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DOI:10.1111/hpb.12335

HOW I DO IT

Longitudinal pancreaticogastrostomy in patients with chronic pancreatitis Laureano Fernández-Cruz1, José-Ignacio Poves2, Santiago Sánchez1, Luis Grande2 & Jorge Ordóñez1 1 Department of Surgery, Institute of Digestive and Metabolic Diseases, Hospital Clinic of the University of Barcelona, Barcelona, Spain and 2Department of Surgery, Hospital del Mar, Autonomous University of Barcelona, Barcelona, Spain

Received 9 June 2014; accepted 10 August 2014

Correspondence Laureano Fernández-Cruz, Department of Surgery, ICMDM, Hospital Clínic de Barcelona, Villarroel 170, Barcelona 08036, Spain. Tel: + 34 932 275559. Fax: + 34 932 275769.E-mail: [email protected]

Introduction The Partington–Rochelle (P–R) or Puestow procedure1 is one of the most commonly performed drainage procedures for chronic pancreatitis and can be achieved with low rates of morbidity and mortality to obtain good relief of chronic abdominal pain.2 Frey and Smith3 combined this with duodenal-preserving limited pancreatic head resection (LHR) and drainage of the resection cavity (in patients in whom pancreatic head enlargement predominated) with similar outcomes.4 The current article presents a new modification of the classical P–R and LHR procedures in which the Roux-en-Y pancreaticojejunostomy has been eliminated, and the dilated pancreatic duct or the locally excised head of the pancreas is covered with a longitudinally opened segment of the stomach. The

laparoscopic technique for the modified P–R procedure and the side-to-side procedure to obtain gastric drainage of the pancreatic remnant after pancreaticoduodenectomy are both described.

Surgical techniques Modified Partington–Rochelle procedure Open approach The pancreas is exposed from the uncinate process to the tail of the pancreas. The distended pancreatic duct is opened

Figure 2 The new gastric plastia is sutured in a side-to-side manner Figure 1 The segment of the stomach after the gastric partition is

opened longitudinally in accordance with the opened main duct

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along the pancreatic duct using posterior and anterior sutures (monocryl 3–0)

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longitudinally under ultrasound guidance to the left of the gastroduodenal artery and extending within a few centimetres of the tail. Pancreatic ductal stones are removed and a probe used to establish patency between the remaining main duct in the head of the pancreas and the lumen of the duodenum. An isolated segment of the greater curvature of the stomach is created (Fig. 1). The segment of the stomach is opened longitudinally to match the length of the opened main duct. A single layer of running 3–0 absorbable sutures is placed directly between the main duct and the full thickness of the stomach inferiorly. The superior sutures consist of interrupted 3–0 absorbable sutures with extraluminal knots (Figs 2 and 3). A single Jackson–Pratt drain is placed within the lesser sac to reach the exterior through a lateral stab wound.

Figure 3 Side-to-side pancreaticogastrostomy in an open procedure

Laparoscopic approach The patient is placed in the anti-Trendelemburg position with the surgeon between the spread legs and an assistant at each side. Five ports are placed: (i) a 12-mm trocar is placed about 4 cm above the umbilicus to allow camera access (30 degrees); (ii) a 12-mm trocar is placed in the left upper quadrant for the right hand of the

Figure 4 Laparoscopic side-to-side pancreaticogastrostomy. The dilated pancreatic duct is longitudinally opened. The gastric plastia is

created by applying two consecutive firings of a 60-mm linear endostapler in the greater gastric curvature. GA, gastric antrum; GP, gastric partition; PD, pancreatic duct; PW, pancreatic wall; STCH, stomach

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Figure 5 Laparoscopic side-to-side pancreaticogastrostomy is performed using two running sutures of 3–0 monofilament. GO, greater

omentum; GP, gastric plastia; MC, mesocolon; PW, pancreatic wall; STCH, stomach

surgeon (and the endoscopic ultrasound probe); (iii) a 5-mm trocar is placed in the right upper quadrant for the left hand of the surgeon; (iv) a 5-mm trocar is placed in the right flank for one assistant, and (v) a 12-mm trocar is placed in the left flank for the other assistant (for placement of the endostapler). The lesser sac is entered through the greater omentum preserving the gastroepiploic vessels and exposing the anterior surface of the pancreas. The stomach is temporarily sutured by two stitches to the abdominal wall. The pancreatic duct is localized by endoscopic ultrasound and opened from the neck to the tail; all ductal stones are then removed. The gastric partition is undertaken as in the open procedure by two or three endostapler firings (Fig. 4). The new gastric tube is sutured in a side-to-side manner along the pancreatic duct using posterior and anterior running sutures (monocryl 3–0) (Fig. 5). Drains are placed on either side of the anastomosis.

