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Pancreaticodigestive tract anastomotic stricture is a long-term complication of pancreticoduodenectomy (PD). However, optimal treatment has not yet been defined. We conducted longitudinal pancreaticojejunostomy (LPJ) in symptomatic patients with anastomotic stricture after PD. This study aimed to evaluate the efficacy of this procedure.Pancreticoduodenectomy was performed in 605 patients at our institution between January 2005 and April 2020. Of these, 15 patients (2.5%) developed symptomatic pancreaticodigestive tract anastomotic stricture after PD. Three patients were referred to our institution owing to recurrent pancreatitis with anastomotic stricture after PD. LPJ was indicated for these 18 patients, and they were enrolled in this study.The median time from the initial operation to LPJ was 2.0 y. Preoperative clinical presentations included obstructive pancreatitis in 10 patients, a rapid deterioration of glucose tolerance in nine, and severe steatorrhea in two. Surgical morbidity ≥grade III defined by the Clavien-Dindo classification was not observed. After LPJ, preoperative symptoms improved in 16 patients (89%) during a median follow-up of 39 mo. Nine of the 10 patients with obstructive pancreatitis achieved complete pain relief. All nine patients with a rapid deterioration of glucose tolerance showed improved endocrine function. Daily insulin requirement was significantly decreased after LPJ (11.6 ± 3.3 vs 3.4 ± 4.3 units,LPJ is a safe and effective surgical procedure for symptomatic patients with stricture of the pancreaticodigestive tract anastomosis after PD.

The Frey procedure is an effective surgery for chronic pancreatitis (CP) patients who have pancreatic head lesions with dilation of the main pancreatic duct. However, pancreatic tail lesions can cause relapsing pancreatitis after the procedure. Therefore, additional distal pancreatectomy (DP) might complement the therapeutic effect of the Frey procedure in controlling inflammation of the pancreatic tail. The Frey procedure with DP (Frey + DP) is indicated for inflammatory lesions in the pancreatic head and tail. In this study, we assessed the usefulness of Frey + DP using the retrospective clinical data of our cases. The clinical outcomes were compared between CP patients who underwent the Frey procedure (N = 44) and Frey + DP (N = 13) from January 2005 to April 2016. Frey + DP showed similarly good therapeutic effects to the Frey procedure with regard to the postoperative stay, morbidity, mortality, pain relief and nutrition, although the Frey + DP had a longer operative time, more bleeding and higher incidence of diabetes mellitus than the Frey procedure because of the additional DP. One patient in the Frey group received additional DP because of recurrent pain due to the tail lesion. Frey + DP can be a promising treatment for CP patients with pancreatic head and tail lesions.

Background/objective Tropical chronic pancreatitis (TCP) is common in developing countries and is defined as a juvenile form of chronic calcific non-alcoholic pancreatitis. Pseudocysts occur in 20–40% of chronic pancreatitis. TCP with pseudocyst has not been reported yet, so we represent this rare case to broaden the horizons regarding pancreatitis. Case presentation A 16-year-old woman suffered a painful lump in the upper abdomen. She came from a low-income family and frequently consumed cassava. There was intolerance of glucose in which admission blood sugar level of the patient increased by 179 mg/dl. An abdominal CT scan showed a mass around the pancreas, 20 cm in diameter, and located in retro-gastric. There were multiple ductal calculi along the major pancreatic duct with the largest stone was 3 cm in the pancreatic head. Longitudinal pancreaticojejunostomy (Partington-Rochelle procedure) has been performed and histopathological results appropriate with a pancreatic pseudocyst. Clinical discussion TCP with a giant pseudocyst is an interesting case report that has not been reported yet. This case met the clinical characteristics of TCP, such as young women, malnourished, history of cassava consumption, abdominal pain, and intolerance of glucose. A surgical intervention provides a satisfactory result to the patient. Conclusion Tropical chronic pancreatitis is a rare case. A pseudocyst adds the uniqueness of this case that has never been reported before. Appropriate management can provide satisfactory results and improve the quality of life for patients., Highlights • Tropical chronic pancreatitis is chronic calcific non-alcoholic pancreatitis. • Tropical chronic pancreatitis (TCP) is common in developing countries. • Tropical chronic pancreatitis accompanied by giant pseudocysts is a rare case. • Partington-Rochelle procedure as surgical intervention for TCP.

