Current Status of Pancreatojejunostomy in the Management of Chronic Pancreatitis George L. Jordan, Jr, MD, Houston, Texas Burt S. Strug, MD,* Houston, Texas William E. Crowder,? Houston, Texas
Obstruction of the pancreatic duct may be a factor in the production of pancreatic pain. About thirty years ago, Cattell [I] advocated decompression of the pancreatic duct obstructed by carcinoma as a palliative procedure. Subsequently, this concept was applied to the treatment of patients with chronic pancreatitis. DuVal[2] in 1954 advocated resection of the tail of the pancreas and a caudal pancreatojejunostomy Roux-en-Y to decompress the pancreatic duct and thus relieve symptoms. Subsequently, because obstructions of the pancreatic duct in chronic pancreatitis were frequently multiple, Puestow and Gillesby [3] modified this procedure making a longitudinal incision into the pancreatic duct from the tail of the pancreas to the region of the gastroduodenal artery to incise all strictures and to remove calculi. The pancreas was freed from surrounding structures and inserted into a loop of jejunum, Roux-en-Y, or a side-to-side pancreatojejunostomy Roux-en-Y was constructed. Partington and Rochelle [4] as well as Thal [5] modified the side-to-side technic to avoid the necessity for splenectomy. A number of other technics of pancreatojejunostomy and pancreatogastrectomy have been employed, including a smaller side-to-side pancreatojejunostomy in the midportion of the duct and a “split” pancreatojejunostomy in which the pancreas is partially divided and an anastomosis made to the two transected ends of the ductal system [WI]. After an initial wave of enthusiasm for these procedures, some reports indicated a high incidence of recurrence of disease.
From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine and the Ben Taub General, Methodist, St. Luke’s Episcopal and Veterans Administration Hospitals, Houston, Texas. Reprint requests should be addressed to George L. Jordan, Jr, MD, Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas 77025. Presented at the Seventeenth Annual Meeting of the Society for Surgery of the Alimentary Tract, Miami Beach, Florida, May 25-26, 1976. * Present address: 3600 Prytonia, New Orleans, Louisiana 76115. t Present address: 4374 Robbins Street, San Diego, California 92122.
46
The total experience with these procedures is limited, there being less than 150 cases of any one of the previously mentioned technics of pancreatojejunostomy with long-term follow-up studies in the American literature. To add to the body of information, we have reviewed our experience with thirty patients during follow-up periods up to twenty years. Clinical Features There were twenty-two males and eight females of whom seventeen were white and thirteen were black. They ranged in age from twenty-five to sixty years (median, 35 years). All had severe pancreatitis over a prolonged period of time. In the majority of patients specific etiologic factors could
F/gure 7. The technk of caudal pancreatojejwnwtomy.
The American Journal of Surgery
Pancreatojejunostomy
Figure 2. The technic of longitudinal pancreatojejmostomy used in one patient. The pancreatic duct is incised: the pancreas is freed from surroundb8g structures and anastomosedtoaR~x~-Yloopa~lnsertknofthebwlyand tall into the #unum. be identified. Twenty-three patients were alcoholics, one had cholelithiasis, one had pancreatitis following trauma, and in five patients pancreatitis was classed as idiopathic. Two of the patients with alcoholic pancreatitis also had gallstones and one had hyperlipemia. All patients had pain. Other features included weight loss in eleven patients, diabetes in five, steatorrhea in five, jaundice in two, and ascites in one. Pathologic features found at operation included severe fibrosis in all patients. There was definite dilatation of the duct of Wirsung in twenty-six patients with demonstrable ductal strictures in twenty-five. Ductal stones were present in thirteen. Retention cysts were present in two, and in two there was no ductal pathology* Caudal pancreatojejuncetomy as described by DuVal[2] was utilized in six patients. (Figure 1.) A longitudinal pancreatojejunostomy as described by Puestow and Gillesby [3] with insertion of the pancreas into a loop of jejunum was utilized in only one patient while the modification of this procedure described by Thal [5] was utilized in twenty-three. (Figures 2 and 3.) Associated procedures were performed in twenty patients, including resection of the tail of the pancreas in sixteen. This was performed in all six of the patients having the DuVal procedure as a standard part of the operation. In thirteen of the twentyfour patients having longitudinal pancreatojejunostomy, amputation of the tail of the pancreas was performed as an aid in identifying the pancreatic duct. In the other patients
Volume 133, January 1977
Figure 3. The technic of side-to-side longitudinal pancreatojemy used in twenty-t/wee pat/en&. The inserf shows detail of the two layer anastomosis. the dilated duct was palpable, and it was identified by aspirating with a needle, or by a direct incision into the pancreas over the anatomic region of the duct. Sphincteroplasty was accomplished in three patients and in one patient with jaundice there was exploration of the common bile duct with T-tube drainage.
Results There directly
was no operative related
mortality.
to the operative
in 10 per cent of patients.
