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Surgery for Chronic Recurrent Pancreatitis
Surgery for Chronic Recurrent Pancreatitis WILLIAM J. GILLESBY, M.D., F.A.C.e. Assistant Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinoi.~
CHARLES B. PUESTOW, M.D., F.A.C.S. Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinois; Clinical Professor of Surgery, University of Illinois College of Medicine, Chicago, Illinois
recurrent pancreatitis is caused, at least in part, by partial pancreatic ductal obstruction. The aim of many of the usual surgical procedures is to relieve this obstruction. Because of the total involvement of the pancreatic ductal system in most of the alcoholic pancreatic cases and some of the biliary tract cases, we feel that adequate and complete drainage of the pancreas is the treatment of choice and is best obtained by the method of pancreaticojejunostomy here described. If the pancreas contains calcified deposits it can reasonably be assumed that ductal obstruction is not limited to the ampullary region and that the entire main ducts must be drained to the proximal stricture. 4 Because of the chronicity of this condition, many of these patients have had previous surgical procedures. Narcotic addiction is present in many. The results in addicts are difficult to assess, but because these unfortunate individuals have been driven to addiction by pain, many can be benefitted, even if not completely rehabilitated. The incision depends on existing scars of previous surgery, and the operator's preference. Because the spleen must be removed in all cases, the incision that the operator prefers for splenectomy is usually satisfactory. We have used left paramedian and transverse incisions and hold no particular brief for either. After the abdomen is opened, the adhesions must be divided to obtain adequate exposure. After exploration for other conditions, the pancreas is exposed by dividing the gastrocolic omentum in its relatively avascular portion. This involves double ligation and division of about six to seven vessels distal to the gastro-epiploic vessels. The spleen is freed from the diaphragm by sharp and manual dissection. The stomach and spleen are delivered and the tail of the pancreas freed from the retroperitoneal CHRONIC
83
84
WILLIAM
J.
GILLESBY, CHARLEs
B.
PuEsTow
Fig. 1. Mobilization and manual compression of the tail of the pancreas. A, Probe in pancreatic duct. B, Release of manual compression with pancreatic juice flowing from the duct.
tissues by manual dissection. Less bleeding is encountered if dissection is begun on the inferior surface of the pancreas. This dissection is usually relatively avascular except in the cirrhotic individual who presents varices in the retroperitoneal area. These are the rarely encountered veins of Sappey and if enlarged can present a serious technical problem requiring careful multiple ligations. These veins are friable and suture ligation is the method of choice in their control. The stomach, spleen, tail and body of the pancreas are delivered into the wound and the pancreas is freed medially as far as the superior mesenteric vessels. The spleen is then removed by ligating the splenic vessels and short gastric arteries. The tail and body of the pancreas are now freed from any remaining retroperitoneal attachments. This renders subsequent hemostasis relatively simple as the pancreas can be manually compressed by the operator's left hand until suture of vessels is accomplished. The use of numerous hemostats is usually a futile procedure and manual control and suturing of vessels saves time and blood. The pancreas is now ready for opening. The body of the pancreas is compressed in the operator's left hand and the tail amputated about 1 em. from the tip with a scalpel (Fig. 1). The duct is usually dilated and easily seen. A spurt of clear pancreatic juice can be seen whenever the compression of the operator's left hand is released. If a duct cannot be found, incisions into the tail, either longitudinal or transverse to the axis of the pancreas, should be used. A dilated duct can almost always be found if one is persistent. In the rare instance in which a duct cannot be
Surgery for Chronic Recurrent Pancreatitis
85
Fig. 2. Stomach retracted to provide exposure of the pancreas. A, Incision of pancreas by inserting point of bandage scissors into dilated duct. B, Opened pancreatic duct with "chain of lakes" dilatation and stenosis.