This chapter discusses technical aspects of open longitudinal pancreaticojejunostomy, including instrumentation and equipment, patient positioning, and surgical steps. The authors also offer pearls and pitfalls.

Longitudinal pancreaticojejunostomy, also known as the Puestow procedure, is a drainage operation performed in selected cases of chronic pancreatitis. This chapter lists the indications, essential steps, common technical variations, and complications of the procedure. A detailed operative dictation note template is included.

Background This study compares clinical and cost outcomes of robot-assisted laparoscopic (RAL) and open longitudinal pancreaticojejunostomy (LPJ) for chronic pancreatitis. Methods Clinical and cost data were retrospectively compared between open and RAL LPJ performed at a single center from 2008–2015. Results Twenty-six patients underwent LPJ: 19 open and 7 RAL. Two robot-assisted cases converted to open were included in the open group for analysis. Patients undergoing RAL LPJ had less intraoperative blood loss, a shorter surgical length of stay, and lower medication costs. Operation supply cost was higher in the RAL group. No difference in hospitalization cost was found. Conclusions Versus the open approach, RAL LPJ performed for chronic pancreatitis shortens hospitalization and reduces medication costs; hospitalization costs are equivalent. A higher operative cost for RAL LPJ is mitigated by a shorter hospitalization. Decreased morbidity and healthcare resource economy support use of the robotic approach for LPJ when appropriate.

症例は27歳の女性で, 男性から胸腹部を殴打された. 腹部CTにて膵頭部の腫大とリング状低濃度域を認め, 外傷性膵損傷と診断した. 当初, 保存的治療を行ったが右下腹部に膵仮性嚢胞を形成した. 経皮ドレナージを施行し瘻孔化したが, ドレーン造影にて膵体尾部の主膵管が明瞭に造影された. 保存的治療での治癒は望めないと判断し, 膵液瘻管空腸吻合術を施行した. しかし, 術後1年以降に膵炎を頻発し, MRCPにて同吻合部が狭窄し, 膵体尾部主膵管の拡張を認めた. 膵炎予防と膵内外分泌能の保持を目的に, 再手術 (膵管空腸吻合術) を施行した. 膵液瘻に対する膵液瘻管空腸吻合術は低侵襲で有用な術式であるが, 瘻孔がもともと瘢痕組織で独自の栄養血管を持たないため, 血流不全による狭窄や壊死を起こしやすいことも指摘されている. 今回, 膵液瘻管空腸吻合術では長期の開存が得られず, 膵管空腸吻合術が有効であった1例を経験した.

Dr. Charles Bernard Puestow (1902–1973) was an American surgeon who is well known for developing the longitudinal pancreaticojejunostomy, which is known as the “Puestow procedure” in his honor. Puestow served in the American military during the Second World War and commanded the 27th Evacuation Hospital, which provided medical and surgical services to wounded individuals in Europe and North Africa. In 1946, he founded the surgical residency training program at the Hines Veterans Hospital, which was the first such program in the United States based at a veterans hospital.

Pancreaticopleural fistula resulting in a chronic pleural effusion is a rare complication of pancreatic duct disruption. We describe the presentation and management of 2 children with pancreaticopleural fistulas. Pleural fluid amylase concentration and contrast computed tomography were sufficient to establish the diagnosis in both cases. The initial management of these fistulas should be conservative, by tube thoracostomy and suppression of pancreatic secretion. Operative treatment is necessary for those who fail to resolve. Complete diversion of the pancreatic juice into the gastrointestinal tract by longitudinal pancreaticojejunostomy has been an effective surgical option leading to fistula closure.

