Surgical therapy for chronic pancreatitis is usually reserved for patients with symptoms that are otherwise intractable to pharmacotherapy and other therapeutic approaches. In over 90% of patients, the main indication for operation is pain. Occasionally, an operation is performed to relieve biliary or gastrointestinal obstruction, to internally drain a symptomatic pseudocyst, or for vascular complications of chronic pancreatitis such as gastric variceal hemorrhage secondary to splenic vein thrombosis.
A number of pancreatic operations have been developed over several decades of international effort. These operations generally involve either ductal drainage, parenchymal resection, or some combination of resection and ductal drainage. The choice of operation depends on anatomic morphology. In many patients, the disease appears to be driven predominantly by pathology within the pancreatic head, sometimes considered the “pacemaker” of chronic pancreatitis, particularly in those with a sizable inflammatory mass in this region of the organ. Others present more diffuse disease involving extensive areas of stricture and dilation of the main pancreatic duct or its ductal tributaries. Occasionally, disease appears limited to the body or tail. Operations on the pancreas may be technically demanding and carry significant risks of postoperative morbidity and mortality. Although in appropriately selected patients, the immediate results may be excellent, long-term success (durable pain relief) is achieved in at most 85% of patients at 5 years of follow-up. Alternatives for surgical intervention are best individualized and considered in the context of the most frequently encountered clinical and anatomic scenarios.
Large-duct chronic pancreatitis is characterized by enlargement of the main pancreatic duct lumen to a diameter exceeding 7–8 mm. Ductal dilation is often diffuse along the length of the organ, but there may be one or more intervening areas of ductal stricture. In many patients, calcific deposits (stones) may be evident on imaging studies within the main or secondary ducts.
Puestow described a procedure to provide enteric drainage to a diffusely dilated main pancreatic duct, with the goal of achieving pain relief by duct decompression. In its initial description, the Puestow procedure consisted of a longitudinal unroofing of the dilated pancreatic duct in the body and neck of the gland, and also involved resection of the pancreatic tail.52 A long segment longitudinal pancreaticojejunstomy was then constructed to establish enteric drainage. A modification reported by Partington and Rochelle in 1960 eliminated the distal pancreatectomy. Lateral pancreaticojejunostomy is now thus referred to as either a (modified) Puestow or Partington-Rochelle procedure53 and continues to be commonly used for disease characterized by a diffusely dilated main pancreatic duct with no significant biliary obstruction and no mass in the pancreatic head.
Lateral Pancreaticojejunostomy— Technique
Midline or transverse upper abdominal incisions provide acceptable exposure for this procedure. The dissection is begun by incising the peritoneal lining adjacent to the lateral border of the second portion of the duodenum, extending laterally to release the hepatic flexure of the right colon. Using electrocautery, the retroperitoneal attachments lateral and posterior to the duodenum are divided to widely mobilize the duodenum and posterior aspect of the head of the pancreas (Kocher's maneuver). This dissection is carried inferiorly to free the third portion of the duodenum from the base of the transverse mesocolon, effectively exposing the head of the pancreas and anterior surface of the duodenum from the pylorus to the level of the superior mesenteric vessels. Exposure of the anterior surface of the pancreatic body and tail requires access to the lesser sac, which is entered by dividing the gastrocolic omentum or by separating the avascular plane of attachment from the transverse colon and mesocolon. Next, the gastroduodenal artery (GDA) is identified at its supraduodenal origin from the common hepatic artery and traced across the head of the pancreas. The GDA is then suture ligated at both the superior and inferior border of the head of the pancreas in an effort to prevent intraoperative