PANCREATITIS

DEFINITION

• Acute pancreatitis (AP) is an inflammation of the glandular parenchyma of the retroperitoneal

organ that leads to injury with or without subsequent destruction of the pancreatic acini. This
inflammatory process can either result in a self-limited disease or involve lifethreatening
multiorgan complications.
• Chronic pancreatitis (CP) is a syndrome that consists of endocrine and exocrine gland
dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the
pancreatic acini with permanent structural damage

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
ANATOMY
 EPIDEMIOLOGY

• AP has an estimated annual incidence of 4.9 to 40 cases per year per 100,000
• The incidence of CP ranges from 5 to 12 cases per year per 100,000, with an estimated
prevalence of 50 per 100,000

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 ETIOLOGY
A C U T E PA NC R E AT IT IS C H R O N IC PA NC R E AT I T IS
• Gallstones • Alcohol consumption
• Alcohol consumption • Cigarette smoking
• Hypercalcemia secondary to • Pancreatic ductal obstruction secondary to
hyperparathyroidism strictures
• Hypertriglyceridemia, endoscopic retrograde • Tumors
cholangiopancreatography (ERCP)
• Pancreatic divisum
• Drugs (6-mercaptopurine, aminosalicylates,
• Hereditary pancreatitis
sulfonamides, diuretics, valproic acid)
• Mutations in the cystic fibrosis
• Infections
transmembrane conductor regulator (CFTR)
gene
Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 PATHOPHYSIOLOGY – ACUTE PANCREATITIS

Di unduh dari https://calgaryguide.ucalgary.ca/acute-pancreatitis/

 PATHOPHYSIOLOGY
CHRONIC PANCREATITIS

Kleeff, J., Whitcomb, D., Shimosegawa, T. et al. Chronic pancreatitis. Nat Rev Dis Primers 3, 17060 (2017).
https://doi.org/10.1038/nrdp.2017.60
 DIAGNOSIS – ACUTE PANCREATITIS
Physical Examination
• Epigastric tenderness
• Fever
• Hypotension
• Hypoxia
• Tachypnea
• Tachycardia
• Abdominal distention
• Hypoactive bowel sounds
• Scleral icterus (AP secondary to choledocholithiasis)

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 DIAGNOSTIC WORKUP – ACUTE
PANCREATITIS
Laboratory :
– Serum amylase and serum lipase levels
– C-reactive protein
– Trypsinogen activation peptide
Imaging :
– Abdominal ultrasonography
– Abdominal computed tomography (CT) with contrast  the gold standard
– MRI
– Common diagnostic modalities that can aid in the diagnosis but are not necessarily needed : endoscopic
ultrasonography (EUS) and ERCP.

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 SCORING

Abu-Eshy, S., Abolfotouh, M., Nawar, E., & Sabib, A.H. (2008). Ranson's Criteria for Acute Pancreatitis in High Altitude: Do they Need to be Modified? Saudi Journal of Gastroenterology : Official Journal of the Saudi
Gastroenterology Association, 14, 20 - 23.
Bezmarević, M., Z. Kostic, M. Jovanovic, S. Micković, D. Mirković, I. Soldatović, B. Trifunović, J. Pejović and S. Vujanić.
“Procalcitonin and BISAP score versus C-reactive protein and APACHE II score in early assessment of severity and
outcome of acute pancreatitis.” Vojnosanitetski pregled 69 5 (2012): 425-31 .
 DIAGNOSIS – CHRONIC
PANCREATITIS
Physical Examination :
• Pain in chronic pancreatitis typically localizes to the left upper quadrant or epigastric region,
often radiating around or into the back
• Weight loss and malnutrition

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 DIAGNOSTIC WORKUP – CHRONIC PANCREATITIS
Laboratory :
– Serum amylase and serum lipase levels
– Sudan red stain of stool samples (previously considered the gold standard in the diagnosis of CP)
– Fecal elastase (the most appropriate test)
– Secretin test

Imaging :
– Abdominal ultrasonography
– Abdominal computed tomography (CT) with contrast
– MRI
– Magnetic resonance cholangiopancreatography (MRCP) : the most accurate and noninvasive imaging modality in
diagnosing CP  show calcifications and biliary/pancreatic duct microlithiasis
– ERCP
– Endoscopic ultrasonography (EUS)
Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
MANAGEMENT – ACUTE
PRANCREATITIS