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy is an effective surgical procedure for patients with chronic pancreatitis. It is simple to perform, and ca

Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) was performed in 50 patients, and the results were reported at the American Surgical Association meeting in San Antonio, Texas, on April 8, 1994. The operation was not performed in patients whose ducts were less than 4.5 mm in diameter. There were no operative deaths. Forty-seven patients were followed for an average of 37 months. Forty-three of the 50 patients were alcoholics. Pseudocysts were present in 50% of the patients. Thirty-five intraabdominal operations had previously been performed on 23 patients. Preoperatively, all patients underwent computed tomography. Endoscopic retrograde cholangiopancreatography was performed in 82% of patients and angiography in 64%. Preoperatively, all patients had pain. Common bile duct obstruction was present in 8% of patients. The average length of hospital stay was 18.7 days. Postoperative complications occurred in 22% of patients. Pain relief was judged excellent in 74.5%, improved in 12.75%, and unimproved in 12.75%. The pain assessment included use of a pain scale and the monitoring of narcotic usage. Progression of diabetes occurred in 2 patients in the immediate postoperative period and in 3 patients at 3, 16, and 22 months, respectively. Exocrine function, based on the presence of steatorrhea, improved in 10 patients (22%) and deteriorated in 5 (11%). Weight gain was noted in 25 patients and weight loss in 13. Few patients not working preoperatively returned to work postoperatively (15.9%). Aside from pain relief, the operation is also useful in the management of patients with stricture of the intrapancreatic portion of the common duct, pseudocysts, pancreatic ascites, and pancreatic fistulas. LR-LPJ is not indicated in patients in whom there is a suspicion of pancreatic cancer, nor in patients with splenic vein thrombosis and left-sided portal hypertension or pseudoaneurysm of the peripancreatic vessels in the absence of some additional procedure to correct these problems. Patients with a small main pancreatic duct

Drainage procedures are conceived to treat the sequels of disruption or dilatation of the pancreatic ductal system. The most common consequence of duct disruption is a pseudocyst which must be disting

The Frey procedure, the coring out of the pancreatic head and longitudinal pancreaticojejunostomy, is a safe, easy, and reliable method to solve most of the problems associated with chronic pancreatitis. During long-term follow up, unexpected relapse in the pancreatic tail was encountered. The pattern of failure and the rationale for a new procedure to treat or prevent such relapse were investigated.From 1992 to 2008, 71 patients with chronic pancreatitis underwent the Frey procedure at Tohoku University Hospital. The etiology was alcoholic in 92.6% of them, followed in incidence by idiopathic and hereditary chronic pancreatitis. In the primary operation, besides the Frey procedure, combined resection of the pancreatic tail was performed in three patients, and choledochoduodenostomy was performed in one patient. The follow-up rate was 92.9%, with a median period of 46 months.The incidence of early postoperative complications was 18.4%, with one reoperation for gastrointestinal bleeding from the splenic artery. Pain control was achieved in all patients and there was no operative mortality. During the long-term follow up of 62 patients with the Frey procedure, eight patients had relapse of inflammation and required reoperation. Five of these eight patients had a pseudocyst in the pancreatic tail and underwent distal pancreatectomy (DP).Relapse occurred in alcoholic middle-aged male patients, and in the patients with hereditary and idiopathic pancreatitis. Frey-DP and Frey-spleen-preserving DP (SPDP) procedures can be performed safely and effectively to treat the relapse and to prevent relapse in the pancreatic tail.

Surgical treatment of chronic pancreatitis remains a major challenge. Most distressing for the patient and his relatives is the finding that, following the trauma and hazards of an operation, relief of symptoms, especially severe pain, has not been achieved. To the surgeon it is no less disturbing to realise that despite technical perfection, a time-consuming procedure has not benefited the patient as expected. Thus, the following main issues have to be considered carefully when surgical treatment of a patient suffering from chronic pancreatitis is planned.