hemorrhage during incision of the pancreatic head and main pancreatic duct during the dissection as well as postoperative bleeding at the site of the pancreaticojejunostomy. The anterior surface of the pancreas is then carefully examined to confirm the presence of main duct dilation and the absence of suspicious mass lesions or unanticipated inflammatory changes in the head of the gland. The dilated pancreatic duct is usually visible by direct inspection or palpation of the anterior surface of the pancreas but can also be accessed by means of a fine needle and low-volume syringe. The duct can also be localized using intraoperative ultrasound, but this is usually not necessary. The pancreatic duct is then incised longitudinally along its full length using electrocautery. This ductotomy should extend across the neck into the head of the organ where the GDA traverses the pancreas, and should extend laterally as far as possible along the length of the tail so that the entire segment of dilated duct is unroofed. The pancreaticojejunal anastomosis is performed in Roux-en-Y fashion using a 40–50 cm defunctionalized jejunal limb. Using a linear gastrointestinal stapler, the proximal jejunum is divided at the apex of a mesojejunal vascular arcade of suitable mobility, typically at least 20–30 cm distal to the ligament of Treitz, although the precise distance is probably unimportant. The distal staple line is inverted using a series of 3-0 silk sutures placed in a Lembert fashion which are tied (but not cut) and then held by a fine clamp that facilitates later positioning of the pancreatic anastomosis. Intestinal continuity is then re-established by a handsewn or stapled enteroenterostomy such that the intestinal conduit is approximately 60 cm in length. The Roux limb is then advanced through the transverse mesocolon either to the right or left of the middle colic vessels. A longitudinal jejunostomy is made to correspond to the pancreatic ductotomy. The pancreaticojejunostomy is handsewn with a running absorbable suture (eg, 4-0 double-armed polyglyconate or polydioxanone suture), which, according to surgeon preference, may be additionally reinforced by an outer later of interrupted nonabsorbable suture (Fig. 56-8). After completion of the anastomosis, the distance between the pancreaticojejunostomy and the enteroenterostomy should measure at least 40 cm to prevent reflux of enteric contents up to the anastomosis.
Cross-section of the anastomosis for a lateral pancreaticojejunostomy (applies to Puestow, Frey, or Izbicki procedures).
Lateral Pancreaticojejunostomy— Outcomes
Results of the Partington-Rochelle procedure in appropriately selected patients are generally favorable. In most series, 75–80% of patients with diffusely dilated main pancreatic ducts (>7 mm) and no dominant inflammatory mass, have achieved durable pain relief over 5–10 years of follow-up.52,54–57 Compared to other major pancreatic operations, perioperative morbidity is low, and because no pancreatic parenchyma is removed, endocrine and exocrine functions are generally preserved relative to preoperative levels. Failure of lateral pancreaticojejunostomy is usually due to inappropriate patient selection (underappreciated extent of disease with the presence of significant fibrosis in the pancreatic head), or ongoing fibrosis with the progressive development of neuropathic pain.
Chronic Pancreatitis with a Dominant Pancreatic Head Mass
Lateral pancreaticojejunostomy has limited applicability in patients without diffuse main duct dilation. Multiple groups have reported that an isolated drainage procedure in patients with complex inflammatory changes in the pancreatic head, body, or tail results in poor clinical outcome with quick recurrence of symptoms of pain and progression to exocrine insufficiency. For patients with an inflammatory mass, extensive calcifications or duct stones in the pancreatic head, results appear to be better either with pure resectional or with hybrid resection and drainage procedures. There are four procedures being used in a great frequency today. These include pancreaticoduodenectomy (Whipple procedure, with or without pyloric preservation) and three forms of duodenum-preserving pancreatic head resection (DPPHR): the Beger procedure, the Berne procedure, and the Frey procedure.
