Pancreatic head resection alongside side-to-side pancreatic duct-jejunostomy for pancreatic stones: A case report and review of literature

Abstract

BACKGROUND

Pancreatic duct stones often develop in the late stage of chronic pancreatitis. However, for complex pancreatic duct stones or stones in the pancreatic body and tail, endoscopic treatment is often ineffective and ultimately requires surgical intervention.

CASE SUMMARY

A young man who had been smoking for 10 years and drinking alcohol for 5 years had a history of abdominal pain for 8 years and diarrhea for 2 years. The patient was diagnosed with “chronic pancreatitis combined with pancreatic duct stones” in other hospitals and underwent several endoscopic treatments, but the abdominal pain still recurred. The patient presented to our hospital one week after another episode of abdominal pain. Our team arranged for computed tomography and magnetic resonance imaging examinations, which revealed a markedly atrophic pancreas and a dilated pancreatic duct, and a large number of stones. Our team convened a multidisciplinary consultation to discuss treatment options and reviewed extensive literature. Ultimately, based on the literature and consultation advice, we implemented a novel, previously unreported surgical procedure. The surgical approach we proposed combines the Beger procedure and the Frey procedure, involving complete pancreatic head resection with duodenal preservation, full-length longitudinal incision of the pancreatic duct in the body and tail, and side-to-side pancreaticojejunostomy. Postoperative follow-up revealed a favorable prognosis.

CONCLUSION

The main contribution of this case is the development of a modified surgical procedure for chronic pancreatitis complicated by complex pancreatic duct stones. For chronic pancreatitis complicated by stones that respond poorly to pharmacotherapy or endoscopic treatment, surgery is a worthy early treatment option. Early surgical intervention can effectively drain pancreatic juice, delay pancreatic atrophy, and protect pancreatic function. Our proposed modified procedure can more thoroughly remove stones and reduce the recurrence rate of stones and pain. Although we successfully treated a patient with this procedure for the first time, its efficacy and safety in a human population are currently lacking validation.

Key Words: Pancreatic duct stone; Surgical treatment; Intraoperative endoscopic lithotomy; Side-to-side pancreaticojejunostomy; Case report

Core Tip: This case report detailed the development of a novel surgical approach by our team for the treatment of pancreatic duct stones, drawing on the contributions of previous researchers. For patients with multiple pancreatic duct stones complicated by pancreatic duct dilatation, this surgical approach can maximize the removal of pancreatic duct stones, reduce the risk of stone recurrence, and alleviate postoperative pain.

INTRODUCTION

Pancreatic duct stones are mainly manifested in patients with chronic pancreatitis[1]. Chronic pancreatitis is caused by a variety of factors. Its pathological and morphological characteristics include chronic, persistent inflammatory damage to the pancreatic parenchyma, irreversible fibrosis, and irreversible changes, such as pancreatic duct dilatation, pancreatic calcification, or formation of pancreatic duct stones. These changes can lead to both pancreatic endocrine and exocrine insufficiency[2-4]. The main clinical manifestations of chronic pancreatitis are persistent abdominal pain, steatorrhea, diabetes, and weight loss. If pancreatic head stones are accompanied by inflammatory masses, they may compress the bile duct and cause biliary obstruction[5,6]. A small number of patients may develop splenic vein thrombosis, showing symptoms of regional portal hypertension, such as splenomegaly and esophageal varices[7]. Impacted stones in the pancreatic duct are commonly associated with pancreatic duct stenosis, impaired drainage of pancreatic secretions, and pancreatic duct hypertension, which are considered the principal etiological factors for the aforementioned symptoms. Additionally, prolonged chronic inflammation has been implicated in the development of secondary malignancies[8].

Endoscopic techniques, such as endoscopic retrograde cholangiopancreatography (ERCP), play an increasingly vital role in managing chronic pancreatitis complicated by pancreatic duct stones[5]. However, owing to the presence of severe pancreatic duct stenosis or complete occlusion, ductal variations, and extensive, calcified pancreatic duct stones, some patients with pancreatic duct stones may still require surgical treatment[9]. Depending on the pancreatic duct pathology and stone distribution, different surgical approaches can be applied. Some of these procedures are principally designed for drainage, such as the Partington and Puestow procedures; others primarily concentrate on resection, such as the Whipple and Beger procedures; and some, such as the Frey procedure, combine both resection and drainage. Each of these surgical approaches possesses its own advantages and limitations[10].

