Laparoscopic side-to-side pancreaticojejunostomy for chronic pancreatitis in children.

Surgical pancreatic duct (PD) drainage for chronic pancreatitis in children is relatively rare. It is indicated in cases of recurrent pancreatitis and PD dilatation that have not responded to medical therapy and therapeutic endoscopy. We performed laparoscopic side-to-side pancreaticojejunostomy for two paediatric patients with chronic pancreatitis. The main PD was opened easily by electrocautery after locating the dilated PD by intraoperative ultrasonography. The dilated PD was split longitudinally from the pancreatic tail to the pancreatic head by laparoscopic coagulation shears or electrocautery after pancreatography. A laparoscopic side-to-side pancreaticojejunostomy was performed by a one-layered technique using continuous 4-0 polydioxanone (PDS) sutures from the pancreatic tail to the pancreatic head. There were no intraoperative or postoperative complications or recurrences. This procedure has cosmetic advantages compared with open surgery for chronic pancreatitis. Laparoscopic side-to-side pancreaticojejunostomy in children is feasible and effective for the treatment of chronic pancreatitis.

INTRODUCTION

Laparoscopic surgery for the pancreas is a relatively immature field in comparison with that for other organs. Techniques in pancreatic surgery are not easy, and few paediatric patients have indications for such surgery. In adult patients, laparoscopic side-to-side pancreaticojejunostomy was reported to achieve similar symptomatic relief and a shorter hospital stay in comparison with conventional pancreaticojejunostomy.[12] Previously, there has been only one report about laparoscopic pancreaticojejunostomy for the treatment of pancreatic duct (PD) dilatation in children.[3] In this report, we describe our surgical technique and the outcome of laparoscopic pancreaticojejunostomy for chronic pancreatitis in two children.

CASE REPORTS

Case 1

A 13-year-old boy had been admitted to the hospital more than ten times for recurrent pancreatitis since the age of 3 years. Medical therapy was not effective. Endoscopic sphincterotomy (EST) and the insertion of a PD stent were performed with no relief for this chronic pancreatitis. Endoscopic retrograde pancreatography (ERP) revealed dilation (7 mm) and tortuosity of the main PD [Figure 1a].

Figure 1

(a) Preoperative endoscopic retrograde pancreatography (ERP) in Case 1, which revealed dilation and tortuosity of the main pancreatic duct (→) and dilatation of the branching pancreatic duct (b) Preoperative endoscopic retrograde pancreatography (ERP) in Case 2, which revealed pancreas divisum and dilatation (→) and stenosis of the main pancreatic duct (c) Intraoperative ultrasonography under laparoscopic side-to-side pancreaticojejunostomy in Case 1 (d) Dilated pancreatic duct was split longitudinally from the pancreatic head to the pancreatic tail in Case 1 (→)

Case 2

A 6-year-old girl had been repeatedly admitted to the hospital for recurrent pancreatitis over the 2 previous years. Ultrasonography and ERP revealed pancreas divisum and dilatation of the main PD [Figure 1b]. Although the patient was managed medically and a PD stent was inserted via endoscopy, she experienced repeated pancreatitis after this treatment.

Because the diagnosis of chronic pancreatitis was made in the early stage, treatment by surgical PD drainage was administered in both patients. Under general anaesthesia, the patient was placed in supine position with the legs spread out and the surgeon standing between the patient's legs. Carbon dioxide pneumoperitoneum was set at 8-12 mmHg.

A multiport device was inserted through the umbilical Benz incision that can provide a wide enough fascial opening with minimal aesthetic effects.[4] A 12-mm port for a camera and ultrasound probe was inserted via the umbilical Benz incision. A 5-mm port was inserted into both sides of the abdomen as working ports and another was inserted into the left upper quadrant of the abdomen as a supporting port. In Case 1, an additional 5-mm port was inserted into the right upper quadrant of the abdomen.

The stomach was lifted up and sutured to the abdominal wall. The gastrocolic ligament was divided widely by laparoscopic coagulation shears (LCS). After locating the dilated PD by intraoperative ultrasonography [Figure 1c], the main PD was opened by electrocautery. Pancreatography was performed by the catheter to delineate the whole PD. The dilated PD was split longitudinally from the pancreatic tail to the pancreatic head by LCS or electrocautery [Figure 1d]. Roux-en-Y jejunojejunostomy was performed and the Roux limb was brought via the retrocolic route extracorporeally.

A laparoscopic side-to-side pancreaticojejunostomy was performed by a one-layered technique using continuous 4-0 polydioxanone (PDS) sutures from the pancreatic tail to the pancreatic head.

The laparoscopic side-to-side pancreaticojejunostomy was completely performed in both cases. There were no intraoperative and postoperative complications. The postoperative hospital stay was 9 days in Case 1 and 14 days in Case 2. There was no recurrence of pancreatitis postoperatively during the 2-year follow-up. The dilatation of the PD was improved to 2 mm in both cases.

DISCUSSION

Chronic pancreatitis in children has various etiologies such as idiopathy (Case 1), heredity and congenital anatomical anomalies such as pancreas divisum (Case 2).[5] The first treatment in children consists of medical therapy and dietary restrictions. If those are ineffective, endoscopic treatments such as EST and the insertion of a PD stent should be tried. In a certain number of cases, the pancreatitis recurs repeatedly. Surgical PD drainage is indicated in those cases.

Using laparoscopic ultrasonography, the main PD was easily detected and opened. Furthermore, the dilated PD was split safely from the pancreatic head to the pancreatic tail under intraoperative pancreatography. Laparoscopic single layer and continuous side-to-side anastomosis can be performed fairly easily by changing working ports so that the approach can be made from another angle. It was reported that single-layer anastomosis was not associated with a PD leak and is safe and comparable to two-layer anastomosis.[3]

Laparoscopic side-to-side pancreaticojejunostomy in children with chronic pancreatitis is feasible and effective and provides cosmetic advantages, when it is performed or supported by experienced laparoscopic surgeons. Our series is only 2 cases and our follow-up is notable but not long enough to define our procedure as curative. Further experience in laparoscopic side-to-side pancreaticojejunostomy and longer observation periods are needed to confirm our conclusion.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

We have no financial relationships to disclose.