Chapter 88: Pancreaticojejunostomy (Puestow–Gillesby Procedure)

INDICATIONS

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.

PREOPERATIVE PREPARATION

Preoperative assessment of patient narcotic use is warranted. Patients should cease alcohol intake. Abstinence for at least 6 months or even 1 year has been associated with better outcomes. Evidence of advanced pancreatic disease may include diabetes, steatorrhea, and poor nutrition. The pancreatic and biliary systems are evaluated with endoscopic retrograde cholangiopancreatography and with a dye study of both duct systems. Stones in the gallbladder or common duct should be suspected, and ulceration of the duodenum is not uncommon. Evidence of 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 paid to restoring the blood volume and controlling existing diabetes. Blood calcium and phosphorus levels should be determined to rule out a parathyroid adenoma.

ANESTHESIA

General anesthesia is used. An epidural may be used for postoperative pain control.

POSITION

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

OPERATIVE PREPARATION

The skin of the upper abdomen is prepared in the usual manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

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 also may be used.

DETAILS OF THE PROCEDURE

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 performed through the cystic duct as clinically necessary. 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 ...