Longitudinal Pancreaticojejunostomy (Puestow procedure)

Longitudinal pancreaticojejunostomy, also known as Puestow procedure, is a surgery done for the management of chronic pancreatitis symptoms such as severe abdominal pain.

The food you eat is digested by your gastrointestinal system (digestive system). 

Food from the mouth moves to the oesophagus (food pipe) and then to the stomach where it is turned into a paste-like consistency. Thereafter, it is passed into the small intestine that is divided into three sections - duodenum (initial part), jejunum (middle part), and ileum (end part). Here, the food gets digested, and the body absorbs nutrients from the small intestine. Food that cannot be digested is left as waste. From the ileum, the waste passes into the large intestine, from where it is expelled as stools through the anus (back passage).

The digestive system also includes the liver, pancreas, and gallbladder. The pancreas and liver produce digestive juices that help in the digestion process of different nutrients. The gallbladder does not produce digestive juices, but it stores the digestive juices produced by the liver and releases them when the food is eaten. 

Pancreas is a flat pear-shaped organ with the first part called the head, the central portion called the neck or body, and the thin end is known as the tail. Pancreatic juices that are required for digestion are released from the head of the pancreas into the junction between the stomach and duodenum. Along with the digestive juices, pancreas also produces hormones — insulin and glucagon — that control the blood sugar.

Inflammation of the pancreas due to the accumulation of pancreatic juices is known as pancreatitis. In this condition, the digestive juices start acting on and digesting the pancreatic tissues. Long term inflammation of the pancreas is called chronic pancreatitis. It may lead to pancreatic cancer if not controlled in time.

A longitudinal pancreaticojejunostomy is performed for the management of abdominal pain occuring due to chronic pancreatitis.  

Symptoms of chronic pancreatitis are as follows:

• Weight loss
• Abdominal pain
• Diabetes 
• Oily, smelly stools
• Vomiting
• Nausea

The following are some contraindications for longitudinal pancreaticojejunostomy:

• Suspected cancer
• Cirrhosis of the liver 
• Chronic pancreatitis with a pancreatic duct that is smaller than 5 mm
• Obstruction in a vein of the liver

The following preparations are needed before the surgery:

• Your doctor will conduct a physical examination and will ask you to get the following tests done:
  • Blood tests
  • Stool test
  • Abdominal ultrasound
  • Computed tomography (CT) scan
  • Magnetic resonance cholangiopancreatography (a type of magnetic resonance imaging technique used to view the pancreatic ducts)
  • Endoscopic ultrasound (a technique in which a tube with a camera is inserted into the stomach through the mouth to view the pancreas and other organs in the region)
  • Chest X-ray
  • Electrocardiogram (ECG)
• You will have to share the following details with the surgeon:
  • Your medical history 
  • Pregnancy status
  • A list of medicines that you take, including prescribed and non-prescribed drugs.
• Your surgeon will ask you to stop taking aspirin, warfarin, and other blood-thinning medicines a few days before the surgery.
• If you are a smoker, it is best to avoid smoking a few weeks (or as your doctor suggests) before the operation. This will help reduce the risk of complications associated with the surgery.
• You will have to fast from midnight prior to the operation.
• if you agree to the procedure, the medical staff will ask you to sign an approval form.
• Arrange for a family member, friend, or responsible adult to drive you home from the hospital after the surgery.

Once you are in the hospital, you will be given a hospital gown to wear. A nurse will give you special stockings or medicines to prevent blood clot formation in your legs. The medical staff will place an intravenous (IV) line in your arm to administer essential fluids and medicines during the surgery.

You will then be taken to the operating room where you will lie on a medical table. Different devices will be attached to you to detect your vitals, including your heart rate, oxygen levels, and blood pressure. The surgery is performed with general anaesthesia (a sleep-inducing medicine). After you fall asleep, a catheter (tube) will be inserted into your bladder to remove urine.

Longitudinal pancreaticojejunostomy may be performed by open, laparoscopic, or robotic methods.

The following steps are performed for open surgery:

• The surgeon will make a straight or curved incision (cut) on your abdomen. 
• He/she will examine your stomach and duodenum for ulcers and your gallbladder for stones. 
• Next, the surgeon will lift up your duodenum to examine the head of your pancreas. 
• He/she will place a cut along your pancreatic duct to divide the duct but leave the tip of the pancreatic tail.
• Next, the surgeon will remove any stones that may be present in your pancreatic duct. 
• He/she will make a long cut on your jejunum and connect the divided pancreatic duct to the opening in the jejunum with the help of sutures (anastomosis). 
• The surgeon will then place drainage tubes near the pancreaticojejunostomy, close the abdominal tissue with stitches and the incision with staples.

In a laparoscopic procedure, a few small cuts are made (instead of one large cut) on the abdomen. Through one of these cuts, the surgeon passes a tube with a camera to view the internal structures, and through the other openings, special tools are inserted to perform the surgery. 

Robotic surgery is an advancement to laparoscopic surgery, in that, it is done with special robotic tools that move the equipment and perform the surgery, and the viewing of the internal organs is magnified and three dimensional.

The surgery takes about two and a half hours. Once the procedure is over, the medical staff will move you to the recovery room and monitor your vital signs. When you wake up, you may feel pain, for which the nurse may provide medication. You will be asked to perform chest and lung exercises and encouraged to walk around after the surgery. You will need to take pancreatic enzyme therapy and get checked for diabetes. The catheter will be taken out after two days.

Initially, you will be given fluids through the IV, on the third day after the surgery, you will be able to eat food, and over the next few days, you will be able to take your regular diet. You will be discharged from the hospital after five days.

Some tips to keep in mind for self-care after longitudinal pancreaticojejunostomy are as follows:

• Medicines: You may need prescription pain medication initially, but as you feel better, your doctor may suggest you to take over-the-counter painkillers.
• Incision care: You should not apply any cream or ointment on the surgical area. Avoid any fabric or article of clothing that may irritate the skin at the incision site or around it. 
• Showering: You can take a shower each day. Wash the incision with mild soap and gently pat it to dry. Do not go for a swim or use a bathtub until the first follow-up visit.
• Diarrhoea: It occurs when your pancreas is not producing enough digestive enzymes. Your doctor may prescribe pancreatic enzyme therapy. 
• Exercises: Avoid lifting any heavy weights. You may perform activities like climbing stairs and walking to feel better. You may also be able to perform household chores like preparing basic meals and washing dishes. 
• Driving: Avoid driving while you are on pain medication. Your doctor will let you know when you can drive after the first follow-up.
• Diet: Due to the surgery, you may have difficulty in eating. Take small meals multiple times a day instead of three big meals. Increase your protein intake to help in healing. Take a good amount of fluids to keep yourself hydrated.
• Work: You may be able to resume work after about nine days.

When to see the doctor?

You may need to see the doctor in the following cases:

• Fever
• Vaginal bleeding
• Drainage from the operated area
• Redness or swelling at the incision site
• Increased pain
• Opening of the incision
• Nausea
• Vomiting 
• Constipation 
• Excessive sweating 
• Chills

Some of the complications of this surgery include:

• Infection 
• Fistula (channels) formation in the pancreas and intestines
• Bleeding in the stomach 
• Dark stools 
• The inability of the intestines to move and excrete the waste products for a prolonged time
• Anastomotic leakage
• Hernia

The follow-up will take place two weeks, three months, six months, and one year after discharge to determine if you have any abdominal pain, if your sugar was controlled, liver was functioning normally, if you had gained weight or had any local abdominal findings. The doctor will remove your staples and drains during the first follow-up visit.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.