This study reports a case of chronic pancreatitis complicated by pancreatic duct stones who underwent duodenum-preserving total pancreatic head resection, combined with complete incision of the pancreatic duct in the body and tail, and side-to-side pancreaticojejunostomy. This approach successfully achieved both lesion resection and adequate drainage of the pancreatic duct, resulting in excellent therapeutic outcomes. This surgical technique, pioneered by our team, has not been previously reported. Additionally, a literature review provides a comparative analysis of this novel approach with traditional surgical methods, systematically discussing their respective advantages, disadvantages, and areas of application.

CASE PRESENTATION

Chief complaints

A 24-year-old unmarried man was admitted to our hospital with severe abdominal pain for one week.

History of present illness

The patient had a 10-year history of smoking and a 5-year history of alcohol abuse, with an average daily intake of approximately 200 g of Chinese liquor. The primary concern is recurrent epigastric pain, which has been ongoing for 8 years, and chronic diarrhea has persisted for approximately 2 years. The patient has sought medical attention at several hospitals due to the exacerbation of pain. Diagnostic evaluations demonstrated a diagnosis of chronic pancreatitis with pancreatic duct stones, and the patient has undergone six ERCP procedures and pancreatic duct stone removal at external institutions. However, each time the patient presented with pain, new pancreatic duct stones were identified, which had developed after the previous stone removal. Furthermore, there was progressive dilation of the pancreatic duct, accompanied by atrophy of the pancreatic parenchyma. One week prior, the patient presented to our hospital with significantly worsened abdominal pain. The pain was persistent and dull in nature, and although the diarrhea had not worsened, the patient reported no other complaints.

History of past illness

The patient had been hospitalized multiple times in the past, but no disease was diagnosed except for pancreatic duct stones.

Personal and family history

The patient denied any other medical history or family history of genetic disorders.

Physical examination

On admission, the patient’s vital signs were normal, his body mass index was within normal limits, and only diffuse, mild abdominal tenderness was noted.

Laboratory examinations

A complete blood biochemistry test revealed a serum amylase level of 152 U/L (normal range: 25-125 U/L, enzyme-coupled assay). No other significant abnormalities were found.

Imaging examinations

Computed tomography (CT) scan revealed remarkable pancreatic atrophy and a prominent dilatation of the main pancreatic duct, reaching 1.6 cm. Multiple high-density stones were observed in the main pancreatic duct and pancreatic parenchyma. Magnetic resonance imaging confirmed the presence of pancreatic duct dilation, approximately 1.5 cm at its widest point. Multiple nodular filling defects were identified in the main pancreatic duct, and their largest reached a diameter of 1.2 cm (Figure 1).

Figure 1 Preoperative and postoperative imaging images. A: Preoperative plain computed tomography (CT) scan. As indicated by the orange arrows, high-density stones were predominantly located in the pancreatic duct of the pancreatic head; B: Preoperative plain CT scan. As indicated by the orange arrows, multiple high-density stones were scattered in the main pancreatic duct of the pancreatic body and tail; C: Preoperative coronal contrast-enhanced CT scan of the pancreatic head. As indicated by the orange arrows, high-density stones were scattered in the pancreatic duct and pancreatic parenchyma; D: Postoperative plain CT scan of the pancreatic head; E: Postoperative plain CT scan of the pancreatic body and tail; F: Postoperative plain CT scan of the anastomosis. As shown by the orange arrow, no pancreatic duct stones were found at the pancreatic duct-jejunostomy; G: T2-weighted magnetic resonance imaging (MRI) scan of the pancreatic head. As indicated by the orange arrows, a nodular filling defect is observed in the pancreatic duct; H: T2-weighted MRI scan of the pancreatic body. As indicated by the orange arrows, multiple nodular filling defects are observed in the pancreatic duct; I: MRI shows multiple low-intensity signal nodules in the main pancreatic duct.

FINAL DIAGNOSIS

The patient was diagnosed with chronic pancreatitis combined with multiple pancreatic duct stones.

