Laparoscopic Puestow Procedure for Chronic Pancreatitis in Children.

Chronic pancreatitis (CP) is a sequelae characterized by recurrent attacks of pancreatitis leading on to fibrosis and calcification of both ductal and parenchymal elements of the pancreas. Most of these, if left untreated at the right time, will lead on to burnt-out pancreas with complete atrophy of the parenchyma, leading on to endocrine/exocrine insufficiency. The pain in such patients is most likely due to ductal hypertension, parenchymal hypertension, and head mass causing perineural inflammation. Puestow procedure (longitudinal pancreaticojejunostomy) is the surgery of choice in selected patients with ductal hypertension where decompression of the duct provides symptomatic relief. Performance of such procedures in children by minimal access laparoscopic method is still evolving. We report a series of three patients (aged 10, 12, and 16 years) diagnosed with CP and successfully managed by laparoscopic Puestow procedure. Copyright:

INTRODUCTION

While pancreatic illnesses are relatively rare in the pediatric population,[1] recurrent attacks of pancreatitis leading on to chronic pancreatitis (CP) sometimes require surgical intervention.

Laparoscopic surgery for pancreatic pathologies in children is relatively a premature field, in comparison to adults. In adults, minimally invasive technique for CP is a standard practice in most of the high-volume centers. Till date, there are only two reports of laparoscopic pancreaticojejunostomy in children for CP.[23] There is a nihilistic attitude that cripples laparoscopic management in children and is mainly due to limited working space, need for intracorporeal suturing, and difficult localization of the pancreatic duct (PD), which may require intraoperative laparoscopic ultrasound probe for localization. Of course, the most dreaded postoperative complication is a pancreatic leak. All these hurdles can be overcome by proper patient selection, preoperative imaging, use of correct instrumentation, and postoperative care with monitoring of drain output levels. We report three of our cases of CP managed by laparoscopic pancreaticojejunostomy.

CASE REPORT

Three patients aged 10, 12, and 16 years, respectively, were diagnosed to have CP. Each of the three patients who had 2–3 years' history of recurrent attacks of abdomen pain were diagnosed to have CP which required multiple admissions. They were evaluated for congenital anatomical anomalies such as pancreas divisum, hereditary causes, and endocrine and exocrine deficiencies of the pancreas. No exact cause was determined; hence, they were branded as idiopathic pancreatitis.

Imaging [Figure 1] in the form of either contrast-enhanced computerized tomography (CECT) of the abdomen or magnetic resonance cholangiopancreatography (MRCP) was preferred. Two patients underwent CECT abdomen and one underwent MRCP to establish the diagnosis. All three patients had a dilated PD (0.9 cm, 1.0 cm, and 1.1 cm diameter, respectively) with intraductal stones and intraparenchymal calcifications.

Figure 1

Contrast-enhanced computerized tomography (image on the left) and magnetic resonance cholangiopancreatography image showing dilated pancreatic duct with multiple intraductal calculi

The cases were operated under general anesthesia, in the supine position with legs spread out and the primary operating surgeon standing between the legs. With a slight reverse Trendelenburg tilt, 10-mm optical port in the umbilicus was made and two 5-mm lateral working pararectal ports slightly above the level of umbilicus in the midclavicular line were introduced under vision. Pneumoperitoneum using carbondioxide was created at 10–12 mmHg.

As a first step, lesser sac was entered, by opening the gastrocolic omentum with harmonic scalpel. A silk stitch was taken on the posterior aspect of the stomach and was anchored to the anterior abdominal wall to facilitate retraction. Following which, the anterior, superior and inferior surfaces of the pancreas were bared of omental attachments and surrounding soft tissues were cleared. Localization of the PD is the rate-limiting step in the entire procedure. In our series, the PD was identified with a needle-tip suction cautery. In two cases, PD was quite easily identified due to its prominence of the ductal calculi in an otherwise atrophic and calcified pancreas. In one case, a vertical cut was made in the mid-body region, staying well away from the superior mesenteric artery and superior mesenteric vein, which led us to identify the duct. The PD was completely laid open with electrocautery from the head region till the tail after identification. The PD was flushed with saline after removing all the intraductal stones [Figure 2].

Figure 2

Laparoscopic stone extraction from the pancreatic duct (image on the left) and completed single-layer continuous side-to-side pancreaticojejunostomy

A 40cm Roux limb was brought retrocolic and otomy on the jejunum was made using monopolar hook, corresponding to the length of the opened out pancreatic duct. A single-layer side-to-side pancreaticojejunostomy was done using 3-0 Mersilk from the pancreatic head to the tail [Figure 2].

