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Laparoscopic Longitudinal Pancreaticojejunostomy for Chronic Pancreatitis JOP. J Pancreas (Online) 2015 Sep 08; 16(5):438-443. REVIEW ARTICLE Laparoscopic Longitudinal Pancreaticojejunostomy for Chronic Pancreatitis Tamotsu Kuroki, Susumu Eguchi Department of Surgery, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan ABSTRACT function. Pancreatic ductal drainage is one of the most important factors for the management of chronic pancreatitis. A longitudinal pancreaticojejunostomyChronic pancreatitis is ischaracterized a simple and byradical severe surgical abdominal treatment pain for and pancreatic progressive ductal insufficiency drainage. However, of pancreatic in recent endocrine/exocrine years laparoscopic pancreatic procedures have developed rapidly, and reports concerning laparoscopic pancreatic resection including laparoscopic longitudinal for chronic pancreatitis compared with conventional open surgery are unclear. In this review, we note that laparoscopic longitudinal pancreaticojejunostomy ishave a technically increased feasible, in number. safe and Nevertheless, effective surgical the benefits procedure of inlaparoscopic selected patients longitudinal with chronic pancreaticojejunostomy pancreatitis. INTRODUCTION Laramée et al. [22] found that surgical drainage treatment was highly cost-effective compared to endoscopic In patients with chronic pancreatitis, severe recurrent drainage treatment for patients with obstructive chronic pancreatitis. debilitatingabdominal [1–7].pain Theand elevated functional pressure endocrine/exocrine in the pancreatic Laparoscopic surgery was proposed as a minimally ductsinsufficiency due to ofthe the obstruction pancreas are of commonthe pancreatic and frequently ducts is one of the main causes of the severe abdominal pain [8– of the pancreatic surgery [23–27]. Longitudinal 10]. The combination of the ductal decompression and pancreaticojejunostomyinvasive alternative surgical is a procedurecommon andin thesuitable field continuous drainage using a surgical procedure or an surgical procedure to treat chronic pancreatitis patients endoscopic approach comprise the basis for the treatment with an obstructed and dilated main pancreatic duct of patients with chronic pancreatitis [11–14]. With the [28–32]. Many studies of limited series of laparoscopic recent development of various endoscopic instruments longitudinal pancreaticojejunostomy for the management of chronic pancreatitis have been reported [33–43], but the evaluations of the laparoscopic longitudinal [15–19].and techniques, However, endoscopic the authors treatment of twocan nowstudies be usedthat pancreaticojejunostomy procedure have been limited and comparedas a first-line endoscopic medical and option surgical for treatmentschronic pancreatitis of chronic controversial. In this review, we discuss the current status pancreatitis patients reported that surgical treatment was of laparoscopic longitudinal pancreaticojejunostomy for more effective than endoscopic treatment [20, 21]. In a chronic pancreatitis. prospective randomized trial, Dite et al. [20] observed that OPERATIVE TECHNIQUE surgical treatment was superior to endoscopic treatment for long-term pain reduction in patients with painful Laparoscopic trocars position of laparoscopic obstructive chronic pancreatitis. Cahen et al. [21] also longitudinal pancreaticojejunostomy is about the same with laparoscopic distal pancreatectomy. We used were demonstrated by more rapid, effective, and sustained (Figure 1). Severe adhesion between the painreported relief that compared the benefits to endoscopic of a surgical treatment. drainage In procedure addition, posterior wall of the stomach and the anterior surface of thefive pancreastrocars is often observed in patients with chronic pancreatitis. Such adhesion has been released with the Received June 28th, 2015-Accepted July 29th, 2015 use of several laparoscopic devices including laparoscopic Keywords Minimally Invasive Surgical Procedures; coagulating shears (SonoSurg; Olympus, Tokyo), a Pancreaticojejunostomy; Pancreatitis, Chronic Correspondence Tamotsu Kuroki vessel-sealing instrument (LigaSure; Covidien, Norwalk, Department of Surgery CT), and an ultrasonically activated scalpel (Harmonic Graduate School of Biomedical Sciences ACE; Ethicon, Cincinnati, OH). In these procedures, it is Nagasaki University, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan Phone +81-95-819-7316 Fax +81-95-819-7319 E-mail [email protected] ofimportant the pancreas, to obtain the stomacha sufficient is tapedworking using space sutures and ensurein two an adequate laparoscopic view. To maintain the exposure JOP. Journal of the Pancreas - - Vol. 16 No. – 2015. [ISSN 1590-8577] http://pancreas.imedpub.com/ 5 Sep 438 JOP. J Pancreas (Online) 2015 Sep 08; 