Lateral Pancreaticojejunostomy Research Articles

Outcome of surgery for chronic pancreatitis related pancreatic ascites and pancreatic pleural effusion

BackgroundAn internal pancreatic fistula involves an abnormality in the way that the pancreas communicates with organs and spaces within the body. This is usually due to a disrupted pancreatic duct or psuedocyst leakage (Ascitic or pleural fluid amylase level >1000 S units/dl and fluid protein level >3 g/dl). The study aims to report our experience with surgery for chronic pancreatitis-related pancreatic ascites and pancreatic pleural effusions. MethodsAll the patients, who underwent surgical intervention for pancreatic ascites and pancreatic pleural effusion between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. ResultsOf the total 14 patients, 10 (71.4%) were men with a median age of 40 (4–49) years. The median interval between onset of symptoms of CP and diagnosis of IPF was 27 (3–60) months. All patients had a history of chronic abdominal pain and 5 (35.7%) had a prior history of hospitalization for pain. Eleven patients (78.5%) presented with abdominal distension and 3 (21.4%) patients had respiratory distress. Six (42.8%) patients had undergone endotherapy before surgery. Contrast-enhanced computed tomography detected pancreatic pseudocyst in 10 (71.42%) patients. The most commonly performed operation was lateral pancreaticojejunostomy (n = 11, 78.5%). Seven postoperative complications developed in 4 (28.5%) patients. After a median follow-up of 60 (6–86) months, no patient developed recurrence of pancreatic ascites or pleural effusion. ConclusionIn the experienced hand, surgery can be performed with acceptable perioperative morbidity and mortality and long-term satisfactory outcomes.

Robotic Puestow for Chronic Pancreatitis

Introduction: Patients with chronic pancreatitis often present with debilitating pain that limits their day to day function. Numerous drainage and resection procedures have been described. For patients with dilation of the pancreatic duct, a lateral pancreaticojejunostomy (Puestow) can offer significant relief. These patients often have difficult pain control postoperatively due to chronic pain and a minimally invasive approach may offer a benefit. Methods: The accompanying figure demonstrates representative views from a video of a robotic Puestow. The patient had a history of alcoholic pancreatitis, with daily narcotic use. Imaging demonstrated dilated pancreatic duct to 11 mm with presence of intraductal stones, without significant disease in the head. She was motivated to pursue surgery and abstained from alcohol and tobacco products. The da Vinci Xi robotic system was used. The gastrocolic ligament was opened and gastropancreatic folds were divided. The superior and inferior borders of the pancreas were mobilized and a pancreatic ultrasound was performed to delineate the extent of duct dilation. The gastroepiploic vein and gastroduodenal artery were divided to access the neck and head of the pancreas. A longitudinal pancreatic ductotomy was created with cautery and stones were retrieved (top panel). A pancreaticojejejunal anastomosis was created in two layers using V-Loc sutures (bottom panel). Results: The patient recovered uneventfully and was discharged on POD 5. The patient was able to decrease her narcotic use with significant symptomatic improvement. Conclusion: Minimally invasive approaches to management of chronic pancreatitis should be considered to expedite recovery and weaning from narcotics.

Minimally invasive surgery of the pancreas: a narrative review of current practice

Minimally invasive surgery has moved from the fringe of pediatric surgery to the mainstream to address a variety of problems. Pancreatic pathology, though uncommon and complex, is frequently amenable to laparoscopic intervention. Indications for pediatric pancreatic operative intervention includes trauma, congenital hyperinsulinemia and neoplasm. Children may require distal pancreatectomy, subtotal pancreatectomy, enucleation, lateral pancreaticojejunostomy and pancreaticoduodenectomy. Of these operations, all but pancreaticoduodenectomy have been successfully described in children using a minimally invasive approach. Traumatic transection of the main pancreatic duct may require operative intervention if endoscopic techniques are unsuccessful. Distal pancreatectomy has been successfully utilized in this circumstance. Additionally, near total pancreatectomy may also be performed laparoscopically although successful reports are limited. Enucleation, especially with the use of intraoperative ultrasound may avoid a large laparotomy for isolated benign masses. Finally, chronic pancreatitis resulting in a dilated main pancreatic duct may benefit from a lateral pancreaticojejunostomy. This operation has also successfully been performed in children. Included is a review of pediatric pancreatic minimally invasive operations paired with corresponding pathology.

