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info@pancreascenter.it
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DRAINAGE PROCEDURES

Drainage procedures (anastomoses between the pancreas or a pseudocyst  and a segment of intestine) are performed to relieve intra-pancreatic  and ductal pressure, re-establish an adequate pancreatic juice outflow,  and resolve pain. Internal drainage may be necessary to resolve symptoms  caused by a large or infected pseudocyst.

LATERAL PANCREATICOJEJUNOSTOMY

DECOMPRESSION PROCEDURES FOR CHRONIC PANCREATITIS
A dominant component of chronic pancreatitis is the pancreatic duct hypertension,  caused by fibrotic replacement of normal pancreatic tissue. Duct  stenosis and hypertension are the basis of the duct pressure-pain  hypothesis. Drainage operations are performed on the assumption that  pain relief is obtained by drainage of the main pancreatic duct.

Longitudinal decompression of the main pancreatic duct (at the level  of the body-tail) was proposed in the ’50s by Puestow and modified in  1960 by Partington and Rochelle (latero-lateral Wirsung-jejunostomy)  became the first surgical treatment widely considered to be effective  for pain in chronic pancreatitis. Briefly, after accessing the lesser  sac, a ventral incision of the main pancreatic duct is made until the  head of the pancreas, at the level of gastroduodenal artery. The Wirsung  duct is then anastomosed with a Roux-en-Y loop. Only patients with  dilated pancreatic duct are amenable of lateral pancreatico-jejunostomy.  According to the current literature, the immediate success rate is  about 80%, but 30% experience pain recurrence after 3-5 years, probably  because of concomitant inflammatory mass in the head of the pancreas.

Izbicki et al. proposed a technical modification (pancreatic  longitudinal excavation and lateral pancreatico-jejunostomy) to treat  patients with small, non-dilated main pancreatic duct (< 5 mm).

HYBRID PROCEDURES

In the early 1970s, it was observed that many patients with chronic  pancreatitis had an inflammatory mass in the head of the pancreas. The  three principal ductal systems (Wirsung duct, Santorini duct, and  uncinate process duct) adjoin in the head of pancreas, that may  represent the “core”in which the disease begins. Therefore, hybrid  approaches that associate partial pancreatic head resection with  drainage of the main pancreatic duct were proposed.

In 1972 Beger introduced the duodenum-preserving pancreatic head resection.  By subtotal resection of the pancreatic head and by preserving the body  and tail of the pancreas, pylorus, duodenum, and extra-pancreatic bile  ducts, this operation preserves the normal anatomy of the upper gut and  the normal passage of food. The intention of this operation is to treat  only the enlarged pancreatic head. Reconstruction involves an  end-to-side pancreaticojejunostomy and a side-to-side  pancreaticojejunostomy. If necessary, the body and the tail can be  drained via a longitudinal pancreaticojejunostomy. Immediate relieve of  pain has been reported in 80% of patients.

Combining the surgical principles of drainage and organ-preserving resection, Frey introduced in 1987 a modification of the duodenum-preserving pancreatic head resection, the longitudinal pancreatojejunostomy with local pancreatic head resection. Key  steps in the performance of the Frey procedure include preservation of  the pancreatic neck as well as the capsule of the posterior pancreatic  head. The ducts of Wirsung and Santorini are excised, and the excavation  is created in continuity with the longitudinal dochotomy of the dorsal  duct. The locally excised head of the pancreas is covered with the  opened Roux-en-Y limb of jejunum in continuity with the opened main  pancreatic duct in the body and tail of the pancreas. Results are  similar to those of the Beger procedure.

INTERNAL DRAINAGE OF PSEUDOCYSTS

Drainage of pancreatic pseudocysts can be performed either percutaneously, endoscopically or surgically.

Percutaneous drainage of pseudocyst is the least employed technique. Endoscopic drainage  is the treatment of choice if there is abutment of the pseudocyst  against the stomach or duodenal wall. The procedure involves  endoluminal ultrasonographically guided transgastric puncture of the  pseudocyst, insertion of single or multiple stents, and – if necessary –  transpapillary stenting of the pancreatic duct.
Surgical drainage is indicated when endoscopic  drainage is not feasible (there is no abutment of the pseudocyst against  the stomach or duodenum, there is extensive collateral circle) or after  multiple endoscopic drainage failure.

The surgical approach involves a pseudocystogastrostomy on the posterior stomach wall (that can be fashioned via an anterior gastrotomy), or a pseudocystojejunostomy on a Roux-en-Y loop. The pseudocyst wall should be thick and solid enough to allow the fashioning of the anastomosis.
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