploration at time of surgery can decrease the risk of missing a malignancy. Biopsies of the pancreas can help in excluding cancer before LPJ is performed.[55]