Overview
Definition:
The Puestow procedure, also known as lateral pancreaticojejunostomy, is a surgical technique employed to manage symptomatic chronic pancreatitis characterized by ductal dilation
It involves creating a longitudinal opening in the anterior wall of the dilated pancreatic duct and anastomosing it to a Roux-en-Y loop of jejunum to facilitate drainage of pancreatic secretions.
Epidemiology:
Chronic pancreatitis affects approximately 0.05% of the general population, with a higher incidence in alcohol users and certain genetic predispositions
Puestow procedure is indicated in a subset of these patients with significant ductal obstruction and symptoms refractory to medical management.
Clinical Significance:
This procedure offers significant symptomatic relief from pain and prevents further pancreatic damage by decompressing the pancreatic duct system
It is a crucial option for surgical candidates with specific anatomical criteria in chronic pancreatitis, impacting patient quality of life and preventing severe complications.
Indications
Indications:
Puestow procedure is primarily indicated for patients with symptomatic chronic pancreatitis who have a significantly dilated pancreatic duct (typically > 7 mm), especially in the head and body of the pancreas, and evidence of intraductal obstruction or pancreatic ductal stones
Patients must have refractory pain despite maximal medical therapy and be fit for major surgery
Specific indications include: Painful chronic pancreatitis with ductal dilation
Main pancreatic duct strictures with upstream dilation
Pancreatic duct stones contributing to obstruction
Recurrent acute pancreatitis episodes in the setting of ductal abnormalities.
Contraindications:
Absolute contraindications include unresectable pancreatic malignancy, severe coagulopathy, and patients who are not medically fit for surgery
Relative contraindications may include diffuse small duct pancreatitis without significant dilation, or very limited pancreatic parenchyma.
Preoperative Assessment:
Thorough preoperative assessment includes detailed history and physical examination, laboratory investigations (amylase, lipase, liver function tests, glycemic control), and advanced imaging
Key imaging modalities are CT scan with intravenous contrast, MRCP (Magnetic Resonance Cholangiopancreatography), and sometimes ERCP (Endoscopic Retrograde Cholangiopancreatography) for detailed ductal anatomy and stone localization
Nutritional status and comorbidities are also assessed
Pain scores and analgesic requirements are meticulously documented.
Procedure Steps
Surgical Approach:
The standard approach is a laparotomy, typically a midline or chevron incision, providing adequate exposure to the pancreas and duodenum
Laparoscopic or robotic approaches are also being increasingly adopted.
Pancreatic Duct Dissection:
Following mobilization of the pancreas (often requiring a Kocher maneuver for the head), the anterior surface of the dilated main pancreatic duct is carefully identified and dissected
The length of the incision into the duct is critical, often extending from the tail to the head to adequately decompress the entire dilated system.
Anastomosis Creation:
A Roux-en-Y jejunal limb is created and brought up to the opened pancreatic duct
The pancreatic duct is then anastomosed to the jejunum using fine sutures, creating a wide opening to ensure maximal drainage
The pancreatic stump if any is closed and gastrojejunostomy is performed.
Completion:
Hemostasis is ensured, and drains are placed in the pancreatic bed
The abdomen is closed in layers
The goal is to create a wide, tension-free anastomosis to allow effective flow of pancreatic juice into the jejunum.
Postoperative Care
Pain Management:
Aggressive pain control is paramount using epidural analgesia or patient-controlled analgesia (PCA) with opioids
Regular assessment of pain levels is essential.
Nutritional Support:
Patients are typically kept nil by mouth initially and gradually advanced to enteral or parenteral nutrition as dictated by bowel function and pancreatic drain output
Pancreatic enzyme supplements may be required long-term.
Drain Management:
Pancreatic drains are monitored for output, amylase content, and consistency
Drains are typically removed when output is low and amylase levels are normalized
Close monitoring for leaks is crucial.
Monitoring For Complications:
Patients are closely monitored for signs of complications such as pancreatic fistula, intra-abdominal abscess, bleeding, pancreatitis recurrence, and ileus
Regular laboratory tests and imaging may be performed as needed.
Complications
Early Complications:
Early complications include pancreatic fistula (leakage of pancreatic fluid from the anastomosis), intra-abdominal abscess, bleeding from the pancreatic bed or anastomosis, pancreatitis exacerbation, and wound infection
Postoperative ileus is also common.
Late Complications:
Late complications can include anastomotic stricture leading to recurrence of symptoms, pancreatic duct stones, exocrine insufficiency (malabsorption), endocrine insufficiency (diabetes mellitus), jejunal ulcer, and cholangitis
Nutritional deficiencies may persist.
Prevention Strategies:
Meticulous surgical technique, achieving wide ductal opening, tension-free anastomosis, adequate drainage, and careful postoperative management are key to preventing complications
Early recognition and prompt treatment of leaks or infections are vital.
Prognosis
Factors Affecting Prognosis:
Prognosis is generally favorable for symptomatic relief, with a significant reduction in pain scores in a majority of patients
Factors influencing outcomes include the underlying etiology of pancreatitis, extent of pancreatic damage, success of ductal decompression, and presence of comorbidities
Patients with better pancreatic ductal drainage and fewer complications tend to have better long-term outcomes.
Outcomes:
The Puestow procedure is effective in relieving pain in 60-80% of appropriately selected patients
It can also help prevent further progression of pancreatic damage
However, it does not reverse existing fibrosis or cure diabetes if already present.
Follow Up:
Long-term follow-up is essential and involves regular clinical assessment, monitoring for recurrent pain, symptoms of exocrine and endocrine insufficiency, and periodic imaging (ultrasound, CT, or MRCP) to assess the patency of the anastomosis and the state of the pancreatic duct
Nutritional status and glycemic control are closely managed.
Key Points
Exam Focus:
Understand the indications for Puestow (dilated duct >7mm, obstruction, refractory pain)
Recognize the procedure involves a longitudinal pancreaticojejunostomy (Roux-en-Y)
Key complications are fistula, abscess, bleeding, and late stricture.
Clinical Pearls:
Ensure adequate length of pancreatic duct opening to decompress the entire ductal system
Achieve a wide, tension-free anastomosis
Careful drain management is critical for early detection of leaks.
Common Mistakes:
Inadequate ductal decompression, performing the procedure in patients with small duct pancreatitis, poor anastomotic technique leading to leaks or strictures, and insufficient postoperative monitoring for complications.