International Journal of Surgery Science 2020; 4(3): 71-76

E-ISSN: 2616-3470
P-ISSN: 2616-3462
© Surgery Science Open modified puestow procedure in an advanced
www.surgeryscience.com
2020; 4(3): 71-76
endoscopic era for chronic pancreatitis with dilated
Received: 06-05-2020
Accepted: 08-06-2020
pancreatic duct and stones
Dr. Ajay A Gujar
Department of General Surgery, Dr. Ajay A Gujar, Dr. Amrita A Gujar and Dr. Aashay Dharia
Amruta Surgical and Maternity
Hospital, Mumbai, Maharashtra,
DOI: https://doi.org/ 10.33545/surgery.2020.v4.i3b.471
India

Dr. Amrita A Gujar Abstract

K J Somaiya Hospital and Background: Chronic pancreatitis has been defined as a continuing inflammatory disease of the pancreas
Research centre, Sion, Mumbai, characterized by irreversible morphological changes. These changes typically cause pain and loss of
Maharashtra, India exocrine and endocrine pancreatic function.
The most common symptom of chronic pancreatitis is pain, which can be severe and intractable in some
Dr. Aashay Dharia patients. Although it is itself benign, chronic pancreatitis can significantly affect quality of life and can
Dharia K J Somaiya Hospital and cause significant distress with its complications [1].
Research centre, Sion, Mumbai, The initial treatment for pain in most cases is to start of enzyme replacement, control of diabetes with
Maharashtra, India insulin, and administration of oral analgesics.
Surgical intervention is required in patients with intractable pain that is resistant to conventional
nonsurgical therapy, in patients with associated or suspected malignancy, and in patients who have
developed complications such as biliary or duodenal obstruction, pancreatic fistulae, pancreatic
ascites/pleural effusion, pseudocyst, or rare hemosuccus pancreaticus [2].
The aetiology of pain in chronic pancreatitis is unclear. Some evidence has suggested that perineural
inflammation may be the cause of pain. A dilated pancreatic duct, secondary to obstruction, may cause
increased intraductal pressures, resulting in pain [3].
The primary aim of therapy is the achievement of primary pain relief and an improvement in quality of life.
This could be achieved by means of endoscopic, open or laparoscopic /robotic lateral
pancreaticojejunostomy [4, 13].
Methods: We selected 41 cases of chronic pancreatitis of both genders with moderate to intractable pain
hampering routine life. All patients tried conservative treatment for more than 6 months. All selected
patients underwent haematological and radiological work up. MRCP of all patients showing dilated
pancreatic duct more than 7mm. in size. All of these patients operated for longitudinal
pancreaticojejunostomy (Modified Puestow’s). Follow up done for one year to ten years
Results: All 41 patients in long term follow up were recovered well from pain and abdominal discomfort.
Appetite were improved and weight gain noted in the patients after surgery.
Conclusions: Longitudinal pancreaticojejunostomy is still safe, simple and timely approved procedure for
pain associated with chronic pancreatitis.

Keywords: Chronic pancreatitis, pancreatitis pain, partington and Rochelle pancreaticojejunostomy,

modified puestow pancreaticojejunostomy

Introduction
Gould successfully removed calculi from the Wirsung duct in 1898 [5].
Moynihan in 1902 [6] and subsequently Mayo-Robson in 1908 [7] reported that timely removal of
calculi from the pancreatic duct prevented atrophy of the pancreas and relieved pain.
Coffey first performed distal pancreatectomy with pancreaticoenterostomy in dogs. He
suggested that this procedure may be beneficial in various conditions [8].
Link reported the first pancreatic duct drainage operation for chronic pancreatitis in 1911. In this
Corresponding Author: procedure, a catheter was placed in the pancreatic duct to drain the pancreatic juice through the
Dr. Ajay A Gujar skin, providing pain relief and restoring the patient’s normal weight [9].
Department of General Surgery, Duval reported on distal pancreatectomy, splenectomy, and pancreaticojejunostomy in 1954 [10].
Amruta Surgical and Maternity
In this procedure, an end-to-end distal pancreaticojejunostomy was performed, and the
Home 408/C wing Bhaveshwar
Plaza CHS LBS road, Ghatkopar pancreatic duct was decompressed in a retrograde manner. The disadvantage of this procedure
West, Mumbai, Maharashtra, India was that, if the ductal system contained strictures, the entire duct would not be decompressed.

