Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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STEP 1: SURGICAL ANATOMY

◆ The head of the pancreas is surrounded by the C-loop of the duodenum laterally. It is fully

evaluated after mobilizing the duodenum and head of the pancreas from its retroperitoneal

location.

◆ The right gastroepiploic artery and vein are located in the space between the pylorus of the

stomach and the head of the pancreas.

◆ The anterior superior and the anterior inferior pancreaticoduodenal artery and vein parallel

the course of the C-loop of the duodenum, and they are located 1 to 2 mm onto the lateral

aspect of the head of the pancreas.

◆ The body and tail of the pancreas are located posterior to the stomach and can be accessed

by dividing the gastrocolic omentum.

◆ In chronic pancreatitis the transverse mesocolon may be adherent to the anterior and infe-

rior border of the pancreas.

◆ The dilated pancreatic duct may be palpated in the mid-portion of the body and head of

the pancreas running longitudinally (Figure 50-1).

Pancreaticojejunostomy

(Puestow)

William H. Nealon

CHAPTER

CHAPTER 50 • Pancreaticojejunostomy (Puestow) 565

Spleen

Duodenojejunal flexure

and jejunum

Liver

Duodenum

Superior mesenteric artery and vein

Gallbladder

Cystic duct

Portal vein

Anterior, superior

pancreaticoduodenal artery

Gastroduodenal artery

Common bile duct

Splenic artery and vein

Pancreatic duct

Left kidney

Inferior mesenteric vein

Transverse colon (cut)

Pancreas

Stomach (cut)

Aorta

Celiac trunk

Common hepatic artery

Common hepatic duct

FIGURE 50 –1

566 Section VII • Pancreas

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Indications: This procedure is indicated only in patients with chronic pancreatitis.

◆ The primary indication for operation in chronic pancreatitis is chronic unremitting

abdominal pain. This operation is restricted to patients who have evidence of pancreatic

ductal dilation, and most agree that the dilation should be 7 mm or greater in diameter.

The secondary but well-recognized indication is recurring acute exacerbations of chronic

pancreatitis. We have identiﬁ ed three categories of patients: patients who have chronic

unremitting abdominal pain only; patients with recurring acute exacerbations only; and

patients with both manifestations of chronic pancreatitis. Typically some element of

dependence on narcotic analgesics to manage the pain is anticipated.

◆ Important considerations in preoperative planning for a Puestow procedure include es-

tablishing the nutrition status of the patient. Typically patients with this diagnosis present

with functional derangements including endocrine and exocrine dysfunction. They also

typically have pain worsened by meals, and for that reason nutritional deﬁ cits are com-

mon. It is therefore vital to determine the nutritional status of patients.

◆ Pertinent to functional derangements, it is important to maximize the replacement ther-

apy for patients with functional derangements. This includes insulin therapy for patients

who have glucose intolerance and enzyme replacement for patients who have pancreatic

malabsorption.

◆ The most common cause of splenic vein thrombosis is chronic pancreatitis. It is impor-

tant to determine those patients who have either splenic vein thrombosis or portal vein

thrombosis as a complication of their chronic pancreatitis. These may result in left-sided

portal hypertension or in cavernous transformation in the area of the head of the pan-

creas. These ﬁ ndings can greatly worsen the outcomes in operations for this disease

because of the potential of signiﬁ cant hemorrhage during operation.

◆ One must also consider the two associated complications of chronic pancreatitis in addition

to pancreatic ductal dilation, which may be seen. First, common bile duct dilation occurs

because of the narrowing of the distal bile duct created by the ﬁ brotic mass in the head of

the pancreas. This can be seen in 30% to 50% of patients with chronic pancreatitis.

◆ Finally, one must be cognizant of the possibility of duodenal narrowing caused by

chronic pancreatitis. This complication is seen in less than 5% of patients, but it must be

recognized as a possible complication. Each of these may require a simultaneous opera-

tive intervention during the primary operation for the drainage of the pancreatic duct.

◆ All patients undergo bowel preparation with a cathartic combined with oral antibiotic

doses of neomycin and erythromycin. Finally, a dose of intravenous antibiotics is admin-

istered within 1 hour of the skin incision.

CHAPTER 50 • Pancreaticojejunostomy (Puestow) 567

STEP 3: OPERATIVE STEPS

1. INCISION

◆ We favor a midline incision for this procedure. Historically, many have advocated bilateral

subcostal incision, but we have recently modiﬁ ed this approach for many pancreatic opera-

tive procedures and we favor a midline incision (Figure 50-2).

Midline incision

FIGURE 50 –2

568 Section VII • Pancreas

2. DISSECTION

◆ After entering the abdomen, the surgeon performs a general evaluation of the peritoneal

cavity as a routine.

◆ A Kocher maneuver is performed by incising the peritoneum lateral to the C-loop of the

duodenum. After mobilizing the duodenum and head of the pancreas medially one can

readily palpate the head and neck of the pancreas (Figure 50-3).

◆ The lesser sac is entered by dividing the attachments in the avascular plane between the gastro-

colic omentum and the transverse colon. This is accomplished by grasping the omentum and

reﬂ ecting it anteriorly and superiorly, exposing the posterior aspect of the attachment between

the omentum and the transverse colon. Electrocautery is used to divide the peritoneal attach-

ments beginning approximately 5 cm to the left of the spine and continuing the dissection

toward the right. In this area, it is possible to establish the plane that leads to the lesser sac.

