Download PDF
Eur J Pediatr Surg 2016; 26(03): 232-239
DOI: 10.1055/s-0035-1551565
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Surgical Success in Chronic Pancreatitis: Sequential Endoscopic Retrograde Cholangiopancreatography and Surgical Longitudinal Pancreatojejunostomy (Puestow Procedure)

Kathryn Ford
1   Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, United Kingdom
,
Anu Paul
1   Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, United Kingdom
,
Phillip Harrison
2   Institute of Liver Studies, King's College Hospital, Denmark Hill, London, United Kingdom
,
Mark Davenport
1   Department of Paediatric Surgery, King's College Hospital, Denmark Hill, London, United Kingdom
› Author Affiliations
Further Information

Publication History

03 November 2014

29 January 2015

Publication Date:
19 May 2015 (online)

    Permissions and Reprints

Abstract

Introduction Chronic pancreatitis (CP) can be a cause of recurrent, severe, disabling abdominal pain in children. Surgery has been suggested as a useful therapy, although experience is limited and the results unpredictable. We reviewed our experience of a two-stage protocol—preliminary endoscopic retrograde cholangiopancreatography (ERCP) and duct stenting, and if symptoms resolved, definitive surgical decompression by longitudinal pancreatojejunostomy (LPJ) (Puestow operation).

Patients and Methods This is a single-center, retrospective review of children with established CP who underwent an LPJ between February 2002 and September 2012. A questionnaire was completed (incorporating visual analog scale pain and lifestyle scores) to assess functional outcome. Data are expressed as median (range).

Results In this study, eight (M:F ratio of 4:4) children underwent an LPJ and one female child had a more limited pancreatojejunostomy anastomosis following preliminary ERCP and stent placement where possible. Diagnoses included hereditary pancreatitis (n = 3), idiopathic or structural pancreatitis (n = 5), and duct stricture following radiotherapy (n = 1). Median duct diameter presurgery was 5 (4–11) mm. Endoscopic placement of a Zimmon pancreatic stent was possible in six with relief of symptoms in all. Median age at definitive surgery was 11 (range, 7–17) years with a median postoperative stay of 9 (range, 7–12) days and a follow-up of 6 (range, 0.5–12) years. All children reported markedly reduced episodes of pain postprocedure. One developed diabetes mellitus, while three had exocrine deficiency (fecal elastase < 200 µg/g) requiring enzyme supplementation. The child with limited LPJ had symptomatic recurrence and required restenting and further surgery to widen the anastomosis to become pain free.

Conclusion ERCP and stenting provide a therapeutic trial to assess possible benefit of a definitive duct drainage procedure. LPJ—the modified Puestow operation was safe and complication-free with good medium-term relief of symptoms. We were not able to identify a consistent etiology-associated outcome.

Keywords

chronic pancreatitis - Puestow procedure - hereditary pancreatitis - ERCP

Supplementary Material

 