The outcomes associated with these procedures have been compared in several randomized trials enrolling small numbers of patients with head predominant morphology. None of these studies has demonstrated any one of the techniques to be clearly superior to others (Table 56-5). There are no measurable differences in outcomes compared, the numbers in the trials are small and the metrics used to evaluate the outcomes are variable and imperfect.58–61 As a result, no consensus opinion among pancreatic experts about which procedure is the best in any given clinical situation has emerged. In recent years, European surgeons have tended to favor a duodenum-preserving approach and American surgeons have tended to favor pancreaticoduodenectomy. One recent survey of American surgeons who were members of the Pancreas Club found that of 59 surgeons surveyed, only 34 had ever performed DPPHR and that only 23 US surgeons continue to perform these procedures on a regular basis.62
Table 56-5: Long-Term Follow-Up from Randomized Comparisons of Surgical Methods Addressing Head Dominant Morphology ||Download (.pdf)
Table 56-5: Long-Term Follow-Up from Randomized Comparisons of Surgical Methods Addressing Head Dominant Morphology
|Number of Patients||Perioperative Morbidity (%)||Proc. A vs Proc B|
|Author||Year||Procedures Compared||Proc. A||Proc. B||Follow-Up||Proc. A||Proc. B||p Value||QoL Difference|
|Buchler58||2008||DPPHRa(A) vs PPPDb(B)||40||40||14 years||35||37||>0.05||None|
|Izbicki67||2005||LR-LPJc(A) vs DPPHRa(B)||36||38||9 years||22.0||32.0||>0.05||None|
|Izbicki68||2008||LR-LPJc(A) vs PPPDb(B)||31||30||7 years||17.0||53.0||<0.05||None|
|Buchler59||2008||Berne(A) vs DPPHRa(B)||35||35||2 Years||21.0||20.0||>0.05||None|
In spite of the lack of data supporting the relative superiority of any given procedure, we do believe that each has specific applicability to certain subtypes of head predominant morphology. A reasonable approach is to tailor the procedure to the anatomic morphology seen on the preoperative axial imaging and ductography. Patients with a dominant head mass and a dilated main pancreatic duct but no biliary dilation, may be best served by a Frey procedure (limited duodenum-preserving resection of the pancreatic head with extended lateral pancreaticojejunostomy). Patients with a dominant head mass without main duct dilation and no biliary obstruction may be better suited for the Berne modification of the Beger procedure (limited duodenum-preserving resection of the pancreatic head without extension of the lateral pancreaticojejunostomy toward the tail). Patients with biliary obstruction or imaging characteristics more suspicious for the presence of malignancy should probably undergo pancreaticoduodenectomy rather than any form of DPPHR.
The early primary objective in the pancreaticoduodenectomy is making an efficient determination of whether or not the pathology allows safe resection. This typically involves a thorough manual examination of the abdomen to rule out metastatic cancer and then a rapid exposure of the pancreatic neck superiorly and inferiorly in an effort to assess the operator's ability to free the hepatic artery, superior mesenteric vein, and superior mesenteric artery from the pathology in the pancreatic head safely. Pancreaticoduodenectomy may be performed through a midline laparotomy or bilateral subcostal incision. Careful inspection and palpation of the peritoneal surfaces and liver is performed first, with frozen-section biopsy obtained of any suspicious lesions. Small areas of fat necrosis or fibrosis from prior attacks of pancreatitis are easily mistaken for metastatic deposits. The base of the transverse mesocolon should be inspected for evidence of foreshortening or inflammatory involvement that may herald a difficult or dangerous dissection in the vicinity of the superior mesenteric vessels, and to confirm the absence of otherwise unsuspected tumor extension. The hepatic flexure of the colon is mobilized by freeing the lateral retroperitoneal attachments using the electrocautery, an extended Kocher maneuver is performed, and the lesser sac is then entered by separation or division of the gastrocolic omentum, as described in the previous section. The mass in the head of the gland is palpated and determined to be safely free from the superior mesenteric vein (SMV) at the inferior border of the neck of the pancreas by preliminary dissection of the plane anterior to the SMV posterior to the neck of the pancreas. Attention is then turned to the supraduodenal region. A cholecystectomy is performed, and the portal dissection is initiated by isolating the common bile duct (CBD) at the level of the cystic duct stump. The bile duct is carefully freed from the anterolateral surface of the portal vein and secured temporarily with a vessel loop. The common hepatic artery is usually found anteromedially to the portal vein, and it should be carefully isolated with a vessel loop and preserved. The lateral, free edge of the gastrohepatic ligament at the foramen of Winslow should be carefully inspected and palpated for an accessory or replaced right hepatic artery, which, if present, should also be isolated and protected during the subsequent resection. The GDA is isolated at its origin from the common hepatic artery and secured temporarily with a vessel loop. The continued presence of pulsatile flow in the proper hepatic artery after temporary occlusion of the GDA should be assured, both to confirm the vascular anatomy and to ensure that there is no stenosis in the proximal common hepatic artery or celiac trunk due to atherosclerotic plaque. Preliminary dissection of the plane anterior to the portal vein is begun. These measures demonstrate that there is no evidence of unresectable cancer and that the pancreatic head can be removed without concern for undue injury to the blood supply of the small intestine and liver.
