Chronic Pancreatitis: Laser Technologies for Double Balloon Enteroscopy of Pancreatojejunostomy Complications and Reducing the Peripheral Ductal Hypertension
Journal of Surgery
Volume 3, Issue 4, August 2015, Pages: 32-38
Received: Jun. 29, 2015;
Accepted: Jul. 6, 2015;
Published: Jul. 17, 2015
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Aliaksandr Varabei, Belarusian Medical Academy of Postgraduate Education, Minsk, Belarus
Anatoli Shuleika, Belarusian Medical Academy of Postgraduate Education, Minsk, Belarus
Yury Vizhinis, Belarusian Medical Academy of Postgraduate Education, Minsk, Belarus
Yury Arlouski, Belarusian Medical Academy of Postgraduate Education, Minsk, Belarus
Natalia Lagodich, Minsk Regional Clinical Hospital, Endoscopy Unit, Minsk, Belarus
Introduction: Drainage procedures are conventional modifications of surgical treatment for chronic pancreatitis (CP). Nevertheless, the relapse of chronic abdominal pain after the surgery occurs in more than 50% of cases. Aim: To explain the pathogenesis of intractable abdominal pain following the traditional surgery of CP and to propose new laser and double balloon enteroscopy (DBE) technologies for its relief. Materials and methods: Pancreatojejunoanastomosis (PJA) lumen was examined using the videoenteroscope EN-450P5/20 (Fujifilm group, Fujinon Co, Tokio, Japan) for the first time in the world. All 20 patients had had CP and underwent an elective surgery earlier. During 2010-2014, 198 resections were performed, with 159 (80,3%) being laser drainage procedures. Results: DBE revealed strictures of PJA and open common bile duct, residual pancreatoliths in PJA lumen, and PJA leakage. After DBE laser lithotripsy of pancreatoliths in tributary ducts, a free outflow of pancreatic juice from the lumen was obtained. DBE findings were supported by the morphological study of excised pancreatic specimen, CT-scans before the surgery and the staining of PJA lumen. All these data suggest that 17,7% of CP patients along with magistral ductal hypertension had peripheral ductal hypertension (PDH), which seems to be a new cause of severe abdominalgia. The latter arises when pancreatoliths block the orifices of tributary ducts. For reducing the PDH, we have developed a new surgical procedure named «laser cylindric wirsungectomy» (n=26) and proposed our own classification of pancreatic duct stones. Conclusions: DBE has great opportunities for the diagnosis of complications and their mini-invasive treatment after pancreatojejunostomy (PJ). Laser technologies are considered to be a new approach to the effective open and mini-invasive surgical treatment of CP.
Chronic Pancreatitis: Laser Technologies for Double Balloon Enteroscopy of Pancreatojejunostomy Complications and Reducing the Peripheral Ductal Hypertension, Journal of Surgery.
Vol. 3, No. 4,
2015, pp. 32-38.
Di Sebastiano P, Di Mola FF, Bockman DE, Friess H, Buchler MW. Chronic pancreatitis: the perspective of pain generation by neuroimmune interaction. Gut 2003; 52: 907-911.
Bockman DE, Buchler M, Malfertheiner P, Beger HG. Analysis of nerves in chronic pancreatitis. Gastroenterology 1988; 94: 1459-1469.
Buchler M, Weihe E, Friess H, Malfertheiner P, Bockman E, Muller S, Nohr D, Beger HG. Changes in peptidergic innervation in chronic pancreatitis. Pancreas 1992; 7 (2): 183-192.
Bradley EL. Pancreatic duct pressure in chronic pancreatitis. Am J Surg 1982; 144: 313-316.
Markowitz JS, Rattner DW, Warshaw AL. Failure of symptomatic relief after pancreatojejunal decompression for chronic pancreatitis. Arch Surg 1994; 129: 374- 380.
Izbicki JR, Bloechle C, Broering DC, Kuechler T, Broelsch CE. Longitudinal V- shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure. Ann Surg 1998; 227: 213-219.
