Puestow surgery

Puestow surgery is used for the surgical treatment of chronic pancreatitis. Puestow surgery has two types of Duval (1954) surgery and Puestow (1958) surgery. The former is to fit the end of the pancreas and the end of the jejunum into the anastomosis. The latter is the extensive incision of the pancreatic duct into the anastomosis of the pancreatic duct. The other surgical procedures are basically the same. The late results of Duval surgery are not satisfactory. Considering the stenosis in the late stage of the pancreatic duct, this operation is currently used less frequently. Both require splenectomy, which is complicated. Treatment of diseases: chronic pancreatitis Indication Puestow surgery is suitable for: 1. Chronic pancreatitis is mainly in the tail of the pancreas and has pancreatic duct dilatation. 2. Left chronic pancreatitis with intractable pain. 3. A lump or cyst in the tail of the pancreas. 4. Chronic pancreatitis with splenic vein obstruction and left portal hypertension. 5. It is difficult to exclude tumors from the tail of the pancreas. Contraindications 1. No pancreatic duct expansion. 2. The pancreatic duct is difficult to pass through the tail of the pancreas. Preoperative preparation 1. Examination of vital organs such as heart, lung, liver and kidney. 2. Chest X-ray to exclude metastatic lesions. 3. Inject vitamin K to increase prothrombin activity. 4. Correct the electrolyte imbalances such as low potassium and low sodium. 5. For those who have obvious malnutrition due to too little food intake, intravenous nutrition is added 1 week before surgery to transfer whole blood and plasma to correct anemia and hypoproteinemia. 6. For patients with obstructive jaundice, oral bile salt preparations 1 week before surgery to reduce bacterial growth in the intestine. 7. Serve ranitidine 150mg before surgery to reduce stomach acid. 8. Apply prophylactic antibiotics. 9. Patients with serum bilirubin >171mol/L, the physical condition is still suitable for the operator, do not emphasize the routine use of preoperative transhepatic biliary drainage (PTBD) to reduce jaundice, if PTBD has been done, special attention should be paid to Electrolyte disorders caused by loss of bile, usually performed 2 to 3 weeks after drainage, to prevent biliary infection caused by PTBD. Percutaneous transhepatic gallbladder drainage can also achieve the same goal. In the case of the condition, it is feasible to introduce the drainage through the endoscope before the operation, and insert a thicker special built-in drainage tube through the common bile duct opening to the upper of the obstruction, so that the patient's condition can be improved quickly. 10. Place the gastrointestinal decompression tube before surgery. Surgical procedure 1. A long left abdomen straight incision, if necessary, a transverse incision is made to the left side of the left side; in addition, a left inferior oblique incision or a transverse incision in the upper abdomen may be used. If the patient has a cyst of the pancreas, splenomegaly or left portal hypertension, splenectomy and free pancreatic tail are often difficult, and the left upper abdomen should be better exposed. 2. Incision of the gastric collateral ligament, gastric spleen ligament, exploration of the lesions and extent of the pancreas; adhesion of the spleen and the surrounding, whether it is easy to free. For chronic recurrent pancreatitis, especially those with acute necrotizing pancreatitis and pancreatic pseudocyst, the adhesion between the pancreas and the retroperitoneum, the spleen and its surroundings is severe, and most of them are fibrous scar adhesions and blood vessels. The operation is quite difficult. . 3. On the left side of the mesenteric blood vessel, cut the peritoneum of the lower edge of the pancreas, bluntly separate the retroperitoneal space on the back of the pancreas until the upper edge of the pancreas, and introduce a F8 rubber catheter with a right angle vascular clamp to lift the pancreas In order to separate the posterior pancreatic space and block the pancreatic tail and spleen pedicle blood vessels when needed, this is an important measure to increase the safety of surgery. 4. Cut the spleen and kidney ligament, free the spleen, turn the spleen to the right side, separate the posterior pancreatic space, cut off the gastric spleen ligament and spleen ligament, the spleen and the tail of the pancreas can be turned to the right, select the appropriate plane, cut off The tail of the pancreas was identified, and the spleen blood vessels were ligated and cut at about 2.0 cm above the broken end. The bleeding point of the pancreatic end was sutured with a 3-0 silk thread to remove the spleen. 5. Have suffered from acute necrotizing pancreatitis, pseudo-pancreatic cyst, peri-pancreatitis or inflammation around the spleen. The scar adhesion around the spleen is tight, or there is left portal hypertension, which makes the routine free spleen very difficult. In the case, the tail of the pancreas and the spleen can be removed by retrograde method, and sometimes the spleen under the capsule is required to be in the place where the adhesion is too tight. The surgical method is to first cut off the tail of the pancreas and cut off the spleen pedicle blood vessels, and then gradually separate into the direction of the spleen, and finally remove the spleen from the lower pole of the spleen. 6. Prepare a piece of Roux-en-Y jejunal fistula that is pulled through the avascular zone on the left side of the transverse mesenteric to the left upper abdomen to anastomosis with the pancreas. The pancreatic duct at the end of the pancreatic tail is probed to the proximal end, and an intraoperative pancreatic duct angiography can be performed if necessary. According to the condition of the pancreatic duct, Duval or pancreatic tail excision pancreatic jejunostomy was performed. 7. Duval surgery is generally only used for the pancreatic duct to have a significant expansion throughout the process, blocking the head of the pancreas. The operation is to fit the end of the pancreas with the opposite end of the jejunum. A rubber tube can be placed in the pancreatic duct and ejected through the jejunum. 8. Pancreatic tail resection Pancreatic jejunostomy is used for the presence of stones in the pancreatic duct, stenosis of the pancreatic duct, chronic inflammation of the pancreas, and it is estimated that Duval surgery is prone to pancreatic duct stenosis. The surgical procedure is to cut a distance from the front of the pancreas along the pancreatic duct, or to remove a small amount of pancreatic tissue to reduce its volume, and then insert the pancreas into the jejunum. The purpose of this procedure is to cut the longitudinal section of the pancreatic duct to reduce the occurrence of advanced stenosis. 9. Pancreatic jejunal anastomosis is placed around the abdominal drainage, which is drawn through the left upper abdomen. The incision was sutured in layers with silk.