TREATMENT

Utilizing imaging examinations, numerous stones were lodged in the main pancreatic duct and the uncinate duct in the pancreatic head, and additional stones were scattered throughout the pancreatic body and tail. The patient has experienced recurrent abdominal pain for the past 8 years and has undergone multiple ERCP procedures with limited success. Currently, significant atrophy of the pancreatic parenchyma is present. After a multidisciplinary team consultation, it was decided that surgical intervention was necessary due to the patient’s ongoing symptoms and the condition of the pancreas. The primary objectives of the surgery are to alleviate the patient’s symptoms and remove as several stones as possible, preserving the function of the remaining pancreatic tissue (Figure 2). The planned surgical approach included: (1) Complete resection of the pancreatic head with preservation of the duodenum and bile duct (Figure 2A); (2) Full opening of the pancreatic duct in the body and tail to remove stones, followed by a side-to-side anastomosis with the jejunum (Figure 2B); and (3) Intraoperative choledochoscopy (CHF-V; Olympus, Tokyo, Japan) to facilitate complete stone removal and minimize the risk of residual stones.

Figure 2 Intraoperative field of view and postoperative specimen. A: The pancreatic head has been fully resected. As indicated by the large oval, the pancreatic duct in the body and tail has been fully opened longitudinally. The pancreatic parenchyma is atrophic and thin, and the duodenum (indicated by the small oval) is visible below; B: The white oval indicates the pancreatic duct-jejunal anastomosis, with the stump of the main pancreatic duct identifiable on the right side (indicated by the white arrow). The common bile duct remains intact (indicated by the blue arrow) and flows into the duodenum; C: Postoperative specimen. Bracket 1 indicates the intact pancreatic head, and bracket 2 represents the stones removed intraoperatively; D: Pathological hematoxylin and eosin staining of pancreatic head specimen postoperatively.

Postoperative pathology revealed cystic dilatation of the pancreatic duct, periductal fibrosis, and chronic inflammatory cell infiltration. Pancreatic tissue degeneration, glandular atrophy, and interstitial fibrosis were also identified, thereby confirming chronic pancreatitis (Figure 2D). Postoperative blood biochemistry monitoring revealed transient leukocytosis and elevated serum amylase level, peaking on the first day after surgery and returning to normal after one week. The patient’s blood sugar remained normal postoperatively.

OUTCOME AND FOLLOW-UP

One year after surgery, the patient’s abdominal pain was completely resolved. The follow-up CT scan demonstrated complete stone removal with no recurrence (Figure 1D and E). Compared with the preoperative level, the patient’s postoperative follow-up showed normal serum amylase and blood glucose levels.

DISCUSSION

Pancreatic duct stones are a late complication of chronic pancreatitis, and approximately 50%-90% of patients with chronic pancreatitis may develop pancreatic duct stones[1,11]. The pathogenesis of pancreatic duct stones is multifactorial, with primary associations to abnormal pancreatic anatomy and metabolism[2-4]. Stones primarily form in the pancreatic duct, while they can also be found in duct branches and the pancreatic parenchyma. Their primary clinical manifestation is abdominal pain, with some patients experiencing diarrhea, weight loss, and even diabetes[12,13]. Conservative management and endoscopic interventions are the cornerstone of the treatment of pancreatic duct stones[14]. A limitation of endoscopy is that complex stones may require frequent invasive endoscopic procedures[15,16]. Without addressing the underlying cause of the disease, a chronic course increases the risk of acute exacerbations of pancreatitis and also poses long-term nutritional risks[8].

The patient had previously undergone 6 ERCP-guided stone removal procedures or endoscopic treatments at other hospitals. CT and magnetic resonance imaging examinations, performed at the time of the presentation, revealed remarkable dilatation of the main pancreatic duct, multiple calculi of varying sizes, and a thin pancreatic parenchyma. Furthermore, the patient presented with recurrent abdominal pain and chronic diarrhea, demonstrating that endoscopic treatment had failed. Surgical interventions have been employed to alleviate pain, including procedures aimed at disrupting visceral nerve pathways, such as severing the sympathetic or vagus nerves. While these procedures often provide short-term pain relief, they do not address the underlying problem, and pain gradually returns to pre-operative levels[17-19]. Nerve blocks can provide short-term pain relief; however, they often necessitate frequent repeat treatments[20].

