Content uploaded by Kalpesh Jani
Author content
All content in this area was uploaded by Kalpesh Jani on Oct 12, 2022
Content may be subject to copyright.
Laparoscopic lateral pancreaticojejunostomy
A new remedy for an old ailment
C. Palanivelu, R. Shetty, K. Jani, P. S. Rajan, K. Sendhilkumar, R. Parthasarthi, V. Malladi
Gem Hospital, 45 A, Pankaja Mill Road, Coimbatore 641045, Tamilnadu, India
Received: 7 October 2005/Accepted: 8 November 2005/Online publication: 19 January 2006
Abstract
Background: Lateral pancreaticojejunostomy is consid-
ered as the standard surgery for chronic pancreatitis.
Yet there are very few reports of this procedure being
done laparoscopically. We present our experience with
laparoscopic lateral pancreaticojejunostomy till date
and describe our technique.
Material and method: Since 1997, we have done 12 lap-
aroscopic lateral pancreatojejunostomies. There were 9
females and 3 males and the average age was 29.3 years.
The indication for surgery in all patients was intractable
abdominal pain and significant weight loss. Addition-
ally, two patients were also suffering from pancreatic
ascites.
Results: The average diameter of the pancreatic duct was
14.7 mm. We used a four-port technique. All surgeries
were completed without any conversion to open surgery.
Post-operatively, there were no major morbidity and nil
mortality. The average operating time was 172 minutes.
Post-operative stay was short (average 5 days) and on
median follow-up of 4.4 years, 83.3%patients had
complete pain relief while 16.7%had partial relief. All
patients had significant weight gain.
Conclusions: Laparoscopic lateral pancreaticojejunos-
tomy is safe, effective and feasible in experience hands.
Mastery of intracorporeal knotting and suturing
techniques is mandatory before embarking on this
surgery.
Key words: Lateral pancreatojejunostomy — Chronic
pancreatitis
Chronic pancreatitis is a condition characterized by
irrecoverable destruction and fibrosis of exocrine
parenchyma leading to pancreatic exocrine insuffi-
ciency and progressive endocrine failure. Chronic
obstructive calculous pancreatitis has a high prevalence
in South India [5, 6], with the majority being tropical
chronic pancreatitis (TCP). TCP can be defined as a
juvenile form of chronic calcific nonalcoholic pancre-
atitis prevalent almost exclusively in developing coun-
tries of the tropical world. Some of its distinctive
features are younger age of onset, the presence of large
intraductal calculi, an accelerated course of the disease
leading to diabetes and/or steatorrhea, and a high
susceptibility to pancreatic cancer [1–3, 9]. The etiol-
ogy is not know, but genetic mutations such as the
SPINK1 gene mutation and environmental factors are
likely causes [13].
The majority of patients with dilatation of ducts
develop pain due to increased intraductal pressure,
with a stone or multiple stones obstructing the proxi-
mal duct. In such patients, decompression of the ductal
system often relieves the pain. We advocate spleen-
preserving lateral pancreaticojejunostomy as a method
of ductal decompression in these patients. We per-
formed our first laparoscopic lateral pancreaticojejun-
ostomy for chronic pancreatitis in 1997 [11]. The
earliest report of a similar procedure came from Jurian
et al. in 1999 [8].
Materials and methods
Since 1997, 12 patients with chronic calculous pancreatitis have
undergone laparoscopic spleen-preserving lateral pancreaticojejun-
ostomy. All patients underwent routine hemotological investigations,
x-ray of the abdomen, ultrasonography (USG), and CT scan. Once
the decision to operate was made, endoscopic retrograde cholan-
giopancreatography (ERCP) was performed. In 2000, magnetic
resonance cholangiopancreatography (MRCP) became available to
us, and thus we have avoided ERCP in these patients since that
time. ERCP and MRCP helped in documenting the ductal size and
anatomy. Moreover, ductal disruption in two cases, which presented
with ascites, was documented by ERCP. Stenting of the pancreatic
duct was done in both cases, but the ascites persisted and increased,
causing discomfort for the patients.
