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262 Atlas of Gastrointestinal Surgery: Pancreas
The portal and superior mesenteric
veins are dissected completely free from
the uncinate process. The uncinate
process is then dissected away from the
superior mesenteric artery (2). After the
uncinate process has been extensively
mobilized, the head of the pancreas and
uncinate process are resected by dividing
Uncinate
process
Superior
mesenteric
v. and a.
the head of the pancreas in the duodenal
C loop, leaving only a 4 to 5 mm rim of
pancreas in the C loop (3). This is accomplished
2
much more safely when the duodenum and head of the
pancreas have been extensively mobilized, and the sur-
geon can place the left hand posterior to the uncinate
process. One has to be very careful that the distal common
bile duct is not injured during this process.
Balloon catheter
in bile duct
If a cholecystectomy has not been
performed, we perform a cholecystectomy and pass a biliary Fogarty balloon
catheter distally through the ampulla into
the duodenum so that, as the pancreatic
head is being resected, one knows the
Rim of
pancreas
in C loop
exact position of the bile duct (3). If a
cholecystectomy has previously been performed, a choledochotomy should be carried out and a Bakes dilator passed down into
the duodenum. Performing the head resection, so
that all of the uncinate process as well as the neck
and most of the head of the pancreas are resected,
Pancreas
Superior
mesenteric v.
3
Superior
mesenteric a.
is a tedious process. The benefit of
this operative procedure over the
Puestow and Frey procedures is that
it can be performed in the face of a
non-dilated pancreatic duct.
The reconstruction is carried out
with a Roux-en-Y jejunal loop 60
cm in length. The creation of this
Duodenal Preserving Pancreatectomy for Chronic Pancreatitis (The Beger Procedure) 263
End-to-end
pancreatiocjejunostomy
4
Roux-en-Y loop has been previously described. The Roux-en-Y
loop is brought up through a rent
in the transverse mesocolon and an
end-to-end pancreaticojejunostomy
is performed (4) utilizing the invagination technique, as follows. A posterior outer row of interrupted 3-0
silk Lembert sutures is placed first.
The inner layer is then run with a
continuous locking suture of 3-0
synthetic absorbable material,
including the pancreatic duct in
the anastomosis. This locking
Side-to-side
pancreaticojejunostomy
suture is continued anteriorly
using an over-and-over suture.
The anastomosis is completed by
invaginating the pancreas into the
end of the jejunum with a row of interrupted 3-0 silk sutures.
264 Atlas of Gastrointestinal Surgery: Pancreas
After this end-to-end pancreaticoje-
junostomy is performed, a side-to-side
pancreaticojejunostomy is performed
between the rim of pancreas left in the C
loop and the side of the jejunum just beyond
the end-to-end pancreaticojejunostomy
(5). Ideally, this can be performed with
the same type of two layered anastomo-
junostomy, but at times (because of
exposure), a single layer of interrupted
3-0 silk suture material is utilized. The
pancreatic duct is incorporated in the
inner layer if two layers are used, and in the
End-to-end
pancreatiocjejunostomy
interrupted silk layer if just one layer is per-
Side-to-side
pancreaticojejunostomy
formed. In coring out the head of the pancreas in the
duodenal C loop, one should make an effort to not injure the superi-
5
or and inferior pancreaticoduodenal arcade that resides in the pancreaticoduodenal groove, both anteriorly and posteriorly. This is usually easily done.
If one of the arcades is interrupted, however, this rarely leads to problems with duodenal ischemia.
This operative procedure drains the body and tail of the pancreas into the Roux-en-Y loop, as well as excising the
majority of the inflammatory mass in the head of the pancreas. The small pancreatic remnant left in the C loop is also drained
into the jejunal loop. Many believe that the pacemaker of chronic pancreatitis resides in the large inflammatory mass in the
head of the pancreas, and this operation is designed to remove that inflammatory mass.
Duodenal Preserving Pancreatectomy for Chronic Pancreatitis (The Beger Procedure) 265
Modification 1: Additional lateral pancreaticojejunostomy
Filleted pancreatic duct
If the pancreatic duct is dilated, but one
decides the patient is not an ideal candidate
for the Puestow or Frey procedures, one
can perform the Beger procedure, and
in addition to resecting the head of
the pancreas, one can add a lateral pancreaticojejunostomy (6,7).
This is ideally carried out in two
layers, an inner continuous layer
6
Lateral pancreaticojejunostomy
of 3-0 synthetic absorbable
material, and an outer layer of
interrupted 3-0 silk. The rest of the
procedure is carried out in a fashion as
previously described.
7
Side-to-side
pancreaticojejunsotomy
266 Atlas of Gastrointestinal Surgery: Pancreas
Bile duct
Choledochojejunostomy
diverts bile into jejunum
Modification 2: Choledochojejunostomy
8
Some patients with chronic pancreatitis will have a degree of distal biliary stenosis in that portion of the common bile
duct that passes through the posterior aspect of the head of the pancreas. This results in dilatation of the biliary tree, and
such a dilated biliary tree can be decompressed through the rim of pancreatic tissue left in the duodenal C loop. This choledochojejunal anastomosis can be carried out at the same time that one performs the second pancreatic anastomosis, the
side-to-side pancreaticojejunostomy. In addition, if one should inadvertently injure the bile duct while carrying out resection of the head of the pancreas and preserving the duodenum, this modification can also be added (8). We often prefer, however, when there is a tight stricture of the distal common duct, to add a hepaticojejunostomy to whatever procedure is being performed for the chronic pancreatitis.