  • References

  • 1 Nydegger A, Heine RG, Ranuh R, Gegati-Levy R, Crameri J, Oliver MR. Changing incidence of acute pancreatitis: 10-year experience at the Royal Children's Hospital, Melbourne. J Gastroenterol Hepatol 2007; 22 (8) 1313-1316
    CrossrefPubMedGoogle Scholar
  • 2 Lopez MJ. The changing incidence of acute pancreatitis in children: a single-institution perspective. J Pediatr 2002; 140 (5) 622-624
    CrossrefPubMedGoogle Scholar
  • 3 Rosendahl J, Bödeker H, Mössner J, Teich N. Hereditary chronic pancreatitis. Orphanet J Rare Dis 2007; 2: 1
    CrossrefPubMedGoogle Scholar
  • 4 Howes N, Lerch MM, Greenhalf W , et al; European Registry of Hereditary Pancreatitis and Pancreatic Cancer (EUROPAC). Clinical and genetic characteristics of hereditary pancreatitis in Europe. Clin Gastroenterol Hepatol 2004; 2 (3) 252-261
    CrossrefPubMedGoogle Scholar
  • 5 Whitcomb DC, Gorry MC, Preston RA , et al. Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene. Nat Genet 1996; 14 (2) 141-145
    CrossrefPubMedGoogle Scholar
  • 6 Witt H, Beer S, Rosendahl J , et al. Variants in CPA1 are strongly associated with early onset chronic pancreatitis. Nat Genet 2013; 45 (10) 1216-1220
    CrossrefPubMedGoogle Scholar
  • 7 Cohn JA, Friedman KJ, Noone PG, Knowles MR, Silverman LM, Jowell PS. Relation between mutations of the cystic fibrosis gene and idiopathic pancreatitis. N Engl J Med 1998; 339 (10) 653-658
    CrossrefPubMedGoogle Scholar
  • 8 Blejter J, Weller S, Pace R, Cusumano H, Giambini D. Autoimmune pancreatitis: an adolescent case and review of literature. J Pediatr Surg 2008; 43 (7) 1368-1372
    CrossrefPubMedGoogle Scholar
  • 9 Refaat R, Harth M, Proschek P, Lindemayr S, Vogl TJ. Autoimmune pancreatitis in an 11-year-old boy. Pediatr Radiol 2009; 39 (4) 389-392
    CrossrefPubMedGoogle Scholar
  • 10 Warshaw AL. Conservation of pancreatic tissue by combined gastric, biliary, and pancreatic duct drainage for pain from chronic pancreatitis. Am J Surg 1985; 149 (4) 563-569
    CrossrefPubMedGoogle Scholar
  • 11 Puestow CB, Gillesby WJ. Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis. AMA Arch Surg 1958; 76 (6) 898-907
    CrossrefPubMedGoogle Scholar
  • 12 Lowenfels AB, Maisonneuve P, DiMagno EP , et al; International Hereditary Pancreatitis Study Group. Hereditary pancreatitis and the risk of pancreatic cancer. J Natl Cancer Inst 1997; 89 (6) 442-446
    CrossrefPubMedGoogle Scholar
  • 13 Joergensen MT, Brusgaard K, Crüger DG, Gerdes AM, Schaffalitzky de Muckadell OB. Genetic, epidemiological, and clinical aspects of hereditary pancreatitis: a population-based cohort study in Denmark. Am J Gastroenterol 2010; 105 (8) 1876-1883
    CrossrefPubMedGoogle Scholar
  • 14 Dzakovic A, Superina R. Acute and chronic pancreatitis: surgical management. Semin Pediatr Surg 2012; 21 (3) 266-271
    CrossrefPubMedGoogle Scholar
  • 15 Moir CR, Konzen KM, Perrault J. Surgical therapy and long-term follow-up of childhood hereditary pancreatitis. J Pediatr Surg 1992; 27 (3) 282-286 , discussion 286–287
    CrossrefPubMedGoogle Scholar
  • 16 Chiu B, Lopoo J, Superina RA. Longitudinal pancreaticojejunostomy and selective biliary diversion for chronic pancreatitis in children. J Pediatr Surg 2006; 41 (5) 946-949
    CrossrefPubMedGoogle Scholar
  • 17 Clifton MS, Pelayo JC, Cortes RA , et al. Surgical treatment of childhood recurrent pancreatitis. J Pediatr Surg 2007; 42 (7) 1203-1207
    CrossrefPubMedGoogle Scholar
  • 18 Iqbal CW, Moir CR, Ishitani MB. Management of chronic pancreatitis in the pediatric patient: endoscopic retrograde cholangiopancreatography vs operative therapy. J Pediatr Surg 2009; 44 (1) 139-143 , discussion 143