process. All tissue in the pancreatic head, including the duct of Santorini, is excised. The resultant cavity and duct are anastomosed to an isolated segment of stomach in a similar fashion to that described previously. A single Jackson–Pratt drain is placed in the lesser sac.

Side-to-side pancreaticogastrostomy after pancreaticoduodenectomy The opened main pancreatic duct in the body and tail of the pancreas is anastomosed to an isolated segment of the stomach after gastric partition (Fig. 6). Two Jackson–Pratt drains are placed, one in the lesser sac and the other adjacent to the bilioenteric anastomosis.

Results Modified Frey's technique The main pancreatic duct is opened longitudinally and local resection of the pancreatic head is performed from the back wall of the opened duct of Wirsung to the duct from the uncinate

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Between April 2009 and June 2012, 10 consecutive patients underwent longitudinal pancreaticogastrostomy for chronic pancreatitis. Among these, five patients were submitted to a modified P–R procedure (using an open approach in three and a laparoscopic

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single anastomosis, the preservation of physiological gastrointestinal continuity, and the confinement of the operative field to the region above the transverse mesocolon. The P–R procedure is rarely performed laparoscopically because it is anatomically complex and requires advanced laparoscopic surgery skills. In a recent review of 37 patients submitted to laparoscopic pancreaticojejunostomy for chronic pancreatitis, Khaled et al.5 reported morbidity and mortality of 5% and 0%, respectively, and a median hospital stay of 5.5 days. The present authors’ preliminary experience with a short-term follow-up suggests that the less invasive laparoscopic approach is feasible and effective in treating the abdominal pain of chronic pancreatitis. It is this group’s belief that longitudinal pancreaticogastrostomy allows for the wide and complete drainage of the pancreatic remnant, and avoids the occurrence of the longterm complication of anastomotic stricture, which may be associated with end-to-side pancreaticoenteric anastomosis. Conflicts of interest Figure 6 Side-to-side pancreaticogastrostomy after pancreatico-

None declared.

duodenectomy

References 1. Partington PF, Rochelle RL. (1960) Modified Puestow procedure for retro-

approach in two patients), one patient to a modified Frey’s technique, and four patients to pancreaticoduodenectomy. No postoperative complications were observed. The median hospital stay was 11 days (range: 5–12 days). After a median follow-up of 15.5 months (range: 6–37 months), all patients remained alive and pain-free without requirements for analgesia. Nine of the 10 patients retained good endocrine pancreatic function and one required insulin. All patients had exocrine pancreatic insufficiency controlled by oral pancreatic enzymes.

grade drainage of the pancreatic duct. Ann Surg 152:1037–1043. 2. Isaji S. (2010) Has the Partington procedure for chronic pancreatitis become a thing of the past? A review of the evidence. J Hepatobiliary Pancreat Sci 17:763–769. 3. Frey CF, Smith GJ. (1987) Description and rationale of a new operation for chronic pancreatitis. Pancreas 2:701–707. 4. Izbicki JR, Bloechle C, Broering DC, Knoefel WT, Kuechler T, Broelsch CE. (1998) Extended drainage versus resection in surgery for chronic pancreatitis.

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prospective

randomized

trial

comparing

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pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg 228:771–

Discussion

779. 5. Khaled Y, Ammori MB, Ammori BJ. (2011) Laparoscopic lateral

The benefits of the lateral pancreaticogastrostomy technique in both modified P–R and LHR procedures include the creation of a

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pancreaticojejunostomy for chronic pancreatitis: a case report and review of the literature. Surg Laparosc Endosc Percutan Tech 21:36–40.

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Longitudinal pancreaticogastrostomy in patients with chronic pancreatitis.

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