CASE REPORT – OPEN ACCESS

International Journal of Case Reports 15 (2015) 85–88

Contents lists available at ScienceDirect

International Journal of Surgery Case Reports

journa l homepage: www.casereports.com

“Puestow modified procedure in the era of advanced endoscopic

interventions for the management of chronic lithiasic pancreatitis. A two cases report”

a,∗,1 a,1 a,1 a,1

Georgios P. Fragulidis , Antonios Vezakis , Dionissios Dellaportas , Ira Sotirova ,

b,2 a,1 a,1

Vassilis Koutoulidis , Elliseos Kontis , Andreas Polydorou

a

2nd Department of Surgery, Aretaieio Hospital, University of Athens, Medical School, Athens, Greece

b

1st Department of Radiology, Aretaieio Hospital, University of Athens, Medical School, Athens, Greece

a r t i c l e i n f o a b s t r a c t

Article history: INTRODUCTION: calculi in (CP) patients are the main cause of

Received 23 May 2015

intractable pain which is their main symptom. Decompression options of for the main pancreatic duct

Received in revised form 14 August 2015

are both surgical and advanced endoscopic procedures.

Accepted 14 August 2015

PRESENTATION OF CASES: A 64-year-old male with known CP due to alcohol consumption and a 36-year-

Available online 20 August 2015

old female with known idiopathic CP and pancreatic duct calculi were managed recently in our hospital

where endoscopic procedures were unsuccessful. A surgical therapy was considered and a longitudinal

Keywords:

pancreaticojejunostomy (modified Puestow procedure) in both patients was performed with excellent

Modified Puestow procedure results.

Partington-Rochelle procedure

DISCUSSION: Over the last 30 years, endoscopic procedures are developed to manage pancreatic duct

Chronic lithiasic pancreatitis

Surgical treatment strictures and calculi of the main pancreatic duct in CP patients. In both of our cases endoscopic therapy

Pancreatic duct calculi was first attempted but failed to extract the pancreatic duct stones, due to their size and speculations.

Endoscopy Modified Puestow procedure was performed for both and it was successful for long term pain relief.

CONCLUSION: Despite advancement in endoscopic interventions and less invasive therapies for the man-

agement of chronic lithiasic pancreatitis we consider that classic surgical management can be appropriate

in certain cases.

© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open

access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction 2. Methods – surgical approach

Chronic pancreatitis (CP) is a chronic inflammatory disease of A modified Puestow procedure (lateral pancreaticojujenos-

the pancreatic parenchyma and is commonly caused by alcohol tomy) was performed in both patients. Partington and Rochelle

consumption. Up to 90% of CP patients develop calcifications of the introduced the modification of Puestow procedure in 1960 [3]. The

pancreatic duct during long-term follow-up [1]. Pancreatic duct cal- following modification is the elimination of the resection of the

culi cause upstream obstructive phenomena and result in increased pancreatic tail and therefore did not require distal ,

pressure of the pancreatic parenchyma, ischemia and can lead to splenectomy, or mobilization of the from its retroperi-

abdominal pain [2]. Both surgical drainage and endoscopic pro- toneal attchments. Briefly, after a bilateral subcostal incision, the

cedures are options in the multidisciplinary treatment plan. With gastrocolic ligament is dissected and divided for the exposure of

the opportunity of two patients with Chronic Lithiasic Pancreatitis the entire anterior surface of the pancreas and to trace the pan-

(CLP) treated in our hospital where endoscopic procedures failed creatic duct. A needle-tip electrocautery and a tonsil clamp are

and were finally surgically managed, the main considerations in used to make a long longitudinal opening of the duct to ensure

patients with CLP are highlighted. full decompression. After the removal of ductal calculi and con-

cretions, resected or cored out pancreatic parenchyma should be

sent for frozen section to rule out occult malignancy. Next, a 50 cm

Roux-en-Y limb is constructed and the is divided 20–30 cm

∗

Corresponding author at: G.P.Fragulidis MD, PhD, 2nd Department of Surgery

distal to the ligament of Tretz. Subsequently, a side-to-side jejuno-

Aretaieio Hospital, University of Athens Medical School, 76, Vas. Sophias Ave., 11528,

is performed between the proximal jejunum and the

Athens, Attica, Greece. Fax: +30 210 72 86 128.