At this point, technical resectability of the pancreatic head has been assured (Fig. 56-9). The GDA is divided between clamps and is doubly tied or suture ligated. The common hepatic duct is divided just proximal to the cystic duct entry, and bile flow is controlled with a small bulldog clamp. The right gastric artery is divided between suture ligatures. For a standard pancreaticoduodenectomy, the greater omentum is divided to a point on the greater curvature of the stomach in the vicinity of the junction of the right and left gastroepiploic arteries. The lesser omentum is divided at the level of the incisura of the lesser curvature of the stomach, and the descending branch of the left gastric artery is carefully secured. The stomach is then divided with two firings of a linear gastrointestinal stapler. The lesser curve staple line is inverted with silk Lembert sutures. For pyloric-preserving pancreaticoduodenectomy, the duodenum is divided using a stapler approximately 2 cm distal to the pyloric ring. The ligament of Treitz is taken down with electrocautery, being certain to avoid injury to the inferior mesenteric vein. The proximal jejunum is divided approximately 15 cm distal to the ligament of Trietz with a linear gastrointestinal stapler. The distal staple line is oversewn with interrupted Lembert sutures, initially left long to use for traction and positioning of the limb during the reconstruction. The short mesojejunal vessels of the proximal segment are carefully isolated and secured close to the mesenteric border of the jejunum using fine nonabsorbable ligatures, surgical clips, or an electrosurgical vessel-sealing device. This dissection is continued proximally to the duodenojejunal junction, and then the proximal jejunum is advanced into the supracolic compartment by passing it under the superior mesenteric vessels. At this point blunt dissection is used to complete development of a tunnel between the neck of the pancreas and the SMV or portal vein. The superior and inferior pancreatic vascular arcades are then ligated on either side of the planned transection site at the neck of the pancreas using nonabsorbable suture. The neck is then divided with electrocautery. Gentle retraction of the pancreatic head, distracting it from the right lateral wall of the SMV or portal vein, helps to expose small venous tributaries from the uncinate process, which should then be carefully controlled with fine ties or suture ligatures. The first jejunal venous tributary may be quite large and is easily injured during this dissection. The uncinate branches from the superior mesenteric artery (SMA) are then divided sequentially between clamps with great care to preserve the integrity of the SMA. The specimen is then oriented and submitted for pathological examination.
Retroperitoneal dissection for pancreaticoduodenectomy. Note the ligated gastroduodenal artery (GDA), portal vein, inferior vena cava (IVC), superior mesenteric artery and vein (SMA, SMV), and the main pancreatic duct at the edge the transected pancreas. (Reproduced from, Ahmad SA, Wray C, Rilo HL, et al. Chronic pancreatitis: recent advances and ongoing challenges. Curr Probl Surg. 2006;43(3):127–238.)
