Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Abstract

Chronic pancreatitis is a progressive fibrosis of the pancreas that leads to loss of endocrine and exocrine function. The most common symptom in this disease is intractable pain. The etiology of pain in chronic pancreatitis is not clearly understood. However, many of these patients have dilated ducts consisting of saccular dilations and intervening constructions referred to as the "chain of lakes" phenomenon. These patients can be diagnosed with either endoscopic retrograde cholangiopancreatography (ERCP) or computed tomography (CT). These patients are best treated by the Partington Rochelle modification of the Puestow Procedure otherwise known as lateral pancreaticojejunostomy. Overall pain relief in published studies occurs in 50-90% of patients. Another proposed advantage of the lateral pancreaticojejunostomy is preservation of endocrine and exocrine pancreatic function as long as the pancreas is not further damaged by alcohol.

Diagnosis and management of pancreaticopleural fistula

“…(15) First described by Partington and Rochelle, the modified Puestow procedure is, in brief, a lateral pancreaticojejunostomy that involves side-to-side anastomosis of a longitudinal opening in the jejunum to a longitudinally opened PD. (27) The original Puestow procedure included splenectomy, distal pancreatectomy and longitudinal opening of the main PD with insertion of the pancreas into a Roux-en-Y limb of the jejunostomy, which then acts as a sleeve around the pancreas. (27) The Partington and Rochelle modification obviated the need for removal of the spleen and distal pancreas, and achieved extended drainage of the PD, which was not possible with the original Puestow procedure, where the proximal PD was left undrained because the jejunum could not be brought past the superior mesenteric vessels.…”

“…(27) The original Puestow procedure included splenectomy, distal pancreatectomy and longitudinal opening of the main PD with insertion of the pancreas into a Roux-en-Y limb of the jejunostomy, which then acts as a sleeve around the pancreas. (27) The Partington and Rochelle modification obviated the need for removal of the spleen and distal pancreas, and achieved extended drainage of the PD, which was not possible with the original Puestow procedure, where the proximal PD was left undrained because the jejunum could not be brought past the superior mesenteric vessels. (27) One of the key proposed advantages of Puestow and other drainage procedures over resection procedures is the preservation of pancreatic tissue, and hence, exocrine and endocrine functions of the pancreas.…”

Has the Partington procedure for chronic pancreatitis become a thing of the past? A review of the evidence

“…The results of the Partington procedure in patients with chronic pancreatitis are summarized in Table 1 [3,[11][12][13][14][15][16][17][18][19][20]. This procedure relieves chronic abdominal pain in 66-91% of patients with a mean follow-up of 3.5-9.1 years.…”

“…It is very important to note that the Partington procedure is used for inflammatory disease left of the gastroduodenal artery and specifically not used as the procedure of choice for inflammatory disease of the head of the pancreas. For the inflammatory pancreatic head mass, extended drainage procedures such as the original Frey procedure [6], minimum Frey procedure [26] and extended LPJ [3,25] should be employed.…”

“…The two approaches were founded on differing pathophysiological theories of the etiology of the pain. Proponents of drainage procedures such as the lateral pancreaticojejunostomy (LPJ), which is also known as the modified Puestow procedure or Partington procedure, insist that decompressing the affected ductal system suffices, whereas proponents of resectional procedures such as pancreaticoduodenctomy insist that removing the portion of pancreas with affected neural tissue, especially the pancreatic head, is mandatory because the pancreatic head is a pacemaker in chronic pancreatitis [3].…”