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30 Chronic Pancreatitis: Puestow and Frey Procedures 389
Table 30.3 Rosemont criteria for diagnosis of chronic pancreatitis
Rosemont endoscopic features of CP
Major A features Hyperechoic foci ( 2 mm)
MPD calculi
Major B features Lobularity or honeycombing of parenchyma
Minor features Anechoic Cysts
Hyperechoic stranding ( 3 mm)
Hyperechoic foci ( 2 mm)
Dilated duct ( 3.5 mm in body, 1.5 in tail)
Irregular MPD contour
3 dilated side branches ( 1 mm)
Hyperechoic MPD wall
Rosemont criteria for diagnosis of CP
Consistent with CP 1 major A feature AND 3 minor features
1 major A feature AND 1 major B feature
2 major A features alone
Suggestive of CP 1 major A feature AND < 3 minor features
1 major B feature AND 3 minor features
5 minor features
Indeterminate for CP 3–4 minor features alone
major B feature alone AND < 3 minor features
Normal 1 or 2 minor features
Case Presentation: Surgical Treatment of Chronic Pancreatitis
A 42-year-old gentleman with a history of long-standing alcohol abuse and gallstone pancreatitis 2 years prior presents to the emergency department with complaints of abdominal pain. He reports his symptoms were provoked by alcohol
consumption 1 day prior, and radiates bilaterally from the epigastric region to the
spine. He also endorses nausea and anorexia. Review of his medical history reveals
two prior episodes of self-limited abdominal pain in the current year, with no other
contributing medical, surgical, or social comorbidities.
Differential Diagnosis
A broad differential diagnosis for the case of acute or recurrent epigastric abdominal
pain includes, but is not limited to, the following:
• Pancreatitis
• Peptic ulcer disease
390 A. Chang and D. Abbott
• Gastritis
• Intestinal obstruction
• Mesenteric ischemia
• Cardiac and pleural sources
In the United States, alcohol abuse continues to be the prominent risk factor for
chronic pancreatitis, responsible for 45% of cases [17]. Chronic pancreatitis
attributed to alcohol consumption usually presents in the fourth to sixth decades of
life, and correlates with cumulative alcohol intake. While the patient in this case
presented with a history of heavy alcohol intake, there is no safe level of alcohol
consumption with regard to risk of chronic pancreatitis [18, 19]. A minority of
alcoholics will develop alcoholic chronic pancreatitis, suggesting a genetic predisposition or other susceptibility in some patients [20].
A majority of cases of chronic pancreatitis not related to alcohol use are idiopathic. The presentation of idiopathic chronic pancreatitis has a bimodal age distribution, with an early onset group presenting during adolescence, and another
late-onset group occurring at a mean age of 56 years. Pain is almost uniformly the
first symptom in early onset chronic pancreatitis. Some cases can be attributed to an
initial episode of severe acute pancreatitis, sometimes called the sentinel acute
pancreatitis event, or SAPE. Late-onset disease is commonly associated with pain,
however episodes of severe pain are less frequently reported [21].
The natural history of pain in all types of pancreatitis improves in severity and
frequency in approximately two-thirds of cases. In a minority of cases, pain
becomes worse over time. The course of progression in alcoholic chronic pancreatitis is reciprocal to the degree of alcohol abstinence. The pattern of recurrent pain
also appears to follow two distinct patterns. In its early course, symptoms are akin
to recurrent episodes of acute pancreatitis, with prolonged periods of absence
between episodes. In later stages, many develop a “smoldering” pancreatitis, with
episodes of exacerbation and associated endocrine dysfunction [22]. A sizable
number of cases reach a terminal “burn out” of chronic pancreatitis, in which pain is
improved or absent, and exocrine/endocrine deterioration comes to a halt [23, 24].
Long-standing chronic pancreatitis often leads to local complications responsible
for significant additional morbidity. Intraductal calculi (pancreatolithiasis) and
ductal stenosis are common and lead to duct dilation. Splenic vein thrombosis can
occur due to its close proximity to the inflammatory process, and leads to hypersplenism and gastric varices. Pancreatic pseudocysts are common and frequently
cause pain, portal vein compression, and sometimes even intestinal obstruction.
Rarely, erosion into major vascular structures can lead to life-threatening hemorrhage. The risk of malignancy arising from a background of chronic pancreatitis is
elevated four to six times that of the general population; however, the absolute risk
is still low and may not warrant additional screening. In some cases, ductal dilation
is accompanied by fibrosis and phlegmon of the pancreatic head. This can be
concerning not only due to mass effect on surrounding structures, but also in
shrouding the diagnosis of pancreatic head malignancies.