The reconstruction begins with the pancreaticojejunostomy (Fig. 56-10). The jejunum is advanced through the transverse mesocolon either to the right or left of the middle colic vessels according to surgeon's preference. Several techniques of pancreaticojejunostomy have been described. One commonly used approach is a two-layer method that is begun by placing a posterior row of interrupted nonabsorbable sutures between the pancreatic capsule and the seromuscular layer at the antimesenteric aspect of the jejunum. A small enterotomy is then made with bovie cautery across from the site of the main pancreatic duct at the pancreatic neck. An inner layer of four to eight interrupted fine absorbable monofilament sutures is used to secure the pancreatic duct to the intestinal wall at the enterotomy in a duct-to-mucosa fashion. An anterior row of interrupted nonabsorbable suture is then used to secure the anterior pancreatic capsule to the anterior serosa at the antimesenteric border of the jejunal limb. The duct-to-mucosa anastomosis may also be performed over a 5F pediatric feeding tube, which can then be exteriorized through the jejunal limb using a Witzel-type closure. The choledochojejunostomy is then constructed at a site approximately 15 cm distal to the pancreaticojejunostomy. A small enterotomy is made at the antimesenteric border of the jejunal limb at this location. The choledochojejunostomy is also performed in a duct-to-mucosa fashion, either with a single layer of interrupted absorbable monofilament suture or, if the bile duct is dilated, using absorbable continuous suture. The pancreaticobiliary limb is then secured to the transverse mesocolon using interrupted sutures and any potential gap through which herniation may occur is closed. The retroperitoneal space at the level of the ligament of Treitz is also closed. Gastric continuity is reestablished by means of an antecolic loop gastrojejunotomy performed at a site sufficiently distal to the transverse mesocolon closure to prevent angulation of the afferent limb. A Hofmeister-type configuration is typically used, wherein the lesser curvature half of the gastric transection line is oversewn and the anastomosis is performed to the greater curvature half. The jejunal limb is oriented with the afferent limb toward the lesser curvature, efferent limb to the greater curvature. A two-layered anastomosis is preferred, with an outer layer of nonabsorbable interrupted seromuscular Lembert sutures and an inner continuous absorbable Connell-style layer. The abdomen is then irrigated with saline or dilute antibiotic solution and the abdominal wall closed. No closed suction peritoneal drains are necessary.
Pancreaticojejunostomy. At left, a duct-to-mucosa anastomosis is constructed using fine absorbable mattress sutures over a small (5F) pediatric feeding tube. At right, the completed anastomosis, with transanastomotic stent exteriorized through the jejunum and abdominal wall to divert pancreatic secretions. (Reproduced from Ahmad SA, Wray C, Rilo HL, et al. Chronic pancreatitis: recent advances and ongoing challenges. Curr Probl Surg. 2006;43(3):127–238.)
Duodenum-preserving pancreatic head resection was first described by Beger in 1972. The operation evolved from the premise that a pancreaticoduodenectomy was unnecessarily radical for benign pathology and that a more limited resection preserving the duodenum would avoid some of the adverse sequelae associated with pancreaticoduodenectomy such as delayed gastric emptying and insulin-dependent diabetes.63 The procedure is performed through a midline laparotomy or bilateral subcostal incision. As at the start of the pancreaticoduodenctomy, the gastrocolic ligament is separated or divided, the transverse mesocolon is mobilized off the head of the pancreas and duodenum, and a wide Kocher maneuver is performed. A cholecystectomy is performed. The GDA is isolated and divided. A tunnel is then created between the pancreatic neck and superior mesenteric vein or portal vein. The pancreatic neck is divided at this location and the pancreatic head manually rotated out of the retroperitoneum so that the cut edge faces up into the midline wound. The cystic duct is cannulated with a Bakes dilator and the CBD manually palpated in the head of the pancreas. Electrocautery is then used to core out the head of the gland with care taken to leave a rim of pancreas attached to the duodenum and to leave the bile duct intact within that rim (Fig. 56-11). The specimen is submitted to pathology for frozen-section examination to confirm the absence of malignancy. Pancreaticoenteric drainage is then reestablished by means of a two-sided Roux-en-Y pancreaticojejunostomy (Fig. 56-12). A Roux limb of jejunum is fashioned and advanced into the supracolic compartment through the transverse mesocolon as described for the lateral pancreaticojejunostomy. A two-layered handsewn duct to mucosa pancreaticojejunostomy is constructed at the neck margin as done for a typical pancreaticoduodenectomy with the exception that the anastomosis is sited closer to the mesenteric margin of the jejunum. The jejunal limb is then laid such that the antimesenteric border of the limb faces the midline wound. A second long pancreaticojejunostomy is constructed here by opening the border of the jejunal limb contralateral to the first pancreaticojejunostomy at the neck for a distance appropriate to include the entire length of the proximal pancreatic rim. This pancreatic margin is then secured to the long longitudinal enterotomy by means of a single layer of interrupted nonabsorbable suture. Intestinal continuity is then reestablished by means of a jejunojejunostomy performed as described earlier for the lateral pancreaticojejunostomy. The abdomen is irrigated and closed. No closed suction drains are necessary.