16(5):438-443. Figure 2. abdominal Towall. maintain the exposure of the pancreas, the stomach is taped using sutures in two places, and then the stomach is fixed to the Figure 1. Placement of the five trocars. wall. We called this method of retraction of the stomach theplaces, “stomach-hanging and then the stomachmethod” is(Figure fixed to2) [44].the abdominal It is often at the pancreatic tail. In this case, we used an endoscopic surgicaldifficult tospacer secure (Securea; an adequate Hogy laparoscopic Medical Co., surgical Tokyo) field to make the surgical space with appropriate isolation of the stomach and mesocolon without grasping organs [45]. In the longitudinal pancreaticoduodenectomy procedure for chronic pancreatitis, the main pancreatic A duct is opened wide for complete drainage of the main pancreatic duct. To identify the main pancreatic duct, a thin needle such as a lumbar puncture needle is useful [36, 37]. aspirating pancreatic juice. Laparoscopic ultrasound also helps to identifyThe main the dilatedpancreatic main pancreaticduct is confirmed duct [43]. byIn addition, ultrasound is a useful tool for detection of the laparoscopic ultrasound probe (Hitachi Aloka, Ltd., Tokyo) (Figurespancreatic 3a, stones b). Pancreatic in the pancreatic stones cause duct. Wethe usedobstruction a flexible of the main pancreatic duct and then cause the elevation of the pressure in the main pancreatic duct. The removal of the pancreatic stones is necessary to release the elevated pressure in the main pancreatic duct. Usually, the pancreatic stones are removed under direct vision using laparoscopic grasping forceps. Sahoo et al. [43] reported that an endoscopic retrograde cholangiopancreatography basket viewed under a cystoscope was useful to remove leftover pancreatic stones in both the pancreatic head and tail end during a laparoscopic longitudinal pancreaticojejunostomy. B InHowever, fact, Tantia the identification et al. [36] reportedof the main that pancreatic four patients duct under laparoscopic guidance is unexpectedly difficult. Figure 3. (a.). Laparoscopic ultrasound is useful to identify the dilated procedures the main pancreatic duct could not be isolated pancreatic stones. (b.). Intraoperative laparoscopic ultrasound showing laparoscopically.required conversion to open surgery, and in three of these amain dilated pancreatic main pancreatic duct, ductal duct andstrictures, a pancreatic pancreatic stone. calcification, and JOP. Journal of the Pancreas - - Vol. 16 No. – 2015. [ISSN 1590-8577] http://pancreas.imedpub.com/ 5 Sep 439 JOP. J Pancreas (Online) 2015 Sep 08; 16(5):438-443. Khaled et al. [42] reported that the diameter of serious complications after pancreatic surgery [49– undergone a complete laparoscopic longitudinal 51].Pancreatic We suspected fistula isthat one a oflaparoscopic the most commonlongitudinal and pancreaticoduodenectomythe main pancreatic duct wasin five6–11 patients mm. Theywho alsohad pancreaticojejunostomy for chronic pancreatitis would noted that the use of laparoscopic ultrasound facilitated et for chronic pancreatitis. Glaser et al. [35] reported the al. [37] reported that a good candidate diameter of the userequire of a alaparoscopic long operative linear time, stapler but thisdevice procedure in laparoscopic is safer mainthe identification pancreatic ductof the for pancreatic a laparoscopic duct. Palanivelulongitudinal longitudinal pancreaticojejunostomy. Anastomosis using a laparoscopic linear stapler is a familiar procedure for Sahoo et al. [43] reported that all 12 of their patients showedpancreaticoduodenectomy a diameter of more wasthan approx. 14 mm. 10 mm or larger. is simple, easy and useful when the main pancreatic duct the drainage of the pancreatic pseudocyst. This technique stones or stenosis of the main pancreatic duct. brought to the lesser sac via the retrocolic route. A side-to- is extremely dilated and there are no residual pancreatic sideIn longitudinal most cases, pancreaticojejunostomya Roux loop of jejunum is isfashioned reconstructed and is OPERATIVE OUTCOMES laparoscopically using a single layer of continuous The main published series of laparoscopic longitudinal or interrupted sutures. The pancreaticojejunostomy pancreaticojejunostomy for chronic pancreatitis are should cover nearly the entire length of the dilated main listed in Table 1. A total of 60 patients in the 11 available reports are featured in this review. Conversion to open pancreaticojejunostomy presents the risk of obstructing thepancreatic pancreaticojejunostomy, duct; otherwise, the and insufficient this result length causes of the conversion was an inability to detect the main pancreatic recurrence of the severe pancreatic pain post-surgery. We ductsurgery under was laparoscopic required in fiveguidance patients in (8%).three
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