Evolving Technique for Puestow-Type Procedure for Chronic Pancreatitis: The Combined Rouxen-Y Proximal End-to-Side and Distal Longitudinal Pancreatojejunostomy

Background

Chronic pancreatitis is a progressive and irreversible fibroinflammatory disorder affecting approximately 50 per 100 000 people in the United States; it can be caused by alcohol consumption or by hereditary, autoimmune, or idiopathic etiologies [1–3]. Longstanding inflammation results in parenchymal fibrosis and loss of endocrine and exocrine function. The most significant clinical manifestation of this disorder is disabling pain, with significant decreased in quality of life, increased health-care resource utilization, and loss of income for the patients [4].

Initial management is best accomplished as part of a multi-disciplinary team to encourage alcohol and smoking cessation (when relevant), palliate pain management (with medication or celiac neurolysis), and addressing of pancreatic exocrine insufficiency with pancreatic enzyme replacement therapy. Endoscopic management focuses on resolving main pancreatic duct obstruction with techniques such as endoscopic retrograde cholangiopancreatography with stent. However, for a subset of patients, surgical treatments should be pursued when there are refractory symptoms despite less invasive therapies or when endoscopic drainage procedures are not a durable solution with periodic stent replacement. Surgical options include drainage, resection, resection with drainage, and pancreatic denervation and have been shown to be more efficacious and longer lasting than endoscopic treatment. Understanding pancreatic duct morphology and the presence of an inflammatory mass in the pancreas will guide the surgical procedure.

Historically, with a dilated pancreatic duct and no inflammatory changes in the pancreatic head, a modified Puestow or longitudinal pancreatojejunostomy is recommended. The Frey procedure, which includes a partial resection of the head of the gland as well as drainage of the body and tail, is indicated for a dilated pancreatic duct with non-malignant pancreatic head inflammation. If there is no dilated duct but inflammatory changes are present in the pancreatic head, the Beger procedure, a duodenum-sparing pancreatic head resection, should be considered. With suspicious or confirmed malignancy in the head or body/ tail of the pancreas, anatomic resection of the involved segment should be pursued. The Whipple operation has also been performed in patients with small ducts and head-dominant disease [5]. However, diverse anatomy can challenge the use of any of the above interventions. Herein, we describe a novel procedure to address chronic pancreatitis with pancreatic duct dilation and extensive ductal and parenchymal pancreaticolithiasis.

Case Report

The patient was a 48-year-old woman with no history of alcohol use or smoking and a diagnosis of chronic pancreatitis with multiple gene mutations associated with pancreatitis, including CFTR, CASR, CTRC, SLC6A9, and SPINK1. Her condition was managed initially with multiple prior endoscopic retrograde cholangiopancreatography with pancreatic duct lithotripsy and stenting, without durable or consistent resolution of her symptoms. She was eventually referred for a surgical consultation. Her workup was notable for a computed tomography scan that revealed extensive coarse globular calcifications replacing the pancreatic parenchyma and marked pancreatic duct dilatation up to 10 mm, particularly in the neck and extending to the uncinated, as seen in Figure 1.

Endoscopic ultrasound confirmed the findings of pancreatic atrophy and parenchymal changes, with a dilated pancreatic duct in the pancreatic head measuring up 14 mm, with a 12 mm stone, and further dilatation in the body. Given her disease presentation with a dilated pancreatic duct in the gland without a dominant inflammatory mass in the head, the patient was deemed an appropriate candidate for a Roux-en-Y longitudinal pancreatojejunostomy (or modified Puestow procedure).

For the surgical approach, the peritoneal cavity was accessed via a vertical upper midline incision. The dissection proceeded by entering the lesser sac to expose the pancreas. Inflammatory adhesions between the posterior stomach and the anterior pancreas were carefully lysed with electrocautery. Visualization of the pancreatic duct using ultrasound was challenging due to the large stone burden both in the duct and the parenchyma of the pancreas, as shown in Figure 2. Thus, a longitudinal ductotomy could not be performed. Blindly dissecting through the pancreatic parenchyma was thought to be unsafe. The pancreas was then transected at the neck over the superior mesenteric and portal veins to expose the cut-end of the duct. A ductotomy proceeded from the cut end of the duct distally to create a wide pancreatotomy of the body and tail, and numerous stones were removed.

A Roux limb was created by dividing the jejunum approximately 40 cm distal to the ligament of Treitz. An anastomosis between the proximal limb and a portion of the jejunum 40 cm distal to the point of division was created using a double-stapled technique. The mesenteric defect was closed with a running absorbable braided suture. The Roux limb was brought into the lesser sac through a rent in the transverse mesocolon. An anastomosis between the distal pancreatotomy and the Roux limb was fashioned in a single layer using an absorbable monofilament. Because of obstructing pancreaticolithiasis near the ampulla, duct-to-mucosa anastomosis with the Roux limb and the proximal pancreas duct was also created to facilitate drainage of that stump (Figure 3).

A Petersen defect was closed in the inframesocolic abdomen with a running absorbable braided suture, with the final reconstruction illustrated in Figure 4. A 19-Fr Blake drain was placed around the anastomoses and secured to the skin with nylon suture. The fascia was closed with an absorbable mono-filament in a running fashion, and the skin was closed with staples. Sterile dressings were applied. The patient tolerated the procedure well, was extubated in the operating room, and was brought to the recovery room in stable condition.