located, the pancreas should be incised longitudinally three or four times to a depth of half the diameter of the pancreas. When a duct is found, it is probed to determine its direction and patency. For opening the pancreas after the duct is located a small bandage scissors has been found to be of use (Fig. 2). The pancreas is split open on its anterior surface as far as the superior mesenteric vessels. Hemostasis is then obtained by suture ligature using fine catgut to the cut pancreatic surface. The operator's left hand can control bleeding as he sutures with his right and alternately compresses and releases pressure to locate bleeding points. In a particularly vascular pancreas, continuous suture of the duct edge to the cut pancreatic edge without regard to individual vessels will save time. However, this should not be done routinely as it may ligate tributary pancreatic ducts. The major portion of the remaining intact duct is now unroofed by alternately opening duct and suturing bleeding vessels. Suture of the pancreas is safe as the traumatized pancreatic tissue will be covered by intestinal mucosa and will drain intraluminally rather than intraperitoneally. The duct is opened to the junction of the ducts of Wirsung and Santorini. These ducts may be opened for a short distance (1 to 2 em.) if desired. If duct cannot be found, the opened jejunum is used to cover the
86
WILLIAM
J.
GILLESBY, CHARLES
B.
PuEsTow
Fig. 3. Method of bringing distal segment of divided jejunum through the mesocolon to be used for the pancreaticojejunostomy.
incised pancreas as previously mentioned. It is probable that openings develop between the pancreatic ducts and jejunal lumen. If calcific deposits are present they may be removed but usually they are in tissue rather than duct and are difficult to dislodge. They will dissolve later and removal is not essential. During the above dissection, a rent in the mesocolon is frequently produced near the ligament of Treitz. This may be used for the Roux en Y procedure to follow. If a rent has not been accidentally made, an opening in an avascular area in the left transverse mesocolon is made. The point of division of the jejunum-usually about 12 to 20 em. (5 to 8 inches) from the ligament of Treitz-is selected where the mesenteric vessels are easily seen. A crushing hemostatic forceps is applied to the proximal jejunum transversely and a long crushing hemostatic forceps is introduced through the mesocolon, opened and applied in an oblique manner, making the mesenteric side of the jejunum 3 to 6 em. (1 to 2 inches) longer than the antimesenteric side (Fig. 3). The jejunum is divided twice along the edges of the crushing clamps. The triangular wedge between the two clamps is discarded. The clamp through the mesocolon opening is drawn upward to prepare for the retrocolic pancreaticojejunostomy. The jejunum is now tested against the opened pancreas to
Surgery for Chronic Recurrent Pancreatitis
87
A
Fig. 4. A, Payr clamp to crush antimesenteric jejunum. B, Incision along crushed area for 7 to 10 em. (3 to 4 inches). C, Completion of pancreaticojejunostomy showing complete coverage of opened pancreas by opened jejunum.
determine proper length of jejunal opening. A mark is made on the serosa to indicate the length of opened duct that must be covered. The clamp on this segment is removed and the jejunum is pulled open. One blade of a large Payr clamp is introduced into the lumen and both blades applied to the antimesenteric jejunum (Fig. 4, A). This clamp is introduced to within 2 to 3 em. (1 inch) of the serosal mark previously made. This clamp is then closed. Upon removal there is a crushed area that is incised longitudinally so that one-half of the crushed portion is on each side of the opened jejunum (Fig. 4, B). The jejunal edges do not bleed if this is done. The opened tail of the pancreas is inserted into the jejunal lumen. The edges of the opened jejunum are sutured to the surface of the pancreas adjacent to the cut edge of the pancreas by continuous fine catgut suture beginning at the upper medial surface and continuing laterally until the covered pancreas is reached. The crushed edge of jejunum is not removed as it functions as a hemostatic device and makes suturing a simple procedure. The suture is then continued around the posterior surface of the tail of the pancreas and then the inferior edges are sutured by the same method. In this way the opened pancreas is
88
WILLIAM
J.
GILLESBY 7 CHARLES
B.
PUESTOW
Fig. 5. Completed pancreaticojejunostomy with Roux en Y restoration of bowel continuity.