Accessory Duct Papillotomy for
Pancreas Divisum
Operative Indications:
Pancreas divisum is a relatively common anomaly of the pancreatic ductal system that is present in between 5 to 15% of
the general population. Whether or not this anomaly, which results from a failure of fusion of the dorsal pancreatic duct
and the duct draining the uncinate process and head of the pancreas (1), is causative in producing pancreatitis and abdominal pain remains controversial. There is some evidence to suggest that abdominal pain associated with amylase elevations
may occur when this anomaly is associated with a relative mucosal stenosis of the accessory papilla. Clinically, this condition of pancreas divisum associated with abdominal pain and hyperamylasemia is seen most often in young females. If the
combination of abdominal pain, hyperamylasemia, and pancreas divisum is present, and no other causes of pancreatitis can
be identified, many surgeons feel that an accessory duct papillotomy is indicated.
Main pancreatic duct
Common bile duct
Accessory
papilla
Ampulla
Pancreas
1
Duodenum
Duct to uncinate
process
268 Atlas of Gastrointestinal Surgery: Pancreas
Operative Technique:
The abdomen can be entered through either a midline or right subcostal incision. If the
gall bladder is still present, a cholecystectomy is generally performed. This is to eliminate
any possibility of the gall bladder playing a role in the pancreatitis. Others have also suggested a sphincteroplasty of the main ampulla should be performed as well. These procedures have been demonstrated previously. Only the accessory papillotomy will be
described here.
A longitudinal duodenotomy is performed after palpating the ampulla to identify the
location for the enterotomy. The accessory papilla is generally 1 to 2 cm proximal to the
main ampulla and about 0.5 cm more anteriorly placed (2). Once the duodenotomy
has been performed, the accessory papilla and its pinpoint opening usually can be identified with careful palpation and
visualization. One has to be certain to cannulate the accessory papilla atraumatically. If any trauma occurs and edema and/or
a hematoma results, thereafter cannulation is virtually impossible. If one takes great care, however, the accessory papilla can
always be identified and safely cannulated. Once a small lacrimal duct probe is inserted, a papillotomy is performed using
the electrocautery (2). Because the dorsal pancreatic duct enters the duodenal wall and the accessory papilla perpendicularly, unlike the main ampulla, the papillotomy can be extended for only a 3 to 5 mm length.
Accessory
papilla
opened
2
Main ampulla
Accessory Duct Papillotomy for Pancreas Divisum 269
Once the papilla is opened, the ductal and duodenum mucosa are approximated with interrupted 5-0 synthetic
absorbable sutures (3, 4). When the papillotomy is completed, the largest lacrimal duct probe and/or the smallest Bakes
dilator should be accommodated. Following the papillotomy, pancreatic juice, which initially spurts out of the accessory
papilla with a stream, flows out easily and rapidly, unimpeded. The duodenotomy is closed with an inner continuous layer
of synthetic absorbable 3-0 suture material placed in a Connell fashion. The outer layer is placed using interrupted 3-0
silk sutures. The duodenotomy may be drained with a closed suction Silastic drain.
Duodenal
mucosa
Duct
mucosa
Papillotomy
3
4
Drainage of Pancreatic Pseudocyst into a
Roux-en-Y Jejunal Loop
Operative Indications:
A pancreatic pseudocyst results from disruption of the main pancreatic duct. This is often associated with an episode of
acute pancreatitis, but a pseudocyst can also develop in the setting of chronic inflammation. Even less common, a pancreatic pseudocyst can develop following trauma or distal to a pancreatic neoplasm. Many pancreatic pseudocysts resolve
spontaneously. The duct disruption will cicatrix and close and the pancreatic secretions in the cyst will be rapidly reabsorbed. If the cyst does not resolve, operative drainage may be required. Pseudocysts 5 or 6 cm in diameter or less are
generally asymptomatic and do not result in life-threatening complications. Pseudocysts over 6 cm in diameter, however,
can potentially cause life-threatening complications.
Pseudocysts can cause pain, duodenal obstruction, and biliary obstruction; they can erode into adjacent structures,
most commonly the colon or duodenum; they can become secondarily infected; they can be associated with life-threatening hemorrhage, often from a false aneurysm bleeding into the cyst. For these reasons, most pseudocysts over 6 cm in diameter that do not spontaneously resolve after a period of observation and/or remain symptomatic, should be considered for
drainage. The drainage procedure of choice, if the cyst can be drained dependently, is through the transverse mesocolon
into a Roux-en-Y jejunal loop. One can also drain pseudocysts percutaneously, or internally using endoscopic techniques.
However, complications are significant and recurrences common. We therefore continue to favor open internal drainage.
Operative Technique:
rule out other pathology.
Gall bladder
Drainage of Pancreatic Pseudocyst into a Roux-en-Y Jejunal Loop 271
Stomach
Liver
1
Spleen
Pseudocyst
behind
stomach
Hepatic
flexure
of colon
Omentum
In this example, a sizable pseudocyst can be visualized and palpated posterior to the stomach (1). Since the cyst is directly
behind the stomach with the posterior wall of the stomach comprising the anterior wall of the cyst, it could easily be drained by a cystogastrostomy. To avoid the constant alkaline bathing of the antrum
that results following a cystogastrostomy, and owing to the small
incidence of bleeding, we favor a cystojejunostomy into a Roux-enY jejunal loop as the treatment of choice whenever possible.