The umbilical incision was increased by 1 to 2 cm, and the jejunojejunostomy was done extracorporeally handsewn in two layers with 3-0 Vicryl. A tube drain was placed in the lesser sac in all three cases.

All patients were operated by the same surgeon. The results are summarized in Table 1. All three patients are on follow-up till date.

Table 1

Outcomes in our series of Laparoscopic Puestow’s procedure

Parameters	Case 1	Case 2	Case 3	Mean
Mean operating time (min)	130	120	130	126
Average blood loss (ml)	20	25	30	25
Postoperative pain management	IV to oral paracetamol on day 3	IV to oral paracetamol on day 3	IV to oral paracetamol on day 3	IV to oral paracetamol on day 3
Mean hospital stay (days)	6	7	6	6.5
Cosmetic satisfaction	Excellent	Excellent	Excellent	Excellent
Postoperative complication	Nil	Nil	Re-admission for pain abdomen - managed conservative	One patient with pain abdomen requiring re admission
Time required to start oral feeds	POD 4	POD 4	POD 4	POD 4
Drain removal	POD 5	POD 5	POD 5	POD 5
Follow-up (months)	28	32	24	16
Recurrence	-	-	-	Nil

IV: Intravenous, POD: Postoperative day

DISCUSSION

The first performed laparoscopic pancreaticojejunostomy was reported in adults by Kurian and Gagner, following which there were a lot of modifications in the technique, and now, it has been widely accepted standard practice.

The most common symptom of CP in children is abdomen pain. Epigastric pain in CP is attributed to increased intraductal pressure due to obstruction by calculi in children.

As per the International Study Group of Pediatric Pancreatitis: In Search of a Cure (INSPPIRE) consortium, CP requires at least one of the following three criteria:[4]

Abdominal pain consistent with pancreatic origin and imaging findings suggestive of CP damage

Evidence of exocrine pancreatic insufficiency and suggestive pancreatic imaging findings

Evidence of endocrine pancreatic insufficiency and suggestive pancreatic imaging findings or

Surgical or pancreatic biopsy specimen demonstrating histopathologic features compatible with CP.

All our patients fulfilled the first criteria.

As per the International draft consensus,[5] CP is defined as “a continuing inflammatory disease of the pancreas, characterized by irreversible morphological change, and typically causing pain and/or permanent loss of function.”

In CP, there are morphological alterations such as fibrosis, calcifications, and pseudocysts formation. If left untreated, it will lead on to severe endocrine and exocrine insufficiencies. There are multiple options to treat CP depending on the morphology of the gland. Endoscopic management such as endoscopic retrograde cholangiopancreatography (ERCP) and PD stenting is reported earlier. Different surgical options (resective and decompressive) such as cystoenterostomy, Frey's procedure, Puestow procedure, Whipple procedure, Duval's procedure, and distal pancreatectomy procedure are described.

Laparoscopic side-to-side pancreaticojejunostomy in children is reported in two small case series and one robotic case report.[23] Deie et al. reported two patients with CP, who underwent ERCP and stenting of PD in the initial management. Both patients underwent side-to-side pancreaticojejunostomy as a definitive procedure. The mean postoperative hospital stay in our series was 6.5 days which is comparable to that in published literature. The jejunojejunostomy was performed extracorporeally by extending the umbilical incision.

Another series of laparoscopic side-to-side pancreaticojejunostomy by Zhang JS et al. had four boys aged between 6 and 12 years.[2] All patients were diagnosed to have sludge causing PD obstruction for which laparoscopic pancreaticojejunostomy was performed. In contrast to previous studies, we encountered intraductal calculi in all three patients causing obstruction. Both the previous series had excellent cosmetic results and no complications in the postoperative period. There was no recurrence of pancreatitis up to 3-year follow-up. On comparison with other series, our results match with regard to operating time, blood loss, pain relief, cosmetic outcome, and overall hospital stay.

CONCLUSION

Laparoscopic single-layer longitudinal pancreaticojejunostomy in children is a safe and effective option in select patients. Our patients experienced the additional advantages of minimal postoperative pain, excellent cosmesis and early discharge from the hospital. Our initial experience of laparoscopic pancreaticojejunostomy in children has shown promising results, in terms of adequate drainage of the pancreatic duct, operating times being comparable to the open procedure, and no recurrence till the 3 year follow up period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.