Pancreatic malignancy in the backdrop of chronic pancreatitis: How much to push the boundaries to achieve R0 resection

Abstract Tumors of the body and tail of the pancreas are often more aggressive than tumors of the head and would have often undergone metastatic spread to other organs at the time of diagnosis. Most patients with carcinoma of the body and tail of the pancreas present at a late stage. Surgery is only indicated in those patients in whom there is no evidence of metastatic spread. Surgery is often not possible in cancers of the body and tail of the pancreas if the tumor invades celiac artery. Controversy exists regarding the margin status impact of microscopic resection margin involvement (R1) after pancreaticoduodenectomy (PD) for PDAC. There are reports indicating the rate of R1 resections increases significantly after PD if pathological examination is standardized. In this report, we present the case of a 56-year-old female who had undergone lateral pancreaticojejunostomy for chronic pancreatitis 8 years ago, but has now developed malignancy of the body and tail of the pancreas involving multiple organs. This patient underwent en bloc resection involving: 1. distal pancreatectomy with jejunal loop (lateral pancreaticojejunostomy) resection; 2. splenectomy; 3. left nephrectomy; 4. total gastrectomy; and 5. segmental colectomy with reconstruction by esophagojejunostomy, jejunojejunostomy, and colocolic anastomosis. The infrequent occurrence of tumor in the distal gland and advanced tumor stage at the time of diagnosis have both combined to produce therapeutic nihilism/dilemma in the minds of many surgeons. This report highlights the decision on how much to the push limits for multi-organ resection (en bloc resection with distal pancreatectomy, gastrectomy, splenectomy, colectomy, nephrectomy) with the intent of achieving R0 status in spite of the complexity of surgery in selected patients.

A clinical study on lateral pancreaticojejunostomy in a case of chronic pancreatitis

Lateral pancreaticojejunostomy is a seldom performed procedure in a peripheral tertiary health care centre. Very few numbers of cases are reported that undergoes surgical procedures for chronic pancreatitis. We report a such rare case in our institute that undergone pancreatic drainage procedure. A 70 year old poor patient was admitted in our institute with a complaint of chronic abdominal pain, subsequently diagnosed to be having chronic pancreatitis with complications with pancreatic duct calculus. Pancreatic drainage procedure, lateral pancreaticojejunostomy was performed and we analysed for the outcome of the procedure with regards to pain relief, anastomotic leak, quality of life and return to work. Patient recovered well post-operatively, reported pain relief, suffered no anastomotic leak and experienced improved quality of life. Lateral pancreaticojejunostomy provides excellent surgical choice for patients of chronic pancreatitis with pancreatic duct calculus with acceptable rates of pain relief, morbidity and mortality, without worsening pancreatic insufficiency.

Laparoscopic versus open surgical management of patients with chronic pancreatitis: Amatched case-control study.

Background:The safety and feasibility of laparoscopic surgery in patients with chronic pancreatitis (CP) have been established, but its outcome has not been compared to that of open surgery.Patients and Methods:This retrospective study was conducted on patients with CP who were treated by a single surgical team from 2012 to 2018. The medical records of patients with surgical treatment of CP were reviewed. Patients were divided into laparoscopic group (LG) and open group (OG). Both the groups were matched for age and procedures. The matched groups were compared.Results:The total number of unmatched patients was 99 and post matching, there were 38 patients in each group. The demographic, aetiological, clinical and laboratory parameters were comparable. The number of each surgical procedure including bilio-enteric anastomosis was also similar. Lateral pancreaticojejunostomy was the most common surgical procedure in both the groups. An additional surgical procedure (bilio-enteric bypass) was required in 10.5% of the patients in LG and 21% of the patients in OG groups (P = 0.3). Significantly lower blood loss (100 vs. 120 ml) and higher operation time (300 vs. 210 min) were observed in LG. The post-operative complication rate was 7.9% in LG group versus 10.5% in OG group. More than 85% of the patients in both the groups had a significant relief from pain. The impact of exocrine and endocrine insufficiency was not remarkable in both the groups. The requirement of an additional surgical procedure was associated with a high conversion rate.Conclusions:The outcomes of laparoscopic surgery in patients with CP were similar to that of open surgery, and requirement of an additional surgical procedure is associated with a high conversion rate.