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In 1958, Puestow and Gillesby introduced the lateral Forty-one patients from 36 to 70 years of age were selected for
(longitudinal) pancreaticojejunostomy (LPJ), which consists of a surgeries in 10 years of duration from January 2009 to January
longitudinal incision of the pancreatic duct and implantation of 2019. Thirty-Five were men and six were women.
the tail of the gland into the Roux-en-Y limb of the jejunum Out of 35 men 28 had alcoholic pancreatitis 5 had gall stone
following splenectomy and distal pancreatectomy [11]. Although biliary pancreatitis remaining 2 had idiopathic aetiology.
this procedure decompressed a greater length of pancreatic duct One male patient (65 years old) had recurrent formation of
and was useful in patients with strictures in the main pancreatic pancreatic duct calculi after 18 yrs. of previously inadequately
duct, it did not satisfactorily decompress the pancreatic head and performed Puestow’s surgery.
the uncinate ducts. Out of 6 female 5 had biliary pancreatitis and 1 from Kerala had
In 1963, Partington and Rochelle modified the Puestow-Gillesby tropical pancreatitis?
pancreaticojejunostomy by creating an anastomosis between a All patients’ detailed history were taken to rule out aetiology,
longitudinally incised anterior surface of the pancreas and duct characteristic of pain, abdominal discomfort and weight loss.
from the head to the tail with a longitudinally incised Roux-en-Y In all 41 patients, severe pain with hampered routine activity
jejunal loop [12]. This modification did not require distal was a main symptom. Associated symptoms were loss of
pancreatectomy, splenectomy, or mobilization of the pancreas appetite, belching, gaseous distension and weight loss.
from its retroperitoneal attachments. Symptoms used to aggravate mainly after meals. Weight loss
Open, laparoscopic or robotic lateral pancreaticojejunostomy is was significant 10 to 15% of body weight in 3 to 4 months in all
one of the answer for relief of pain and better life. patients.
‘Wong-Baker FACES pain rating scale’ system was used for
Methods assessment and improvement in pain.

Fig 1: Wong-Baker FACES pain rating scale

Complete haematological check-up was done in all patients. ERCP pancreatic ductal clearance tried and could not achieved
Serum Amylase and Lipase were normal in 30 patients and complete clearance in 6 patients.
mildly elevated in 11 patients. Out of 10 gall stone (biliary aetiology) patients 4 were required
USG abdomen followed by MRI (MRCP) in all patients. All ERCP bile duct clearance before surgery. All patients received
these patients had pancreatic ductal size from 7mm to 15mm. conservative management for six months and not responded to
Small to large multiple ductal calculi were present in almost 38 it.
patients.

Fig 2: ERCP showing large dilated pancreatic duct

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Fig 3: Showing recurrent stones in head and body of pancreatic duct, in previously inadequately performed Puestow’s technique
Surgical technique:

It is actually modification of original Puestow’s surgery loop of small intestine so that the pancreas drains directly into
(Partington and Rochelle) still goes with Puestow name. the intestine duct in order to allow its drainage. 4/0 polygalactic
The abdomen is opened with an incision from the xiphisternum acid on round body needle suture material (interrupted or
to the umbilicus. continuous according to pancreatic duct condition) were used.
The pancreas is exposed through lesser sac and the main Minimum 8cm. wide anastomosis was done for every patient.
pancreatic duct is opened from the head to the tail of the Patients who had biliary pancreatitis additional
pancreas. Identification of ducts were easy in patients with large cholecystectomies were performed. Single abdominal 28 number
pancreatic calculi. In some cases, ducts were only dilated drain kept for all patients.
without stones, in those cases needle and syringe used to locate One advantage of this procedure compared to a Frey's procedure
duct and incision taken over needle. All ductal stones were is that pancreatic tissue is preserved, which may be of critical
removed. Especially all stones were cleared from head of the importance in patients with exocrine or endocrine insufficiency
pancreas. from their chronic pancreatitis.
The opened pancreatic duct is then connected to a Roux-en-Y

Fig 4: Diagrammatic representation showing operative technique of Modified Puestow surgery

Fig 5: Patent with ERCP of pic 2 Re- pancreaticojejunostomy with same Roux-e-y loop in inadequately performed Puestow s 18 years back with
complete pancreatic ductal clearance with difficult cholecystectomy.

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Post-operative: all patients kept nil by mouth for three days. Drain removed on fourth day. One patient developed pancreatic ascites in
whom drain removed on tenth day.

Results

Table 1: Gender and aetiology

Gender and aetiology Alcoholic Biliary Others Total
Male 28 5 2 35
Female 0 5 1 06
Total 28 10 3 41

Table 1 clearly shows male predominance 68% with commonest aetiological factor is alcohol 68.29% followed by biliary calculi
24.39% and other causes are 7.32%.

