1. Roux-en-Y Lateral pancreaticojejunostomy
Mohit Srivastava
Lecture #5

2. Lateral Pancreaticojejunostomy
Background:
Progressive damage
Exocrine/Endocrine malfunction
Signs/Sx:
Intractable pain
Inflammatory process surrounding the nerves
Several theories
Glandular HTN:
Ductal dilation, elevated pressures, relief
Not all get relief though…

3. Lateral Pancreaticojejunostomy
Etiology:
ETOH, ETOH, ETOH
Trend towards narcotic abuse
Other infrequent causes…
Preop intervention:
Medical intervention
Surgical intervention:
Pseudocyst, ascites, Sx obstruction, malignancy
Pain most common reason
Goal of surgery is to relieve pain while maintaining/preserving function
LATERAL PANCREATICOJEJUNOSTOMY IS THE PREFERRED METHOD

4. Lateral Pancreaticojejunostomy
History:
1908 – Coffey
1911 – Link
Several decades later – Duval
Puestow and Gillesby
Partingon and Rochelle
Frey
Preop planning:
Careful Hx very important
Tenderness/abdominal mass/jaundice
Imaging:
Duct must be at least 5 mm in caliber for operation to be done
CT scan
ERCP (MRCP, U/S)

5. Lateral Pancreaticojejunostomy
Metabolic status:
All preop workup must include this assessment
Preop HAL
Blood sugars…
Images to follow…

6. CT scan

7. MR

8. MR

9. MR

10. Lateral Pancreaticojejunostomy
Surgical Technique:
Broad Spectrum IV ABx (Gram neg coverage)
Bowel Preparation
SCD’s
Radiographic assistance ready

11. Lateral Pancreaticojejunostomy
Surgical Technique (cont’d):
B/L subcostal incision vs midline
Explore to confirm first…
Uniform, firm, and fibrotic consistency
Any suspicious lesions are sent for frozen; any hard masses – FNA
Lesser sac entered through gastrocolic ligament
All fibrous adhesions are taken down – cautery or sharp dissection

13. Lateral Pancreaticojejunostomy
Surgical technique (cont’d):
Additional time spent clearing the anterior surface of the gland
Transverse colon and the splenic flexure mobilized downward
Pancreatic head is mobilized by a Kocher maneuver (hepatic flexure mobilized inferiorly)
Duodenum is bluntly delivered from the retroperitoneum
The head of the pancreas is exposed and the adjacent mesocolon is mobilized downward
Division of the gastrocolic ligament and extended kocherization allow bimanual palpation of the head of the pancreas
Pancreatic duct adequately identified
Confirmed by needle aspiration
Cautery,U/S used to eventually cut down onto the needle/into the duct lumen

15. Lateral Pancreaticojejunostomy
Surgical techique:
Ductotomy extended to within 1 cm of the tip of the tail
Duct of Wirsung and Santorini are opened as close the wall of the duodenum as possible
All pesky veins are suture ligated
Sometimes with bulky pancreatic head disease, local resection is indicated
With fingers overlying the posterior wall of the gland, cautreyis used to remove the capsule and tissue until the duct of wirsung is encountered
SMV and portal vein are identified; probe/balloon catheter can be placed to protect the intrapancraetic CBD
Remember, by palpating the surgeon can drain any “leftover” areas

17. Lateral Pancreaticojejunostomy
Surgical technique:
Frozen section routinely attained
Try and remove all calculus debris
Anastomoses must be cm to provid adequate results
Traditional Roux-en-Y done:
Limb brought up through a retrocolic window
Enterotomy in the antimesenteric end of the loop of bowel
Suture techniwues can vary ( they advocate running one layer)
Full thickness of bowel and only capsule of the pancreas
Contruction of the Roux-en-Y limb is completed via an end-side enteroenterostomy
Opening around mesocolic window closed
Cholecstectomy, J-tube, NGT, drains

20. Lateral Pancreaticojejunostomy
Results;
0-4% mortality
5-20% overall complication
Fistula rate not that high
Fibrosis
Documented alleviation in 65-90% pts
Complete relief in 37% pts, substantial relief in 45% pts
No standardization of methods in which they test for pain relief
Operation itself does not impair function, and in some studies, it has been shown to retard metabolic derangement.