Chapter 17. Operative Management of Chronic Pancreatitis

Longitudinal Pancreaticojejunostomy

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

Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-Jejunostomy

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

Longitudinal Pancreaticojejunostomy

Absolute

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

Relative

• Cardiopulmonary comorbidities.

Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-Jejunostomy

Absolute

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

Relative

• Cardiopulmonary comorbidities.

Expected Benefits: Longitudinal Pancreaticojejunostomy

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

Expected Benefits: Pancreatic Pseudocyst-Gastrostomy and Pseudocyst-Jejunostomy

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

Potential Risks Associated with Both Procedures

• 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.

• 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.

• 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.

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

Longitudinal Pancreaticojejunostomy

• 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 ...