Puestow Procedure for the Management of Pediatric Chronic Pancreatitis

Abstract

Objective Recurrent pancreatitis significantly impacts childhood development and quality of life. Our goal was to evaluate the efficacy of the Puestow procedure.

Materials and Methods After obtaining the Institutional Review Board approval, we reviewed the charts of all patients who underwent lateral pancreaticojejunostomy from January 1999 to January 2014. Statistical analysis was performed using paired Student's t-test and Fisher's exact test as appropriate.

Results During the 15-year study period, 13 patients underwent a lateral pancreaticojejunostomy for chronic pancreatitis. The most common causes of pancreatitis were hereditary (n = 5) or obstructive (n = 5); pancreas divisum (n = 2), one iatrogenic stricture, one idiopathic stricture, and one unresectable pancreatic head mass); two patients had idiopathic disease, and one case was drug-induced. Six patients had failed management with endoscopic retrograde cholangiopancreatography and pancreatic duct stenting. Preoperatively, the median body mass index (BMI) percentile-for-age was 61.0% (range 11.0–99.0%). Median age at operation was 12.8 years (range 7.7–16.7). There were no deaths, four patients developed postoperative ileus, and one patient developed an intra-abdominal abscess, which resolved with antibiotics. Median postoperative length of stay was 7 days (range 5–15).

Two patients were lost to follow-up; median follow-up for the remaining 12 patients was 35.5 months (range 4.9–131.2). Four patients were readmitted within 90 days: three due to abdominal pain which were not recurrences of pancreatitis, and one due to complications of chemotherapy. Postoperatively, there was no change in the average BMI percentile-for-age (p = 0.64). Seven patients reported resolution or significant improvement in their abdominal pain symptoms at the time of last follow-up. Patients with obstructive causes of pancreatitis were not more likely to experience relief than those with nonobstructive causes (42.9 vs. 80.0%, p = 0.29).

Conclusion In our experience, lateral pancreaticojejunostomy results in durable improvement or resolution of abdominal pain symptoms in nearly 60% of patients with chronic pancreatitis regardless of etiology.

Keywords

chronic pancreatitis - pediatrics - lateral pancreaticojejunostomy - Puestow

• References

• 1 Clifton MS, Pelayo JC, Cortes RA. , et al. Surgical treatment of childhood recurrent pancreatitis. J Pediatr Surg 2007; 42 (07) 1203-1207
• 2 Adzick NS. The pancreas. In: Coran AG, Adzick NS. , T.M K, et al., eds. Pediatric Surgery. Philadelphia, PA: Mosby; 2012: 1371-1384
• 3 Partington PF, Rochelle RE. Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 1960; 152: 1037-1043
• 4 Center for Disease Control and Prevention; BMI Percentile Calculator for Child and Teen, 2015. Available at: https://nccd.cdc.gov/DNPABMI/Calculator.aspx . Accessed September 20, 2017
• 5 Kargl S, Kienbauer M, Duba HC, Schöfl R, Pumberger W. Therapeutic step-up strategy for management of hereditary pancreatitis in children. J Pediatr Surg 2015; 50 (04) 511-514
• 6 Wilson GC, Sutton JM, Salehi M. , et al. Surgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients. Surgery 2013; 154 (04) 777-783
• 7 O'Neill Jr JA, Greene H, Grishan FK. Surgical implications of chronic pancreatitis. J Pediatr Surg 1982; 17 (06) 920-926
• 8 Laje P, Adzick NS. Modified Puestow procedure for the management of chronic pancreatitis in children. J Pediatr Surg 2013; 48 (11) 2271-2275
• 9 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 (02) 343-348
• 10 Schwarzenberg SJ, Bellin M, Husain SZ. , et al. Pediatric chronic pancreatitis is associated with genetic risk factors and substantial disease burden. J Pediatr 2015; 166 (04) 890-896.e1
• 11 Andersen DK, Frey CF. The evolution of the surgical treatment of chronic pancreatitis. Ann Surg 2010; 251 (01) 18-32
• 12 Nealon WH, Townsend Jr CM, Thompson JC. Operative drainage of the pancreatic duct delays functional impairment in patients with chronic pancreatitis. A prospective analysis. Ann Surg 1988; 208 (03) 321-329
• 13 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 (01) 139-143
• 14 Azhari H, Rahhal R, Uc A. Is total pancreatectomy with islet autotransplantation a reasonable choice for pediatric pancreatitis?. JOP 2015; 16 (04) 335-341
• 15 Rork JF, Berde CB, Goldstein RD. Regional anesthesia approaches to pain management in pediatric palliative care: a review of current knowledge. J Pain Symptom Manage 2013; 46 (06) 859-873
• 16 Varni JW, Bendo CB, Nurko S. , et al; Pediatric Quality of Life Inventory (PedsQL) Gastrointestinal Symptoms Module Testing Study Consortium. Health-related quality of life in pediatric patients with functional and organic gastrointestinal diseases. J Pediatr 2015; 166 (01) 85-90
• 17 Crombleholme TM, deLorimier AA, Way LW, Adzick NS, Longaker MT, Harrison MR. The modified Puestow procedure for chronic relapsing pancreatitis in children. J Pediatr Surg 1990; 25 (07) 749-754