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7 Chronic Pancreatitis: Drainage Procedures (Open Vs. MIS)
119
pancreaticojejunostomy by preventing the dense pancreatic head tissue from naturally closing the longitudinal incision made in this part of the duct.
Preparation ofthePatient
The patient is usually prepared through the ERAS pathway. This includes aggressive prehabilitation with physical therapy and nutritional interventions, especially in
malnourished patients. The patient is started on gabapentin which is increased to at
least 900mg/day. They are then given a high carbohydrate drink 2h prior to surgery
unless they are diabetic or have DGE.In these latter cases, the patient is kept NPO
for at least 8h.
On the morning of the surgery, the patient’s abdomen is clipped in the preoperative area, and they receive Alvimopan and Acetaminophen. They are taken to the
surgical suite where appropriate antibiotics are given for a case that will involve
entering the gastrointestinal tract.
The patient is generally positioned supine on the operating table with the right
arm tucked. This allows for the self-retaining retractor to be positioned high enough
on the bed that it will be out of the way of the operating surgeon standing on the
patient’s right side. In addition, when there are other learners in the room, they can
comfortably stand above the surgeon on the right side without straddling an outstretched arm.
The surgeon must ensure that all anesthesia lines are not in the way of the railing
on the side of the bed; this will result in cutting of critical lines when placing the
retractor.
Operative Technique—Open Approach.
A midline incision is made in most circumstances. If the patient is very obese, a
left-leaning bilateral subcostal incision may be necessary. In this case, the left arm
is tucked so that the retractor can be placed on the left side of the patient and achieve
greatest leftward retraction. The authors favor the former incision as closure is more
straightforward; this exposure can be used in the future for other surgeries, and
midline hernia repairs are more straightforward than a subcostal hernia. Important
elements to placing the retractors are:
1. Place the post of the retractor far enough towards the patient’s head, but do not
place the post on the headpiece. This will tilt the headpiece upward when the
blades are placed.
2. Angle the retractor bars downward so that the surgeons do not have to operate
over the bars.
3. Achieve the greatest traction with the blades on the side that needs the great-
est—left sided for left-sided surgery. Do not over-retract in the other direction as
this will not allow for greatest exposure towards the side that you are focusing on.
4. If a subcostal incision is chosen, the inferior ap can be sewn with a number 2
nylon stitch to allow for inferior and constant retraction.
120
D. R. Jeyarajah and H. G. Osman
The steps of the drainage procedure are as follows:
1. Enter the lesser sac between the stomach and the colon.
2. Follow the right gastroepiploic vein to its origin from the superior mesenteric
vein (SMV). This will allow you to nd the SMV and know where the area of
danger lies.
3. The authors leave the short gastric vessels alone and place a fenestrated retrac-
tor cephalad to hold the stomach upward and allow access to the lesser sac.
4. The ultrasound is then used to identify the pancreatic duct (PD). Use of the nar-
rowest prole probe can be very helpful as the space is limited and long-axis
view of the duct is really of critical importance.
5. Using a 21–25 gauge needle and using ultrasound in the long axis to follow the
complete track of the needle, the duct is entered. A word of caution is to not get
so excited when one sees pancreatic uid in the syringe avoid the surgeon aspirating aggressively and collapsing the duct. One should stop aspirating when
clear pancreatic uid is seen in the syringe. Electrocautery is then used to cut
down onto the needle to nd the duct. A needle tip electrocautery may minimize
charring and allow for better visualization and precise cut.
6. A right-angle clamp is then inserted longitudinally into the duct and cautery is
used to spatulate the duct longitudinally towards the patient’s left rst. Care
must be taken to stay in the center of the pancreatic parenchyma, as wandering
cranially may cause injury to the splenic artery, which runs very close.