E-mail addresses: [email protected], [email protected] (G.P. Fragulidis). distal part of the Roux limp. Then the proximal Roux-en-Y limp is

1

76, Vas. Sophias Ave., Aretaieio Hospital, Athens, 115 28, Attica, Greece. passed retrocolic and positioned next to the lateral opening of the

2

76, Vas. Sophias Ave., Aretaieio Hospital, Athens, 115 28, Attica, Greece.

http://dx.doi.org/10.1016/j.ijscr.2015.08.025

2210-2612/© 2015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

CASE REPORT – OPEN ACCESS

86 G.P. Fragulidis et al. / International Journal of Surgery Case Reports 15 (2015) 85–88

Fig. 3. Abdominal c/t scan showing multiple calculi into the pancreatic duct.

Fig. 1. MRCP showing dilated pancreatic duct (arrow) and multiple large pancreatic

calculi.

pancreatic duct. An enterotomy is made along the antimesenteric

border of the jejunal loop, slightly shorter than the length of the

duct incision as the intestine will stretch. We performed the pan-

creaticojejunal anastomosis with a single layer of a running 4–0

absorbable suture between full thickness small bowel and pancre-

atic duct, though that the pancreatic stitch might include a small

portion of the transected parenchymal edge. Yet, if the pancreatic

parenchyma is indurated the pancreatic stitches can be attained

directly to the pancreas. Fig. 4. A plastic 5F stent placed into the main pancreatic duct on a plain abdominal

X-ray.

3. Presentation of case #1

A 64-year-old male with known CP due to alcohol consumption 4. Presentation of case #2

was admitted to our hospital complaining of intractable pain after

meals. MRCP showed a dilated pancreatic duct measuring 9 mm in A 36-year-old female with known idiopathic chronic pancre-

diameter and multiple large pancreatic calculi (Fig. 1). Attempts for atitis was admitted for the management of main and secondary

stone extraction via ERCP failed twice due to the size of the stone pancreatic duct enlargement due to multiple pancreatic duct

and the inability to catheterize proximal to that obliterating cal- stones. Multiple pancreatic duct calculi were known for the last

culi. Patient underwent a lateral pancreaticojejunal anastomosis three years (Fig. 3) managed unsuccessfully with ERCP and multiple

after stone extraction and confirmation of pancreatic duct clear- stenting of the main pancreatic duct with 5F plastic stents (Fig. 4).

ance of calculi duct up to Vater’s ampulla (Fig. 2a and b). The patient She underwent lateral pancreaticojejunal anastomosis after pan-

had an uneventful postoperative course and twelve months post creatic duct clearance of calculi and (Fig. 5). The

surgery he remains pain free avoiding also alcohol consumption patient had an uneventful course and remains symptom free for

after psychiatric consultation. the last three years.

Fig. 2. (a) Intraoperative view of a longitudinally open pancreatic duct after removal of the intraductal calculi, and (b) of the pancreaticojejunal anastomosis.

CASE REPORT – OPEN ACCESS

G.P. Fragulidis et al. / International Journal of Surgery Case Reports 15 (2015) 85–88 87

explain why pancreatic stones imply difficulties for extraction.

Endoscopic stone removal is successful in 50% of cases with stan-

dard techniques [7].

Extracorporeal shock wave (ESWL) points to frag-

mentation of large stones in smaller pieces in order to be removed

with standard ERCP techniques afterwards. With the adjunct of

ESWL, endoscopic therapy is reported successful in up to 90% of

cases. In a retrospective study by Tandan et al., the authors conclude

that ESWL should be offered as the first-line therapy in patients

who have duct stones confined to the head, genu, and body regions

of the pancreas and those who do not have concomitant multiple

pancreatic duct strictures especially in young patients with chronic

CP [8].

On the other hand, proponents of surgical therapy highlight

that surgery results in opening of the pancreatic capsule, which

alleviates interstitial pressure, whereas longitudinal anastomo-

sis ensures full drainage of the whole pancreatic duct length.

Moreover, endoscopic stenting of the main pancreatic duct may

interfere with secondary ducts clearance, or even make things

worse [9]. The decision for surgical therapy depends on many

factors: pancreatic duct diameter, duct strictures, pain severity

indexes, malignancy concerns, associated biliary duct obstruc-

tion and operative risk. Resection, drainage and decompression,

Fig. 5. Intraductal pancreatic calculi removed. or denervative and combination procedures have been described.

