Question

A patient presented with features of chronic pancreatitis with recurrent attacks and has a 10 mm dilatation of the pancreatic duct with intraductal calculi present. Which of the following isthe surgery of choice?

• A. Pancreaticoduodenectomy
• B. Longitudinal pancreaticojejunostomy
• C. ERCP and sphincterotomy
• D. Coring of pancreas head

Answer 1

The Correct Option is B

For a patient with chronic pancreatitis presenting with recurrent attacks, a 10 mm dilatation of the pancreatic duct, and intraductal calculi, the optimal surgical intervention is longitudinal pancreaticojejunostomy. This procedure, also known as the Puestow procedure, is designed to relieve ductal pressure and pain by creating a drainage pathway. Let's explore why this is the surgery of choice:

• Chronic Pancreatitis Context: Chronic pancreatitis leads to fibrosis, stenosis, and obstruction of the pancreatic duct due to persistent inflammation. This can cause pain and further morbidity.
• 10 mm Pancreatic Duct Dilatation: A significantly dilated pancreatic duct (greater than 7 mm) is a key indication for surgical intervention focused on ductal decompression.
• Intraductal Calculi: The presence of stones within the duct can exacerbate blockages, increasing pressure and causing pain. These need to be addressed to reduce symptoms.

Longitudinal Pancreaticojejunostomy Procedure:

• Ductal Access: The procedure involves making an incision along the length of the dilated pancreatic duct.
• Jejunum Attachment: The incised pancreatic duct is then anastomosed with a loop of jejunum, allowing pancreatic secretions to drain into the small intestine.
• Benefits: This relieves pressure, reduces the frequency of painful episodes, and manages the symptoms related to chronic pancreatitis.

Alternative options, like pancreaticoduodenectomy, are more radical, ERCP and sphincterotomy are suitable for more isolated stone-induced obstructions, and coring of the pancreas head is less commonly indicated compared to decompressive strategies for ductal dilation with intraductal calculi. Therefore, given the specifics of duct dilation and presence of intraductal calculi, longitudinal pancreaticojejunostomy best addresses the pathophysiology involved in this clinical scenario.