Table 2: Percentage of relief of symptoms post-operatively

Before pain Before weight loss/after Gaseous distension and Fluctuation in sugar level
Gender and symptomatology
after no pain weight gain malabsorption Before yes after no before yes after no
Before After Before After Before After Before After
Male 35 35 31 31 28 24 10 10
Female 6 6 5 5 3 2 2 2
Total 41 41 36 36 31 26 12 12

Above table 2 shows symptomatology before and after surgery. the crystallization and deposition of calcium carbonate as long
Pain was relieved immediately postoperative in all 41(100%). as alcohol and CP cause hyper saturation of pancreatic juice
The Wong-Baker FACES pain rating score were above 6 for all with calcium.
patients which improved to 0-4. The diagnosis of chronic pancreatitis is set by clinical means and
Weight loss was in 36 patients, after the surgery all 36 (100%) imaging modalities. On plain X-ray pancreatic calcifications are
patients gain weight to normal. detected in 30% of CP patients [15]. Abdominal ultrasound has
Malabsorption related symptoms were present 31 patients out of limited value, but computed tomography (CT) scan provides
which 26(84%) patients had good recovery. detailed imaging of pancreatic stones. Endoscopic retrograde
Fluctuation in sugar levels observed in 12 patients in spite of cholangiopancreatography (ERCP) and magnetic resonance
regular adjustment of antidiabetic drug doses, but after the cholangiopancreatography (MRCP) are valuable adjunct to the
surgery it was easy to control their diabetes mellitus with evaluation of the exact location of the calculi and duct system
suitable fix antidiabetic drugs. anatomy. Moreover, ERCP may be therapeutic, if the stones are
extracted.
Table 3: Size of the pancreatic duct on MRCP In older randomized trials is demonstrated that surgical therapy
Gender and size 7-9 mm 9-12 mm 12-15 mm >15mm turns to have more durable results and results in pain relief for
male 16 13 5 1 longer intervals [16]. Today, due to further development of
female 2 3 1 0 endoscopic techniques, endoscopic therapy is usually the first
total 18 16 6 1 preferred option because of less invasiveness. Positive response
to endoscopic treatment is a predictor of good surgical results
18 (44%) patients had 7-9mm duct size.16 (39%) had 9-12mm, when operative approach is administered in the course of the
6 (15%) had 12-15mm.and only one (2%) had 17mm size. disease [17]. Endoscopic stone removal is attempted when
upstream pancreatic duct dilatation is present. However,
Table 4: Complications of surgery pancreatic stones are harder and speculated in comparison to bile
duct stones and these features explain why pancreatic stones
Complications Number of patients
imply difficulties for extraction. Endoscopic stone removal is
On table haemorrhages 4 -required blood transfusion
successful in 50% of cases with standard techniques [18].
Pancreatic ascites 1
Wound site infection 5
The decision for surgical therapy depends on many factors:
Splenic vein damage 1 splenectomy done pancreatic duct diameter, duct strictures, pain severity indexes,
malignancy concerns, associated biliary duct obstruction and
Table 4 shows complications we come across during this operative risk. Resection, drainage and decompression and
surgery. Complication rate was low and complications were combination procedures have been described. Regarding
manageable. surgical treatment, lateral pancreaticojejunostomy or modified
Puestow procedure is the most common and well-studied
Discussion surgical technique for such cases [19]. It is successful in chronic
Pain is the predominant symptom in chronic pancreatitis; 80– pancreatitis without an inflammatory mass in the head of the
90% of patients present with pain as the primary symptom either pancreas for pain relief in 90% of patients and is suited for
at the first attack of acute pancreatitis or as the main reason for pancreatic ducts >8mm [20]. Pancreatic leak is low (0.03-5%) in
hospital readmissions in the following months and years, as the appropriately selected patients with a fibrotic gland [19].
disease progresses to what could be defined as chronic Postoperative mortality rate and disease incidence of patients
pancreatitis. who underwent the Partington-Rochelle procedure were lower
The formations of stones in chronic pancreatitis are caused by than among those who had the original Puestow procedure, at
approximately 3% and 20%, respectively [21.22].

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Surgical treatment of the pain of chronic pancreatitis chronic pancreatitis is severe, unremitting pain that is resistant to
Many operations have been described. They can be divided into other measures. Examples of the commonly used surgical
decompression and drainage procedures and resection procedures in the management of chronic pancreatitis are shown
procedures. The primary indication for surgical intervention in in Table 5.

Table 5: Surgical procedures performed in chronic pancreatitis

Decompression/drainage operations procedures Resection
Longitudinal pancreaticojejunostomy (modified Puestow procedure) pancreaticoduodenectomy (Whipple procedure)
Lateral pancreaticojejunostomy Beger procedure (duodenum-preserving pancreatic head resection)
Frey procedure (resection of the pancreatic head with longitudinal
Lateral pancreaticoduodenectomy
pancreaticojejunostomy)
Pancreatic pseudocyst drainage Total pancreatectomy and islet cell autotransplant Distal pancreatectomy

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