Open modified puestow procedure in an advanced endoscopic era for chronic pancreatitis with dilated pancreatic duct and stones

Background: Chronic pancreatitis has been defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphological changes. These changes typically cause pain and loss of exocrine and endocrine pancreatic function. The most common symptom of chronic pancreatitis is pain, which can be severe and intractable in some patients. Although it is itself benign, chronic pancreatitis can significantly affect quality of life and can cause significant distress with its complications [1]. The initial treatment for pain in most cases is to start of enzyme replacement, control of diabetes with insulin, and administration of oral analgesics. Surgical intervention is required in patients with intractable pain that is resistant to conventional nonsurgical therapy, in patients with associated or suspected malignancy, and in patients who have developed complications such as biliary or duodenal obstruction, pancreatic fistulae, pancreatic ascites/pleural effusion, pseudocyst, or rare hemosuccus pancreaticus [2]. The aetiology of pain in chronic pancreatitis is unclear. Some evidence has suggested that perineural inflammation may be the cause of pain. A dilated pancreatic duct, secondary to obstruction, may cause increased intraductal pressures, resulting in pain [3]. The primary aim of therapy is the achievement of primary pain relief and an improvement in quality of life. This could be achieved by means of endoscopic, open or laparoscopic /robotic lateral pancreaticojejunostomy [4, 13]. Methods: We selected 41 cases of chronic pancreatitis of both genders with moderate to intractable pain hampering routine life. All patients tried conservative treatment for more than 6 months. All selected patients underwent haematological and radiological work up. MRCP of all patients showing dilated pancreatic duct more than 7mm. in size. All of these patients operated for longitudinal pancreaticojejunostomy (Modified Puestow’s). Follow up done for one year to ten years Results: All 41 patients in long term follow up were recovered well from pain and abdominal discomfort. Appetite were improved and weight gain noted in the patients after surgery. Conclusions: Longitudinal pancreaticojejunostomy is still safe, simple and timely approved procedure for pain associated with chronic pancreatitis.

Lateral Pancreato-Jejunostomy in Chronic Pancreatitis: An appraisal of 32 cases

Background: Lateral Pancreaticojejunostomy (LPJ) has recognized applications in the management of Chronic Pancreatitis (CP). It is done for patients with severe pain, obstructed and dilated pancreatic duct.

Variation in reporting of the Frey pancreatico-jejunostomy: Current world experience

Introduction: In 1987 Frey and Smith described their operation for chronic pancreatitis which involved an extended lateral pancreaticojejunostomy combined with removal by coring of the parenchyma in the anterior aspect of the head of the gland. The Frey pancreaticojejunostomy has now been reported from centres across the world. However, unlike more clearly defined procedures such as pancreatoduodenectomy, there is no standardization of the Frey operation resulting in potential heterogeneity. This study is an overview of the current world experience of the Frey operation with emphasis on variance in reporting. Methods: A search of the literature was performed using the Scopus database for publications between 1st January 1970 and January 2018. The keyword and MESH heading “chronic pancreatitis”, was used together with the term “Frey Pancreaticojejunostomy”. The risk of bias was assessed using the Cochrane collaboration’s tool for assessing risk of bias in non-randomized studies of interventions. The protocol was reviewed by the research and development department of Central Manchester University Hospitals NHS Foundation Trust. There were 34 reports of the Frey pancreaticojejunostomy and these constitute the study population Results: Data are affected by selection bias and reporting bias. In terms of assessing the morphology of the gland being operated, maximum antero-posterior diameter of the main pancreatic duct was reported in 19 (56%) of reports, antero-posterior diameter of pancreatic head in 13 (38%). Portal vein patency was confirmed in 4 (12%). The presence or absence of a concomitant biliary stricture was reported in 22 (65%) and a duodenal stricture in 14 (41%). Conclusion: The Results demonstrate that there is substantial variation between centres in reporting of the Frey operation. This variance compromises the value of comparative outcomes of this procedure and highlights the need for better standardization of the reporting of outcomes of surgery for chronic pancreatitis.