The treatment of chronic pancreatitis commonly yields disappointing results. Patients with chronic pancreatitis and a dilated pancreatic duct can be treated by longitudinal pancreaticojejunostomy. In order to evaluate the procedure, 20 patients undergoing pancreaticojejunostomy were followed for a median time of more than 5 years. Their clinical characteristics and outcomes have been compared with a group of 43 patients with chronic pancreatitis and small pancreatic ducts. There were no differences between the two groups in the major epidemiological parameters, except that calcification in the gland was more frequently noted in those with large ducts. The operation of longitudinal pancreaticojejunostomy could be accomplished with an acceptable morbidity. There was one death in the postoperative period. Seventy-six per cent of patients were found to have benefited clinically at five years, compared with 48% of those with small duct disease. This difference was statistically significant. Patients who benefited were defined by four factors; they were carrying out their usual occupation at the time of surgery, they were not narcotic dependent at the time of surgery, they had a pancreatic duct width greater than 7 mm and, they had totally abstained from alcohol from before the operation to the time of follow-up. Longitudinal pancreaticojejunostomy probably remains the best surgical treatment for suitable patients with chronic pancreatitis. The operation should only be performed when the pancreatic duct is greater than 7 mm in width. In such patients the operation produces considerable improvement of pain with minimal metabolic disturbance.

Fifteen children and 23 adults with complications of chronic pancreatitis were managed in Zaria, Nigeria from 1971 to 1987. They comprised 26 patients with chronic pseudocysts, 9 with chronic abdominal pain, and 3 with obstructive jaundice. Internal drainage was performed for 22 (85%) of the pseudocysts, with resection and external drainage, respectively, in 2 each. A longitudinal pancreaticojejunostomy was performed in a child with juvenile tropical pancreatitis syndrome and biliary bypass was performed in the jaundiced patients. The cause of chronic pancreatitis was known only in 8 (31%) of the patients.

Despite the rarity of chronic relapsing pancreatitis in children, in the last 15 years at Vanderbilt University Medical Center and its Children's Hospital we have used longitudinal pancreaticojejunostomy in treatment of eight patients whose symptoms began in childhood. Duration of symptoms ranged from 2 to 36 years. Seven of the eight patients had hereditary pancreatitis. Recurrent epigastric pain was characteristic and serum amylase was elevated in all patients on admission or shortly thereafter. Demonstration of an obstructed dilated pancreatic duct in all and stones in seven of eight patients by operative pancreatography in three early patients and by endoscopic retrograde cholangiopancreatography (ERCP) in five others established the therapeutic problem and facilitated treatment by removal of stones and longitudinal pancreaticojejunostomy. Results were uniformly excellent, both in the early postoperative period and in long-range follow-ups. Early diagnosis and early surgical drainage of the obstructed pancreatic duct by longitudinal pancreaticojejunostomy are desirable objectives in chronic relapsing pancreatitis with onset in childhood.

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunosotomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.

Recurrent pain after a drainage procedure for chronic pancreatitis is considered an indication for pancreatectomy. To evaluate whether redrainage might be a better alternative, 14 patients who underwent redrainage after a failed pancreaticojejunostomy were reviewed. Patients with previous pseudocyst drainage were excluded. Initial operations included five caudal, three longitudinal, and six side-to-side pancreaticojejunostomies. Nine patients treated since 1974 had ERCP, which showed obstructed segments of pancreatic duct in the head of the gland. Two caudal pancreaticojejunostornies and one longitudinal pancreaticojejunostomy were revised to longitudinal pancreaticojejunostomies. The other 11 were revised to side-to-side pancreaticojejunostomies. Operative findings confirmed undrained segments of the pancreatic duct in the pancreatic head. Postoperatively, one patient died from hemorrhage and four patients had complications. At most recent follow-up from 6 months to 20 years postoperatively, three patients were pain free and six had substantial relief from pain (71 percent). Of eight patients who were not diabetic before redrainage, diabetes developed in only two. Only one of seven patients without pancreatic exocrine insufficiency required pancreatic enzymes after redrainage. Patients with recurrent pain after pancreaticojejunostomy should undergo ERCP. If segments of the pancreatic duct are obstructed, redrainage can provide satisfactory pain relief with a minimal loss of endocrine and exocrine function. This problem is best avoided by initial complete drainage of the major and minor pancreatic ducts.