There were no immediate postoperative complications. She started drinking clear liquid on postoperative day 1 and a regular diet was added the following day, with pancreatic enzyme replacement. She was discharged home on postoperative day 3. At her scheduled 2-week postoperative visit, she was pain-free and endorsed good oral intake, with continued use of enzyme supplements. A month after her surgery, she presented to the Emergency Department with a urinary tract infection, which was treated with a short course of antibiotics. Six months later, she remained on pancreatic enzyme supplementation, with no opiate requirement.

Discussion

Chronic pancreatitis is an irreversible condition characterized by chronic progressive inflammation and fibrosis with loss of exocrine (acinar) and endocrine (islet) cells. Although incidence rate is low (7 per 100 000), chronic pancreatitis has a disproportionate impact on health. Healthcare costs related to the treatment of chronic pancreatitis exceed $3 billion in the United States, with associated significant loss in quality of life for the patient, potential issues with addiction to opiates, and an increased risk of malignancy [6]. Although medical management is usually the first step in treating chronic pancreatitis, studies have shown that surgery will eventually be required in 40% to 75% of these patients [7]. Numerous endoscopic and interventional techniques are available as well but are short-term solutions with high recurrence rates necessitating re-interventions with potential complications. Indications for surgery in chronic pancreatitis include intractable pain, common bile duct obstruction, pancreatic pseudocyst, vascular complications, such as arterial pseudoaneurysms, and pancreatic malignancy. The development of drainage procedures has allowed less morbid operations to be performed to achieve symptom relief, including pain and malabsorption. Currently, the Whipple operation is performed for chronic pancreatitis with head-dominant fibrotic disease with or without suspicion for malignancy.

In select patients with an inflammatory mass in the head of the pancreas without suspicious features, the Beger procedure is a safe and effective procedure, with 92% of patients pain-free after a median follow-up of 5.7 years [8,9]. The Beger procedure is described as a duodenum-preserving resection of the head with an end-to-side pancreatojejunostomy. A modification of this procedure involving limited resection of the head mass combined with pancreatojejunostomy known as the Berne modification is also reported [10]. A similar operation, also duodenum-preserving, colloquially known as the Frey operation, removes only the involved mass in the head with a longitudinal pancreatojejunostomy along a dilated duct [11]. In a recent publication, 91% of patients had complete relief of their pain with the Frey procedure after a median follow-up of 77 months [12].

The Roux-en-Y lateral pancreatojejunostomy, or modified Puestow procedure, involves the dilated duct being opened with overlying parenchyma along its length and anastomosed to a Roux limb of jejunum. This procedure is indicated in cases of dilated pancreatic duct (³6 mm) without inflammatory mass in the head of the pancreas [13]. Identification of the main pancreatic duct is critical to a successful modified Puestow procedure, and the use of ultrasound facilitates finding the duct. Successful symptom relief has been reported in up to 80% of patients who underwent the Puestow procedure [14]. Nevertheless, there are subgroups of patients in whom drainage procedures are ineffective and thus they are offered a total pancreatectomy, or in cases of minimal change pancreatitis, the pancreas appears normal anatomically with pancreatic duct dilation or inflammatory masses.

With regard to concerns about anastomotic leakage, it is relevant to consider that the texture of the pancreas in cases of chronic pancreatitis such as this, where the gland is firm, fibrotic, with large pancreas ducts, make the risk of pancreatic anastomotic leak much less concerning. It is well known that the risk of leak increases with small ducts and soft glands. Thus, in this case, the benefit of additional anastomoses and wider pancreas drainage outweighs the likely much lower risk of pancreatic leak. Further studies are necessary to fully evaluate anastomotic leak rates with this modification.

We provided a novel modification of the lateral pancreatojejunostomy to expand drainage procedures to more chronic pancreatitis patients with a dilated duct but heavy stone burden, precluding the identification of the pancreatic duct by ultrasound. Unlike resection and drainage procedures such as the Frey, Beger, or Berne, this technique preserves the parenchyma and enhances drainage of the entire pancreatic duct. It also avoids focal decompression of the ductal system with inherent high failure rates due to calculi. Although anatomy can challenge more established drainage procedures, the combined Roux-en-Y proximal end-to-side pancreatojejunostomy to the head and lateral longitudinal pancreatojejunostomy to the body and tail potentially avoids future endoscopic procedures and provides a successful therapeutic option without resorting to a total pancreatectomy. Moreover, pursuing surgery at this stage could potentially curb the progression of exocrine and endocrine insufficiency.

Conclusions

A combined proximal end-to-side and distal longitudinal pancreatojejunostomy can be safely performed in patients with chronic pancreatitis and extensive pancreaticolithiasis, with promising short-term outcomes and adequate symptom relief. This procedure should be considered in those patients with significant pancreaticolithiasis, in which clear visualization of the main pancreatic duct is limited, precluding a lengthy pancreatojejunostomy. This modification of the Puestow-type procedure allows drainage of the entire pancreas parenchyma and avoids further endoscopic intervention to relieve proximal obstruction in the head of the pancreas, between the ampulla and the anastomosis.