Correspondence to: R. Shetty
Surg Endosc (2006) 20: 458–461
DOI: 10.1007/s00464-005-0680-x
ÓSpringer Science+Business Media, Inc. 2006
Operative technique
The patient is placed in Trendelenburg Lloyd–Davies position. A small
sandbag is placed under the left side of the chest with 20–30°lateral tilt
of the operating table, which provides optimum position for adequate
exposure. Pneumoperitoneum is established with the closed Veress
needle technique or open Hasson method. Intraperitoneal pressure of
12–14 mmHg is established.
The port sites are detailed in Table 1.
Operative steps
Exposure of pancreas
The lesser sac is entered through the gastrocolic omentum. The gas-
trocolic omentum is opened widely and the entire anterior surface of
the pancreas is exposed from head to tail. Adhesions of the posterior
wall of the stomach to the surface of the pancreas are released.
Identification and exploration of the pancreatic duct
The pancreatic duct can be identified by palpation with blunt probes
and confirmed by percutaneous aspiration using a thin lumbar punc-
ture needle (Fig. 1). Laparoscopic ultrasound helps in the identifica-
tion of the main pancreatic duct. An electrocautery hook dissector or
ultrasonic shears are used to open the pancreatic duct longitudinally
from the head to the tail of the pancreas (Fig. 2). The impacted stones
in the duct can be removed with a right-angled dissector.
Roux-en-Y loop
The proximal jejunum is identified and the Roux-en-Y loop is fash-
ioned using an EndoGIA stapler. The distal limb is taken to the lesser
sac through a window in the mesocolon. The proximal jejunum is
anastomosed to the side of the long limb, at a distance of approxi-
mately 40 cm, in a side-to-side fashion using an EndoGIA stapler. The
enterotomy is sutured with a layer of 2–0 Vicryl sutures.
Pancreaticojejunostomy anastomosis
The long limb of the Roux-en-Y loop is taken to the supracolic
compartment through a window in the mesocolon. The enterotomy is
performed on the antimesenteric border and is placed side to side along
the open pancreatic duct. The enterotomy may be extended according
to the length of the pancreatic duct. Few interrupted stitches are placed
between the seromuscular layer of the jejunum and surface of the
pancreas. The posterior layer of anastomosis consists of continuous
suturing of pancreatic duct mucosa to jejunal mucosa using 3–0 Vicryl
starting from the pancreatic tail to head (Fig. 3). The anterior layer is
performed with interrupted stitches starting from the ends, moving
toward the center. A fourth layer of interrupted stitches between the
jejunal seromuscular layer and the pancreatic surface is placed. The
entire anastomosis is completed by intracorporeal knotting and
suturing techniques (Fig. 4).
Results
The epidemiological data and common clinical presen-
tation are detailed in Table 2. Pain and weight loss were
the most common presenting features. Females were
predominantly affected. The age range varied from 6 to
50 years. The average age of the patients was 29.3 years.
There was a predominance of female patients (mal-
e:female ratio, 1:3). The primary indication for surgery
was severe unremitting pain, unrelieved or partially re-
lieved with analgesics, and significant weight loss due to
sitophobia. Two patients had pancreatic ascites, con-
firmed by ascitic fluid analysis showing high amylase
and lipase levels and ERCP demonstrating leak from the
pancreatic duct. These patients had a trial of pancreatic
duct stenting but without any beneficial reduction in the
ascites.
Table 1. Port site details
Port site Port size (mm) Function
Umbilical 10 Camera
Left midclavicular
supraumbilical
10 Right hand working port
for the surgeon
Right midclavicular
supraumbilical
5 Left hand working port
for the surgeon
Epigastric 5 Gastric retraction
Fig. 1. Localizing the pancreatic duct by aspiration with a lumbar
puncture needle.
Fig. 2. The pancreatic duct has been widely opened and all stones and
sludge have been removed.