An operation is described that is useful in the management of patients with chronic pancreatitis and its complications. The operation features duodenal-preserving resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas. The operation has application to patients with pain or complications of chronic pancreatitis with dilated ducts in the body and tail of the pancreas who have small strictured ducts and/or small pseudocysts or ducts impacted with calculi in a markedly enlarged fibrotic pancreatic head. It also has application to patients with chronic pancreatitis complicated by common duct obstruction from small pseudocysts, fibrosis, or inflammation in the head of the pancreas. With this procedure, the common duct can often be freed up from the structures compressing it within the substance of the pancreas doing away with the necessity of a separate biliary bypass. The operation also has application to patients with a previous longitudinal pancreaticojejunostomy who have recurrent or persistent pain associated with small strictured ducts in an enlarged fibrotic pancreatic head with or without common bile duct obstruction.

Management of patients with pain associated with chronic pancreatitis or its complications is handicapped by our lack of knowledge as to the cause of pain in chronic pancreatitis and the natural history of chronic pancreatitis associated with alcoholism. However, as our ability to assess the structural pathology associated with chronic pancreatitis and its complications improves through endoscopic retrograde cannulation of the pancreas, ultrasound, and computerized axial tomography scan, it is possible to select operations designed to meet the specific needs of the patient. Some structural changes resulting from chronic pancreatitis are best treated by subtotal pancreatectomy and others by longitudinal pancreaticojejunostomy, and some could be managed by either procedure.

Surgical therapy of 37 patients with chronic pancreatitis is reviewed. Procedures included longitudinal pancreaticojejunostomy (10), DuVal (5), distal resection (4), pancreaticoduodenectomy (2), sphincteroplasty (7), pseudocyst drainage (6) and other miscellaneous procedures. Complication rates were 30 percent for lateral pancreaticojejunostomy, 28.5 percent for sphincteroplasty and 72.7 percent for resection procedures. The overall complication rate was 54.5 percent, and there were two deaths (5.4 percent). Follow-up is presented on 20 patients, of whom 16 are improved, 2 are unchanged and 2 are worse. Eight patients are dead and nine are lost to follow-up. Ductal anatomy is the most important consideration in the selection of a procedure. Lateral pancraticojejunostomy, when applicable, is the procedure of choice. Resection should be considered when pancreaticojejunostomy has failed or is not indicated with pancreaticoduodenectomy, the procedure of choice in the diffusely diseased gland. Sphincteroplasty should be reserved for use in stenosing papillitis or as an ancillary procedure. Splanchnicectomy can be used for temporary palliation.

Modified Puestow Procedure for Retrograde Drainage of the Pancreatic Duct* Philip Partington;Robert Rochelle; Annals Of Surgery

ACUTE and chronic pancreatitis is etiologically related to alcohol ingestion in 40% of cases. 1-3 This incidence varies depending on the type of institution. Our hospital is in a slum area near "Skid Row" and alcoholic pancreatitis predominates. Pathogenesis of this disorder is not completely understood, but chronic methanol poisoning continues to appear related to the condition as suggested 13 years ago. 4 Many victims of this disease admitted drinking denatured or rubbing alcohols (filtered by amateur methods). "Smoke" is a common beverage and has many variations. One pint of paint and varnish remover (Solax) in a quart of orange drink is a popular formula. The paint and varnish remover contains the ingredients shown in Table 1. Ingestion of "smoke" produces severe hypoglycemia (H. C. Lee, written communication to authors) and elevated amylase levels. This study was undertaken to learn the clinical course of alcoholic pancreatitis, acute and chronic, and