completely covered by opened viable jejunum (Fig. 4, C). A second layer of interrupted sutures from pancreatic adventitia to jejunal serosa completes this procedure. The opening of the mesocolon is then closed around the distal jejunal segment by interrupted mesocolon-to-serosa sutures. The choice of suture material is probably of little concern but we have used catgut throughout on most occasions. The proximal jejunal segment is now anastomosed to the distal jejunal segment in a Roux en Y manner. Our method of choice is to anastomose the mesenteric edges of each portion together and the antimesenteric edges together in a true end-toside manner, avoiding torsion of any segments. The mesenteric openings are now sutured to prevent internal hernia openings (Fig. 5). One author (W.J.G.) inserts a split Penrose drain from the pancreaticojejunostomy site through a stab wound in the left subcostal anterior axillary line. This permits drainage of pancreatic leakage or accumulations in the splenic bed which may occur. The other author (C.B.P.) does not drain. A Foley tube gastrostomy is inserted as these patients require gastric suction for several days. 3 Recovery poses no unusual problems. It has been noted that the nagging, unrelenting pancreatic pain has been relieved immediately and patients volunteer that except for the pain of the operation they feel better than for a long time. 2
Surgery for Chronic Recurrent Pancreatitis
89
In previous reports, insertion of the opened pancreas into the stomach through a posterior gastrotomy was suggested.' This procedure is to be avoided. We also have used insertion of the opened pancreas into the lumen of jejunum cut at right angles. The technical problems of this procedure become much easier if the oblique anastomosis as here described is used. 1 SUMMARY
1. A method of pancreaticojejunostomy is presented that provides drainage from the full length of the pancreatic ductal system to a Roux en Y defunctionalized jejunal segment. 2. Suture of the pancreas is safe if the sutured area drains into the jejunum. Uncovered damaged pancreas permits drainage into the free peritoneal cavity with serious consequences. 3. The preferred technique at present is to perform an anastomosis between opened pancreas and opened jejunum with about 2 to 3 em. (1 inch) of pancreatic tail placed intraluminally. REFERENCES 1. Carnevali, J. F., ReMine, W. H., Dockerty, M. B., Bollman, J. L. and Grindlay,
J. H.: An Experimental Study of Side-to-Side Pancreaticojejunostomy After Ductal Obstruction. A.M.A. Arch. Surg. 80: 774-787 (May) 1960. 2. Gillesby, W. J.: Discussion of paper cited in reference 1. 3. Gillesby, W. J. and Puestow, C. B.: Tube Gastrostomy in Abdominal Surgery. Am. Surgeon 25: 927-930 (Dec.) 1959.1 4. Puestow, C. B. and Gillesby, W. J.: Retrograde Surgical Drainage of Pancreas for Chronic Relapsing Pancreatitis. A.M.A. Arch. Surg. 76: 898-905 (June) 1958. Veterans Administration Hospital Hines, lllinois
CHARLES B. PUESTOW, M.D., F.A.C.S. Chief, Surgical Service, Veterans Administration Hospital, Hines, Illinois; Clinical Professor of Surgery, University of Illinois College of Medicine, Chicago, Illinois
recurrent pancreatitis is caused, at least in part, by partial pancreatic ductal obstruction. The aim of many of the usual surgical procedures is to relieve this obstruction. Because of the total involvement of the pancreatic ductal system in most of the alcoholic pancreatic cases and some of the biliary tract cases, we feel that adequate and complete drainage of the pancreas is the treatment of choice and is best obtained by the method of pancreaticojejunostomy here described. If the pancreas contains calcified deposits it can reasonably be assumed that ductal obstruction is not limited to the ampullary region and that the entire main ducts must be drained to the proximal stricture. 4 Because of the chronicity of this condition, many of these patients have had previous surgical procedures. Narcotic addiction is present in many. The results in addicts are difficult to assess, but because these unfortunate individuals have been driven to addiction by pain, many can be benefitted, even if not completely rehabilitated. The incision depends on existing scars of previous surgery, and the operator's preference. Because the spleen must be removed in all cases, the incision that the operator prefers for splenectomy is usually satisfactory. We have used left paramedian and transverse incisions and hold no particular brief for either. After the abdomen is opened, the adhesions must be divided to obtain adequate exposure. After exploration for other conditions, the pancreas is exposed by dividing the gastrocolic omentum in its relatively avascular portion. This involves double ligation and division of about six to seven vessels distal to the gastro-epiploic vessels. The spleen is freed from the diaphragm by sharp and manual dissection. The stomach and spleen are delivered and the tail of the pancreas freed from the retroperitoneal CHRONIC
83
84
WILLIAM
J.
GILLESBY, CHARLEs
B.