459
The pancreatic duct was abnormally dilated in all
patients on USG (median, 14.2 mm; range, 9.8–22). The
operating time ranged from 113 to 225 min (median,
178.5). Oral fluids were started on postoperative day 1
or 2 with the occurrence of bowel movements. The pa-
tients were usually discharged on postoperative days 4–7
(median hospital stay, 5 days) (Table 3).
There were no major perioperative complications.
One patient developed port site infection, which was
controlled by antibiotics and conservative management.
The follow-up ranged from 6 months to 7 years
(median, 4.4 years). Pain relief was complete in 10 pa-
tients (83.3%). In two patients (16.7%), after initial pain
relief, it recurred after approximately 3–6 months but
was milder in intensity, occasional, and relieved with
oral analgesics. Both patients with pancreatic ascites
recovered well, with complete relief from ascites. There
has not been any recurrence of ascites. All patients have
had significant weight gain (5–12 kg).
Discussion
Chronic obstructive calculous pancreatitis and its com-
plications occur quite commonly in the state of Kerala
in south India, where the incidence has been reported to
be as high as 125/100,000 population. However, the
frequency is probably much lower in other areas of
India [3, 5, 6].
Many of these patients present with dilated ducts
and intraductal calculi that do not respond to other
modalities of treatment. Lateral pancreaticojejunostomy
(LPJ) is the procedure of choice in the conventional
approach. Various studies have shown favorable inter-
mediate- and long-term outcomes after performing LPJ
alone or in combination with resection of the head of the
pancreas [4, 7, 12].
Improved clinical experience and introduction of
new technology have extended the indications of lapa-
roscopic surgery. In our patients, we successfully per-
formed the same procedure laparoscopically with
equally good or even better results. However, experience
with intracorporeal knot tying is essential to perform
such an anastomosis [10]. Whereas Kurian and Gagner
[8] reported the same procedure using five ports, we
managed all our cases through four ports.
Although initially the operating time was more than
3½ h, with experience the surgery time decreased. Now,
it takes approximately 2 h to complete the procedure.
The exceptions to this norm were the two cases with
pancreatic ascites, in which the operating time was
longer than the average time. This was in part due to the
time spent completely evacuating the ascites. Second,
both these patients had dense adhesions between the
anterior surface of the pancreas and the posterior gastric
wall. The adhesions were divided sharply using a com-
bination of scissors and ultrasonic shears, which was a
time-consuming process.
In conventional surgery, lateral pancreaticojejunos-
tomy may be performed successfully in patients with
pancreatic ducts of more than 7 mm dilatation. In our
series, the smallest duct size was 9.8 mm. With increas-
ing duct size, the surgery becomes easier and faster.
There were no conversions in our series, and all cases
were completed laparoscopically. We consider this to be
due to proper selection of cases—only patients with a
duct size of approximately 10 mm or larger were offered
this approach. Patients with a mass lesion in the head of
the pancreas on CT scan were not operated
laparoscopically.
As a result of the minimally invasive approach, pa-
tients recovered faster, with oral fluids being started on
postoperative day 1 or 2 and soft diet on the following
day. The average hospital stay of 5 days is much shorter
than that reported for open LPJ [7].
All our patients came from the state of Kerala,
where this form of obstructive chronic pancreatitis is
endemic. A previous study demonstrated high morbidity
Fig. 3. Posterior layer of pancreaticojejunostomy anastomosis
completed.
Fig. 4. The completed lateral pancreaticojejunostomy.
460
and mortality associated with conventional LPJ in this
group of patients [14]. In contrast, in our series, there
was no mortality and no major morbidity.
During an average follow-up of 4.4 years, the results
have been fairly encouraging. There have been no major
complications; pain relief has been complete in 83.3%of
patients and partial in 16.7%of patients. Weight gain
has been universal. The surgery also afforded complete
relief to both patients with pancreatic ascites.
