Pancreas: Drainage Procedures

Puestow Procedure (Lateral Pancreaticojejunostomy)

Basics

  • Opening of Lateral Main Pancreatic Duct with Anastomosis to Roux-en-Y Jejunal Limb

Indication

  • Chronic Pancreatitis with Severe Pain or Complications
  • Criteria: Enlarged Ducts (> 6 mm) & No Head Mass

Procedure

  • Open Duct Anteriorly
    • Medial to GDA
    • Lateral to Tail Past All Strictures
    • Minimum Length: 6 cm
  • Clear Intraductal Stones
    • Consider Head Pancreatoscopy or Electrohydraulic Lithotripsy
  • Anastomose Duct to Roux-en-Y Jejunal Limb

Complications

  • Bleeding – Postoperatively Usually From GDA
  • Leak
  • Pancreatic Function Usually Preserved (No Parenchymal Resection)

Puestow Procedure 1

Frey Procedure

Basics

  • Lateral Pancreaticojejunostomy with “Core Out” of Fibrotic Head Mn

Indication

  • Chronic Pancreatitis with Severe Pain or Complications
  • Criteria: Enlarged Ducts (> 6 mm) & Inflammatory Head Mass

Procedure

  • Open Duct Anteriorly Along Its Entire Length
  • “Core Out” Fibrotic Pancreatic Head Without Transecting Neck
    • Preserve Peripheral Parenchyma at Lateral Margin, Posterior Margin & Duodenum
    • Spares More Pancreas Than Beger
  • Anastomose Duct to Roux-en-Y Jejunal Limb

Frey Procedure 2

Beger Procedure

Basics

  • Duodenal Preserving Pancreatic Head Resection & Pancreaticojejunostomy Mn

Indication

  • Chronic Pancreatitis with Severe Pain or Complications
  • Criteria: Small-Normal Ducts & Isolated to Head

Procedure

  • Transect Pancreatic Neck at Portal Vein
    • *If Unable to Divide at Neck: Transition to Frey Procedure
  • Subtotal Head Resection
    • Preserve Peripheral Parenchyma Along Duodenum
    • Spares Duodenum & CBD
  • Anastomose Duct to Roux-en-Y Jejunal Limb

Beger Procedure 3

Mnemonics

Pancreas Drainage Procedures

  • “Fried” Out Head
    • Frey Just Cores Out the Head, Not Full Resection
  • Just a “Burger” or “Burger & Fries”
    • Beger (Burger) is Just the Head Resection
    • Frey (Fry) Cores Out the Head with a Lateral Pancreaticojejunostomy

References

  1. Terrone DG, Lepanto L, Billiard JS, Olivié D, Murphy-Lavallée J, Vandenbroucke F, Tang A. A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review. Insights Imaging. 2011 Dec;2(6):631-638. (License: CC BY-2.0)
  2. Tan CL, Zhang H, Yang M, Li SJ, Liu XB, Li KZ. Role of original and modified Frey’s procedures in chronic pancreatitis. World J Gastroenterol. 2016 Dec 21;22(47):10415-10423. (License: CC BY-NC-4.0)
  3. Koninger J, Seiler CM, Wente MN, Reidel MA, Gazayakan E, Mansmann U, Müller MW, Friess H, Buchler MW. Duodenum preserving pancreatectomy in chronic pancreatitis: design of a randomized controlled trial comparing two surgical techniques. Trials. 2006 May 8;7:12. (License: CC BY-2.0)