PuEsTow
Fig. 1. Mobilization and manual compression of the tail of the pancreas. A, Probe in pancreatic duct. B, Release of manual compression with pancreatic juice flowing from the duct.
tissues by manual dissection. Less bleeding is encountered if dissection is begun on the inferior surface of the pancreas. This dissection is usually relatively avascular except in the cirrhotic individual who presents varices in the retroperitoneal area. These are the rarely encountered veins of Sappey and if enlarged can present a serious technical problem requiring careful multiple ligations. These veins are friable and suture ligation is the method of choice in their control. The stomach, spleen, tail and body of the pancreas are delivered into the wound and the pancreas is freed medially as far as the superior mesenteric vessels. The spleen is then removed by ligating the splenic vessels and short gastric arteries. The tail and body of the pancreas are now freed from any remaining retroperitoneal attachments. This renders subsequent hemostasis relatively simple as the pancreas can be manually compressed by the operator's left hand until suture of vessels is accomplished. The use of numerous hemostats is usually a futile procedure and manual control and suturing of vessels saves time and blood. The pancreas is now ready for opening. The body of the pancreas is compressed in the operator's left hand and the tail amputated about 1 em. from the tip with a scalpel (Fig. 1). The duct is usually dilated and easily seen. A spurt of clear pancreatic juice can be seen whenever the compression of the operator's left hand is released. If a duct cannot be found, incisions into the tail, either longitudinal or transverse to the axis of the pancreas, should be used. A dilated duct can almost always be found if one is persistent. In the rare instance in which a duct cannot be
Surgery for Chronic Recurrent Pancreatitis
85
Fig. 2. Stomach retracted to provide exposure of the pancreas. A, Incision of pancreas by inserting point of bandage scissors into dilated duct. B, Opened pancreatic duct with "chain of lakes" dilatation and stenosis.
located, the pancreas should be incised longitudinally three or four times to a depth of half the diameter of the pancreas. When a duct is found, it is probed to determine its direction and patency. For opening the pancreas after the duct is located a small bandage scissors has been found to be of use (Fig. 2). The pancreas is split open on its anterior surface as far as the superior mesenteric vessels. Hemostasis is then obtained by suture ligature using fine catgut to the cut pancreatic surface. The operator's left hand can control bleeding as he sutures with his right and alternately compresses and releases pressure to locate bleeding points. In a particularly vascular pancreas, continuous suture of the duct edge to the cut pancreatic edge without regard to individual vessels will save time. However, this should not be done routinely as it may ligate tributary pancreatic ducts. The major portion of the remaining intact duct is now unroofed by alternately opening duct and suturing bleeding vessels. Suture of the pancreas is safe as the traumatized pancreatic tissue will be covered by intestinal mucosa and will drain intraluminally rather than intraperitoneally. The duct is opened to the junction of the ducts of Wirsung and Santorini. These ducts may be opened for a short distance (1 to 2 em.) if desired. If duct cannot be found, the opened jejunum is used to cover the
86
WILLIAM
J.
GILLESBY, CHARLES
B.
PuEsTow
Fig. 3. Method of bringing distal segment of divided jejunum through the mesocolon to be used for the pancreaticojejunostomy.
incised pancreas as previously mentioned. It is probable that openings develop between the pancreatic ducts and jejunal lumen. If calcific deposits are present they may be removed but usually they are in tissue rather than duct and are difficult to dislodge. They will dissolve later and removal is not essential. During the above dissection, a rent in the mesocolon is frequently produced near the ligament of Treitz. This may be used for the Roux en Y procedure to follow. If a rent has not been accidentally made, an opening in an avascular area in the left transverse mesocolon is made. The point of division of the jejunum-usually about 12 to 20 em. (5 to 8 inches) from the ligament of Treitz-is selected where the mesenteric vessels are easily seen. A crushing hemostatic forceps is applied to the proximal jejunum transversely and a long crushing hemostatic forceps is introduced through the mesocolon, opened and applied in an oblique manner, making the mesenteric side of the jejunum 3 to 6 em. (1 to 2 inches) longer than the antimesenteric side (Fig. 3). The jejunum is divided twice along the edges of the crushing clamps. The triangular wedge between the two clamps is discarded. The clamp through the mesocolon opening is drawn upward to prepare for the retrocolic pancreaticojejunostomy. The jejunum is now tested against the opened pancreas to
Surgery for Chronic Recurrent Pancreatitis
87
A
Fig. 4. A, Payr clamp to crush antimesenteric jejunum. B, Incision along crushed area for 7 to 10 em. (3 to 4 inches). C, Completion of pancreaticojejunostomy showing complete coverage of opened pancreas by opened jejunum.
