Plate 119

Drainage of the pancreatic duct by anastomosis to the jejunum may be indicated in the treatment of symptomatic chronic recurrent calcific pancreatitis. Before this procedure is carried out, all stones from the biliary tract should be removed by cholecystectomy and choledochostomy. There should be evidence of free drainage of bile through the papilla of Vater into the duodenum. Decompression of the obstructed pancreatic duct should be considered because of recurrent or persistent pain and evidence of progressive destruction of the pancreas.

All too often, these patients are addicted to alcohol and/or narcotics because of persistent pain. Evidence of advanced pancreatic disease may be diabetes, steatorrhea, and poor nutrition. The entire gastrointestinal tract should be surveyed with barium studies or endoscopy. The pancreatic and biliary systems are evaluated with ERCP and with dye study of both duct systems. Stones in the gallbladder or the common duct should be suspected, and ulceration of the duodenum is not uncommon. Evidence for or against gastric hypersecretion should be determined by secretion studies. The stools should be examined to determine the degree of pancreatic insufficiency, insofar as fats are concerned. Particular attention should be given to restoring the blood volume and controlling existing diabetes. Blood calcium and phosphorus levels should be determined to rule out a parathyroid adenoma.

General anesthesia is used.

The patient is placed supine on the table that is positioned for a cholangiogram or pancreatogram.

The upper abdomen is prepared in the usual manner.

A curved incision following the costal margin on the left and extending across the midline around to the right or a long midline incision, which may extend below the umbilicus on the left side, may be used. An upper midline incision may be used.

The stomach and duodenum should be evaluated thoroughly for evidence of an ulcer. Likewise, the gallbladder should be palpated carefully for evidence of stones, and the size of the common duct determined. In the presence of stones the gallbladder is removed and a cholangiogram is taken through the cystic duct. A small amount of contrast medium (5 mL) is first injected to avoid a dense shadow, which may hide small calculi in the common duct. Sufficient contrast medium should be injected subsequently to determine the patency of the papilla of Vater by visualization of the duodenum. It is advisable to carry out a Kocher maneuver to palpate the head of the pancreas, especially if there is radiographic evidence of an enlarged C-loop. Under such circumstances, needle aspiration may be carried out to search for evidence of a pancreatic cyst. The omentum, which is often quite vascular, is freed in the usual fashion from the transverse colon across to the region of the splenic flexure. The lesser sac may be obliterated, and sharp dissection may be required to separate the adhesions between the stomach and the pancreas that may be due to chronic pancreatitis. The stomach should be freed until the entire length of the fibrotic and lobulated pancreas can be explored easily (Figure 1). The transverse colon is returned to the peritoneal cavity, while the stomach is retracted upward with a large S retractor. The posterior wall of the antrum should be freed from the pancreas so that the pancreatic duct can be palpated and opened as far to the right as possible to remove any calculi that might be impacted in the duodenal end (Figure 2). After the lobulated fibrotic pancreas has been exposed clearly, an effort is made to identify the location of the pancreatic duct by needle aspiration (Figure 1). Occasionally, it is desirable to aspirate pancreatic juice from the dilated pancreatic duct and then to inject a limited amount of contrast medium to ensure x-ray visualization of the pancreatic duct. Evidence of calculi in the duct is obtained as well as evidence to indicate whether the papilla of Vater is blocked or patent.

If there is evidence of a large and obstructed pancreatic duct, decompression is performed by anastomosing it to the jejunum. The capsule of the pancreas is incised directly over the needle (Figure 3). This is done with a small scalpel or with an electrocautery unit. Some prefer the electrocautery unit to control the bleeding; otherwise, the bleeding points need to be grasped with fine forceps and ligated as the fibrotic pancreas overlying the duct is divided.

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