30 Chronic Pancreatitis: Puestow and Frey Procedures 391
Technical Pearls
• Identifying a dilated pancreatic duct with a small-gauge needle and syringe, with or without ultrasound guidance, can help minimize blind
attempts in finding the duct, and minimizing chances of unnecessary
trauma to the pancreas.
• Ensure the Roux limb is at least 40 to 60 cm in length, to minimize the
risk of gastrointestinal content reflux into the pancreaticojejunostomy.
• When performing a Frey procedure, ensure that the SMV and portal vein
are clearly identified so as to minimize the risk of inadvertent injury.
• When performing a Frey procedure, perform a full Kocher maneuver to
appreciate the thickness of the pancreatic head, and minimize the chance
of full-thickness debridement.
Workup
Eliciting a history of recurrent abdominal pain, anorexia, and nausea which is
exacerbated by food intake should provoke an investigation toward pancreatitis as a
possible diagnosis. Patients may also exhibit hyperglycemia, jaundice, steatorrhea,
weight loss, and endorse a history of heavy alcohol use. Symptoms are variable, and
up to 20% of patients with pancreatitis will present with “painless pancreatitis.”
Initial laboratory testing should include serum amylase and lipase levels, however
these markers may lose sensitivity after extensive glandular injury has impaired
exocrine enzyme production. Extensive fibrosis and edema may lead to elevation of
serum bilirubin and alkaline phosphatase in a minority of patients. Additionally,
fecal fat excretion can be detected (alternatively Sudan stai ning of the feces can be
utilized), although it is neither sensitive nor specific. Fecal chymotrypsin, trypsin,
and elastase testing are now widely available, but suffer from low sensitivity in all
but very late-stage disease. Enhanced pancreatic function tests have been studied,
including MRCP and endoscopic-assisted secretin stimulation testing, but these
techniques have yet to be widely adopted [25].
Endoscopic retrograde pancreatography (ERCP) was classically the reference
imaging modality for the diagnosis of chronic pancreatitis, however, increasing
consensus is developing around the use of endoscopic ultrasound (EUS) criteria.
Studies comparing EUS to ERCP in the diagnosis of chronic pancreatitis have
found good correlation between morphologic abnormalities seen on EUS with a
sensitivity of 85–97% [26, 27]. However, in practice, computed tomography is
almost always included as a powerful adjunct; modern CT scanning has 60–90%
sensitivity, as well as 85–95% specificity in the diagnosis of chronic pancreatitis,
with increasing sensitivity in more advanced disease [27, 28]. CT findings in
392 A. Chang and D. Abbott
chronic pancreatitis include parenchymal atrophy, inflammatory changes, calcifications, pseudocysts, and pancreatic and bile duct dila tion. Irregular ductal contour,
strictures, and side-branch abnormalities may be more prominent on ERCP and
assist in classification and treatment planning. Transabdominal ultrasonography and
plain films may detect large cysts, ductal dilation, and calcification, but are rarely
used in guidance of treatment algorithms. Magnetic resonance imaging, while
promising, is not clearly superior to ERCP and CT [5, 29].
Preoperative Evaluation for CP and a Dilated MPD
Preoperative laboratory evaluation revealed mildly elevated serum amylase and
lipase, normal serum trypsin, glucose, calcium, and triglycerides. Nutrition status
was normal. CT scan revealed multiple 8–10 mm dilations of the MPD in the body
and tail of the pancreas, with a prominence of the pancreatic head. EUS confirms
dilation of the MPD, lobularity in the remaining parenchyma, and multiple minor
features of chronic pancreatitis.
Multidisciplinary approaches to the patient with chronic pancreatitis are recommended to achieve optimal results. Surgical therapy is reserved for patients in
whom there is a high likelihood of symptomatic relief and preservation of exocrine
and endocrine function. Resection may be required if pancreatic carcinoma cannot
be excluded, or if there is concern for ineffective gland preservation. In the patient
presented, classic endoscopic and laboratory findings combined with a history of
recurrent episodes of abdominal pain, as well as a history of heavy alcohol use,
confirmed a diagnosis of chronic pancreatitis. A dilated MPD with multiple strictures as well as an inflammatory mass in the pancreatic head is amenable to surgical
therapy.