Regarding surgical treatment, lateral pancreaticojejunostomy or

modified Puestow procedure is the most common and well-studied

5. Discussion surgical technique for such cases [10]. It is successful in CLP without

an inflammatory mass in the head of the pancreas for pain relief

The formations of stones in CP are caused by the crystalliza- in 90% of patients and is suited for pancreatic ducts >8 mm [11].

tion and deposition of calcium carbonate as long as alcohol and CP Pancreatic leak is low (0.03–5%) in appropriate selected patients

cause hypersaturation of pancreatic juice with calcium with stones with a fibrotic gland [10]. Postoperative mortality rate and disease

formation. Over the last 30 years, endoscopic procedures are devel- incidence of patients who underwent the Partington–Rochelle pro-

oped to manage pancreatic duct strictures and calculi of the main cedure were lower than among those who had the original Puestow

pancreatic duct in CP patients. Small stones can be extracted using procedure, at approximately 3% and 20%, respectively [12,13].

various endoscopic techniques such as balloon or basket sweeping. Nevertheless, this is a debatable issue and there are data to sup-

Larger and impacted stones typically require lithotripsy or surgery. port all the various procedures for surgical drainage for chronic

The diagnosis of CP is set by clinical means and imaging modal- lithiasic pancreatitis. Pancreatic head resections with drainage pro-

ities. On plain X-ray pancreatic calcifications are detected in 30% cedures (Beger, Berne, and Frey) have all been proven to be equally

of CP patients [4]. Abdominal ultrasound has limited value, but effective in terms of morbidity, mortality, and improvement of pain

computed tomography (CT) scan provides detailed imaging of symptoms in small, randomized controlled trials [10].

pancreatic stones. Endoscopic retrograde cholalangiopancreatog- Two RCTs have addressed the controversy whether endoscopic

raphy (ERCP) and magnetic resonance cholalangiopancreatography or surgical treatment is superior in patients with obstructive

(MRCP) are valuable adjunct to the evaluation of the exact location chronic pancreatitis [14]. Dite et al. reported for the first time that

of the calculi and duct system anatomy. Moreover, ERCP may be surgery is superior to endotherapy for long-term pain reduction

therapeutic, if the stones are extracted. and gain in body weight [5]. Cahen and colleagues showed that

Initial conservative measures for CP patient’s management are compared with endoscopic drainage, lateral pancreaticojejunos-

low fat diet, oral pancreatic enzymes supplementation, and simple tomy has the advantage of providing improvement of quality of

analgesics, and of course alcohol usage cessation. By these means life and pain relief, while patients receiving endoscopic treatment

stones are not resolved but at least stop increasing in size, while required additionally procedures [9]. Furthermore, at long-term

cholecystokinin stimulation is reduced, and as a result the pain is follow-up of up to 7 years, the authors also reported that 47% of

controlled as well. Trimethadione is reported to cause stone disso- endoscopically treated patients eventually underwent surgery and

lution, but hepatotoxicity issues make that option not applicable in confirm that surgery is the preferred treatment in symptomatic

most cases. patients with advanced chronic pancreatitis [15]. Nevertheless,

In older randomized trials is demonstrated that surgical ther- a subgroup of patients in both RCTs representing about 30% of

apy turns to have more durable results and results in pain relief for the study population do seem to profit, even in long term, from

longer intervals [5]. Today, due to further development of endo- endoscopic treatment alone [14]. Endoscopic therapy was first

scopic techniques, endoscopic therapy is usually the first preferred attempted in both of our cases but failed to extract the pancreatic

option because of less invasiveness. Balloon or basket sweep- duct stones due to their size and speculations. Modified Puestow

ing, pancreatic sphincterotomy, pancreatic stricture dilation and procedure was performed for both and it was successful for long-

intraductal lithotripsy are the various endoscopic techniques that term pain relief.

are implemented in such cases. Positive response to endoscopic

treatment is a predictor of good surgical results when operative

approach is administered in the course of the disease [6]. Endo- 6. Conclusion

scopic stone removal is attempted when upstream pancreatic duct

dilatation is present. However, pancreatic stones are harder and Patients with CLP are difficult to manage and multidisciplinary

speculated in comparison to stones and these features approach should be introduced. Endoscopic therapy is always the

CASE REPORT – OPEN ACCESS

88 G.P. Fragulidis et al. / International Journal of Surgery Case Reports 15 (2015) 85–88

first choice, but despite advances and expertise, surgical options [2] D.K. Bhasin, S.S. Rana, R.S. Sidhu, B. Nagi, B.R. Thapa, U. Poddar, et al., Clinical

presentation and outcome of endoscopic therapy in patients with

are invaluable and maybe more advantageous in time.

symptomatic chronic pancreatitis associated with pancreas divisum, JOP 14

(2013) 50–56.

