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Modified Puestow Procedurefor Retrograde Drainage

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Modified Puestow Procedurefor Retrograde Drainage Modified Puestow Procedure for Retrograde Drainage of the Pancreatic Duct' PHILIP F. PARTINGTON, M.D., ROBERT E. L. ROCHELLE, M.D. From the Veteran's Administration Hospital, Cleveland, Ohio and the Department of Surgery, Western Reserve University School of Medicine PERMANENT decompression of the pan- tail of the pancreas after the gland had creatic duct is the objective of the direct been mobilized as far as the superior mes- surgical attack on chronic relapsing pan- enteric vessels. A probe was passed down creatitis. This has been attempted from the dilated pancreatic duct and the duct both ends and the middle with varying split as far toward the right side as possible. success. Sphincterotomy, popularized by Hemostasis from the cut edges was ob- Doubilet and Mulholland,2 provides drain- tained with mattress sutures. The mobilized age when obstruction of the duct is con- portion of the gland was then inserted into fined to its terminal portion. In recognition a Roux loop of jejunum which covered it of the inadequacy of this procedure in some like a sheath. The diagonal free end of the cases, Doubilet 1 has recently proposed di- jejunal loop was sutured to the capsule of viding the body of the pancreas and im- the pancreas to cover the opened duct com- planting both severed ends of its duct into pletely. This procedure is appealing from a a Roux Y jejunal loop. theoretical point of view, particularly for Link5 is given credit by Puestow and the patient with several areas of constric- Gillesby 7for the first retrograde drainage of tion in the duct and saccular dilatation be- the pancreatic duct in the treatment of pan- tween as in the authors' illustrations. An creatitis. His cutaneous fistula required fre- alternate method involved opening the dis- quent probing, however, to keep it patent. tal 4 to 6 inches of the Roux loop of jejunum Internal retrograde drainage as a pancrea- along its antimesenteric border and sewing ticojejunostomy was described by Zollinger, this to the pancreas on either side of the Keith and Ellison, in 1954 9 and later in the split. The present paper is concerned with same year by DuVal.3 In 1956, in their a simplified modification of this alternate article on resection of the pancreas for the method. treatment of chronic relapsing pancreatitis, Modified Technic Longmire, Jordan and Briggs 6 mentioned having tried caudal pancreatectomy with Patients suffering from the chronic re- anastomosis of the remaining pancreas to lapsing pancreatitis have frequently had a Roux loop of jejunum, in 1951. They had several upper abdominal procedures before given up the procedure, however, because architectural changes in the gland make of poor results. them candidates for retrograde drainage. Retrograde drainage through the side of Multiple adhesions resulting from surgery the duct opened throughout the tail, body or the inflammatory process itself may ren- and part of the head was described by Pues- der mobilization of the pancreas and spleen tow and Gillesby,7 in 1958. They described quite time consuming. This is especially removing the spleen and amputating the true in the presence of dilated veins along both edges of the pancreas which may be * Submitted for publication February 18, 1960. associated with portal hypertension caused 1037 Annals of Surgery 1038 PARTINGTON AND ROCHELLE December 1960 FIG. 1. Operative pancreatogram through a needle showing a diffusely dilated pancreatic duct with calcification in the head of the gland. Note contrast material in duodenum. a FIG. 2. a. Dilated pancreatic duct split longitudinally toward the tail and somewhat to the right of the mesenteric vessels. b. Ellipse of pan- creas removed from body of gland with needle inserted into exposed duct. c. Opened pancreatic duct cov- ered by retrocolic Roux loop of je- junum with free end toward the tail of the pancreas to minimize angula- tion. Volume 152 RETROGRADE DRAINAGE OF PANCREATIC DUCT Number 6 1039 FIG. 3. Operative pan- creatogram through fine polyethylene catheter (ar- row) inserted into duct exposed by removing an ellipse of pancreas. by inflammatory constriction of the splenic (Fig. 3) for the performance of a pan- and portal veins. Needless sacrifice of the creatogram. In removing the ellipse of tis- spleen may rob a patient with such pathol- sue, it is important to leave a margin of ogy of the only available means for a intact gland for later suture to a jejunal splenorenal shunt should it become neces- loop. A pancreatogram is helpful in indicat- sary. It may also make him vulnerable to ing the extent of the operation necessary complications such as intravascular clotting to relieve the various areas of obstruction