7. The ductotomy is carried towards the right of the patient. The gastroduodenal
artery (GDA) will be encountered and the authors place two gure-of-eight
suture cranially and caudad to control this vessel with permanent suture. The
authors feel that the lack of efcacy of this procedure is related to lack of
decompression of the pancreas head. The inexperienced surgeon will stop when
they encounter bleeding at the GDA and will not adequately drain the head of
the pancreas when indicated.
8. Adequate pancreatic ductotomy in the head of pancreas is paramount for a suc-
cessful drainage procedure. The bile duct typically travels posterior to the pancreatic ductotomy plane, and the surgeon must not perform inadequate
pancreatic head drainage in fear of enteric the bile duct.
9. When performing Frey procedure, the head of pancreas is then cored at this
point. This addition can allow for greater decompression of the head of the
gland, thought to be the pacemaker for pain in this disease. The authors favor
resection and drainage options (see below) rather than the Frey procedure.
10. The roux limb is created and the anastomosis to the PD which has been opened
for at least 10cm is performed. The authors use a double-armed 4–0 polypropylene suture and start from the left side of the patient. The inferior aspect of
the anastomosis is created rst allowing for an easier cephalad aspect that is
well visualized. It is sometimes necessary to use a 3–0 polypropylene on a CT-1
needle if there is very rm pancreatic parenchyma.
11. A drain is left and placed inferior to the anastomosis.
7 Chronic Pancreatitis: Drainage Procedures (Open Vs. MIS)
121
Minimally Invasive Approach toPancreatic
Drainage Procedures
The authors rmly believe that MIS adoption of any surgery must not limit the main
principles of the surgery itself. Therefore, the key steps to the drainage procedure
are as outlined above. Specic modications to allow for easy MIS adaptation are
mentioned below. The authors generally use robotic-assisted laparoscopy for operations that require signicant suturing. The key areas of robotic adaptation are outlined below:
1. The patient is positioned supine with both arms tucked. There are securing straps
on the thighs and chest, as well as a footboard. Positioning is checked to allow
for 30 degrees of reverse Trendelenburg without the patient moving.
2. Prior to positioning, laparoscopy is used to identify and run the bowel distal to
the Ligament of Treitz (LOT). The identied proximal loop of bowel (about
40cm distal to LOT, but much dependent on body habitus and the thickness of
the mesentery) is tacked in the left upper quadrant of the patient in preparation
for the roux limb. Clear knowledge of proximal and distal is essential to allow
for appropriate construction of the roux limb.
3. The patient is positioned as above, and the robot docked form the patient’s
left side.
4. The steps outlined above are performed and the loop of jejunum is anastomosed
to the PD.One tip is that any larger needle (CT-1 for example) must be passed
through a larger port such as a 10/12mm port.
5. The Roux limb is constructed by running the bowel distally and constructing the
jejunojejunostomy in the left upper quadrant using a stapler from the 12mm port
on the patient’s right mid-clavicular line. This will allow for a greater distance
from port to stapler device, allowing for use of the robotic stapler and the ability
to manipulate intracorporeally. The enterotomy is then closed using a 3–0 selflocking suture.
6. The Roux limb is completed by dividing the bowel to the patient’s left of the
pancreaticojejunostomy. This makes the conguration a Roux from a loop.
Postoperative management of the patient will be discussed with resection below.
Resection forPatients withChronic Pancreatitis
Indications forResection
The authors believe that resection is the best option for the treatment of CP when
possible. They believe that the pacemaker for pain in CP is the head of the gland,
and therefore any reasonable way to achieve resection of this area is benecial. The
patient who is especially suited for a resection option is one that has dilation of both
122
D. R. Jeyarajah and H. G. Osman
the bile duct and the PD.This patient will inevitably require a biliary drainage procedure and a pancreatic drainage procedure (double bypass) and so resection of the
head will allow for successful dual drainage and resection of the pacemaker for pain.
