Surgical and Endoscopic Intervention for Chronic Pancreatitis in Children: The Kings College Hospital Experience

Abstract

Paediatric chronic pancreatitis (CP) is a rare and debilitating pathology that often requires invasive diagnostics and therapeutic interventions either to address a primary cause such as a pancreaticobiliary malunion or to deal with secondary complications such as chronic pain. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are two endoscopic modalities that have an established diagnostic role in paediatric CP, and their therapeutic utilisation is increasing in popularity. Surgical decompression of the obstructed and dilated pancreatic duct plays a role in alleviating pancreatic duct hypertension, a common association in CP. Surgery equally has a role in certain anatomical abnormalities of the pancreaticobiliary draining system, or occasionally in some CP complications such as drainage of a symptomatic pancreatic pseudocyst.

Keywords: ERCP; Puestow procedure; chronic pancreatitis; cystogastrostomy; endoscopic ultrasound (EUS); pancreatojejunostomy; pseudocyst.

Figure 1

PRISMA flow chart summarising literature review.

Figure 2

Schematic illustrating causes of chronic pancreatitis in children.

Figure 3

Schematic illustration of longitudinal pancreatojejunostomy (Puestow procedure) (reproduced with permission from Davenport M., “Chronic Pancreatis In Surgery of the Liver, Bile Ducts and Pancreas in Children” (eds). Davenport M, Heaton ND, Superina R, CRC Press 2016) [25]. (a) Mobilisation of tail of pancreas from splenic hilum with freeing of splenic vein and artery. Amputation of the tail to identify the dilated pancreatic duct. Sometime, an on-table ultrasound may help to identify the dilated duct more proximally. (b) Laying open the duct along the body to the neck. (c) Creation of an isograde Roux loop and pancreatojejunostomy.

Figure 4

Longitudinal pancreatojejunostomy (Puestow procedure) [25]. Operative photographs showing (A) initial amputation of tail and identification of distal duct using a lacrimal probe; (B) opening of duct along length exposing indwelling stent. The dotted line shows margins that will form the longitudinal anastomosis.

Figure 4

Longitudinal pancreatojejunostomy (Puestow procedure) [25]. Operative photographs showing (A) initial amputation of tail and identification of distal duct using a lacrimal probe; (B) opening of duct along length exposing indwelling stent. The dotted line shows margins that will form the longitudinal anastomosis.