There
Complications
procedure
occurred
were two pancreatic
fistulas and one wound abscess. One of the pancreatic
fistulas required an operation for better drainage, but both fistulas ultimately closed spontaneously on conservative management. Thus, all patients were discharged from the hospital with full recovery from the operation. Although there was a variety of deficiency syndromes, as indicated previously, the primary purpose for operation was the relief of chronic pain or the interruption of recurrent acute of subacute attacks of pancreatitis. Thus, the results are predicated on evaluation of achievement of this goal. An “excellent” result indicates complete relief of pain and absence of attacks of pancreatitis. Patients classed as “improved” had partial relief of symptoms evidenced by decrease in the pain problem or severity and frequency of recurrent attacks. The term “improved” is used also for patients who had periods as long as
47
Jordan, Strug, and Crowder
TABLE
I
Comparison 2 Technics Chronic
of Early and Late Results after of Pancreatojejunostomy
and Relapsing
for
Pancreatitis
Result Procedure Caudal Early Late Longitudinal Early Late
Improved
Poor
2 1
0 2
4 3
14 9
5 8
5 6
Excellent
two to three years without symptoms during the first five year follow-up period even though they may have had one or two attacks previously or after the asymptomatic period. As all patients had severe problems preoperativejy, early as well as late follow-up studies may be of significance. Early results relate to the patient’s status during the first postoperative year. Late results extend for one to twenty years. The recent status of twenty-eight patients is known. One was lost to follow-up during the second postoperative year and the other during the fifth postoperative year. Early results of patients with caudal pancreatojejunostomies have been previously reported [9]. Two patients had no symptoms during the first year postoperatively and were classed as early excellent results, while the remaining four had recurrent disease and were classed as poor. One of the patients initially classed as excellent had recurrence of symptoms after two years. He has now been followed for 143 months and has had limited difficulty with his disease and, therefore, is classed as improved. A second patient who was classed as an early poor result because of a recurrent disease within one year subsequently had a period of several years’ relief from pancreatic problems and is classed as improved in the late follow-up period. Thus, in the late classification, one patient was worse and one patient improved as compared with the first year. Only one patient, followed four and a half years, is an excellent result (17 per cent), and the incidence of excellent and improved results on a long-term basis is 50 per cent. The shortest follow-up period in this group is forty months. This patient died at that time. The longest follow-up period is 240 months, this patient still being alive. Among this group, three patients, all initially classed as poor results, have died. One died of myocardial infarction, one of alcoholism, and one of pneumonia with survival periods after operation being three and a half, ten, and twelve years and ages at death being twenty-nine, forty-one, and forty-five
48
years, respectively. Thus, half of these individuals died at an early age, with two of the deaths being related to the problems associated with pancreatitis, although none of the deaths were the specific result of progressive pancreatic disease. Among the twenty-four patients undergoing longitudinal pancreatojejunostomy, fourteen were initially classed as excellent, five as improved, and five as poor. Thus, nineteen of the twenty-four (79 per cent) were improved. One patient died suddenly of unknown cause four months postoperatively and is excluded from the long-term results. The follow-up periods in the remaining twenty-three patients range from 12 to 123 months (average, 58 months). At this time, the classification is nine excellent, eight improved, and six poor. Two patients initially listed as having poor results were later put into the improved group because of long periods of freedom from symptoms in the late follow-up period, these patients having been followed for 76 to 116 months, respectively. Five patiepts were dowugraded from the excellent classification. Three were reclassified as good on the basis of long-term follow-up and two reclassified as poor, and one patient originally classified as improved was reclassified as poor on the basis of later follow-up data. (Table I.) Six of the twenty-four patients (25 per cent) have died during the follow-up period. The patient who died during the first postoperative year was classified as an improved early result. The remaining patients died after survival periods of two to six years and in a majority of patients the deaths were directly related to alcoholism, malnutrition, or pancreatitis. The specific causes of death were pancreatitis in three patients, one of whom also had the complication of cirrhosis. The fourth died of hepatic failure and the fifth died of pneumonia, having suffered from severe malnutrition and recurrent pancreatic disease. These patients died at ages ranging from thirty-six to fifty-nine years, and none of those who have died lived a normal life span. Only a third of them have lived past the age of fifty years. Results were tabulated as related to the pathologic condition within the gland. The most significant pathologic factor was the presence of pancreatic calculi. The only patient undergoing the DuVal procedure who had an excellent result in the late postoperative period had pancreatic calculi. Among the patients undergoing longitudinal pancreatojejunostomy, ten of eleven were improved in the early postoperative period, and long-term improvement was observed in eight of ten patients (80 per cent) with ductal stones. Six of these eight remain in the excellent category. Seven of twelve patients (58 per
The American Journal of Surgery
Pancreatojejunostomy
cent) having ductal strictures without stones were improved. Only three of the seven were in the excellent category. The one patient having longitudinal pancreatojejunostomy with no ductal pathology also had an excellent result. The overall incidence of improvement in patients followed for an average of more than five years was 70 per cent (16/23).