The anatomy following transection of the neck of the pancreas and removal of the head during the Beger procedure.
Final anatomy of the reconstruction following a Beger procedure.
Beger Procedure versus Pancreaticoduodenctomy—Outcomes
Beger has recently reviewed his three-decade experience with DPPHR for chronic pancreatitis presenting with an inflammatory mass in the pancreatic head. His perioperative results demonstrate very reasonable rates of morbidity and mortality and an impressive improvement in pancreatic pain. His pancreatic fistula rate is reported as 3.3%, the rate of delayed emptying reported is 1.5%, and perioperative mortality rate is 0.7% in 603 consecutive patients. Late outcomes reported in this series demonstrated 91.3% of patients are free of pain at a median follow-up of 5.7 years.64 There have been two randomized trials that have attempted to compare outcomes from DPPHR to those achieved with pylorus-preserving pancreatoduodenectomy (PPPD). The most widely cited is by Buchler and colleagues and has been recently represented with long-term results. In this study 40 patients with chronic pancreatitis and a dominant focus in the pancreatic head were randomized to PPPD or DPPHR. The initial paper reported 6-month outcomes. This demonstrated a statistical advantage to DPPHR with regard to pain (75% of patients undergoing DPPHR were pain free at 6 months vs 40% of patients undergoing PPPD) and weight gain (average weight gain for those undergoing DPPHR was 4.1 kg whereas that for those undergoing PPPD was 1.9 kg).65 Length of hospital stay, perioperative morbidity and perioperative mortality rates were statistically identical. The authors of this study have recently presented their long-term results. At median follow-up of 7 years, the early advantages of the DPPHR were no longer evident with patients in each group having identical health-related quality of life scores, identical pain scores, and identical rates of exocrine and endocrine insufficiency. The other randomized comparison again studied only 40 patients for 12 months. This study demonstrated statistically identical rates of pain relief but a slight statistical advantage in terms of scores seen on a general assessment of health-related quality of life for patients undergoing DPPHR relative to those undergoing PPPD.58
The disadvantage of the DPPHR as described by Beger is that it does not address disease (either diffuse parenchymal fibrosis with side branch disruption or stricturing with upstream dilation of the main pancreatic duct) that may coexist in the pancreatic body and tail. Late failures of the Beger procedure have been attributed to poor drainage of the pancreatic body and tail. In an effort to overcome this, and in large part to avoid the certain exocrine and endocrine insufficiency that comes with the near-total pancreatectomy pioneered by one of his early mentors, Frey and colleagues developed a procedure that combines a duodenum-preserving pancreatic head resection with a hybrid resection or drainage procedure at the pancreatic body and tail (referred to as a local resection of the pancreatic head with longitudinal pancreaticojejunostomy or LR-LPJ) (Fig. 56-13). In this procedure, no tunnel is created behind the pancreatic neck. Instead the entire length of the pancreas is exposed anteriorly. The GDA is ligated. The gallbladder is removed. The cystic duct is cannulated using a Bakes dilator and the bile duct is identified in its course through the head of the pancreas by palpating the dilator. The pancreatic head is then excavated down to the level of the portal vein with care taken to leave a rim of tissue surrounding the bile duct at the duodenal margin. From this cavity an extensive longitudinal unroofing of the pancreatic duct through the body and tail is made using electrocautery. If the duct is not dilated in the tail, then the body and tail may simply be excavated as done at the pancreatic head (Fig. 56-14). Pancreaticoenteric drainage is then accomplished by means of a lateral pancreaticojejunostomy covering the entire excavation cavity, typically constructed using a Roux-en-Y jejunal limb sewn to the pancreatic capsule in one or two layers.