determine proper length of jejunal opening. A mark is made on the serosa to indicate the length of opened duct that must be covered. The clamp on this segment is removed and the jejunum is pulled open. One blade of a large Payr clamp is introduced into the lumen and both blades applied to the antimesenteric jejunum (Fig. 4, A). This clamp is introduced to within 2 to 3 em. (1 inch) of the serosal mark previously made. This clamp is then closed. Upon removal there is a crushed area that is incised longitudinally so that one-half of the crushed portion is on each side of the opened jejunum (Fig. 4, B). The jejunal edges do not bleed if this is done. The opened tail of the pancreas is inserted into the jejunal lumen. The edges of the opened jejunum are sutured to the surface of the pancreas adjacent to the cut edge of the pancreas by continuous fine catgut suture beginning at the upper medial surface and continuing laterally until the covered pancreas is reached. The crushed edge of jejunum is not removed as it functions as a hemostatic device and makes suturing a simple procedure. The suture is then continued around the posterior surface of the tail of the pancreas and then the inferior edges are sutured by the same method. In this way the opened pancreas is
88
WILLIAM
J.
GILLESBY 7 CHARLES
B.
PUESTOW
Fig. 5. Completed pancreaticojejunostomy with Roux en Y restoration of bowel continuity.
completely covered by opened viable jejunum (Fig. 4, C). A second layer of interrupted sutures from pancreatic adventitia to jejunal serosa completes this procedure. The opening of the mesocolon is then closed around the distal jejunal segment by interrupted mesocolon-to-serosa sutures. The choice of suture material is probably of little concern but we have used catgut throughout on most occasions. The proximal jejunal segment is now anastomosed to the distal jejunal segment in a Roux en Y manner. Our method of choice is to anastomose the mesenteric edges of each portion together and the antimesenteric edges together in a true end-toside manner, avoiding torsion of any segments. The mesenteric openings are now sutured to prevent internal hernia openings (Fig. 5). One author (W.J.G.) inserts a split Penrose drain from the pancreaticojejunostomy site through a stab wound in the left subcostal anterior axillary line. This permits drainage of pancreatic leakage or accumulations in the splenic bed which may occur. The other author (C.B.P.) does not drain. A Foley tube gastrostomy is inserted as these patients require gastric suction for several days. 3 Recovery poses no unusual problems. It has been noted that the nagging, unrelenting pancreatic pain has been relieved immediately and patients volunteer that except for the pain of the operation they feel better than for a long time. 2
Surgery for Chronic Recurrent Pancreatitis
89
In previous reports, insertion of the opened pancreas into the stomach through a posterior gastrotomy was suggested.' This procedure is to be avoided. We also have used insertion of the opened pancreas into the lumen of jejunum cut at right angles. The technical problems of this procedure become much easier if the oblique anastomosis as here described is used. 1 SUMMARY
1. A method of pancreaticojejunostomy is presented that provides drainage from the full length of the pancreatic ductal system to a Roux en Y defunctionalized jejunal segment. 2. Suture of the pancreas is safe if the sutured area drains into the jejunum. Uncovered damaged pancreas permits drainage into the free peritoneal cavity with serious consequences. 3. The preferred technique at present is to perform an anastomosis between opened pancreas and opened jejunum with about 2 to 3 em. (1 inch) of pancreatic tail placed intraluminally. REFERENCES 1. Carnevali, J. F., ReMine, W. H., Dockerty, M. B., Bollman, J. L. and Grindlay,
J. H.: An Experimental Study of Side-to-Side Pancreaticojejunostomy After Ductal Obstruction. A.M.A. Arch. Surg. 80: 774-787 (May) 1960. 2. Gillesby, W. J.: Discussion of paper cited in reference 1. 3. Gillesby, W. J. and Puestow, C. B.: Tube Gastrostomy in Abdominal Surgery. Am. Surgeon 25: 927-930 (Dec.) 1959.1 4. Puestow, C. B. and Gillesby, W. J.: Retrograde Surgical Drainage of Pancreas for Chronic Relapsing Pancreatitis. A.M.A. Arch. Surg. 76: 898-905 (June) 1958. Veterans Administration Hospital Hines, lllinois