Ebbehoj N, Svendsen LB, Madsen P. Pancreatic tissue pressure in chronic obstructive pancreatitis. Scand J Gastroenterol 1984; 19: 1066-1068.
Limrner JC, Knoefel WT, Bloechle C, Izbicki JR. Correlation between intraductal and intraparenchimatous pressure and pain in chronic pancreatitis [abstract], Int J Pancreatol 1996; 19: 237.
Karanjia ND, Widdison AL, Leung FW. Compartment syndrome in experimental chronic obstructive pancreatitis: effect of decompressing the main pancreatic duct. Br J Surg 1994; 81: 259-264.
Rios GA, Adams DB. Does intraoperative electrohydraulic lithotripsy improve outcome in the surgical management of chronic pancreatitis? Am Surg 2001; 67: 533- 537.
ll.Sanerbruch T, Holl J, Sackman M, Paumgartner G. Extracorporal lithotripsy of pancreatic stones in patients with chronic pancreatitis and pain: a prospective follow- up study. Gut 1992; 33, 969-972.
Ramesh H. Proposal of a new grading system for chronic pancreatitis: the ABC system. Clin Gastroenterol 2002; 35: 67-70.
Buchler M, Martignoni M, Friess H, Malfertheiner P. A proposal for a new clinical classification of chronic pancreatitis. Gastroenterol 2009; 9: 93-100.
Schneider A, Lohr S, Singer M. The M-ANNHEIM classification of chronic pancreatitis: introduction of a unifying classification system based on a review of previous classifications of the disease. Gastroenterol 2007; 42: 1-19.
Partington RF, Rochelle REL. Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 1960; 152: 1037-1042.
Frey CF, Smith GJ. Description and rationale of a new operation for chronic pancreatitis. Pancreas 1987; 2: 701-707.
Frey CF, Kathrin L, Mayer M. Comparison of local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (Frey procedure) and duodenum-preserving resection of the pancreas head (Beger procedure). World J Surg 2003; 27: 1217-1230.
Beger HG, Schlosser W, Friess HM, Buchler MW. Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single- center 26-year experience. Ann Surg., 1999; 230: 512-519.
Gloor B, Friess H, Uhl W, Buchler M. A modified technique of the Beger and Frey procedure in patient with chronic pancreatitis. Digest Surg 2001; 18: 21-25.
Varabei A, Shuleika A, Arlouski Y, Vizhinis Y, Lagodich N. Tributaryliths as a reason of peripheral pancreatic hypertension in chronic pancreatitis. Proceeding of the 45th Meeting of the EPC. Zurich. 26-29 June 2013. Pancreatol 13 (39): 556.
Yamamoto H, Sugano K. A new method of enteroscopy - the double balloon method. Can J Gastroenterol 2003; 17: 4, 273-274.
Koornstra JJ, Fry L, Monkemuller K. ERCP with balloon-assisted enteroscopy technique: A systematic review. DigDis 2008; 26: 324-329.
Parlak E, Cicek B, Disibeyaz S. Endoscopic retrograde cholangiography by double balloon endoscopy in patients with Roux-en-Y hepaticojejunostomy. Surg Endosc 2009; 6: 45-47.
Chu YC, Yang CC, Yen YH, Chen CH, Yueh SK. Double-balloon enteroscopy application in biliary tract disease - its therapeutic and diagnosis function. Gastrointest Endosc 2008; 68 (3): 585-591.
Varabei A, Arlouski Y, Vizhinis Y, Shuleika A, Lagodich N, Derkacheva N. The use of double balloon enteroscopy for diagnosis and treatment of strictures of hepaticojejunal anastomoses after primary correction of bile duct injuries. Videosurgery Miniinv 2014; 9 (2): 219-225.
Varabei A, Shuleika A, Arlouski Y, Vizhinis Y, Lagodich N, Lurie V. Chronic pancreatitis: basing of peripheral pancreatic hypertension and method of its surgical correction. Proceedings of the 44* Annual Meeting of the EPC. Prague. 22-23 June 2012: 40.