Comments A partial review of the recent American literature plus our own data, some of which are not reported, allowed a tabulation of treatment of chronic and relapsing pancreatitis in 1,558 patients [6-8, 10-291. Patients treated for complications of pancreatitis, including pseudocyst formation, abscess, and fistulas, were excluded. (Table II.) The most common procedure employed was resection, including pancreatoduodenectomy, caudal pancreatectomy, and total pancreatectomy. Pancreatojejunostomy was the second most common procedure having been performed in 318 patients (20 per cent); 165 of these 318 patients had undergone longitudinal pancreatojejunostomy. Thus, longitudinal pancreatojejunstomy was employed in only 11 per cent of patients treated for recurrent or chronic pancreatitis reported in the literature and there are as many patients with other types of pancreatojejunostomy. There were only four deaths among the 318 patients, a mortality of less than 2 per cent. It is apparent that this procedure can be accomplished as safely as any of the other procedures commonly employed in the treatment of chronic pancreatitis. It is safer than a major resection. There are few data to document accurately the fate of the anastomosis. How often recurrence of symptoms after initial success is due to stenosis of the anastomosis is not known. It has been stated that after relief of ductal obstruction, there may be improvement of nutrition and there may be regeneration of pancreatic tissue. Although some patients do have nutritional improvement after this operation, it is entirely possible that it is relief of recurrent attacks and improvement of appetite due to relief of pain. We are aware of no patient in our own series who, at autopsy, had evidence of significant improvement in the pathologic changes in the pancreatic parenchyma. Furthermore, we have performed pre- and postoperative metabolic studies in a few patients and these did not demonstrate an improvement in fecal loss of fat and nitrogen in the postoperative period. The number which we have studied, however, is too small to allow any firm conclusions. Most authors, however, have re-
Volume 133, January 1977
TABLE
II
Incidence Chronic Collected
of Various
Procedures
and Relapsing from
for
Pancreatitis
Recent American
Literature Procedure Resection Pancreatojejunostomy Longitudinal Caudal Other Bilary tract procedures Sphincteroplasty Other Total
Number 428 318 165 72 81 279 271 262 1,558
Per Cent 28 20 11 5 5 18 17 17 100
ported a significant number of patients who had diabetes or findings of exocrine insufficiency leading to deficiency syndromes in the postoperative period, even without recurrence of pain. An interesting sidelight has been the difficulty of diagnosis of carcinoma in patients with severe changes in the gland. ‘White and Keith [28] in a report of fifty patients treated by pancreatojejunostomy found that nine of these patients died of carcinoma in the follow-up period, though none had proved carcinoma at the time of surgery. In our own experience, there was one patient who had undergone this procedure who died of carcinoma in the followup period. This patient is not included in this series nor are the other patients reported in the literature included in the tabulation of the following results. The data collected from the literature and the data reported here from our own studies indicate that pancreatojejunostomy is a useful procedure in the treatment of chronic and relapsing pancreatitis when there is ductal stricture or ductal stones and that longitudinal pancreatojejunostomy is somewhat better than caudal pancreatojejunostomy. When one considers the patient population having this type of pancreatitis, 70 per cent good results are most encouraging, for our data on the natural history of alcoholic pancreatitis indicate that only 6 per cent have improvement on nonoperative treatment. Thus, we continue to utilize this procedure as the initial therapy for those patients who have significant ductal disease. Summary Thirty patients with chronic pancreatitis were treated by pancreatojejunostomy, six caudal and twenty-four longitudinal anastomoses. Follow-up data up to twenty years are reported and the early and long-term results compared. There were no
49
Jordan, Strug, and Crowder
deaths. Long-term results with caudal pancreatojejunostomy were 50 per cent excellent or improved and with longitudinal pancreatojejunostomy, 70 per cent excellent or improved. The best results were obtained when intraductal calcification was present. Longitudinal pancreatojejunostomy is recommended as the initial treatment of choice for chronic pancreatitis in patients with ductal obstruction, particularly when calcification is present. References 1. Cattell RB: Anastomosis of the duct of Wirsung. Surg C/in North Am 27: 636, 1947. 2. DuVal MK Jr: Caudal pancreatojejunostomy for chronic relapsing pancreatitis. Ann Surg 140: 775, 1954. 3. Puestow CB, Gillesby WJ: Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. Arch Surg 76: 898, 7958. 4. Partington PF, Rochelle REL: Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 152: 1037,196O. 5. Thal AP: A technique for drainage of the obstructed pancreatic duct. Surgety51: 313, 1962. 6. Leger L, Lenriot JP. Lemaigre G: Five to twenty year followup after surgery for chronic pancreatitis in 146 patients. Ann Surg 180: 185, 1974. 7. James M: Treatment of pancreatic duct obstruction by “split” pancreaticojejunostomy. Am Surg 33: 1, 1967. a. Priestley JT. ReMine WH, Barber KW Jr, Gambill EE: Chronic relapsing pancreatitis: treatment by surgical drainage of pancreas. Ann Surg 161: 636, 1965. 9. Jordan GL Jr, Howard JM: Caudal pancreatojejunostomy in the management of chronic relapsing pancreatitis. Surgery 44: 303, 7958. 10. Cahow CE, Hayes MA: Operative treatment of chronic recurrent pancreatitis. Am JSurg 125: 391, 1973. 11. Child CG Ill, Frey CF, Fry WJ: A reappraisal of removal of ninety-five per cent of the distal portion of ihe pancreas. Swg Gyneco/ Obstet 129: 49, 1969. 12. Child CG Ill, Fry WJ: Current status of pancreatectomies. Surg C/in North Am 42: 1353, 1962. 13. Cox WD, Gillesby WJ: Longitudinal pancreaticojejunostomy in alcoholic pancreatitis. Arch Surg 94: 469, 1967. 14. DuVal MK Jr, Enquist IF: The surgical treatment of chronic pancreatitis by pancreaticojejunostomy: an a-year reappraisal. Surgery 50: 965, 1961. 15. Griffin JM. Starkloff GB: Surgery of chronic pancreatitis. Am JSurg 122: 18, 1971. 16. Guillemin G. Cuilleret J, Michel A, Berard P, Feroldi J: Chronic relapsing pancreatitis. Am J Surg 122: 602, 1971. 17. Haynes CD, Sanders SL: Surgical treatment of chronic relapsing pancreatitis. South &fed J 61: 622, 1966. 78. Hermann RE, AlJurf AS, Hoerr SO: Pancreatitis. Arch Surg 109: 298,1974. 19. Jones SA, Steedman RA, Keller TB, Smith LL: Transduodenal sphincteroplasty (not sphincterotomy) for biliary and pancreatic disease. Am J Surg 116: 292, 1969. 20. Keel/k M, FriE P, Smat V, Freidberger V: Chronic pancreatitis and choledochoduodenal anastomosis. Gut 9: 311, 1966. 21. Marks C: Chronic relapsing pancreatitis. Am J Surg 113: 340, 1967. 22. Nardi GL, Acosta JM: Papillitis as a cause of pancreatitis and abdominal pain. Ann Surg 164: 611, 1966. 23. Pradhan DJ, Leveque H, Jaunteguy JM, Seligman AM: Pancreatitis. The role of vagotomy, antrectomy and Billroth II gastroenterostomy in the treatment of alcoholic pancreatitis. Am JSurg 124: 21, 1972.