    CrossrefPubMedGoogle Scholar
  • 19 DuBay D, Sandler A, Kimura K, Bishop W, Eimen M, Soper R. The modified Puestow procedure for complicated hereditary pancreatitis in children. J Pediatr Surg 2000; 35 (2) 343-348
    CrossrefPubMedGoogle Scholar
  • 20 Lal A, Lal DR. Hereditary pancreatitis. Pediatr Surg Int 2010; 26 (12) 1193-1199
    CrossrefPubMedGoogle Scholar
  • 21 Stringer MD, Davison SM, McClean P , et al. Multidisciplinary management of surgical disorders of the pancreas in childhood. J Pediatr Gastroenterol Nutr 2005; 40 (3) 363-367
    CrossrefPubMedGoogle Scholar
  • 22 Partington PF, Rochelle RE. Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 1960; 152: 1037-1043
    CrossrefPubMedGoogle Scholar
  • 23 Rollins MD, Meyers RL. Frey procedure for surgical management of chronic pancreatitis in children. J Pediatr Surg 2004; 39 (6) 817-820
    CrossrefPubMedGoogle Scholar
  • 24 Bellin MD, Carlson AM, Kobayashi T , et al. Outcome after pancreatectomy and islet autotransplantation in a pediatric population. J Pediatr Gastroenterol Nutr 2008; 47 (1) 37-44
    CrossrefPubMedGoogle Scholar
  • 25 Chinnakotla S, Bellin MD, Schwarzenberg SJ , et al. Total pancreatectomy and islet autotransplantation in children for chronic pancreatitis: indication, surgical techniques, postoperative management, and long-term outcomes. Ann Surg 2014; 260 (1) 56-64
    CrossrefPubMedGoogle Scholar
  • 26 Zhang JS, Li L, Liu SL , et al. Laparoscopic pancreaticojejunostomy for pancreatic ductal dilatation in children. J Pediatr Surg 2012; 47 (12) 2349-2352
    CrossrefPubMedGoogle Scholar
  • 27 Meehan JJ, Sawin R. Robotic lateral pancreaticojejunostomy (Puestow). J Pediatr Surg 2011; 46 (6) e5-e8
    CrossrefPubMedGoogle Scholar
  • 28 Sakorafas GH, Tsiotou AG, Peros G. Mechanisms and natural history of pain in chronic pancreatitis: a surgical perspective. J Clin Gastroenterol 2007; 41 (7) 689-699
    CrossrefPubMedGoogle Scholar
  • 29 Sakorafas GH, Farnell MB, Farley DR, Rowland CM, Sarr MG. Long-term results after surgery for chronic pancreatitis. Int J Pancreatol 2000; 27 (2) 131-142
    CrossrefPubMedGoogle Scholar
  • 30 Perrelli L, Nanni L, Costamagna G, Mutignani M. Endoscopic treatment of chronic idiopathic pancreatitis in children. J Pediatr Surg 1996; 31 (10) 1396-1400
    CrossrefPubMedGoogle Scholar
  • 31 Vaughan D, Imrie C, Kelleher J, Drumm B, Osborne H. Pancreatic duct stenting as a treatment for hereditary pancreatitis. Pediatrics 1999; 104 (5, Pt 1) 1129-1133
    CrossrefPubMedGoogle Scholar
  • 32 Hsu RK, Draganov P, Leung JW , et al. Therapeutic ERCP in the management of pancreatitis in children. Gastrointest Endosc 2000; 51 (4, Pt 1) 396-400
    Google Scholar
  • 33 Laje P, Adzick NS. Modified Puestow procedure for the management of chronic pancreatitis in children. J Pediatr Surg 2013; 48 (11) 2271-2275
    CrossrefPubMedGoogle Scholar
  • 34 Demir IE, Tieftrunk E, Maak M, Friess H, Ceyhan GO. Pain mechanisms in chronic pancreatitis: of a master and his fire. Langenbecks Arch Surg 2011; 396 (2) 151-160
    CrossrefPubMedGoogle Scholar
  • 35 Scott Jr HW, Neblett WW, O'Neill Jr JA, Sawyers JL, Avant GS, Starnes VA. Longitudinal pancreaticojejunostomy in chronic relapsing pancreatitis with onset in childhood. Ann Surg 1984; 199 (5) 610-622
    CrossrefPubMedGoogle Scholar
  • 36 Rebours V, Boutron-Ruault MC, Schnee M , et al. The natural history of hereditary pancreatitis: a national series. Gut 2009; 58 (1) 97-103
    CrossrefPubMedGoogle Scholar