While resection is optimal, it may not be possible due to anatomic reasons. This
would mainly be related to occlusion of venous structures, namely the SMV/portal
vein junction. Splenic vein occlusion can result in extrahepatic portal hypertension
including huge gastric and peri-pancreatic varices that can make the procedure
unsafe. In these cases, the HPB surgeon should back off to a dual drainage option.
The authors have popularized the “Whip-Stow” procedure where a pancreatoduodenectomy and a drainage procedure are achieved in the same surgery [4]. This
will be the focus of this section.
The patient best suited for the “Whip-Stow” procedure needs surgery for chronic
pain, dilated bile duct, dilated PD, and a rm gland texture (Fig.7.2). The PD diameter does not matter in the case of a rm gland (usually present in CP). This is
because the PD can always be found at the time of transection of the neck of the
pancreas during resective surgery. The details will be outlined below.
Steps of the “Whip-Stow” procedure (see Fig.7.3):
1- The surgeon should set up and proceed as for a Whipple procedure.
2- Once the resection is complete, the surgeon can place a Pean clamp into the cut
edge of the pancreas. The PD is then opened along its length taking care to not
veer off the gland and accidentally lacerate the splenic artery. This can be easy
to do as the gland gets thinner towards the tail.
3- The aim is to provide as long a ductotomy as possible—ideally at least 10cm.
4- Reconstruction of the pancreatoduodenectomy is performed as usual. The
authors bring the transected jejunum in line with the resected duodenum during
standard reconstruction for a pancreatoduodenectomy (i.e., jejunal limb lies
under the SMA). However, when performing the pancreaticojejunostomy for the
“Whip-Stow,” the authors nd that bringing the transected jejunum through the
transverse mesocolon mesentery can allow for a more natural lay of the recon-
struction loop.
Fig. 7.2 Chronic pancreatitis patient with diseased head of pancreas and dilated duct
7 Chronic Pancreatitis: Drainage Procedures (Open Vs. MIS)
Fig. 7.3 Schematic
representation of the
Whip-Stow procedure
123
5- The authors use a single layer of 4–0 polypropylene on an SH needle for this
anastomosis (as outlined above). Using a 3–0 on a CT-1 needle can be useful if
the gland is very rm.
6- A close-suction drain is laid posterior to the pancreatic anastomosis.
Postoperative Care
The authors follow the general guidelines for post PD patients with an aggressive
enhanced recovery after surgery (ERAS) pathway. This includes avoidance of nasogastric tubes, aggressive removal of urinary catheters, advancement of diet based on
patient desire, and aggressive weaning of opioids. Physical therapy and occupational therapy services are used to have patients mobilized within 4h of surgery.
Shower and self-care are encouraged immediately, but certainly at day 1 and thereafter. The authors do not use the intensive care unit, where the focus is not on mobilizing the patient and normalizing their activity. This is a very important aspect to
recovery.
References
1. Puestow CB, Gillesby WJ. Retrograde surgical drainage of pancreas for chronic relaps-
ing pancreatitis. AMA Arch Surg. 1958;76(6):898–907. https://doi.org/10.1001/
archsurg.1958.01280240056009.
2. Partington PF, Rochelle RE.Modied Puestow procedure for retrograde drainage of the pan-
creatic duct. Ann Surg. 1960;152(6):1037–43. https://doi.
org/10.1097/00000658- 196012000- 00015. PMID: 13733040; PMCID: PMC1613865
124
3. Frey CF, Smith GJ.Description and rationale of a new operation for chronic pancreatitis.
Pancreas. 1987;2:701–7.
4. Jeyarajah DR, Khithani A, Curtis D, Galanopoulos CA.The ‘Whip-Stow’ procedure: an inno-
vative modication to the whipple procedure in the management of premalignant and malignant pancreatic head disease. Am Surg. 2010;76(1):70–2. PMID: 20135943
D. R. Jeyarajah and H. G. Osman
Chapter 8
Chronic Pancreatitis: Resection
JonathanC.DeLong andBrendanC.Visser
Background
Chronic pancreatitis is a slowly progressive, but unrelenting chronic condition in
which patients without access to specialized gastrointestinal or surgical services
become debilitated and often self-treat with escalating doses of opioid analgesics.