50
24. Sato T, Saitoh Y. Noto N. Matsuno K: Appraisal of operative treatment of chronic pancreatitis with special reference to side to side pancreaticojejunostomy. Am J Surg 129: 62 1, 1975. 25. Warren KW: Surgical management of chronic relapsing pancreatitis. Am J Surg 117: 24, 1969. 26. Way LW, Gadacz T, Goldman L: Surgical treatment of chronic pancreatitis. Am J Surg 127: 202, 1974. 27. Weiland DE, Kuntz DJ, Kimball HW: Subtotal pancreatectomy for chronic pancreatitis. Am J Surg 116: 973, 1969. 26. White TT, Keith RG: Long term follow-up of fifty patients with pancreaticojejunostomy. Surg Gynecol Obstet 136: 353. 1973. 29. Wolfe WG, Gamburg D, Shingleton WW: Surgical treatment of chronic pancreatitis. Am Surg 36: 9. 1970.
Discussion Charles F. Frey (Martinez, CA): The authors have delineated the specific indications for the use of the longitudinal pancreatojejunostomy, that is, patients with pancreatolithiasis. The high percentage of good long-term results in these patients was most encouraging. This confirms, I believe, the thinking of Doctor Kenneth Warren, who for so long has emphasized that when we have a destroyed pancreas and are operating to relieve the pain of chronic pancreatitis, we should look very carefully at the anatomy of the ductal system and our choice of operation should be determined largely by this consideration. However, to evaluate our long-term operative results judged by the number of late deaths and the incidence of pancreatic exocrine and endocrine insufficiency in survivors, it is necessary to separate the effects of alcoholism from those of the operation, to determine which operations are most appropriate. Survival tables comparing the alcoholic and nonalcoholic subjected to a particular operation is one means of resolving this dilemma. What is the incidence of exocrine and endocrine insufficiency during the period of follow-up after the caudal pancreatojejunostomy or longitudinal pancreatojejunostomy? Thomas T. White (Seattle, WA): I agree that the sideto-side anastomosis is not only easier to make but it has worked very well in our fifty-seven patients followed for five years or more. One patient drank heavily for eighteen years and finally died of other pancreatic complications of his alcoholism. Nonalcoholic patients have much better results, which parallel the general population in our survival curves. Six of the seventy patients on whom we have operated by pancreatojejunostomy have eventually had carcinoma of the pancreas. Those patients who have a big inflamed pancreas do poorly with pancreatojejunostomy and do well with 95 per cent resection. Have the authors had poor results with pancreaticojejunostomy in this group of patients? Lastly, splanchnicectomies have not significantly helped these patients. Bernard Gardner (Brooklyn, NY): As you know, in the historical development of treatment for pancreatitis in the early literature, decompression of the biliary tree played
The American Journal of Surgery
Pancreatojejunostomy
a very prominent role. This led us years ago to report on patients undergoing before-and-after drainage of the pancreas, combining sphincteroplasty with lateral jejunostomy. In the three patients presented who had combined sphincteroplasty, I would be interested to know how the results developed with respect to the combination of operations. M. M. Eisenberg (Minneapolis, MN): The authors noted that we are operating for pain primarily. I think one of the difficulties is determining when a patient with chronic relapsing pancreatitis deserves to have an operation for pain. As a corollary, I would appreciate hearing specific attitudes you have developed as to when you operate on these patients. Also, would you comment further on the splan&nice&my alluded to and what your experience has been. I noticed you did not report it today as an ancillary procedure. I would also appreciate knowing what preoperative attempts and what sort of procedures you use to control pain nonoperatively and how enthusiastically you attempt to defer surgery for a disease that is characterized, at least in your series, primarily by pain. Robert E. Snodgrass (Indianapolis, IN): I would like Doctor Jordan to recall if he has ever seen a controlled trial of pancreatojejunostomy or Puestow procedure reported anywhere in the world literature. We are not aware of it, control being nonoperative treatment, the natural history of the disease. The reason I ask the question is that the pathologic features of the disease make one wonder whether drainage of the main ductal system can affect the natural history of this disease, because the current work that is being done experimentally and the histologic studies indicate that the locus of the disease is primarily up at the smallest ductal radicals in the smallest ductal system of the pancreas, with plugging. This initial lesion, it seems, could not be drained by draining the large ductal system below. A number of
Volume 133, January 1977
people seriously doubt that the natural history of this disease is changed by draining the large ductal system. Larry C. Carey (Columbus, OH): Doctor Warren has emphasized from the technical standpoint the importance of anastomosing mucosa to mucosa. In your drawings you do not appear to think that is an important part of the procedure. Would you comment on that in your closing remarks? George L. Jordan, Jr (closing): I wish to thank the discussers for their comments and questions. Doctor Carey, I specifically do not make a ductal musoca-to-intestinal mucosa anastomosis because sutures may interrupt small ducts entering the main ductal system. Therefore, these two suture lines, as you correctly interpret, are at the capsule of the pancreas and are not down to the main ductal system. Doctor Snodgrass, I think you are right. Certainly in the English-speaking literature there is no controlled trial. I believe, however, that this procedure does change the course of pancreatitis. We have looked at our patients with pancreatitis due to alcoholism specifically, tabulating seventy-four consecutive patients for long-term follow-up. Only 6 per cent of those patients improved with medical therapy, whereas improvement exceeds 50 per cent in those surgically treated. In the present study, a significant percentage of patients with alcoholism were improved by operation. Of the group with ductal stones, for example, six of the eight who did well were alcoholics. So, although there are no controlled studies, there are data to indicate that surgical intervention is worthwhile. Doctor Eisenberg, the timing of surgery has become shorter and shorter after onset of disease. I operate as soon as I can confirm the diagnosis of recurrent or chronic pancreatitis. I do not use splanchnicectomy often as my results have not been particularly good. Doctor Frey, there has been an increasing incidence of exocrine and endocrine insufficiency with the passage of time, although this has not been as much of a problem as has been reported by some.
