INTRODUCTION

Surgical approaches to chronic pancreatitis are indicated in the setting of intractable pain or anatomic complications of the disease process, such as symptomatic obstruction of the common bile duct, pancreatic duct, or duodenum. From a conceptual standpoint, the surgical procedures offered for chronic pancreatitis can be segregated into resection procedures, drainage procedures, or combinations of the two. The specific approach to surgical management must be individualized because there is a wide variability in symptomatology, gland pathology, and anatomic manifestation.¹

Ductal drainage procedures are used for patients with dilated pancreatic ductal systems, under the theory that the pancreatic duct has a symptomatic and functional obstruction. With a limitation to enzyme secretion into the duodenum, there is a lack of inhibitory feedback, thus allowing an increase in cholecystokinin, which induces further enzyme secretion into a functionally obstructed duct. The increased ductal distention then causes pain.²

No clear consensus exists regarding the definition of a dilated ductal system. Whereas most would agree that pancreatic ducts greater than 1 cm (Fig. 37-1) constitute sufficient dilation, greater controversy exists regarding ducts between 5 mm and 1 cm.^1,³ Although no prospective study exists correlating greater ductal size with superior long-term outcome, increased ductal dilation does facilitate a number of the steps in the procedure. Surgical management of chronic pancreatitis and ductal drainage is technically challenging, requiring a comprehensive and coherent surgical approach to avoid common pitfalls.

Figure 37-1 Dilated pancreatic duct with parenchymal calcifications.

INDICATIONS

• Intractable abdominal pain and/or back pain

• Symptomatic duodenal obstruction

• Symptomatic common bile duct obstruction

OPERATIVE STEPS

Step 1 Skin incision

Step 2 Exploration of peritoneal contents for additional pathology

Step 3 Enter lesser sac to expose anterior pancreas

Step 4 Wide Kocher maneuver

Step 5 Location of pancreatic duct with palpation and needle aspiration

Step 6 Unroofing of pancreatic duct from duodenum to splenic hilum

Step 7 Ensure adequate pancreatic drainage

Step 8 Construction of Roux-en-Y jejunal loop of approximately 60 cm

Step 9 Anastomosis of Roux-en-Y loop in retrocolic, two-layer, side-to-side pancreaticojejunostomy

Step 10 Fixation of Roux-en-Y jejunal loop to transverse mesocolon

Step 11 Closure ^4,⁵

OPERATIVE PROCEDURE

Exploration of Peritoneal Contents for Additional Pathology

Unexpected Intraoperative Findings

• Consequence

Change in operative strategy.

Grade 1/2 complication

• Repair

Appropriate surgical management of another disease process such as pancreatic cancer.

• Prevention

Preoperative planning in the management of chronic pancreatitis is critical to success. Noninvasive imaging with high-quality dynamic bolus-enhanced computed tomography (CT) with thin cuts to evaluate the pancreas helps avoid errors in the management algorithm. Pancreatic cancers will generally appear as hypodense lesions. Preoperative CT scans can also delineate biliary ductal dilation, pseudocysts, and pancreatic duct size.¹ Endoscopic retrograde cholangiopancreatography (ERCP) can provide valuable information about intraductal pathology and should be used when the diagnosis of chronic pancreatitis is in doubt, to evaluate possible ampullary lesions, or to assess duct size if CT cannot provide adequate information. Endoscopic ultrasound (EUS), a newer diagnostic technique, is the most sensitive modality for the diagnosis of pancreatic carcinoma, and although it is invasive, it poses fewer risks than ERCP.⁴ With its ability to assess the pancreatic parenchyma and determine duct size and an increased sensitivity for mass lesions, EUS is becoming a valuable tool in the preoperative planning of chronic pancreatitis management.

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Lateral Pancreaticojejunostomy (Puestow) Procedure