The most common cause of chronic pancreatitis in the developed world is alcohol
consumption and tobacco use. Other causes include gallstones, drugs (valproate,
thiazides, estrogens), hypercalcemia conditions, obstruction of the main pancreatic
duct due to scarring, post-ERCP pancreatitis, recurrent pancreatitis, or malignancy.
Genetic predispositions to chronic pancreatitis include PRSS1, SPINK1, or CFTR
genetic mutations. There is growing data that these patients may benet from early
referral for total pancreatectomy with islet cell autotransplantation (TPIAT) which
is discussed in detail in Chap. 11.
The hallmark of this unyielding disease is severe abdominal pain which may be
associated with exocrine insufciency (bloating, excessive atulence, steatorrhea,
or a documented reduction in fecal elastase), endocrine insufciency (diabetes mellitus), failure to thrive, and an increased risk for pancreatic malignancy.
Histologically, the glandular structure of the pancreatic parenchyma is destroyed
and replaced with interstitial brosis and necrosis due to the chronic and recurrent
bouts of inammation. However, the diagnosis is most frequently made from patient
history and radiographic ndings alone. The histological features are heterogeneous
J. C. DeLong (*)
Division of Surgical Oncology, University of Tennessee Medical Center Knoxville,
Knoxville, TN, USA
e-mail: jcdelong@utmck.edu
B. C. Visser
Division of Hepatobiliary and Pancreas Surgery, Stanford University, Stanford, CA, USA
e-mail: bvisser@stanford.edu
Switzerland AG 2025
E. P. Ceppa et al. (eds.), The SAGES Manual of Evolving Techniques in
Pancreatic Surgery, https://doi.org/10.1007/978-3-031-78409-5_8
125© The Author(s), under exclusive license to Springer Nature
126
and may include gland atrophy, pseudocyst formation, calcications, necrosis, or
ductal abnormalities. It is critical to consider malignancy in cases of pancreatitis, as
a mass-lesion that is obstructing the pancreatic duct may in fact be the inciting factor for the disease.
Various theories exist to explain pathogenesis of the severe pain that is experienced in patients with chronic pancreatitis. One such theory is that chronic calcications and brosis cause hypertension of the pancreatic duct. As such, some surgical
interventions are aimed at decompressing the system. Surgical interventions are categorized as resection procedures, drainage procedures, or combined drainage and
resection procedures. In this chapter, we will discuss the resection procedures
(Whipple/pancreatoduodenectomy and distal pancreatectomy). An operation is
often offered after failure of medical treatment or non-surgical interventions (opioid
analgesics, neural blockade, exocrine replacement therapy). Non-surgical interventional strategies may include percutaneous drainage procedures or endoscopic interventions (cyst gastrostomy, luminal apposing metal stents with or without endoscopic
necrosectomy, sphincterotomy with or without pancreatic duct stenting, and balloon
dilation). Nutritional optimization is imperative when managing chronic pancreatitis
and can be accomplished with enteral feeding with percutaneous gastrostomy, combined percutaneous gastrostomy- jejunostomy, or nasoenteric jejunal feeding tubes.
Thoughtful attention to pancreatic enzyme replacement is necessary to absorb the
nutrients from supplemental feeds. Many patients who ultimately undergo surgery
for chronic pancreatitis have undergone one or more of these interventions.