which occasionally follows splenectomy (Fig. 4) and it also provides a useful rec- done for whatever cause. Removal of even ord of the pathologic change which was a few centimeters of the tail of the pan- present. creas likewise discards valuable islet cells After locating the pancreatic duct and in patients who are likely to develop dia- demonstrating the areas and degree of ob- betes in the course of their disease. struction, the duct is opened longitudinally Most of these disadvantages can be both toward the tail and toward the head avoided by leaving the spleen and tail of the (Fig. 2a). It is rarely necessary to split the pancreas alone. The anterior surface of the distal most portion in the tail as the duct gland is exposed throughout the tail, body is narrowing down there anyway. The split and part of the head if feasible. At times is usually continued somewhat to the right the dilated pancreatic duct may be felt as of the mesenteric vessels. All individual sac- a cystic structure beneath the capsule of culations should be opened if possible but the gland. In such instances it is possible to a uniformly dilated duct need not be insert a needle into this duct and make a opened so extensively. Hemostasis should pancreatogram (Fig. 1), to serve as a guide be obtained by individual suture ligature for subsequent operation. as recommended by Puestow and Gillesby. If the duct cannot be located by palpa- A Roux Y loop of jejunum is then brought tion, removal of a small transverse ellipse up in a retrocolic fashion. The end of the of tissue from the body of the pancreas will loop is beveled and the antimesenteric serve to expose the duct (Fig. 2b). This border is split for a sufficient distance to can then be injected by needle or can- cover the opened pancreatic duct like a nulated with a fine polyethylene catheter roof. Anastomosis is performed to the cap- Annals of Surgery 1040 PARTINGTON AND ROCHELLFV December 1960 sule of the pancreas on either side of the formed previously for ulcer. There was opened duct, in two layers if possible. The x-ray evidence of calcification either of the outer layer should be of nonabsorbable su- head of the pancreas or diffusely through- ture. The direction of the free end of the out the gland in four. The pancreatic duct jejunal loop is toward the tail of the pan- was dilated to from 8 to 20 mm. in four. All creas to minimize angulation (Fig. 2c). patients had had multiple attacks of pan- creatitis with serum amylase levels ranging Surgical Results from 530 to 3,320 Somogyi units. In the two A small group of seven patients was in whom the duct was relatively normal in treated by this modified Puestow procedure size at operation, there had been prolonged between August 1958 and October 1959. elevation of the serum amylase ranging All patients were men between the ages from 1,400 to 2,800. A third patient had a of 32 and 48 years. Three were negro and cavity 4 x 2 x 2 cm. in the body of the four were white. All but one were severe pancreas which contained pancreatic juice alcoholics, three having delerium tremens under pressure in spite of no gross demon- while in the hospital. All of the patients had strable connection with the major pancreatic normal gallbladders by x-ray or direct ob- duct. The patient who maintained the high- servation at operation, but five of the seven est amylase values had developed massive had moderate to severe narrowing of the bilateral pleural effusions of almost pure pancreatic portion of the common duct pancreatic juice and eventually a broncho- with proximal dilatation. This had previ- pleural fistula associated with a 60-pound ously been treated by sphincterotomy in weight loss. three, cholecystojejunostomy en Roux Y in Postoperatively, the most striking observa- one, and cholecystoduodenostomy in one in tion was the immediate relief of pain. This whom a subtotal gastrectomy had been per- was so marked in a few cases that the pa- FIG. 4. Operative pan- creatogram performed through a needle show- ing multiple areas of sac- cular dilatation and no communication with the duodenum. Volume 152 RETROGRADE DRAINAG'JlE OF PANCREATIC DUCT Number 6 1041 tients required no narcotics for the ordinary x-ray studies revealed large esophageal postoperative wound discomfort. In three pa- varices. At reoperation, pressures measured tients, however, there was a recurrence of the in an omental vein and in a jejunal arcade old type of pain during the brief period of averaged 350 mm. of saline and spleno- follow up. One of these recurrences was portagrams showed an extrahepatic block quite mild and was readily relieved by hypo- with marked narrowing of the splenic, su- dermic injections of saline. In one patient, perior mesenteric and proximal portal veins a mild recurrence was followed by an at- in the region of the pancreas.
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