51
Obstruction of the pancreatic duct may be a factor in the production of pancreatic pain. About thirty years ago, Cattell [I] advocated decompression of the pancreatic duct obstructed by carcinoma as a palliative procedure. Subsequently, this concept was applied to the treatment of patients with chronic pancreatitis. DuVal[2] in 1954 advocated resection of the tail of the pancreas and a caudal pancreatojejunostomy Roux-en-Y to decompress the pancreatic duct and thus relieve symptoms. Subsequently, because obstructions of the pancreatic duct in chronic pancreatitis were frequently multiple, Puestow and Gillesby [3] modified this procedure making a longitudinal incision into the pancreatic duct from the tail of the pancreas to the region of the gastroduodenal artery to incise all strictures and to remove calculi. The pancreas was freed from surrounding structures and inserted into a loop of jejunum, Roux-en-Y, or a side-to-side pancreatojejunostomy Roux-en-Y was constructed. Partington and Rochelle [4] as well as Thal [5] modified the side-to-side technic to avoid the necessity for splenectomy. A number of other technics of pancreatojejunostomy and pancreatogastrectomy have been employed, including a smaller side-to-side pancreatojejunostomy in the midportion of the duct and a “split” pancreatojejunostomy in which the pancreas is partially divided and an anastomosis made to the two transected ends of the ductal system [WI]. After an initial wave of enthusiasm for these procedures, some reports indicated a high incidence of recurrence of disease.
From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine and the Ben Taub General, Methodist, St. Luke’s Episcopal and Veterans Administration Hospitals, Houston, Texas. Reprint requests should be addressed to George L. Jordan, Jr, MD, Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas 77025. Presented at the Seventeenth Annual Meeting of the Society for Surgery of the Alimentary Tract, Miami Beach, Florida, May 25-26, 1976. * Present address: 3600 Prytonia, New Orleans, Louisiana 76115. t Present address: 4374 Robbins Street, San Diego, California 92122.
46
The total experience with these procedures is limited, there being less than 150 cases of any one of the previously mentioned technics of pancreatojejunostomy with long-term follow-up studies in the American literature. To add to the body of information, we have reviewed our experience with thirty patients during follow-up periods up to twenty years. Clinical Features There were twenty-two males and eight females of whom seventeen were white and thirteen were black. They ranged in age from twenty-five to sixty years (median, 35 years). All had severe pancreatitis over a prolonged period of time. In the majority of patients specific etiologic factors could
F/gure 7. The technk of caudal pancreatojejwnwtomy.
The American Journal of Surgery
Pancreatojejunostomy
Figure 2. The technic of longitudinal pancreatojejmostomy used in one patient. The pancreatic duct is incised: the pancreas is freed from surroundb8g structures and anastomosedtoaR~x~-Yloopa~lnsertknofthebwlyand tall into the #unum. be identified. Twenty-three patients were alcoholics, one had cholelithiasis, one had pancreatitis following trauma, and in five patients pancreatitis was classed as idiopathic. Two of the patients with alcoholic pancreatitis also had gallstones and one had hyperlipemia. All patients had pain. Other features included weight loss in eleven patients, diabetes in five, steatorrhea in five, jaundice in two, and ascites in one. Pathologic features found at operation included severe fibrosis in all patients. There was definite dilatation of the duct of Wirsung in twenty-six patients with demonstrable ductal strictures in twenty-five. Ductal stones were present in thirteen. Retention cysts were present in two, and in two there was no ductal pathology* Caudal pancreatojejuncetomy as described by DuVal[2] was utilized in six patients. (Figure 1.) A longitudinal pancreatojejunostomy as described by Puestow and Gillesby [3] with insertion of the pancreas into a loop of jejunum was utilized in only one patient while the modification of this procedure described by Thal [5] was utilized in twenty-three. (Figures 2 and 3.) Associated procedures were performed in twenty patients, including resection of the tail of the pancreas in sixteen. This was performed in all six of the patients having the DuVal procedure as a standard part of the operation. In thirteen of the twentyfour patients having longitudinal pancreatojejunostomy, amputation of the tail of the pancreas was performed as an aid in identifying the pancreatic duct. In the other patients
Volume 133, January 1977
Figure 3. The technic of side-to-side longitudinal pancreatojemy used in twenty-t/wee pat/en&. The inserf shows detail of the two layer anastomosis. the dilated duct was palpable, and it was identified by aspirating with a needle, or by a direct incision into the pancreas over the anatomic region of the duct. Sphincteroplasty was accomplished in three patients and in one patient with jaundice there was exploration of the common bile duct with T-tube drainage.
Results There directly
was no operative related
mortality.
to the operative
in 10 per cent of patients.