Levels of endocrine and exocrine function should be carefully documented prior
to proceeding. In the case of alcohol-related pancreatitis, evidence of abstinence
should be demonstrated. The goal of surgery is not to reverse the parenchymal
injury, but to relieve pain, prevent future complications of chronic pancreatit is, and
preserve remaining pancreatic function [30]. If d elayed, chronic pain may become
intractable and opioid-resistant, while endocrine and exocrine function continue to
deteriorate. If operative therapy is undertaken with too much haste, patients with
self-limited or stable chronic pancreatitis will be subjected to significant unnecessary operative risk.
The choice of operation is determined by the anatomic classification and severity
of disease, degree of pancreatic insufficiency, MPD and side-branch anatomy, and
therapeutic effect of previous interventions. Here, we detail two decompressive
techniques commonly utilized for patients with dilated main pancreatic ducts,
without (Puestow) or with (Frey) strictures, inflammatory masses, or stones in the
head of the gland.
30 Chronic Pancreatitis: Puestow and Frey Procedures 393
Operative Techniques
Puestow
The longitudinal pancreaticojejunostomy, first proposed by Puestow and Gillesby
in 1958 [31], was the first most common pancreatic drainage procedure.
A “chain-of-lakes” appearance of the MPD due to multiple strictures and dilations,
or a MPD with diameter 7 mm, is effectively treated by longitudinal drainage
(Figs. 30.1 and 30.2)[32]. The Puestow-Gillesby procedure was modified quickly
by Partington and Rochelle, and this version of the procedure continues in surgical
practice with high rates of success [33, 34].
The abdomen is entered either via upper midline laparotomy or a subcostal
incision. Division of the gastrocolic ligament allows entrance to the lesser sac, and a
Thompson retractor (or similar device) is used to expose the entire anterior surface
of the pancreas. Lysis of adhesions to the posterior gastric wall is often required due
to chronic inflammation of the pancreas and associated viscera. Care is taken to
identify the infrapancreatic SMV, celiac trunk, hepatic artery, and gastroduodenal
artery just cephalad and medial to the pancreatic head, so as not to inadvertently
injure critical vasculature. Identification of the dilated pancreatic duct is accomplished by aspirating pancreatic fluid using a 21-gauge needle, with or without the
assistance of intraoperative ultrasound. The length of the diseased MPD is opened,
and adequate drainage is ensured by passing a blunt surgical probe through residual
normal caliber duct.
Fig. 30.1 Computed tomography of a 10-mm dilated main pancreatic duct in chronic pancreatitis
(white arrows)
394 A. Chang and D. Abbott
Fig. 30.2 Chronic pancreatitis with dilated main duct in the body and tail of the pancreas
The small bowel is divided using a linear cutting GIA stapler 10 to 20 cm distal
to the ligament of Treitz. A 40 to 60 cm Roux limb is created and brought up, in a
retrocolic fashion, to the pancreatic ductotomy. The Roux-en-Y reconstruction can
be performed in a variety of ways. Some advocate a single, interrupted layer of
monofilament suture between the edges of the ductotomy and full-thickness
intestinal wall, while others perform the anastomosis with a single running layer of
monofilament suture (absorbable and nonabsorbable are both used at the surgeon’s
discretion). A two-layer anastomosis can be performed by adding an outer layer of
interrupted 3-0 silk sutures between the seromuscular layer of the jejunum and the
pancreatic capsule. A drain is typically placed in the lesser sac to capture any
clinically meaningful pancreatic leak.
Frey Modification of Beger’s Procedure
In 1987 Frey introduced a technique to address commonly encountered pancreatic
head-dominant disease (fibrosis, stones, or strictures), with a concomitant dilated
MPD [35]. Traditional resectional therapy for pancreatic head-dominant disease
includes pancreaticoduodenectomy and duodenum-sparing resection of the pancreatic head (Beger’s procedure), though these operations are complicated by
technical difficulty and increased operative risk due to scarring and neovascularization of the gland [36]. This modification avoids the dangerous dissection in the
posterior neck of the pancreas, and includes only a single pancreatic anastomosis.
Just as with a longitudinal pancreaticojejunostomy, the ductotomy is completed and
then extended into the uncinated process. The pancreatic head tissue overlying the
ducts of Wirsung and Santorini is removed, taking care to leave a posterior wall of
pancreatic parenchyma intact. The Roux-en-Y reconstruction is then completed
with interrupted suture to the pancreatic capsule and a running layer of monofilament suture to the pancreatic duct edge (Fig. 30.3).