Conflict of interest [3] P.F. Partington, R.E. Rochelle, Modified Puestow procedure for retrograde

drainage of the pancreatic duct, Ann. Surg. 152 (1960) 1037–1043.

[4] G.A. Cote, J. Smith, S. Sherman, K. Kelly, Technologies for imaging the normal

None.

and diseased pancreas, Gastroenterology 144 (2013) 1262–1271 e1.

[5] P. Dite, M. Ruzicka, V. Zboril, I. Novotny, A prospective, randomized trial

Funding comparing endoscopic and surgical therapy for chronic pancreatitis,

Endoscopy 35 (2003) 553–558.

[6] G.H. Elta, Is there a role for the endoscopic treatment of pain from chronic

None. pancreatitis? N. Engl. J. Med. 356 (2007) 727–729.

[7] D.G. Adler, J.D. Conway, F.A. Farraye, S.V. Kantsevoy, V. Kaul, S.R. Kethu, et al.,

Biliary and pancreatic stone extraction devices, Gastrointest. Endosc. 70

Ethical approval

(2009) 603–609.

[8] M. Tandan, D.N. Reddy, R. Talukdar, K. Vinod, D. Santosh, S. Lakhtakia, et al.,

Long-term clinical outcomes of extracorporeal shockwave lithotripsy in

Yes patients approval has been given.

painful chronic calcific pancreatitis, Gastrointest. Endosc. 78 (2013) 726–733.

[9] D.L. Cahen, D.J. Gouma, Y. Nio, E.A. Rauws, M.A. Boermeester, O.R. Busch, et al.,

Consent Endoscopic versus surgical drainage of the pancreatic duct in chronic

pancreatitis, N. Engl. J. Med. 356 (2007) 676–684.

[10] E.P. Ceppa, T.N. Pappas, Modified puestow lateral pancreaticojejunostomy, J.

Patient consent has been obtained.

Gastrointest. Surg. 13 (2009) 1004–1008.

[11] B.N. Liu, T.P. Zhang, Y.P. Zhao, Q. Liao, M.H. Dai, H.X. Zhan, Pancreatic duct

stones in patients with chronic pancreatitis: surgical outcomes, Hepatobiliary

Author contributions

Pancreat. Dis. Int. 9 (2010) 423–427.

[12] K. Bachmann, A. Kutup, O. Mann, E. Yekebas, J.R. Izbicki, Surgical treatment in

G.P. Fragulidis: study concept and design, drafted the chronic pancreatitis timing and type of procedure, Best Pract. Res. Clin.

Gastroenterol. 24 (2010) 299–310.

manuscript writing the paper, revised the manuscript.

[13] Q. Ni, L. Yun, M. Roy, D. Shang, Advances in surgical treatment of chronic

A. Vezakis: contributor.

pancreatitis, World J. Surg. Oncol. 13 (2015) 34, http://dx.doi.org/10.1186/

D. Dellaportas: literature review, writing the draft. s12957-014-0430-4.

I. Sotirova: participated in the care of the patient, assisted in the [14] J.G. D’Haese, G.O. Ceyhan, I.E. Demir, E. Tieftrunk, H. Friess, Treatment options

in painful chronic pancreatitis: a systematic review, HPB (Oxford) 16 (2014) literature review.

512–521, http://dx.doi.org/10.1111/hpb.12173.

V. Koutoulidis: participated in diagnosis and collection of radi-

[15] D.L. Cahen, D.J. Gouma, P. Laramee, Y. Nio, E.A. Rauws, M.A. Boermeester,

ology figures. et al., Longterm outcomes of endoscopic vs. surgical drainage of the

pancreatic duct in patients with chronic pancreatitis, Gastroenterology 141

E. Kontis: revised the manuscript.

(2011) 1690–1695.

A.A. Polydorou: final manuscript revision.

All authors read and approved the final manuscript. All authors

agree to publication if the paper is accepted and declare no conflicts

of interest, sources of funding.

Guarantor

GP Fragulidis MD, PhD.

References

[1] R.W. Ammann, Diagnosis and management of chronic pancreatitis: current

knowledge, Swiss Med. Wkly. 136 (2006) 166–174.

Open Access

This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which

permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.