30-Day outcomes and predictors of complications after Puestow procedure

BackgroundA lateral pancreaticojejunostomy, or a Puestow procedure, is used in chronic pancreatitis with ductal dilation and pain. The current literature on the Puestow is sparse. This study examines outcomes of Puestow procedures nationwide. MethodsUsing ACS-NSQIP database, patients who underwent a Puestow procedure from 2010 to 2016 were identified. Univariate analysis and multivariable regression models were used to identify predictors of mortality and morbidities. Covariates included in the regression models were chosen based on clinical significance. ResultsThe cohort included 524 patients. The 30-day mortality rate was 1.2%(n = 6). At least one major complication occurred in 19.1% of patients including death (1.2%), major organ dysfunction (8.2%), pulmonary embolism (1.3%), and surgical site infections (13.0%). Diabetes, COPD, and transfusions were the strongest predictors of complications. ConclusionsThe Puestow procedure is an acceptable treatment modality with low rates of morbidity and mortality. Minimizing transfusions and optimizing pulmonary status may improve 30-day outcomes.

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

3004 Recurrent Painful Pancreatitis After Puestow Procedure

INTRODUCTION: Chronic pancreatitis (CP) is a progressive, irreversible inflammation and fibrosis of the pancreas, leading to irreversible damage, chronic pain, and pancreatic insufficiency due to loss of endocrine and exocrine function. The most common etiologies are alcohol abuse, autoimmune pancreatitis, ductal obstruction, hypercalcemia, and hypertriglyceridemia.1 CASE DESCRIPTION/METHODS: A 23-year-old male with history pancreatitis, tobacco smoking with multiple admissions due to epigastric pain, nausea, and vomit after lateral pancreatojejunostomy. Prior workup for autoimmune pancreatitis and hypertriglyceridemia was negative. Evaluation was significant for an MRCP (Figure 1) that showed pancreatic duct stones with near complete atrophy of the remaining pancreatic gland and an abdominopelvic CT scan (Figure 2) that showed no gallstones or dilation of the common bile duct. Endoscopic ultrasound showed a duodenal ulcer negative for H. pylori., one major criteria A and three minor criteria. Findings consistent with chronic pancreatitis as per Rosemont classification. Repeated upper endoscopy showed no evidence of prior duodenal ulcer. Abdominal pain, nausea, and pain persisted without significant improvement for months after surgery, with more than four admissions in six months. DISCUSSION: CP is a debilitating painful condition. Pain from CP is associated with mechanical obstruction, damaged intrapancreatic nerves and increased intraductal pressure, leading to dilation of the pancreatic duct.2,3 Treatment is focused on pain control with non-steroidal anti-inflammatory drugs, opioids, and celiac plexus block. Medical therapy often fails, and patients tend to require invasive measures such as endoscopic therapy and surgical procedures.4 Invasive interventions are used to relieve obstruction caused by pancreaticolithiaisis or strictures. Whipple resection and Puestow procedure are surgical procedures used for pain control. Modified Puestow is associated with decreased morbidity and decreases length of hospital stay. This procedure is designed to preserve healthy pancreatic tissue retaining exocrine and endocrine function of the pancreas.5 Complete pain resolution occurs in 80% of patients after lateral pancreaticojejunostomy. Nonetheless, failure rates are prevalent in numerous, creating frustration and depression in patients with this debilitating condition. Newer options are available, but most of them are offered at specialized centers, leading to limited access of these novel therapies.6