30 Chronic Pancreatitis: Puestow and Frey Procedures 395
Fig. 30.3 Chronic pancreatitis with a multiple stones, strictures, and dilated duct in the body and
tail of the pancreas; b coring out of diseased pancreatic parenchyma; c longitudinal ductotomy
with Roux-en-Y pancreatojejunal anastomosis
Outcomes and Pitfalls
Overall operative mortality for a Frey or Puestow procedure is generally 1–3%,
most often related to sepsis following pancreaticojejunal anastomotic dehiscence or
cholangitis [37]. Postoperative morbidity of up to 19–22% is reported, with the
most common complications including delayed gastric emptying, pancreatic fistula,
abdominal abscesses, wound infection, and respiratory complications [38–40].
Studies show short-term pain relief, demonstrated by reduction in analgesia
requirement and reduced admissions for pain following drainage procedures, to be
75–90% [41, 42], with no significant difference between Frey and Puestow
396 A. Chang and D. Abbott
procedures when patients are selected appropriately [43]. Compared to other
resectional therapies, the Frey procedure is equally effective in achieving pain relief
and preserving pancreas function, with the advantage of being a somewhat safer
procedure [44]. Direct comparisons between longitudinal pancreatojejunostomy
and Frey procedures are not forthcoming, as the resectional component of the Frey
procedure addresses a heterogeneous patient population of patients with dilated
MPD (those with head-dominant strictures and/or pancreatic duct stones).
Long-term pain control is a challenge in this patient population, with up to 14–
35% of patients undergoing longitudinal pancreatojejunostomy requiring narcotic
use [40, 45–47]. Compared to endoscopic drainage, surgical drainage procedures
have a greater likelihood of complete or partial pain relief (80% vs. 38%) and
require fewer additional interventions in a 5-year longitudinal study [48]. Pain relief
following surgical drainage is more rapid, effective, and sustained compared to
endoscopic drainage alone [48, 49]. Preoperative narcotic dependence, prior surgical interventions, and continued alcohol consumption are predictors of poor
long-term success, and a lack of commonly accepted staging systems for chronic
pancreatitis makes comparison across studies difficult. While no single intervention
is greatly superior in all cases, surgical intervention should be tailored to each
patient’s anatomical and physiological disease.
Alternatives and Controversies
• Small-duct chronic pancreatitis is not amenable to pancreaticojejunostomy. While large-duct disease is relieved in the short term by surgical
decompression, up to 50% of patients have recurrent pain within 5 years.
• Theoretical suppression of pancreatic exocrine excretion with digestive
enzymes, cholecystokinin receptor antagonists, or somatostatin has shown
some benefit in early trials, but have not gained wide acceptance.
• Endoscopic drainage and pancreatic duct stenting shows promising
short-term results in select patients, however, direct comparison to surgical drainage is forthcoming.
Conclusion
Chronic pancreatitis is a difficult disease process that is best suited for a multidisciplinary approach. Treatment strategies based on patient anatomy and functional status should be tailored with the goal of preserving pancreatic function,
relieving pain, and preventing complications of chronic pancreatitis. Longitudinal
pancreatojejunostomy with or without resection of pancreatic head tissue should be
considered in symptomatic patients if a diagnosis of chronic pancreatitis with main
30 Chronic Pancreatitis: Puestow and Frey Procedures 397
pancreatic duct dilation is clear. Prolonged delays in decompression should be
avoided, to prevent loss of pancreatic function and chronic narcotic dependence.
Summary
• Chronic pancreatitis is characterized by a progressive loss of pancreatic
parenchymal tissue leading to endocrine and exocrine insufficiency, often
with a substantial subclinical phase.
• In general, chronic pancreatitis is caused by relative ductal obstruction
leading to intraductal hypertension, although stone s and intraductal plugs
are rare. Relief of the intraductal hypertension can halt progression of
parenchyma changes.
• Symptomatic chronic pancreatitis and those patients with progre ssive
endocrine or exocrine insufficiency warrant invasive treatment including
endoscopic and surgical decompression.
• Chronic pancreatitis with a dilated pancreatic duct should be treated with
surgical decompression, while small ducts can be given a trial of medical
or endoscopic treatment.
• Dilated pancreatic duct with multiple strictures are best addressed by
lateral pancreaticojejunostomy, while head-dominant disease is best
addressed by Beger or Frey procedures.
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