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Roux-en-Y Lateral pancreaticojejunostomy

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Presentation on theme: "Roux-en-Y Lateral pancreaticojejunostomy"— Presentation transcript:

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.

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