CBD and Pancreatic duct obstruction - Forum

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Resident

CBD and Pancreatic duct obstruction - Ärzteforum

Post#1 »

A question of technique: When confronted with a chronic pancreatitis with CBD and pancreatic duct obstruction resulting in chronic pain, how would the for-surgeons.com community approach reconstruction/ drainage if the duodenum can not be sufficiently mobilized to perform a choledolchoduodenostomy?


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Resident

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#2 »

Answer: Pancreaticoduodenctomy!

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Surgeon

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#3 »

If the pain is significant-i.e. prolonged and requires narcotics- the management of choice would be the resection of the pancreatic head. Beger's or Fry's modifications of Whipple's are to be preferred.

Grandpa Phil

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#4 »

First, very unlikely you cannot mobilize duodenum enough (i.e. very little needed) to perform a choledochoduodenosomy--sounds typical of a resident--I used to do it too--to start imagining scenarios which really do not coincide with reality--once your there more often that practice will abate Anyway, there are plenty of other easy options--swing up a Roux-Y segment of jejunum to do a choledochojejunostomy Even easier--do a loop cholecystojejunostomy--nothing could be easier, assuming there is still an undiseased gallbladder.

Hans

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#5 »

We try to do the simplest operation possible, so do only what we must - choledocho jejunostomy is simple, and can (I would only do this with a very dilated pancreatic duct and pain clearly related to meals) be plumbed into the pancreatic duct and even stomach if gastric outlet obstruction. I would avoid doing ANY major resectional surgery on chronic alcoholics. I don't think the presence of an enlarged duct is reason to operate, or elevated liver enzymes - only jaundice - as this will lead to secondary biliary cirrhosis if left. I would only operate for pain if clearly meal related and a dilated pancreatic duct or persistent pseudocyst.

Hans

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#6 »

Just a note of caution in using a cholecyst jejunostomy in chronic pancreatitis where the patient may be expected to survive for a long time - strictures at the anastamosis are not infrequent. I saw two myself whilst working in Durban - I was trying to find the article my boss at that time (Sandie Thomson) published on it - but failed. He if memory serves correct had documented about 7 in a few years of study.

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Doctor Green

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#7 »

Stricture has nothing to do with whether it is jejunal or duodenal--it seems even you are unaware that it is due simply to how you construct the anastomosis--it should never be done side-to-side in the standard parallel fashion, but only in the perpendicular fashion like we do pyloroplasties--in this way, the anastomosis can not stricture.

Noro

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#8 »

Cholecysto-jejunostomy (C-J) is recognized as an inferior (although acceptable) option for bile-enteric anastomosis in malignant disease. It functions for a year- at most- until the patient succumbs to his/her cancer.

There is no published experience- that I know about- with C-J in benign disease. It is plausible, however, that such bypass will be affected by stasis-lithiasis -leading to infection and jaundice. I doubt whether C-J should be offered as a biliary bypass to patients assumed to survive beyond a year or two.

In a young and fit patient with chronic pancreatitis- the subject of this discussion- C-J is therefore far than ideal option.

Now to the issue of anastomotic strictures. It is my understanding that a bowel-bile anastomosis will remain patent for ever if:

1. there is accurate mucosa to mucosa apposition
2. there is no tension
3. the blood supply of the bowel and bile duct (GB) is adequate
4. the lumen is adequate

If constructed as above it could be end to end, end to side, side to side, corner to corner, corner to side- who cares! Thus, I do not accept the above mentioned neo-hypothesis by our esteemed friend Er. I call upon him to provide some support for his claim.

Now Iain. I have heard much about your ex Boss and I believe him to be a very fine surgeon. I do not believe however that the strictures in C-J anastomoses developed in his own patients. I do not believe that such strictures would have developed in technically adequate anastomoses. Instead, I contend that those strictures developed in too narrow anastomoses, inverting huge amount of tissue with coarse sutures, by junior residents -in the absence of adequate supervision. You and me, Iain, know that such scenario was and is real in some places.

Gemcitabine

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#9 »

Perhaps the anastomotic strictures Ian was talking about were really cystic duct stenoses (or cystic duct occlusions whatever) causing non-function of the anastomosis. It is hard for me to believe that any anastomosis (originally of adequate size) no matter how poorly done between the gallbladder and jejunum could stricture enough to prevent passage of bile through it. The gallbladder and jejunum are both large compared to the bile ducts, which carry bile perfectly adequately--consider for example, the small terminal common bile duct--much smaller than either the gallbladder or jejunum.

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Old surgeon

Re: CBD and Pancreatic duct obstruction - Ärzteforum

Post#10 »

A number of articles in the 1970's showed the higher rate of stricture of parallel side-to-side anastomoses of jejunum to CBD, presumably because the stoma tends to collapse on itself and grow together--by putting the two longitudinal incisions in the jejunum and CBD perpendicular to each other, sewing the middle of the jejunal incision to the superior corner of the CBD incision, etc (just like I would hope we all do in a duodenum to CBD anastomosis, and similar to how we sew a Heinecke-Mikulicz pyloroplasty), the stoma is forced to remain open, and the studies show this to be true in a virtually 0 incidence of stricture. I don't have these studies handy, but this is described in Fromm's text on GI surgery, and I will look them up for your information--it's not often I get to educate you! But another point--in one sentence you admit no knowledge of long-term outcome for C-J anastomosis in benign disease, but then inexplicably call it inferior--how do you justify this?

In fact, I try to avoid C-J anastomosis as much as I can, but this has nothing to do with its natural history (which I maintain is as good as any other CBD- enteric anastomosis--cancer also tends to stricture CBD-duodenum anastomoses) but with the extra time and suture lines required to construct it, and I just find it to be more awkward to perform.

I also disagree with those recommending pancreatic resection in this setting--first bypass the demonstrated CBD obstruction, which is much simpler for surgeon and patient, because that will likely take care of the problem and save those patients a life-threatening procedure. If chronic pain continues, and the pancreatic duct is dilated, a Puestow pancreato-jejunostomy is the procedure of choice, with a high likelihood of success, and a much nicer procedure than Child's pancreatic resection (yekk!) I would honestly like to know if those recommending the latter still really do that outmoded surgery, or if your just parroting your interpretation of some outdated textbooks? My impression is that that procedure is no longer indicated, in view of it's high mortality/morbidity for such small if any gain.

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