There is no consensus among experts regarding the selection criteria for patients
with chronic pancreatitis to undergo surgery, but pain relief and management of
complications from chronic pancreatitis are the main indications. There are three
potential goals of surgery. First, to reduce reliance on opioid analgesics to the point
that patients can be weaned off narcotic pain medication entirely. Second, intervening early may reduce or halt ongoing parenchymal destruction and thus preserve the
remaining pancreatic function. And nally, in some cases, resection is offered to
rule out malignancy as a possible etiology for recurrent bouts of pancreatitis (where
imaging characteristics are suggestive of an underlying mass). Understanding the
location of disease through careful inspection of high-quality axial imaging is
essential to offering the appropriate surgical intervention. In carefully selected
patients, surgical intervention can offer pain reduction 80–90% of the time.
J. C. DeLong and B. C. Visser
Indications forResection
Head-Dominant Disease
In most patients with chronic pancreatitis, the source of inammation and thus the
main site of disease is located in the pancreatic head. This phenomenon has been
termed the “pacemaker” effect that the pancreatic head plays in the disease (see
8 Chronic Pancreatitis: Resection
Fig. 8.1 “Pacemaker”
type, head-dominant
disease
Fig. 8.2 “Normal”
parenchyma in body and
tail of the same patient
127
Figs.8.1 and 8.2). Inammatory enlargement of the pancreatic head can cause local
complications including stricture of the pancreatic duct, common bile duct, and/or
the duodenum.
There is growing evidence that early intervention may preserve pancreatic function by eliminating the cycle of inammatory parenchymal destruction. Surgical
intervention is superior to endoscopic decompression; yet, many patients undergo
endoscopic balloon dilation, sphincterotomy, or pancreatic duct stenting prior to
surgery. A Cochrane review of surgical resection for chronic pancreatitis for disease
that is isolated to the pancreatic head found no difference in perioperative morbidity
or mortality between pancreatoduodenectomy (Whipple) and duodenum-preserving
pancreatic head resection (DPPHR) [1]. The latter is discussed in detail in Chap. 10.
It should be noted that while pancreatoduodenectomy was at one time a mainstay in
the treatment of chronic pancreatitis, both drainage/combined procedures and total
pancreatectomy with islet cell autotransplantation (TPIAT) are performed with
increasing frequency in contemporary pancreatic surgery [2].
128
J. C. DeLong and B. C. Visser
The most common type of chronic pancreatitis is calcifying type which is characterized radiographically by calcications and pancreatic ductal stones. There may
be associated phlegmonous changes from repeated episodes of pancreatitis and the
disease is often most severe in the head. Pancreatic head-dominant disease can be
treated with a pancreatoduodenectomy.
Tail-Dominant Disease
Distal pancreatectomy for chronic pancreatitis is performed less frequently than
pancreatoduodenectomy (Whipple). There are some specic indications where this
is the procedure of choice. In the post-acute setting, some patients develop pancreatic necrosis of the body or neck of the gland such that the distal body and tail are
in discontinuity. This is called disconnected left pancreatic duct remnant (DLPR)
and is the most common indication for distal pancreatectomy for chronic pancreatitis (see Figs.8.3, 8.4, and 8.5) [3]. DP may be warranted for patients with ongoing
symptoms attributed to disease isolated to the tail or recurrent bouts of acute on
chronic pancreatitis from isolated tail disease. Of note, patients with an asymptomatic isolated tail glandular change from chronic pancreatitis do not mandate intervention. The tail can atrophy over time making surgical intervention unnecessary.
Another scenario that occasionally arises is necrosis of the tail that leads to recurrent, symptomatic pseudocyst formation arising from the tail of the gland. First-line
treatment for these patients is internal endoscopic drainage. For the pseudocysts that
recur after endoscopic transgastric cystgastrostomy, distal pancreatectomy can offer
denitive management (see Fig.8.6).
Other patients may develop a midbody stricture of the pancreatic duct or mass
effect by a pseudotumor (non-neoplastic solid lesion of the pancreas following pancreatitis). The key point is that distal pancreatectomy is appropriate for patients
Fig. 8.3 Tail-dominant
disease with abscess and
phlegmon