The main cause of abdominal pain caused by pancreatic duct stones is obstruction of the pancreatic duct by stones, impeding pancreatic fluid drainage and increasing pressure in the distal pancreatic duct. As a result, some researchers have proposed surgical drainage of pancreatic fluid to mitigate pain. Duval[21] was the first to implement a surgical procedure for chronic pancreatitis associated with pancreatic duct stones, involving resecting the pancreatic tail and spleen, followed by an end-to-end anastomosis between the pancreatic duct and jejunum. However, this procedure lacked adequate treatment of pancreatic duct lesions, leading to the progressive segmental stenosis of the duct and, consequently, long-term decompression failure[21-25]. To address this problem, Puestow and Gillesby[23], building on Duval’s method[21], performed a longitudinal incision of the pancreatic duct and a side-to-side anastomosis of the pancreatic duct with the jejunum. Partington and Rochelle[25], on the basis of Puestow and Gillesby’s method[23], only incised the entire pancreatic duct, preserving the pancreatic tail, and subsequently conducted a side-to-side anastomosis of the pancreatic duct and jejunum[24,25]. The Partington and Puestow procedures are effective in resolving stones in the pancreatic body and tail, and in providing adequate drainage of pancreatic fluid, significantly lowering the risk of recurrence of pancreatic duct stones. However, these procedures do not address the underlying etiology of abdominal pain resulting from stones and inflammation in the pancreatic head[26].

As procedures, such as the Partington and Puestow, that primarily concentrate on drainage, have limitations in managing stones and inflammation in the pancreatic head and uncinate process, some scholars have proposed direct resection of the affected pancreatic tissue as a treatment for chronic pancreatitis[27]. Pancreaticoduodenectomy[28], initially described by Whipple[29] for the management of chronic pancreatitis, was later refined by Traverso and Longmire into the pylorus-preserving pancreaticoduodenectomy (PPPD). Although PPPD is an effective approach for pain relief, it carries a significant complication rate of 40%-50%. In certain cases, patients may experience recurrent pancreatic duct stones and obstruction due to anastomotic stenosis. Additionally, the resection of adjacent healthy organs for a benign condition raises concerns about the potential for overtreatment[29,30]. While both total pancreatectomy (TP) and pancreaticoduodenectomy (Whipple procedure) provide comparable pain relief, these procedures are associated with the development of a lifelong, “brittle” form of diabetes, a late complication with a high mortality rate, necessitating permanent insulin therapy and pancreatic enzyme replacement to compensate for the loss of pancreatic function[24]. TP combined with autologous islet cell transplantation may improve this condition[31].

Compared with Whipple, PPPD, and TP procedures, duodenum-preserving pancreatic head resection (DPPHR) significantly preserves pancreatic function and avoids overtreatment. Beger first proposed a procedure involving pancreatic head resection with end-to-end anastomosis of the pancreatic duct and jejunum[32]. This procedure significantly reduces pain and partially preserves the pancreatic endocrine and exocrine functions[32]. The traditional Beger procedure, which preserves a small amount of pancreatic tissue in the head of the pancreas on the duodenal side, carries a higher risk of pancreatic leakage. Furthermore, the end-to-end anastomosis between the pancreatic duct and the jejunum is relatively small, making it prone to strictures and anastomotic stones[13]. In addition, this procedure does not achieve complete decompression of the pancreatic duct at the tail of the pancreas, and there is a risk of long-term stone recurrence[33-35].

Compared with the Beger procedure, the Frey procedure provides a more targeted approach for treating the pancreatic head. The Frey procedure selectively removes the inflammatory mass in the pancreatic head, longitudinally opens the main pancreatic duct, and then performs a side-to-side pancreatic duct-jejunal anastomosis. This procedure has a larger anastomotic opening, remarkably reducing the possibility of anastomotic stenosis and the probability of stone recurrence. However, it is inferior to the Beger procedure in terms of postoperative pain relief[27], which may be associated with the narrow excision of the pancreatic head, residual stenosis of the main pancreatic duct, and incomplete treatment of the branch pancreatic ducts. Gloor et al[36] developed a relatively smaller pancreaticojejunostomy (Berne procedure) based on the Frey procedure. This modification requires lower technical expertise, promoting a faster operation, and it is associated with fewer postoperative complications[36,37]. The Frey procedure requires a full longitudinal pancreatic duct-jejunum anastomosis and is easier to perform in patients with pancreatic duct dilatation. The Beger and Berne procedures, on the other hand, involve only end-to-end anastomosis or short side-to-side anastomosis and may be more appropriate for patients with lesions confined to the pancreatic head and without significant pancreatic duct dilatation. DPPHR is a combination of resection and drainage. Although DPPHR provides comparable pain relief to simple resection, its overall postoperative complications and long-term pain remission rates are superior to those of simple resection or drainage[13]. The Table 1 shows the short-term and long-term pain relief outcomes of common surgical procedures for treating chronic pancreatitis[38].

Table 1 Comparison of postoperative pain relief rates among different surgical procedures[38].