Frey operation for chronic pancreatitis

Background: Chronic pancreatitis is a debilitating disease, and pain is it’s most severe symptom. For pancreatic head inflammatory mass with pancreatic duct dilatation, the Frey procedure can be used. The purpose of the video is to describe effective treatment of this condition by the Frey procedure in a patient previously submitted to pancreatic debridement. Methods: A 44-year-old male patient was initially treated for recurrent acute pancreatitis, one of the episodes being a severe acute pancreatitis that required pancreatic debridement for infected necrosis, laparostomy and lengthy ICU stay. During the following 30 months, the patient was admitted several times because of recurrent episodes of pain, and lastly with jaundice due to CBD compression. Increasing doses of opioids were warranted, eventually becoming insufficient to manage pain. CT showed pancreatic head inflammatory mass and pancreatic duct dilatation. Thereafter, local resection of the pancreatic head combined with lateral pancreaticojejunostomy was performed, with no complications. Results: After 10 months of follow-up, the patient had a 10Kg weight gain, demonstrates normal glucose metabolism, with slight need for enzyme supplementation, and he is jaundice and pain-free, not using any analgesic drugs. Conclusion: Local resection of the pancreatic head combined with lateral pancreaticojejunostomy (Frey procedure) offers a advantageous outcome, even after history of pancreatic debridement for infected necrosis.

Frey operation for chronic pancreatitis

Background: Chronic pancreatitis is a debilitating disease, and pain is it’s most severe symptom. For pancreatic head inflammatory mass with pancreatic duct dilatation, the Frey procedure can be used. The purpose of the video is to describe effective treatment of this condition by the Frey procedure in a patient previously submitted to pancreatic debridement. Methods: A 44-year-old male patient was initially treated for recurrent acute pancreatitis, one of the episodes being a severe acute pancreatitis that required pancreatic debridement for infected necrosis, laparostomy and lengthy ICU stay. During the following 30 months, the patient was admitted several times because of recurrent episodes of pain, and lastly with jaundice due to CBD compression. Increasing doses of opioids were warranted, eventually becoming insufficient to manage pain. CT showed pancreatic head inflammatory mass and pancreatic duct dilatation. Thereafter, local resection of the pancreatic head combined with lateral pancreaticojejunostomy was performed, with no complications. Results: After 10 months of follow-up, the patient had a 10Kg weight gain, demonstrates normal glucose metabolism, with slight need for enzyme supplementation, and he is jaundice and pain-free, not using any analgesic drugs. Conclusion: Local resection of the pancreatic head combined with lateral pancreaticojejunostomy (Frey procedure) offers a advantageous outcome, even after history of pancreatic debridement for infected necrosis.

Laparoscopic pancreaticoduodenectomy: A promising new technique for panreaticojejunostomy using V-Loc suture

Background: Pancreatic fistula rate remains a matter of debate as the most important morbidity after pancreaticoduodenectomy.We have previously described a pancreaticojejunostomy technique using V-Loc suture with promising outcome considering fistula rate.The aim of the present study was to observe whether this new technique,would be feasible and safe during laparoscopic pancreaticoduodenectomy. Methods: Between January 2012-September 2016,39 patients who underwent totally laparoscopic pancreaticoduodenectomy(TLPD) were prospectively included.In all patients, same surgical team performed lateral pancreaticojejunostomy(LPJ) anastomosis using V-Loc suture.Postoperative pancreas fistula(POPF),anastomosis duration,hospital stay, postoperative morbidity and mortality were recorded. POPF was classified up to the international study group definition. Results: There were 22 male and 17 female patients with a mean age of 56 ± 6 (38-76)years.The mean time of surgical procedure and LPJ was 340±36 min(250-385 min) and 36±5 min(30-46 min ),respectively.The number of patients with POPF(12%) were as follows;Grade A:3,GradeB:1,GradeC:1.The rate of overall morbidity was 7.2%(postoperative hemorrhage(n=1) and hepaticojejunostomy stricture(n=1),surgical site infection (n=1),POPF(n=1).There was no 30-d postoperative mortality. Conclusion: This new technique for dunking LPJ anastomosis using V-Loc appears to be remarkably safe and feasible approach to pancreaticojejunostomy without adversely affecting operating time or POPF rate.

