What about pancreatic duct stenting? Do not find it useful?

The pancreatic extent of stenosis precludes endoscopic stenting. It was tried without success.

A stent must be applied.

Need to see MRI/MRCP or CT. The patient should be evaluated for IPMN.

Dear Marcel,

Here is a link which might be useful for your concern:

http://www.managedhealthcareconnect.com/article/8738

In this situation I will recommend an exploration and a pancreato jejununostomy to save  his  distal pâncreas from a  burnout

Dear Marcel, 

In this case, I think that surgical procedure may be indicated, the lateral pancreaticojejunostomy preventing worsening of the endocrine insufficiency. 

In the end, please tell us your decision!

Dear Mehmet, as I said before a stent could not be applied due to the extent of obstruction in the main pancreatic duct. There was no way to insert a stent through this stenosis.

Dear Lena, an ecoendoscopy was performed and it is a dilatation from an obstructed duct after acute pancreatitis and not an IPMN.

I will post the MRI images for your analysis.

No indication of surgery actually.

2 possibilities

1/ dilatation and stenting of the wirsung

2/ if difficult or relapse: due to dilatation of the wirsung, you can with experimented EUS doctor,   put gastro- pancreatic stent plastic stent like drainage of Pseudocyst.

Dr Elias I do not agree with this procedure In pseudocyst  there is adhesion between gastric wall and the  cyst In the presente case this maneuver could lead to a leak of gastric and pancreatic  juiice

 if dilatation is extendig to the whole pancreatic duct, initianting in the pancreatic meatus, there is a probable secondary stenosis at it, providing there is no other pathology in perspective sucha as ipmn. A surgical meatotomy after papilotomy can help and also have some biopsy of the entrance of Wirsung. Endoscopically perhaps feasable.

I think you should to perform operation: procedure by Frey or longitudinal pancreatojejunostomy by Ru. This way for preserving exocrine function of pancreas.

Thanks a lot. Best sucsesses.

But if the pancreas is still soft or tender? There is no information about and the kind of dilatation, if homogeneous or abnormally strictured. The cause and anatomopathology still unclear. Perhaps cleared at surgery, when one can chose the best solution.

dilated out + pancreatitis = IPMN . Would do an endoscopic ultrasound with sampling of the fluid and measurement of CEA.  This would also assist in picking up an isodense lesion in the head of the pancreas that might be the culprit. This could also be sampled. Also has the IG G and IgG4 been measured in the serum ? 

Ecoendoscopy was already performed and it is not an IPMN. He was being followed for 4 years now. The point of obstruction was already biopsied and it is of inflammatory origin. However, despite absence of symptoms, he developed mild diabetes. The consistency of the pancreas is not possible to be sure.

I will wait as there is no pain for doing a PJ..The cause is drug induced and self limiting.

I will request my gastroenterologist to perform a careful sphinctorotomy and stenting.

Follow up is one way to not over treat this patient because he does not has any symptom.

Endoscopic sphincterotomy could be another way to do.

I feel that if the pancreatic atrophy is due to the obstruction of the MPD with secondary diabetes, relieving it by dilatation and stenting via ERCP might be helpful before going for anatomic diversion. This will also settle the issue of the etiology whether there was chronic pancreatitis from the beginning or was it due to the acute pancreatitis induced stricture. 

It may implies that there is a chronic pancreatitis associated

I would suggest to wait and recommend to use pancreatic enzymes as the best option treatment together with the clear recommendation of stopping tobacco and alcohol consumption

There are some reports in literature thatr have shown that decompressing  the pancreatic duct avoids a dterioratioh of pancreatic parenchima and therefore  drcreasing the possibility of pancreatic burnout  I will go ahead and perform a pancreatic junonostomy in this patient

Actually with this new imformation, Prof. Marcel Machado gave a good answer.

Dear Luis Rodrigo, this patient has no signs of exocrine insufficiency. He never smoked and no alcohol abuse whatsoever. It is really a obstruction of the main pancreatic duct followed focal necrosis of the neck of the pancreas.

