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Longitudinal Pancreaticojejunostomy

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  • Severe persistent pain from chronic pancreatitis.
    • Refractory to medical therapy.
    • Repeated hospital admissions.
  • Dilated pancreatic duct > 8 mm in diameter.

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Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-Jejunostomy

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  • Persistent pancreatic pseudocyst present for > 6 weeks (ie, at which time the wall should be mature enough to hold sutures).

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Longitudinal Pancreaticojejunostomy

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Absolute

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  • Absence of pain.
  • Pancreatic cancer.
  • Cirrhosis.

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Relative

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  • Cardiopulmonary comorbidities.

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Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-Jejunostomy

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Absolute

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  • Cystadenocarcinoma is a contraindication to enteric drainage and should be resected.
  • Pseudocyst that has been present for < 6 weeks.

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Relative

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  • Cardiopulmonary comorbidities.

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Expected Benefits: Longitudinal Pancreaticojejunostomy

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  • To provide pain relief while preserving pancreatic function.
  • Pain is improved in 60–70% of cases.

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Expected Benefits: Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-Jejunostomy

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  • Pseudocysts generally do not resolve spontaneously if present for > 6 weeks; therefore, operative drainage is often entertained following that interval.

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Potential Risks Associated with Both Procedures

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  • Surgical site infection (either deep or superficial).
  • Bleeding.
  • Systemic complications of major surgery (pneumonia, venous thromboembolism, and cardiovascular events).
  • Pancreatic leaks and fistula, while possible, are relatively less common than with operations on less fibrotic pancreatic parenchyma.

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  • No special equipment is required.
  • A self-retaining retractor is useful to facilitate exposure of the operative field, and a gastrointestinal anastomosis (GIA) stapler for dividing the small bowel.

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  • A thorough preoperative workup is essential before recommending a pancreaticojejunostomy.
    • The goal is to confirm the diagnosis and rule out other causes of pain.
    • Sources other than the patient should confirm that he or she has abstained from alcohol use for a significant period of time.
    • The diameter of the pancreatic duct and location of the inflammation should be determined.
    • Any biliary or duodenal obstruction or pancreatic pseudocysts should be identified so that these conditions can be addressed concurrently.
  • Potentially useful studies include:
    • Abdominal CT scanning.
    • Ultrasonography.
    • Endoscopic retrograde cholangiopancreatography (ERCP).
    • Magnetic resonance cholangiopancreatography.
  • CT scans can show pancreatic ductal dilation as well as calcifications, pseudocysts, masses, and biliary dilation.
  • If a pseudocyst is present, abdominal CT scan or ultrasonography can usually determine the size, chronicity, and location of the pseudocyst in relation to the stomach or duodenum.
  • The patient's physiologic fitness should also be assessed.

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  • The patient should be supine.
  • The abdomen is entered through a midline incision.

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Longitudinal Pancreaticojejunostomy

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  • Figure 17–1: Abdominal CT in a patient with chronic pancreatitis shows a dilated pancreatic duct (arrow).
  • Figure 17–2: Location of the pancreatic duct.
    • After entering the lesser sac, the stomach is reflected upward.
    • The posterior wall of the stomach may be adherent to the anterior surface of the pancreas due to peripancreatic inflammation.
    • ...

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