The transverse mesocolon will be displaced inferiorly, and the posterior wall of the stomach

will be displaced superiorly. There may be attachments to the appendices epiploicae of the

transverse colon, which need to be carefully separated (Figure 50-4).

◆ After establishing entry into the lesser sac, the opening may be extended to the right well

beyond the midline to facilitate a wide view of the lesser sac. There are typically a number

of adhesions between the posterior wall of the stomach and the anterior surface of the body

of the pancreas, and these can be lysed safely (Figure 50-5).

Mobilization limited to

first and second portion of duodenum

Common bile duct

Major duodenal

papilla (of Vater)

Superior mesenteric artery and vein

Inferior vena cava

Right kidney

FIGURE 50 –3

CHAPTER 50 • Pancreaticojejunostomy (Puestow) 569

Duodenojejunal junction

(Ligament of Treitz)

Electrocautery under

transverse colon

Cystic duct

Gastroduodenal artery

Narrowed common

bile duct

Pancreaticoduodenal

artery

Splenic artery and vein

Dilated pancreatic duct

Superior mesenteric artery

and vein

Transverse colon

Pancreas

(Chronic pancreatitis)

Stomach reflected cephalad

Aorta

Celiac trunk

Common hepatic artery

FIGURE 50 –4

Duodenojejunal flexure

and jejunum

Superior mesenteric artery and vein

Cystic duct

Gastroduodenal artery

Common bile duct narrowed

Splenic artery and vein

Dilated pancreatic duct

Aorta

Celiac trunk

Common hepatic artery

FIGURE 50 –5

570 Section VII • Pancreas

◆ After a wider entry into the lesser sac is established, the tissues overlying the body and head

of the pancreas are carefully dissected free.

◆ The somewhat thickened fatty structure just inferior to the pylorus is the location of the

right gastroepiploic artery and vein. It is at times necessary to divide these structures in per-

forming the pancreaticojejunostomy. Very often there is an anterior branch between the right

gastroepiploic artery and superior mesenteric vein or the superior mesenteric artery, which

courses along the anterior surface of the body/head of the pancreas. It is advised and safe to

divide this arterial connection between clamps as one clears the head of the pancreas

(see Figure 50-5).

◆ In most cases, it is possible to palpate the dilated main pancreatic duct. This should be

done with the ﬁ ngertips and at times by using bimanual palpation by passing the left hand

beneath the head of the pancreas. Typically the ﬁ rm texture of a chronic pancreatitis pan-

creas is easily distinguished from what feels like a canyon through the course of the main

pancreatic duct. Typically in chronic pancreatitis, the duct is displaced more anteriorly and

therefore is easier to palpate (Figure 50-6).

◆ After the location of the pancreatic duct is satisfactorily established, a 20-gauge angiocathe-

ter is passed into the duct, and the clear pancreatic juice is identiﬁ ed (see Figure 50-6).

◆ We will often perform manometry simply to take note of the presence of high pressures in

the main pancreatic duct, which at times have served some predictive value in the success

of relieving pain in this operation.

◆ After the location of the duct with the catheter is established, electrocautery is used to open

down along the angiocatheter tract into the pancreatic duct. Typically, the pancreatic duct

has a reddish smooth surface, which distinguishes it from false passages within the paren-

chyma of the pancreas. Care should be taken not to enter through the lobulated texture of

the pancreas into a false passage. After the duct is established, a tonsil clamp can be used to

probe both toward the tail and toward the head of the pancreas, and the electrocautery

follows the hemostat’s opened blades (Figure 50-7).

CHAPTER 50 • Pancreaticojejunostomy (Puestow) 571

Portal vein

Gastroduodenal artery

Right gastroepiploic artery

Splenic artery and vein

Palpation and aspiration

of dilated pancreatic duct

Common hepatic artery

FIGURE 50 –6

Superior mesenteric artery and vein

Genu

Carry incision all the way

through genu

Gastroduodenal artery

Common bile duct

Splenic artery

Pancreatic duct

Celiac trunk

Common hepatic artery

FIGURE 50 –7

572 Section VII • Pancreas

◆ It is vital to continue the incision in the main pancreatic duct past the genu of the duct.

This portion of the main pancreatic duct courses both inferiorly and posteriorly. Thus the

depth of incision into pancreatic parenchyma is considerably greater in this portion of the

dissection, and the risk of hemorrhage during this dissection is higher. One should be pre-

pared to perform a suture ligature should one encounter any major bleeding during this

dissection. Data conﬁ rm that an adequate incision in the main pancreatic duct must include

a deep incision into the uncinate process in the head of the pancreas. Suture ligation of

these parenchymal arteries is mandatory to prevent postoperative hemorrhage.

◆ After this incision is completed, identify an area of proximal jejunum approximately 15 cm

past the ligament of Treitz. The mesentery is divided between clamps in a vertical fashion

down toward the spine. After acceptable mobility of the limb of jejunum, a GIA stapling

device is placed across the jejunum, and the jejunum is divided (Figure 50-8).

◆ The distal segment of the divided jejunum is passed through a rent in the transverse meso-

colon and placed side-to-side against the body of the pancreas, with the divided end of

jejunum directed toward the left (Figure 50-9).

CHAPTER 50 • Pancreaticojejunostomy (Puestow) 573

Ligament of Treitz

Superior mesenteric

artery and vein

Division of jejunum

with GIA stapler

FIGURE 50 –8

Side-to-side anastomosis

for Roux-en-Y limb

Roux limb brought through

the Roux to the transverse

mesocolon

FIGURE 50 –9