Dear Dr Singh, this obstruction was caused by an acute pancreatitis as a sequelae. It is not self limited because the main pancreatic duct is increasing in size for the last 4 years. We tried pancreatic stenting with no success.

Here are some images from the MRI. We can see a major dilatation of the main duct without dilated bile duct. Wirsung at the head of the pancreas seems normal. MRI cholangiograpy shows normal gallbladder and bile duct with dilated Wirsung from the neck to the tail.

This is chronic pancreatitis as the MPD is dilating since last 4 years and now is unlikely to reverse with stenting. Though patient does not have pain and malabsorption, LPJ may retard progression of his diabetes. But this needs full discussion with the patient.

Watching these pictures strenghts my recommendation to perform a  pancreatojejunostomy

I finally agree that the best option is pancreato-jejunostomy by laparoscopic or open approach. It depends of surgeon specific choice. Good Lucky and hands-on!

Have you excluded IPMN.

Also Dr, Viktor Tsvirkun gave practically the same answer (see on page 2).

Dear Anna, yes IPMN was excluded by echoendoscopy. It was indeed a dilatation secondary inflammatory stenosis of the main duct.

The MRI showed no evident signs of chronic pancreatitis, and the wirsung&"""

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You can try to make and endoscopic dilatation of the Wirsung duct  with an Oddi sphintercetomy to improve its drainage

Its practically turning out to be what I advised before (page 2) and this might be better as patient is relatively younger for removing a good bulk of tissue before settling the proper diagnosis.

Dear Luis and Gautan, ERCP was performed and drainage was attempted without success due to the extent of obstruction. A pancreatic drain was inserted but it failed to relieve the main duct obstruction and it was gone some time after.

Tô me it`s obvious stent was not solution. Partington-Rochelle, as was suggested before

In case of failure of stent dilation it would be recommended to perform a Puestow procedure por pancreatic duct permanent drainage

As I said before pancreatojejunostomy is recommended in this  situation

Vut Prestou openned a fraction of te dúct. Not ideal for tais condition, BUT "whole dúct". 

1963 Partington-Rochelle

I decided to operate him and perform a Roux-en-Y longitudinal pancreato-jejunostomy. I plan to perform it by laparoscopy. I will post the results, such as feasibility of laparoscopy, and postoperative results, as soon as we operate him.

Thank you all for the comments. Your inputs were essential for my decision and also had an impact to the patient. He was reluctant due to the fact that he was asymptomatic but the information that pancreatic fuction would deteriorate was important for decision.

I sincerely hope that everything goes well with your patient and surgery.

We have just operated him two days ago. We successfully performed a Roux-en-Y longitudinal pancreato-jejunostomy totally laparoscopically. The pancreas was somehow atrophic but after opening the main duct longitudinally we observed a consistent rim of viable pancreas. I strongly believe that pancreatic function may recover a little bit after decompressing the Wirsung. I will update once he is discharged from the hospital.

Technical details and tips for those who plan to perform this operation by laparoscopy in the future:

We had one case previously performed and after opening the jejunal loop longitudinally at the same extension of the pancreatic opening, the mucosa had a huge edema and the visualisation of the posterior layer of the anastomosis became impossible. We had to convert to hand-assisted. In this case, we decided to open the jejunum progressively as the posterior running suture was being performed. We used a 3-0 prolene running suture. Two stay-sutures at the borders of the pancreas opening were used to help presentation.

Congratulations. 

This case proves the point that pancreas may atrophy due to long standing obstruction of its duct (not due to chronic pancreatitis but due to obstructive pancreatopathy)and if relieved in early phase, pancreatic function may be preserved

The patient recovery well and he will be discharged tomorrow. He didn´t need intensive care unit or blood transfusion. He did not develop pancreatic fistula. Drain will be removed at discharging day. Here some intraoperative photos of the procedure.

Figure1. Close view of the pancreas shows viable parenchyma

Figure2. End of the anterior layer of running suture

Figure3. Lap Roux-en-Y longitudinal pancreato-jejunostomy completed