Longitudinal Pancreaticojejunostomy (Puestow Procedure) Technique

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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Technique

Longitudinal Pancreaticojejunostomy

Preoperative preparation

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 surgery 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. [38, 39]

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. [36]

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, 36]

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 to 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. [36]

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 has provided sufficient anatomic information, and pancreatography is not 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 the dilate Pancreatic calculi being retrieved from the 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, 35, 36]

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. [36] 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, 36]

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. [36]

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. [21]

The Frey procedure is an appropriate, safe, and effective technique for the management of patients with chronic pancreatitis in the absence of neoplasia. [40] 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. [41]

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

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. [19] Nonabsorbable suture such as polypropylene or slowly absorbable materials such as 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 the loop of Pancreatic duct laid open adjacent to the loop of opened Roux loop of jejunum for starting the 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, 36] 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. [36] 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. Nasogastric decompression is continued postoperatively until bowel function resumes. Oral intake is resumed as after any major abdominal procedure.

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. [42]

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 and Walsner proposed the concept of a fistula between the main pancreatic duct and the pseudocyst. [43] With decompression of the pseudocyst into the jejunum, pancreatic fluid flows into the bowel instead of the pseudocyst. Aspiration allows immediate decompression, and the LPJ provides prolonged drainage so that the pseudocyst does not recur. Potential advantages of aspiration include decreased dissection and operative time. [42, 44]

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. [45]

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. [42, 45]

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. [46]

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Postoperative Care

Postoperatively, 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.

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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. [47]

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. [48]

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. [49]

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 preoperative dependence on narcotic analgesics. [50, 38]

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. [51]

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