Conclusions
Laparoscopic lateral pancreaticojejunostomy for chronic
obstructive calculous pancreatitis is technically
demanding but possible. It should be done selectively by
surgeons who have mastered the techniques of intra-
corporeal suturing and knotting. Early studies show a
favorable outcome for this procedure in terms of recov-
ery, shorter hospital stay, pain relief, and significant in-
crease in weight gain postoperatively. However, before
hailing this procedure as the gold standard in the man-
agement of chronic pancreatitis, further studies of suffi-
cient power and appropriate randomization are required.
References
1. Anonymous (1996) Consensus statement. International workshop
on types of diabetes peculiar to the tropics, October 17–19, 1995,
Cuttack, India. Acta Diabetol Latina 33: 62–64
2. Alberti KGMM, Zimmet PZ (1998) Definition, diagnosis and
classification of diabetes mellitus and its complications. Part 1:
diagnosis and classification of diabetes mellitus: provisional report
of a WHO consultation. Diabet Med 78: 539–553
3. Barman KK, Premalatha G, Mohan V (2003) Tropical chronic
pancreatitis. Postgrad Med J 79: 606–615
4. Frey CF, Amikura K (1994) Focal resection of the head of pan-
creas combined with longitudinal pancreaticojejunostomy in
management of patients with chronic pancreatitis. Ann Surg 220:
492–504
5. Geevarghese PJ (1968) Pancreatic diabetes. Popular Prakashan,
Bombay, pp 110–115
6. Geevarghese PJ (1985) Calcific pancreatitis. Varghese, Bombay,
pp 85–95
7. Kalady MF, Broome AH, Meyers WC, et al. (2001) Immediate
and long term outcomes after lateral pancreaticojejunostomy for
chronic pancreatitis. Am Surg 67: 478–483
8. Kurian MS, Gagner M (1999) Laparoscopic side-to-side pancre-
aticojejunostomy (Partington–Rochelle) for chronic pancreatitis. J
Hepatobiliary Pancreat Surg 6: 382–386
9. Mohan V, Premalatha G (1995) Fibrocalculous pancreatic diabe-
tes. Int J Diabetes 3: 71–82
10. Palanivelu C (2002) Laparoscopic pancreatico jejunostomy for
chronic pancreatitis. In: Palanivelu C (ed). Text book of surgical
laparoscopy. GEM Foundation, Coimbatore, India, pp 363–366
11. Palanivelu C, et al. (1999) Laparoscopic pancreatico-jejunostomy
for chronic obstructive calculous pancreatitis. Sixth World Con-
gress of Endoscopic Surgery, Rome, May 31–June 6 [Abstract]
12. Schnelldorfer T, Adams DB (2003) Outcome after lateral
pancreaticojejunostomy in patients with chronic pancreatitis
associated with pancreatic divisum. Am Surg 69: 1041–1044
13. Tandon RK, Garg PK (2004) Tropical pancreatitis. Dig Dis 22:
258–266
14. Thomas PG, Augustine P (1998) Surgery in tropical pancreatitis.
Br J Surg 75: 161–164
Table 2. Patient data and common clinical presentations
Clinical presentation
Patient No. Age (yr) Sex Pain Ascites Weight loss
1 24 Female + )+
2 38 Female + )+
3 41 Male + )+
4 16 Female + )+
5 6 Female + + +
6 44 Female + + +
7 11 Female + )+
8 32 Female + )+
9 33 Male + + +
10 27 Female + )+
11 50 Male + )+
12 36 Female + )+
Table 3. PatientsÕresults
Patient
No.
Pancreatic
duct diameter
(mm)
Operating
time (min)
Postoperative
hospital
stay (d)
Follow-up
period
1 11.2 225 7 7 yr
2 16 218 5 6 yr 8 mo
3 13 220 5 6 yr
4 18.2 185 6 5 yr
5 20.1 156 4 5 yr
6 15 172 6 4 yr 6 mo
7
a
9.8 205 7 4 yr 4 mo
8 22 113 5 3 yr 6 mo
9 14.8 129 4 2 yr 8 mo
10
a
11 208 7 1 yr 9 mo
11 13.5 110 5 1 yr 6 mo
12 12 118 5 6 mo
a
Patients with pancreatic ascites
461