NONOPERATIVE

OPERATIVE
 NONOPERATIVE

• Aggressive fluids replacement

• Nutrition : enteral feeding was limited in the setting of acute pancreatitis for the purpose of
providing “pancreatic rest”
• Antibiotics : if suspected extrapancreatic infections
• For patients with hypercalcemia : treatment should be directed at normalizing serum calcium
and determining the underlying cause
• For patients with hypertriglyceridemia : controlling triglyceride level should be achieved. Diet
with restricted triglycerides and sugar, exercise, fibrates, niacin, and n-3 fatty acids can be
offered. Apheresis has also been offered with some success

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 OPERATIVE

1. ERCP
2. Surgical

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATOGRAPHY - ERCP
• Peroral flexible endoscopic techniques follow an internal route through either the gastric or
duodenal wall or duodenal papilla, and some authors consider this to be a form of natural
orifice transluminal endoscopic surgery (NOTES)
• Puncture of the posterior gastric wall into the target lesion is performed at the point of maximal
bulging, although confirmation of the location with EUS helps achieve safe deployment to
avoid injury to vessels.
• The injection of contrast with fluoroscopy can be used to determine the extent of the cavity.
• The gastric insertion site is balloon-dilated. For lavage and drainage, a 7 fr nasocystic (lavage)
and a 10 fr pigtail drain (drainage) are placed in the cavity.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• Necrosectomy may be performed with endoscopic instruments (eg, dormia basket or polypectomy
snare), and introduction of a forward-viewing endoscope into the necrotic cavity can be used for
better visualization during the necrosectomy
• The introduction of transgastric self-expanding metal stents (SEMS) has been a significant
advance in the endoscopic treatment of infected ANC and WON.
• These stents are designed with a wide lumen (eg, 2.5 cm), wide flanges (to prevent migration) and
even wall-apposing features (to reduce the risk of leakage)
• Flexible endoscopic debridement has also been used percutaneously (“sinus tract endoscopy”).
• A similar technique has been described following open necrosectomy through a translumbar
incision, where a flexible endoscope is inserted into the cavity for débridement.
• Another endoscopic approach is to debride through a percutaneous endoscopic gastrostomy (peg).

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 SURGICAL DEBRIDEMENT
Bilateral subcostal or midline incision

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 An approach through the mesocolon may avoid the dense
inflammatory process obscuring planes between the stomach
and transverse colon
Pancreatic debridement is accomplished bluntly, using finger
dissection to remove necrotic tissue that easily separates from
surrounding structures

Exposure and removal of all tissue may require access to both

paracolic gutters, the pararenal spaces, retroperitoneum into the
pelvis, or the gastrohepatic omentum.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Irrigation and drainage of pancreatic bed.

Drainage tubes are used for technique of closed drainage

or postoperative saline lavage

Open packing technique, the pancreatic bed is packed with

sterile bandages.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 DIRECT ENDOSCOPIC
NECROSECTOMY
• Retroperitoneal endoscopy via transgastric fenestration
• An approach to the necrotic collection may be obtained from the stomach or duodenum.
• Collections may be identified with endoscopic ultrasound if necessary and are punctured with
serial dilations to allow stent placement.
• Necrotic tissue is evacuated using an endoscopic snare

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 MINIMALLY INVASIVE DEBRIDEMENT

• Laparoscopic
• The technique of video-assisted retroperitoneal debridement (VARD) uses a retroperitoneal
approach via dorsal lumbotomy and an endoscope advanced in the tract of a radiographically
placed drain.
• The tract is serially dilated to allow access of an endoscope or laparoscope to visualize the
necrotic cavity.
• Extraction of the pancreatic necrosum in these cases is limited by the diameter of the access.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 PERCUTANEOUS CATHETER
DRAINAGE (PCD)
• Catheters are placed under CT or ultrasound guidance, with a transperitoneal or retroperitoneal
approach.
• Multiple catheter may be required, and repeat procedures to place new or larger catheters up to
30 Fr may be needed

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
MANAGEMENT – CHRONIC
PRANCREATITIS

NONOPERATIVE

OPERATIVE
 NONOPERATIVE

• General recommendations: initial management includes cessation of alcohol intake, cessation

of smoking, pancreatic enzyme supplements, octreotide, antioxidants, and analgesic
• Pain control
• Radiotherapy
• Pain relief (cholecystokinin (CCK) receptor antagonist-A)

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 OPERATIVE

• Endoscopic drainage
• Extracorporeal shockwave lithotripsy (ESWL) : used for rapid fragmentation of pancreatic duct
stone to facilitate endoscopic extraction
• Surgical : an operation is performed to relieve biliary or gastrointestinal obstruction, to
internally drain a symptomatic pseudocyst, or for vascular complications of chronic
pancreatitis such as gastric variceal hemorrhage secondary to splenic vein thrombosis.

Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 LATERAL PANCREATICOJEJUNOSTOMY
— TECHNIQUE (LARGE-DUCT DISEASE )
• Midline or transverse upper abdominal incisions
• The dissection is begun by incising the peritoneal lining adjacent to the lateral border of the second portion of
the duodenum, extending laterally to release the hepatic flexure of the right colon
• The duodenum are divided to widely mobilize the duodenum and posterior aspect of the head of the pancreas
(kocher’s maneuver)
• Dividing the gastrocolic omentum or by separating the avascular plane of attachment from the transverse colon
and mesocolon
• The gastroduodenal artery (GDA) is then suture ligated at both the superior and inferior border of the head of
the pancreas in an effort to prevent intraoperative hemorrhage during incision of the pancreatic head and main
pancreatic duct during the dissection as well as postoperative bleeding at the site of the pancreaticojejunostomy

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• The pancreatic duct is then incised longitudinally along its full length using electrocautery.
• This ductotomy should extend across the neck into the head of the organ where the gda traverses
the pancreas, and should extend laterally as far as possible along the length of the tail so that the
entire segment of dilated duct is unroofed
• Pancreaticojejunal anastomosis is performed in roux-en-y fashion using a 40- to 50-cm
defunctionalized jejunal limb.
• Using a linear gastrointestinal stapler, the proximal jejunum is divided at the apex of a mesojejunal
vascular arcade of suitable mobility, typically at least 20 to 30 cm distal to the ligament of treitz
• The distal staple line is inverted using a series of 3-0 silk sutures placed in a lembert fashion,
which are tied (but not cut) and then held by a fine clamp that facilitates later positioning of the
pancreatic anastomosis

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• Intestinal continuity is then reestablished by a handsewn or stapled enteroenterostomy such that
the intestinal conduit is approximately 60 cm in length
• A longitudinal jejunostomy is made to correspond to the pancreatic ductotomy.
• The pancreaticojejunostomy is handsewn with a running absorbable suture (eg, 4-0 double-armed
polyglyconate or polydioxanone suture)
• After completion of the anastomosis, the distance between the pancreaticojejunostomy and the
enteroenterostomy should measure at least 40 cm to prevent reflux of enteric contents up to the
anastomosis.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 PANCREATICODUODENECTOMY—TECHNIQUE (CHRONIC
PANCREATITIS WITH A DOMINANT PANCREATIC HEAD
MASS )

• Midline laparotomy or bilateral subcostal incision

• The hepatic flexure of the colon is mobilized by freeing the lateral retroperitoneal attachments
using the electrocautery, an extended kocher maneuver is performed, and the lesser sac is then
entered by separation or division of the gastrocolic omentum, as described in the previous
section.
• The mass in the head of the gland is palpated and determined to be safely free from the
superior mesenteric vein (smv) at the inferior border of the neck of the pancreas by preliminary
dissection of the plane anterior to the smv posterior to the neck of the pancreas

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• Attention is then turned to the supraduodenal region.
• A cholecystectomy is performed, and the portal dissection is initiated by isolating the common bile
duct (cbd) at the level of the cystic duct stump.
• The bile duct is carefully freed from the anterolateral surface of the portal vein and secured
temporarily with a vessel loop.
• The common hepatic artery is usually found anteromedially to the portal vein, and it should be
carefully isolated with a vessel loop and preserved.
• Free edge of the gastrohepatic ligament at the foramen of winslow

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• The GDA is isolated at its origin from the common hepatic artery and secured temporarily with a
vessel loop.
• The continued presence of pulsatile flow in the proper hepatic artery after temporary occlusion of
the GDA should be assured, both to confirm the vascular anatomy and to ensure that there is no
stenosis in the proximal common hepatic artery or celiac trunk due to atherosclerotic plaque.
• Preliminary dissection of the plane anterior to the portal vein is begun.
• These measures demonstrate that there is no evidence of unresectable cancer and that the
pancreatic head can be removed without concern for undue injury to the blood supply of the small
intestine
• The GDA is divided between clamps and is doubly tied or suture ligated. The common hepatic
duct is divided just proximal to the cystic duct entry, and bile flow is controlled with a small
bulldog clamp