There
Complications
procedure
occurred
were two pancreatic
fistulas and one wound abscess. One of the pancreatic
fistulas required an operation for better drainage, but both fistulas ultimately closed spontaneously on conservative management. Thus, all patients were discharged from the hospital with full recovery from the operation. Although there was a variety of deficiency syndromes, as indicated previously, the primary purpose for operation was the relief of chronic pain or the interruption of recurrent acute of subacute attacks of pancreatitis. Thus, the results are predicated on evaluation of achievement of this goal. An “excellent” result indicates complete relief of pain and absence of attacks of pancreatitis. Patients classed as “improved” had partial relief of symptoms evidenced by decrease in the pain problem or severity and frequency of recurrent attacks. The term “improved” is used also for patients who had periods as long as
47
Jordan, Strug, and Crowder
TABLE
I
Comparison 2 Technics Chronic
of Early and Late Results after of Pancreatojejunostomy
and Relapsing
for
Pancreatitis
Result Procedure Caudal Early Late Longitudinal Early Late
Improved
Poor
2 1
0 2
4 3
14 9
5 8
5 6
Excellent
two to three years without symptoms during the first five year follow-up period even though they may have had one or two attacks previously or after the asymptomatic period. As all patients had severe problems preoperativejy, early as well as late follow-up studies may be of significance. Early results relate to the patient’s status during the first postoperative year. Late results extend for one to twenty years. The recent status of twenty-eight patients is known. One was lost to follow-up during the second postoperative year and the other during the fifth postoperative year. Early results of patients with caudal pancreatojejunostomies have been previously reported [9]. Two patients had no symptoms during the first year postoperatively and were classed as early excellent results, while the remaining four had recurrent disease and were classed as poor. One of the patients initially classed as excellent had recurrence of symptoms after two years. He has now been followed for 143 months and has had limited difficulty with his disease and, therefore, is classed as improved. A second patient who was classed as an early poor result because of a recurrent disease within one year subsequently had a period of several years’ relief from pancreatic problems and is classed as improved in the late follow-up period. Thus, in the late classification, one patient was worse and one patient improved as compared with the first year. Only one patient, followed four and a half years, is an excellent result (17 per cent), and the incidence of excellent and improved results on a long-term basis is 50 per cent. The shortest follow-up period in this group is forty months. This patient died at that time. The longest follow-up period is 240 months, this patient still being alive. Among this group, three patients, all initially classed as poor results, have died. One died of myocardial infarction, one of alcoholism, and one of pneumonia with survival periods after operation being three and a half, ten, and twelve years and ages at death being twenty-nine, forty-one, and forty-five
48
years, respectively. Thus, half of these individuals died at an early age, with two of the deaths being related to the problems associated with pancreatitis, although none of the deaths were the specific result of progressive pancreatic disease. Among the twenty-four patients undergoing longitudinal pancreatojejunostomy, fourteen were initially classed as excellent, five as improved, and five as poor. Thus, nineteen of the twenty-four (79 per cent) were improved. One patient died suddenly of unknown cause four months postoperatively and is excluded from the long-term results. The follow-up periods in the remaining twenty-three patients range from 12 to 123 months (average, 58 months). At this time, the classification is nine excellent, eight improved, and six poor. Two patients initially listed as having poor results were later put into the improved group because of long periods of freedom from symptoms in the late follow-up period, these patients having been followed for 76 to 116 months, respectively. Five patiepts were dowugraded from the excellent classification. Three were reclassified as good on the basis of long-term follow-up and two reclassified as poor, and one patient originally classified as improved was reclassified as poor on the basis of later follow-up data. (Table I.) Six of the twenty-four patients (25 per cent) have died during the follow-up period. The patient who died during the first postoperative year was classified as an improved early result. The remaining patients died after survival periods of two to six years and in a majority of patients the deaths were directly related to alcoholism, malnutrition, or pancreatitis. The specific causes of death were pancreatitis in three patients, one of whom also had the complication of cirrhosis. The fourth died of hepatic failure and the fifth died of pneumonia, having suffered from severe malnutrition and recurrent pancreatic disease. These patients died at ages ranging from thirty-six to fifty-nine years, and none of those who have died lived a normal life span. Only a third of them have lived past the age of fifty years. Results were tabulated as related to the pathologic condition within the gland. The most significant pathologic factor was the presence of pancreatic calculi. The only patient undergoing the DuVal procedure who had an excellent result in the late postoperative period had pancreatic calculi. Among the patients undergoing longitudinal pancreatojejunostomy, ten of eleven were improved in the early postoperative period, and long-term improvement was observed in eight of ten patients (80 per cent) with ductal stones. Six of these eight remain in the excellent category. Seven of twelve patients (58 per
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cent) having ductal strictures without stones were improved. Only three of the seven were in the excellent category. The one patient having longitudinal pancreatojejunostomy with no ductal pathology also had an excellent result. The overall incidence of improvement in patients followed for an average of more than five years was 70 per cent (16/23).