Comparison of surgical methods	Short-term pain relief		Long-term pain relief
	OR	95%CI	MD	95%CI
PPPD vs Frey	0.61	0.13-2.6	0.37	-10.0 to 12.0
PPPD vs Beger	0.71	0.30-1.61	-	-
PPPD vs Berne	0.83	0.19-3.85	-	-
Beger vs Frey	0.86	0.19-3.8	-0.74	-11.0 to 0.0
Beger vs Berne	1.16	0.28-4.84	-	-

PPPD: Pylorus-preserving pancreaticoduodenectomy; OR: Odds ratio; CI: Confidence interval; MD: Mean difference. Citation: Mou Y, Song Y, Chen HY, Wang X, Huang W, Liu XB, Ke NW. Which Surgeries Are the Best Choice for Chronic Pancreatitis: A Network Meta-Analysis of Randomized Controlled Trials. Front Surg 2021; 8: 798867. Copyright © 2022 Mou, Song, Chen, Wang, Huang, Liu and Ke. The copyright information was shown in Supplementary material.

A novel surgical approach was described, integrating the advantages of total pancreatic head resection with the decompressive effect of the Partington procedure. Complete resection of the pancreatic head could effectively remove stones in both the pancreatic head and the uncinate process. In contrast, when only the pancreatic duct in the body and tail is opened, and a choledochoscope is used to remove stones, complete stone removal is often compromised due to the complex pancreatic ductal system in the head, or because the large angle of the uncinate process may prevent the choledochoscope from passing through[11,39]. Total resection of the pancreatic head eliminates residual inflammatory tissue and prevents postoperative recurrence of stones, which can arise from the complexity of the pancreatic duct system in this region. Additionally, given the dense distribution of nerves in the pancreatic head, complete removal addresses the primary source of pain, thereby reducing the risk of postoperative pain recurrence[27]. Throughout the procedure, the anatomical integrity and function of the duodenum and common bile duct are preserved with precision. Special attention is required to avoid injury to the vascular arch formed by the superior and inferior pancreaticoduodenal arteries to protect the blood supply to the duodenum. The pancreatic duct is then longitudinally incised for approximately 10 cm along the body and tail of the pancreas to fully expose the stones in the duct lumen. The pancreatic duct in the body and tail is opened throughout, and all stones can be removed under direct vision, so that the pancreatic duct in the body and tail is fully decompressed.

Lithotomy forceps and a choledochoscope are used in combination to thoroughly remove all stones in the pancreatic duct and to ensure patency of the duct lumen. Finally, the digestive tract is reconstructed. The jejunum is transected 20 cm distal to the ligament of Treitz, and the distal jejunum is then mobilized to the pancreas, where a side-to-side anastomosis is performed with the opened pancreatic duct. Furthermore, its large-caliber side-to-side anastomosis minimizes the possibility of postoperative stenosis, possesses advantages in terms of preserving the endocrine and exocrine functions of the pancreas, and a better long-term prognosis may be achieved.

The proposed surgical approach is applicable to cases of chronic complicated pancreatitis with stones obstructing the main pancreatic duct, particularly in cases of significant ductal dilation. This procedure should be considered as an alternative treatment for complicated pancreatitis following the failure of endoscopic interventions. It effectively removes stones that are difficult to extract endoscopically or by other interventional methods. Additionally, compared with conservative treatment or selective visceral nerve transection, this surgical approach possesses the advantage of complete resection of the primary lesion, resulting in more stable long-term pain relief.

However, this surgical approach has limitations and foreseeable risks, similar to other surgical options[13,38]. Long-term, recurrent pancreatic inflammation causes severe edema in the pancreatic head, obscuring anatomical clearances. Under these conditions, performing total pancreatic head resection with duodenum preservation is technically challenging and carries risks of bleeding, bile duct injury, bile duct stenosis, and duodenal ischemia. Therefore, the procedure necessitates the involvement of an experienced pancreatic surgical team at a high-volume center.

CONCLUSION

The main contribution of this case report is the development of a modified surgical procedure for chronic pancreatitis complicated by complex pancreatic duct stones. For chronic pancreatitis complicated by stones that respond poorly to pharmacotherapy or endoscopic treatment, surgery is a worthy early treatment option. Early surgical intervention can effectively drain pancreatic juice, delay pancreatic atrophy, and protect pancreatic function. The proposed modified procedure can more thoroughly remove stones and reduce the recurrence rate of stones and pain. Although this procedure was successfully applied to a patient for the first time, its efficacy and safety in the broader human population should be validated.