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• The right gastric artery is divided between suture ligatures
• The greater omentum is divided to a point on the greater curvature of the stomach in the vicinity of
the junction of the right and left gastroepiploic arteries.
• Pancreaticoduodenectomy is to be peformed, the stomach is then divided with two firings of a
linear gastrointestinal stapler.
• The lesser curve staple line is inverted with silk lembert sutures
• Pyloric-preserving pancreaticoduodenectomy, the duodenum is divided using a stapler
approximately 2 cm distal to the pyloric ring.
• The ligament of treitz is taken down with electrocautery, being certain to avoid injury to the
inferior mesenteric vein.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• Proximal jejunum is divided approximately 15 cm distal to the ligament of treitz with a linear
gastrointestinal stapler
• The short mesojejunal vessels of the proximal segment are carefully isolated and secured close to
the mesenteric border of the jejunum using fine nonabsorbable ligatures, surgical clips, or an
electrosurgical vessel-sealing device
• This dissection is continued proximally to the duodenojejunal junction, and then the proximal
jejunum is advanced into the supracolic compartment by passing it under the superior mesenteric
vessels.
• Complete development of a tunnel between the neck of the pancreas and the smv or portal vein
• The superior and inferior pancreatic vascular arcades are then ligated on either side of the planned
transection site at the neck of the pancreas using nonabsorbable suture.
• The neck is then divided with electrocautery.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• Gentle retraction of the pancreatic head, distracting it from the right lateral wall of the SMV or
portal vein
• The first jejunal venous tributary may be quite large and is easily injured during this dissection
• The uncinate branches from the superior mesenteric artery (SMA) are then divided sequentially
between clamps with great care to preserve the integrity of the SMA
• A two-layer method that is begun by placing a posterior row of interrupted nonabsorbable sutures
between the pancreatic capsule and the seromuscular layer at the antimesenteric aspect of the
jejunum
• A small enterotomy is then made with bovie cautery across from the site of the main pancreatic
duct at the pancreatic neck.
• An inner layer of four to eight interrupted fine absorbable monofilament sutures is used to secure
the pancreatic duct to the intestinal wall at the enterotomy in a duct-to-mucosa

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• An anterior row of interrupted nonabsorbable suture is then used to secure the anterior pancreatic
capsule to the anterior serosa at the antimesenteric border of the jejunal limb
• The duct-to-mucosa anastomosis may also be performed over a 5 fr pediatric feeding tube, which
can then be exteriorized through the jejunal limb using a witzel-type closure
• Choledochojejunostomy is then constructed at a site approximately 15 cm distal to the
pancreaticojejunostomy
• A small enterotomy is made at the antimesenteric border of the jejunal limb at this location
• Choledochojejunostomy is also performed in a duct-to-mucosa fashion, either with a single layer
of interrupted absorbable monofilament suture or, if the bile duct is dilated, using absorbable
continuous suture
• Pancreaticobiliary limb is then secured to the transverse mesocolon using interrupted sutures
• Any potential gap through which herniation may occur is closed.
• The retroperitoneal space at the level of the ligament of treitz is also closed

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• Antecolic loop gastrojejunotomy performed at a site sufficiently distal to the transverse mesocolon
closure to prevent angulation of the afferent limb
• A two-layered anastomosis is preferred, with an outer layer of nonabsorbable interrupted
seromuscular lembert sutures and an inner continuous absorbable connell-style layer
• The abdomen is then irrigated with saline or dilute antibiotic solution and the abdominal wall
closed. No closed suction peritoneal drains are necessary

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 BEGER PROCEDURE—TECHNIQUE

• Midline laparotomy or bilateral subcostal incision

• The gastrocolic ligament is separated or divided, the transverse mesocolon is mobilized off the
head of the pancreas and duodenum, and a wide kocher maneuver is performed
• A cholecystectomy is performed.
• The gda is isolated and divided.
• A tunnel is then created between the pancreatic neck and superior mesenteric vein or portal
vein.
• The pancreatic neck is divided at this location and the pancreatic head manually rotated out of
the retroperitoneum so that the cut edge faces up into the midline wound.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• The cystic duct is cannulated with a Bakes dilator and the CBD manually palpated in the head of
the pancreas.
• Electrocautery is then used to core out the head of the gland with care taken to leave a rim of
pancreas attached to the duodenum and to leave the bile duct intact within that rim
• Pancreaticoenteric drainage is then reestablished by means of a two-sided Roux-en-Y
pancreaticojejunostomy
• A two-layered handsewn duct to mucosa pancreaticojejunostomy is constructed at the neck margin
as done for a typical pancreaticoduodenectomy, with the exception that the anastomosis is sited
closer to the mesenteric margin of the jejunum
• A second long pancreaticojejunostomy is constructed here by opening the border of the jejunal
limb contralateral to the first pancreaticojejunostomy at the neck for a distance appropriate to
include the entire length of the proximal pancreatic rim

