Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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3. RECONSTRUCTION

Pass the distal divided limb of jejunum beneath the prior site of the ligament of Treitz, and position it directly opposite the pancreatic remnant oriented from the divided end of the pancreas to the side of the jejunal limb. The limb will fall into the right upper quadrant in the area where the hepaticojejunostomy will be performed (Figure 49-16).

Identify the pancreatic duct. Make an incision from the anterior surface of the pancreas down to the duct (1.5 cm in length).

Perform an end-to-side pancreaticojejunostomy in a single layer using interrupted 3-0 silk suture. The anterior surface of the jejunum will drape over the 1.5-cm incision in the duct. Place the sutures in the pancreatic parenchyma using a broad passage of the needle to ensure adequate “purchase” and to avoid tearing parenchyma while tying the sutures (see Figure 49-16).

Perform an end-to-side hepaticojejunostomy using a single layer of interrupted 4-0 polydioxanone (PDS) suture on an RB-1 needle. Use absorbable suture (see Figure 49-16).

Fix the limb of jejunum in place as it passes beneath the prior site of the ligament of Treitz using an interrupted 3-0 silk stitch.

Perform a duodenojejunostomy in an antecolic fashion 40 cm distal to the hepaticojejunostomy. The anastomosis is performed in two layers with an outer layer of interrupted 3-0 silk suture and an inner layer of running locking 3-0 Vicryl suture posteriorly, which is converted to a Connell type of stitch anteriorly (Figure 49-17).

Irrigate the peritoneal cavity with warm, sterile saline.

Place two 10-mm Jackson-Pratt drains:

Place one through a stab wound on the left side of the abdomen, and position it posterior to the pancreaticojejunostomy and posterior to the hepaticojejunostomy.

Place the other through a stab wound on the right side of the abdomen, and position it anterior to the hepaticojejunostomy and anterior to the pancreaticojejunostomy.

The drains are fixed in place using drain fixation sutures of 2-0 silk stitch.

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4. CLOSING

Reapproximate the fascia using heavy-gauge Vicryl suture. We favor the Smead-Jones technique. Reapproximate the skin and apply dressings. Place drains to close and bulb suction.

STEP 4: POSTOPERATIVE CARE

In the first 24 hours, the primary concerns are hemorrhage (including monitoring coagulation status) and hyperglycemia. Unexpected glucose intolerance after resection and after the stress of surgery may manifest only as brisk urine output and be interpreted as a sign of euvolemia. Hemoglobin stability must be documented before close, and interval evaluations may be stopped.

Delayed gastric emptying is common, and one must establish low nasogastric tube output before removal ( 150 mL per 8 hours). Most can be removed on postoperative day 1.

Drains must be monitored for volume and character. On postoperative day 3, these should be tested for amylase and bilirubin content. Evidence of biliary or pancreatic fistula is managed by continued drainage.

Intravenous antibiotics are stopped after 24 hours.

Diet is resumed as tolerated. If diet is tolerated and drain output is low and devoid of enzymes or bile, the drains may be removed.

Pain control progresses from epidural to patient-controlled analgesia versus oral narcotics.

Once the patient is tolerating diet, is ambulating, and has pain controlled by oral agents, he or she is discharged home.

We rarely require more than 1 day in a critical care setting.

STEP 5: PEARLS AND PITFALLS

It is best to understand the potential for challenging anatomy. These circumstances include patients with prior pancreatic surgery, patients with chronic inflammation (chronic pancreatitis), patients with prior acute pancreatitis (seen in 37% of patients with IPMN), and patients with tumor close to or invading the superior mesenteric vein and artery.

If severe hemorrhage is encountered beneath the head of the pancreas in the superior mesenteric vein/portal vein or if it is encountered after division of the pancreas, several measures should be considered:

Call for experienced help.

Isolate and control the portal vein, superior mesenteric vein, and splenic vein, and place either vessel loops or vascular clamps.

Compression should always offer time to establish control and obtain help.

Mobilize the pancreas to achieve the best exposure available.

One potentially useful maneuver is to pass Fogarty catheters into the lumen of each vein.

If some length of vein is lost, it is possible to mobilize the vein to permit as much as a 3-cm defect to be repaired primarily.

SELECTED REFERENCES

1. Katz MH, Wang H, Fleming J, et al: Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol 2009;16:836-847.

2. Kow AW, Chan SP, Earnest A, et al: Striving for a better operative outcome: 101 pancreaticoduodenectomies. HPB (Oxford) 2008;10:464-471.

3. Katz MH, Fleming JP, Pisters PW, et al: Anatomy of the superior mesenteric vein with special reference to the surgical management of first order branch involvement at pancreaticoduodenectomy. Ann Surg 2008;248:1094-1102.

C H A P T E R 50

PANCREATICOJEJUNOSTOMY (PUESTOW)

William H. Nealon

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 inferior 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).

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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 identified 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 establishing 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 deficits are common. It is therefore vital to determine the nutritional status of patients.

Pertinent to functional derangements, it is important to maximize the replacement therapy 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 important 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 pancreas. These findings can greatly worsen the outcomes in operations for this disease because of the potential of significant 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 fibrotic 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 operative 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 administered within 1 hour of the skin incision.

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 modified this approach for many pancreatic operative procedures and we favor a midline incision (Figure 50-2).

Midline incision

FIGURE 50–2