Cross-sectional drawing of the pancreas following coring of the pancreatic head during a Frey procedure.
Pancreaticojejunostomy (Frey procedure).
Frey Procedure versus Beger Procedure—Outcomes
In various reports including small randomized trials, the results of LR-LPJ appear similar to those reported for the Beger DPPHR, with postoperative mortality less than 1% and morbidity reported as 19–32%.60,66 Excellent pain relief is obtained in about 75% of patients and the change in postoperative pain scores and rates of postoperative exocrine and endocrine insufficiency are identical over follow-up as long as 9 years. A small prospective randomized trial compared LR-LPJ to PPPD with an average length of follow-up of 2 years. Postoperative morbidity was significantly higher in the PPPD group (53 vs 17% for the LR-LPJ group). Although there was similar improvement in pain symptoms, the LR-LPJ group demonstrated a statistically better overall quality of life as assessed by a general assessment of health-related quality of life.67 The long-term results of the study were published in 2008 with a median follow-up of 7 years. At that length of follow-up, there were no statistical differences with regard to the improvement in pain, health-related quality of life or the incidence of exocrine or endocrine insufficiency.68
Berne Procedure—Technique and Outcomes
There has been one further modification of the Beger DPPHR made in recent years. The Berne procedure adopts the technical safety advantage of the Frey LR-LPJ that comes by avoiding transaction of the neck of the pancreas off the portal vein. In this modification as in the Beger DPPHR, no lateral pancreaticojejunostomy is performed. The anterior surface of the mass in the head is palpated and then cored out by electrocautery. A Roux limb is then sewn to the residual pancreatic rim at this location. One randomized trial comparing the Berne modification to the standard Beger DPPHR showed rough equivalence of outcomes with these procedures.59
Small Duct Disease or Diffuse Sclerosis
In many instances, as the disease progresses there will be no dominant focus of ductal obstruction and no dominant mass. Instead the morphology of the disease is characterized by diffuse calcification and/or diffuse fibrosis with atrophy of the pancreatic parenchyma. In these cases the pancreatic remnant may be quite small and will have a uniform firm consistency. Patients with this morphology of disease present a particular challenge, as there is no discrete target for either endoscopic or surgical intervention. Those manifesting intractable pain syndromes have had, until very recently, few and imperfect options for surgical management. These have included total or near-total pancreatectomy procedures that have traditionally been avoided due to the significant morbidity associated with profound postoperative exocrine and endocrine insufficiency. Autologous islet transplantation may mitigate the diabetic consequences of total pancreatectomy. Another alternative for small duct disease is the V-shaped or wedge pancreatectomy described by Izbicki.69
Total Pancreatectomy with Autologus Islet Transplantation—Technique
Total pancreatectomy is performed as either an en bloc resection of the pancreatic head, body, and tail or, more commonly, in a staged fashion with a left pancreatectomy followed by a head resection (pancreaticoduodenectomy) allowing initial islet processing on the body and tail specimen. The isolation process relies on enzymatic and mechanical mechanisms to dissociate the islets from surrounding acinar tissue and fibrosis. Depending on the proximity of the islet isolation facilities and the efficiency of the process, infusion of the islet preparation into the portal circulation may be performed during the same anesthetic or postoperatively (usually the same day) under radiological guidance.70 Briefly, the resected pancreas is cooled to 4°C in an organ-preserving solution (eg, University of Wisconsin Solution). The pancreas is then transected at the neck of the gland and the pancreatic duct cannulated. The ductal system is then perfused with a cold solution of the purified digestive enzyme collagenase. The gland is sectioned, and then physically shaken in a small digestion chamber at 37°C until the acinar tissue is separated from the endocrine tissue. The islets are then partially purified from the acinar debris by gradient density centrifugation on a cold dextrose gradient. The islets are washed and resuspended in an albumin-rich transplant medium or cultured. The islets are transplanted by direct injection into portal circulation with access to the portal circulation being achieved under ultrasound-guided percutaneous placement of a transhepatic portovenous catheter in interventional radiology or by direct operative cannulation of the portal vein.