Laparoscopic lateral pancreaticojejunostomy (LPJ) for the treatment of chronic calcific pancreatitis

Summary: Introduction: Surgical options for patients of chronic pancreatitis with refractory pain include drainage and or resectional procedures. Lateral pancreatojejunostomy (LPJ), the commonly performed drainage operation has traditionally been done as an open procedure. This video demonstrates the technique of Laparoscopic lateral pancreaticojejunostomy. Methods: During the study period 39 laparoscopic lateral pancreaticojejunostomies for patients of chronic pancreatitis with refractory pain were performed. The procedure involved opening of the gastrocolic ligament to expose the pancreas. The duct was identified either by needle localization, or opening directly over a calculus/pseudocyst. The duct was completely opened in the entire pancreas and all the ductal calculi were removed. In patients with a head mass, a limited head coring was also performed. A roux limb of the jejunum was fashioned and a side-side pancreaticojejunostomy was done using either a continuous or an open suture technique. A side-side jejunojejunal anastomosis was then performed, A drain was placed in the vicinity of the pancreaticojejunostomy and the ports were closed. Postoperatively, patients were managed in surgical intensive care and after discharge followed up at 2 weeks, 1, 3 and 6 months. Satisfactory pain relief was seen in 91% patients. Conclusion: Laparoscopic LPJ is feasible and safe and offers good pain control with the added benefits of laparoscopic approach. This is perhaps the largest reported experience of laparoscopic lateral pancreaticojejunostomy till date.

Laparoscopic lateral pancreaticojejunostomy: an evolution to endostapled technique.

Chronic pancreatitis (CP) is a debilitating condition resulting in severe pain with progressive deterioration of pancreatic function. "Tropical" pancreatitis represents a variant of the disease with widely dilated ducts, numerous calculi, and few strictures. Traditionally, modified Puestow's procedure has been the treatment of choice for a dilated pancreatic ductal system. However, it has only recently been adapted to laparoscopic approach which is a technically demanding procedure primarily due to need for extensive intra-corporeal suturing. Symptomatic cases of CP presenting at our center with minimum 8mm mean ductal diameter at body and head were selected for laparoscopic modified Puestow's procedure. Those with prior pancreatic surgery, pancreatic head masses, endoscopic pancreatic stenting, and portal hypertension were excluded. Twenty-eight cases meeting selection criteria underwent a laparoscopic procedure. Seven patients (25%) underwent a stapled pancreaticojejunal anastomosis, 17 (60.7%) received a sutured anastomosis. Four patients (14.3%) were converted to open surgery due to failure to localize the pancreatic duct with percutaneous needle aspiration. Of those patients who underwent a successful laparoscopic procedure, a single patient developed a pancreatic fistula which resolved spontaneously; another patient had a difficult post-operative course with prolonged intensive care. We suffered no mortality within the series and no patient had any long-term disability. Anastomotic patency rates of 100% were achieved by the third post-operative month. Lateral pancreaticojejunostomy is an effective surgical management for CP with a dilated ductal system. Its laparoscopic adoption is the rational next surgical step. It allows effective duct decompression with low mortality and morbidity. The procedure demands an advanced surgical skill set with an emphasis on intra-corporeal suturing. Those patients suffering from tropical CP with wide ductal dilatation greater than 12mm are suited to an endostapled anastomosis which helps significantly reduce operative time without any corrosion of outcomes.

Outcome of 112 Frey's procedure in head dominant chronic pancreatitis, in tertiary referral centers of Dhaka, Bangladesh

Background: Frey's Procedure is an organ preserving technique with lateral pancreatico-jejunostomy using coring of pancreatic head. Resection of “pacemaker of pain” (Pancreatic head) gives remarkable outcome. Methods: This prospective observational study, intended to further validate Frey's procedure in head dominant chronic pancreatitis, carried out on 112 Bangladeshi patients from January 2000 to December 2017. They were mostly from poor socioeconomic group, followed up for 2–72 months. Result: The study revealed 54 patients (48.21%) in 3rd decade of life with 48 male and 64 female. We found, 81 patients were diabetic, Steatorrhoea in 82 patients and Malnutrition in 85 patients. 101 patients presented with recurrent abdominal pain with moderate pain in 72 patients (64.28 %) and severe or intolerable pain in 24 patients (21.42%). Following Frey's procedure moderate pain control in 37 patients (33.03%), good pain relief in 66 cases (58.98%). Only 09 (8.03%) patients had poor pain relief. Postoperative morbidity was noted in 21 patients (18.75%). Conclusion: Management of Pain and pancreatic insufficiency are major challenges that hampers quality of life in Chronic Pancreatitis. Frey's procedure with adequate ductal clearance and wide pancreato-jejunal anastomosis is key to better pain control, improves quality of life and prevents recurrence.