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• This pancreatic margin is then secured to the long longitudinal enterotomy by means of a single
layer of interrupted nonabsorbable suture.
• Intestinal continuity is then reestablished by means of a jejunojejunostomy performed as described
earlier for the lateral pancreaticojejunostomy.
• The abdomen is irrigated and closed. No closed suction drains are necessary.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 FREY PROCEDURE—TECHNIQUE
• In this procedure, no tunnel is created behind the pancreatic neck. Instead, the entire length of the
pancreas is exposed anteriorly.
• The GDA is ligated.
• The gallbladder is removed.
• The cystic duct is cannulated using a Bakes dilator and the bile duct is identified in its course
through the head of the pancreas by palpating the dilator.
• The pancreatic head is then excavated down to the level of the portal vein, with care taken to leave
a rim of tissue surrounding the bile duct at the duodenal margin.
• From this cavity an extensive longitudinal unroofing of the pancreatic duct through the body and
tail is made using electrocautery.
• If the duct is not dilated in the tail, then the body and tail may simply be excavated as done at the
pancreatic head
Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
Pancreaticoenteric drainage is then accomplished by means of a
lateral pancreaticojejunostomy covering the entire excavation
cavity, typically constructed using a Roux-en-Y jejunal limb
sewn to the pancreatic capsule in one or two layers.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 BERNE PROCEDURE—TECHNIQUE

• Avoiding transaction of the neck of the pancreas off the portal vein
• No lateral pancreaticojejunostomy is performed
• The anterior surface of the mass in the head is palpated and then cored out by electrocautery.
• A roux limb is then sewn to the residual pancreatic rim at this location

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 TOTAL PANCREATECTOMY WITH AUTOLOGUS
ISLET TRANSPLANTATION—TECHNIQUE (TPAIT)

• Total pancreatectomy is performed as either an en bloc resection of the pancreatic head, body,
and tail
• Or left pancreatectomy followed by a head resection (pancreaticoduodenectomy) allowing
initial islet processing on the body and tail specimen.
• The isolation process relies on enzymatic and mechanical mechanisms to dissociate the islets
from surrounding acinar tissue and fibrosis.
• Infusion of the islet preparation into the portal circulation may be performed during the same
anesthetic or postoperatively (usually the same day) under radiological guidance

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• The resected pancreas is cooled to 4°C in an organ-preserving solution (eg, university of
wisconsin solution).
• The pancreas is then transected at the neck of the gland and the pancreatic duct cannulated.
• The ductal system is then perfused with a cold solution of the purified digestive enzyme
collagenase.
• The gland is sectioned and then physically shaken in a small digestion chamber at 37°c.
• The digestion of the gland is monitored continuously by means of a microscopic examination of
samples of the digestate taken throughout the process

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
• The digestion is continued until the acinar tissue is separated from the islets but stopped before the
islets begin to fragment.
• The islets are then partially purified from the acinar debris by gradient density centrifugation on a
cold dextrose gradient.
• The islets are washed and resuspended in an albumin-rich transplant medium or cultured.
• The islets are transplanted by direct injection into portal circulation, with access to the portal
circulation being achieved under ultrasound-guided percutaneous placement of a transhepatic
portovenous catheter in interventional radiology or by direct operative cannulation of the portal
vein.

Patrick J. Javid, J. A. (2013). Pankreatitis. In M. F. Michael J. Zinner, Maingot’s Abdominal Operations (p.
123). The McGraw-Hill Companies, Inc.
 COMPLICATION – ACUTE
PANCREATITIS
• Fluid collections • Systemic inflammatory response syndrome
• Tissue necrosis (SIRS)
• Pseudocyst • Multiple organ dysfunction syndrome
(MODS)
• Venous thrombosis
• Adult respiratory distress syndrome (ARDS)
• Bleeding
• Renal impairment
• Paralytic ileus
• Cardiovascular complications (arrhythmias,
• Intestinal ischemia and necrosis
pericardial effusion, impaired myocardial
• Intestinal obstruction contractility, reduced peripheral vascular
• Cholestasis resistance, and increased permeability)
• Metabolic complications (hypocalcemia)
Hammad, A. Y., Ditillo, M., & Castanon, L. (2018). Pancreatitis. Surgical Clinics of North
America. doi:10.1016/j.suc.2018.06.001 
 COMPLICATION – CHRONIC
PANCREATITIS
• Endocrine Insufficiency (diabetes mellitus)
• Exocrine Pancreatic Insufficiency
• Metabolic Bone Disease
• Pancreatic Cancer
• Pseudocysts
• Duodenal Obstruction
• Biliary Obstruction

Ramsey, M. L., Conwell, D. L., & Hart, P. A. (2017). Complications of Chronic Pancreatitis. Digestive Diseases and Sciences,
62(7), 1745–1750. doi:10.1007/s10620-017-4518-x