Autologus Islet Transplantation—Outcomes
The first human autologous islet transplant was performed at the University of Minnesota in 1977 and since that time several hundred procedures have been reported from Minnesota, Miami, Cincinnati, Leicester, and other emerging centers.71 Taken together, the results from these institutions suggest that in a highly selected group of patients, complete pain relief (without the use of narcotics) can be achieved in approximately 50–60% of patients but that there is a significant rate of recidivism of pain after 1 year of follow-up. Insulin-independence is initially achieved in 40–50% of patients but there is a steady decline in islet function that continues even at 10 years of follow-up. Although reports of assessment of quality of life after total pancreatectomy with autologous islet transplantation suggests that the procedure compares favorably to either total pancreatectomy without islet transplantation or to continue nonoperative management of pain, direct evidence supporting this approach over alternatives in appropriately matched controls is lacking. Total pancreatectomy with autologous islet transplantation is costly and requires a high degree of technical expertise that is difficult to replicate. The indications for islet autotransplantation are controversial and the overall safety and efficacy of the procedure have not been fully validated outside a handful of centers. Questions regarding the long-term viability of the islets and adverse impact on the surrounding liver parenchyma have been raised. Pathologic analysis of liver tissue that has been explanted following islet transplant has demonstrated that the transplanted islets typically migrate across the liver sinusoids and reside in the liver parenchyma. It has also been noted that the transplanted islets exhibit some degree of peri-islet fibrosis in the liver. There have been no reports of chronic hepatic fibrosis or cirrhosis in patients receiving autologous islets but the concern exists. It must be emphasized that complete long-term insulin independence is achieved only in a relatively small minority of patients after islet autotransplantation and that pain is persistent or recurrent in about half of patients even after total pancreatectomy.72 Currently, the strongest arguments in favor of total pancreatectomy and islet autotransplantation can perhaps be made in the setting of a limited subset of patients with hereditary pancreatitis, who otherwise carry a significant long-term risk of developing pancreatic cancer. When a more traditional surgical operation (resection or drainage) is also possible in this setting, decision making must be highly individualized (Fig. 56-15).
Hereditary chronic pancreatitis associated with PRSS1 gene mutation. A single calcification is evident in the pancreatic head, and the main pancreatic duct shows diffuse dilation. Lateral pancreaticoduodenectomy is an appropriate surgical option; total pancreatectomy with islet autotransplantation to eliminate cancer risk associated with hereditary pancreatitis is controversial.
Izbicki Procedure—Technique and Outcomes
An alternative to total pancreatectomy (with or without islet autotransplantation) that may yield similar rates of pain relief yet preserve islet function is the V-shaped longitudinal pancreatic resection introduced by Izbicki and colleagues for patients with small duct disease and diffuse fibrosis. In this procedure the entire pancreas is excavated along the trajectory of the main pancreatic duct from the pancreatic head (as with the Frey procedure) across the body and tail of the organ. Pancreaticoenteric drainage is established by Roux-en-Y lateral pancreaticojejunostomy similar to the Puestow and Frey procedures. The short-term results of the Izbicki procedure compare favorably to those reported in the Minnesota and Cincinnati series of autologous islet transplantation, although the patient populations are not matched.61