Drainage procedures for small duct disease in chronic pancreatitis: a feasible option

Background: Surgery is the treatment of choice for intractable pain in chronic pancreatitis (CP). Drainage procedures are indicated in large duct disease whereas resectional procedures for small duct disease. Aim of this study was to assess prospectively the feasibility of drainage procedures in patients with CP with small duct disease.Methods: All consecutive patients with CP with small duct disease were included in the study. All patients underwent surgical intervention (lateral pancreaticojejunostomy with head coring). Primary outcome measures were pain relief and morbidity. These outcomes were compared with patients with CP with large duct disease.Results: 114 patients with CP underwent surgery. Of these 24(21.05%) patients had CP with small duct disease and 90(78.95%) patients had large duct disease. Demographic profile of the two groups was comparable. Mean pain scores were similar (47.75±6.85 versus 51.38±7.40; p = 0.14). Patients with large duct disease had higher incidence of diabetes mellitus (44.44% versus 8.33%; p = 0.02), but exocrine insufficiency was similar. All patients had calcifications in both the groups. Mean intraductal pressures measured intraoperatively were significantly high in patients with large duct disease (22.99±5.65 versus 18.33±3.52; p = 0.001). Frequency of complications at presentation were similar in both the groups (p = 0.29). Surgery relieved pain in 21/24 (87.5%) patients with small duct disease and 82/90 (91.11%) patients with large duct disease. Mean post-operative pain scores in small duct disease group (7.50±9.61 versus 51.38±7.40; p <0.001) and large duct disease group (5.14±7.88 versus 47.75±6.85; p <0.001) were significantly reduced when compared to preoperative pain scores. Incidence of postoperative complications was similar in both groups (16.66% versus 14.44%).Conclusions: Drainage procedures (lateral pancreaticojejunostomy with head coring) is a feasible for CP patients with small duct disease with good pain relief.

Outcome of Pancreatic Head Coring in as Key Surgical Treatment in Head Dominant Chronic Pancreatitis in Tertiary Referral Centers of Bangladesh

Background: Pancreatic head coring procedure, an organ preserving surgery in which diseased head of pancreas is cored with drainage of main pancreatic duct by lateral pancreatico-jejunostomy. Chronic pancreatitis is a persistently occurring inflammatory disease that causes pancreatic duct stones or calcification, stricture, dilatation of pancreatic duct and irreversible morphological changes resulting intractable pain and losses of exocrine and endocrine function. Appropriate management protocol recognizing underlying pathology, can prevent complications and improves the quality of life. Apart from ductal decompression, in Frey’s’ procedure resection of the “pacemaker of pain” (Head of the pancreas) gives excellent outcome.Methods: In this prospective observational study, we have intended to further validate the Frey’s procedure an effective surgical method in head dominant severe chronic pancreatitis. The study was carried out on 106 Bangladeshi patients who underwent Frey’s Procedure with Lateral Pancreaticojejunostomy from January 2000 to December 2017.Result: The study revealed 51 patients (48.11%) were in 3rd decade of life with 45 male and 61 female. We found 77 patients presented with diabetes mellitus, mostly on insulin. Steatorrhoea was noted in 39 patients and Malnutrition in 79 patients. Visual Analog Scale (VAS) was used for scoring pain. Postoperative morbidity was noted in 29 patients 27.35 % cases, but there was no anastomotic leakage or mortality in the immediate postoperative period in our series.Conclusion: Quality of life has always been the most important decisive factor for patients with severe chronic Pancreatitis. Pain is the predominant clinical feature and very difficult to control. Correction of diabetes and malnutrition are major challenges too. This study revealed, Frey’s procedure with adequate ductal clearance with wide pancreato-jejunal anastomosis in head dominant severe chronic pancreatitis is key to better pain control, improves quality of life and prevents recurrence.Birdem Med J 2018; 8(2): 151-158