Comments A partial review of the recent American literature plus our own data, some of which are not reported, allowed a tabulation of treatment of chronic and relapsing pancreatitis in 1,558 patients [6-8, 10-291. Patients treated for complications of pancreatitis, including pseudocyst formation, abscess, and fistulas, were excluded. (Table II.) The most common procedure employed was resection, including pancreatoduodenectomy, caudal pancreatectomy, and total pancreatectomy. Pancreatojejunostomy was the second most common procedure having been performed in 318 patients (20 per cent); 165 of these 318 patients had undergone longitudinal pancreatojejunostomy. Thus, longitudinal pancreatojejunstomy was employed in only 11 per cent of patients treated for recurrent or chronic pancreatitis reported in the literature and there are as many patients with other types of pancreatojejunostomy. There were only four deaths among the 318 patients, a mortality of less than 2 per cent. It is apparent that this procedure can be accomplished as safely as any of the other procedures commonly employed in the treatment of chronic pancreatitis. It is safer than a major resection. There are few data to document accurately the fate of the anastomosis. How often recurrence of symptoms after initial success is due to stenosis of the anastomosis is not known. It has been stated that after relief of ductal obstruction, there may be improvement of nutrition and there may be regeneration of pancreatic tissue. Although some patients do have nutritional improvement after this operation, it is entirely possible that it is relief of recurrent attacks and improvement of appetite due to relief of pain. We are aware of no patient in our own series who, at autopsy, had evidence of significant improvement in the pathologic changes in the pancreatic parenchyma. Furthermore, we have performed pre- and postoperative metabolic studies in a few patients and these did not demonstrate an improvement in fecal loss of fat and nitrogen in the postoperative period. The number which we have studied, however, is too small to allow any firm conclusions. Most authors, however, have re-
Volume 133, January 1977
TABLE
II
Incidence Chronic Collected
of Various
Procedures
and Relapsing from
for
Pancreatitis
Recent American
Literature Procedure Resection Pancreatojejunostomy Longitudinal Caudal Other Bilary tract procedures Sphincteroplasty Other Total
Number 428 318 165 72 81 279 271 262 1,558
Per Cent 28 20 11 5 5 18 17 17 100
ported a significant number of patients who had diabetes or findings of exocrine insufficiency leading to deficiency syndromes in the postoperative period, even without recurrence of pain. An interesting sidelight has been the difficulty of diagnosis of carcinoma in patients with severe changes in the gland. ‘White and Keith [28] in a report of fifty patients treated by pancreatojejunostomy found that nine of these patients died of carcinoma in the follow-up period, though none had proved carcinoma at the time of surgery. In our own experience, there was one patient who had undergone this procedure who died of carcinoma in the followup period. This patient is not included in this series nor are the other patients reported in the literature included in the tabulation of the following results. The data collected from the literature and the data reported here from our own studies indicate that pancreatojejunostomy is a useful procedure in the treatment of chronic and relapsing pancreatitis when there is ductal stricture or ductal stones and that longitudinal pancreatojejunostomy is somewhat better than caudal pancreatojejunostomy. When one considers the patient population having this type of pancreatitis, 70 per cent good results are most encouraging, for our data on the natural history of alcoholic pancreatitis indicate that only 6 per cent have improvement on nonoperative treatment. Thus, we continue to utilize this procedure as the initial therapy for those patients who have significant ductal disease. Summary Thirty patients with chronic pancreatitis were treated by pancreatojejunostomy, six caudal and twenty-four longitudinal anastomoses. Follow-up data up to twenty years are reported and the early and long-term results compared. There were no
49
Jordan, Strug, and Crowder
deaths. Long-term results with caudal pancreatojejunostomy were 50 per cent excellent or improved and with longitudinal pancreatojejunostomy, 70 per cent excellent or improved. The best results were obtained when intraductal calcification was present. Longitudinal pancreatojejunostomy is recommended as the initial treatment of choice for chronic pancreatitis in patients with ductal obstruction, particularly when calcification is present. References 1. Cattell RB: Anastomosis of the duct of Wirsung. Surg C/in North Am 27: 636, 1947. 2. DuVal MK Jr: Caudal pancreatojejunostomy for chronic relapsing pancreatitis. Ann Surg 140: 775, 1954. 3. Puestow CB, Gillesby WJ: Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. Arch Surg 76: 898, 7958. 4. Partington PF, Rochelle REL: Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 152: 1037,196O. 5. Thal AP: A technique for drainage of the obstructed pancreatic duct. Surgety51: 313, 1962. 6. Leger L, Lenriot JP. Lemaigre G: Five to twenty year followup after surgery for chronic pancreatitis in 146 patients. Ann Surg 180: 185, 1974. 7. James M: Treatment of pancreatic duct obstruction by “split” pancreaticojejunostomy. Am Surg 33: 1, 1967. a. Priestley JT. ReMine WH, Barber KW Jr, Gambill EE: Chronic relapsing pancreatitis: treatment by surgical drainage of pancreas. Ann Surg 161: 636, 1965. 9. Jordan GL Jr, Howard JM: Caudal pancreatojejunostomy in the management of chronic relapsing pancreatitis. Surgery 44: 303, 7958. 10. Cahow CE, Hayes MA: Operative treatment of chronic recurrent pancreatitis. Am JSurg 125: 391, 1973. 11. Child CG Ill, Frey CF, Fry WJ: A reappraisal of removal of ninety-five per cent of the distal portion of ihe pancreas. Swg Gyneco/ Obstet 129: 49, 1969. 12. Child CG Ill, Fry WJ: Current status of pancreatectomies. Surg C/in North Am 42: 1353, 1962. 13. Cox WD, Gillesby WJ: Longitudinal pancreaticojejunostomy in alcoholic pancreatitis. Arch Surg 94: 469, 1967. 14. DuVal MK Jr, Enquist IF: The surgical treatment of chronic pancreatitis by pancreaticojejunostomy: an a-year reappraisal. Surgery 50: 965, 1961. 15. Griffin JM. Starkloff GB: Surgery of chronic pancreatitis. Am JSurg 122: 18, 1971. 16. Guillemin G. Cuilleret J, Michel A, Berard P, Feroldi J: Chronic relapsing pancreatitis. Am J Surg 122: 602, 1971. 17. Haynes CD, Sanders SL: Surgical treatment of chronic relapsing pancreatitis. South &fed J 61: 622, 1966. 78. Hermann RE, AlJurf AS, Hoerr SO: Pancreatitis. Arch Surg 109: 298,1974. 19. Jones SA, Steedman RA, Keller TB, Smith LL: Transduodenal sphincteroplasty (not sphincterotomy) for biliary and pancreatic disease. Am J Surg 116: 292, 1969. 20. Keel/k M, FriE P, Smat V, Freidberger V: Chronic pancreatitis and choledochoduodenal anastomosis. Gut 9: 311, 1966. 21. Marks C: Chronic relapsing pancreatitis. Am J Surg 113: 340, 1967. 22. Nardi GL, Acosta JM: Papillitis as a cause of pancreatitis and abdominal pain. Ann Surg 164: 611, 1966. 23. Pradhan DJ, Leveque H, Jaunteguy JM, Seligman AM: Pancreatitis. The role of vagotomy, antrectomy and Billroth II gastroenterostomy in the treatment of alcoholic pancreatitis. Am JSurg 124: 21, 1972.
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24. Sato T, Saitoh Y. Noto N. Matsuno K: Appraisal of operative treatment of chronic pancreatitis with special reference to side to side pancreaticojejunostomy. Am J Surg 129: 62 1, 1975. 25. Warren KW: Surgical management of chronic relapsing pancreatitis. Am J Surg 117: 24, 1969. 26. Way LW, Gadacz T, Goldman L: Surgical treatment of chronic pancreatitis. Am J Surg 127: 202, 1974. 27. Weiland DE, Kuntz DJ, Kimball HW: Subtotal pancreatectomy for chronic pancreatitis. Am J Surg 116: 973, 1969. 26. White TT, Keith RG: Long term follow-up of fifty patients with pancreaticojejunostomy. Surg Gynecol Obstet 136: 353. 1973. 29. Wolfe WG, Gamburg D, Shingleton WW: Surgical treatment of chronic pancreatitis. Am Surg 36: 9. 1970.
Discussion Charles F. Frey (Martinez, CA): The authors have delineated the specific indications for the use of the longitudinal pancreatojejunostomy, that is, patients with pancreatolithiasis. The high percentage of good long-term results in these patients was most encouraging. This confirms, I believe, the thinking of Doctor Kenneth Warren, who for so long has emphasized that when we have a destroyed pancreas and are operating to relieve the pain of chronic pancreatitis, we should look very carefully at the anatomy of the ductal system and our choice of operation should be determined largely by this consideration. However, to evaluate our long-term operative results judged by the number of late deaths and the incidence of pancreatic exocrine and endocrine insufficiency in survivors, it is necessary to separate the effects of alcoholism from those of the operation, to determine which operations are most appropriate. Survival tables comparing the alcoholic and nonalcoholic subjected to a particular operation is one means of resolving this dilemma. What is the incidence of exocrine and endocrine insufficiency during the period of follow-up after the caudal pancreatojejunostomy or longitudinal pancreatojejunostomy? Thomas T. White (Seattle, WA): I agree that the sideto-side anastomosis is not only easier to make but it has worked very well in our fifty-seven patients followed for five years or more. One patient drank heavily for eighteen years and finally died of other pancreatic complications of his alcoholism. Nonalcoholic patients have much better results, which parallel the general population in our survival curves. Six of the seventy patients on whom we have operated by pancreatojejunostomy have eventually had carcinoma of the pancreas. Those patients who have a big inflamed pancreas do poorly with pancreatojejunostomy and do well with 95 per cent resection. Have the authors had poor results with pancreaticojejunostomy in this group of patients? Lastly, splanchnicectomies have not significantly helped these patients. Bernard Gardner (Brooklyn, NY): As you know, in the historical development of treatment for pancreatitis in the early literature, decompression of the biliary tree played
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Pancreatojejunostomy
a very prominent role. This led us years ago to report on patients undergoing before-and-after drainage of the pancreas, combining sphincteroplasty with lateral jejunostomy. In the three patients presented who had combined sphincteroplasty, I would be interested to know how the results developed with respect to the combination of operations. M. M. Eisenberg (Minneapolis, MN): The authors noted that we are operating for pain primarily. I think one of the difficulties is determining when a patient with chronic relapsing pancreatitis deserves to have an operation for pain. As a corollary, I would appreciate hearing specific attitudes you have developed as to when you operate on these patients. Also, would you comment further on the splan&nice&my alluded to and what your experience has been. I noticed you did not report it today as an ancillary procedure. I would also appreciate knowing what preoperative attempts and what sort of procedures you use to control pain nonoperatively and how enthusiastically you attempt to defer surgery for a disease that is characterized, at least in your series, primarily by pain. Robert E. Snodgrass (Indianapolis, IN): I would like Doctor Jordan to recall if he has ever seen a controlled trial of pancreatojejunostomy or Puestow procedure reported anywhere in the world literature. We are not aware of it, control being nonoperative treatment, the natural history of the disease. The reason I ask the question is that the pathologic features of the disease make one wonder whether drainage of the main ductal system can affect the natural history of this disease, because the current work that is being done experimentally and the histologic studies indicate that the locus of the disease is primarily up at the smallest ductal radicals in the smallest ductal system of the pancreas, with plugging. This initial lesion, it seems, could not be drained by draining the large ductal system below. A number of
Volume 133, January 1977
people seriously doubt that the natural history of this disease is changed by draining the large ductal system. Larry C. Carey (Columbus, OH): Doctor Warren has emphasized from the technical standpoint the importance of anastomosing mucosa to mucosa. In your drawings you do not appear to think that is an important part of the procedure. Would you comment on that in your closing remarks? George L. Jordan, Jr (closing): I wish to thank the discussers for their comments and questions. Doctor Carey, I specifically do not make a ductal musoca-to-intestinal mucosa anastomosis because sutures may interrupt small ducts entering the main ductal system. Therefore, these two suture lines, as you correctly interpret, are at the capsule of the pancreas and are not down to the main ductal system. Doctor Snodgrass, I think you are right. Certainly in the English-speaking literature there is no controlled trial. I believe, however, that this procedure does change the course of pancreatitis. We have looked at our patients with pancreatitis due to alcoholism specifically, tabulating seventy-four consecutive patients for long-term follow-up. Only 6 per cent of those patients improved with medical therapy, whereas improvement exceeds 50 per cent in those surgically treated. In the present study, a significant percentage of patients with alcoholism were improved by operation. Of the group with ductal stones, for example, six of the eight who did well were alcoholics. So, although there are no controlled studies, there are data to indicate that surgical intervention is worthwhile. Doctor Eisenberg, the timing of surgery has become shorter and shorter after onset of disease. I operate as soon as I can confirm the diagnosis of recurrent or chronic pancreatitis. I do not use splanchnicectomy often as my results have not been particularly good. Doctor Frey, there has been an increasing incidence of exocrine and endocrine insufficiency with the passage of time, although this has not been as much of a problem as has been reported by some.
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