Lateral Pancreaticojejunostomy (Puestow)
What the Examiner Expects
A drainage procedure for chronic pancreatitis involving longitudinal incision of the main pancreatic duct along the length of the pancreas (often called 'filleting' the duct) with creation of a side-to-side anastomosis to a Roux-en-Y jejunal limb. The examiner expects you to know this is indicated for chronic pancreatitis with a dilated main pancreatic duct (> 7 mm) — the classic 'chain of lakes' appearance on imaging. The Puestow (modified by Partington-Rochelle) provides decompression of the obstructed duct and relieves pain in 70–80% of patients. If the pancreatic head is the dominant source of pain and obstruction (inflammatory head mass), a Frey procedure (local head coring + lateral PJ) or Beger procedure (duodenum-preserving pancreatic head resection) is preferred.
Key Examiner Focus Points
- Indicated for chronic pancreatitis with dilated main pancreatic duct (> 7 mm)
- Longitudinal opening of the pancreatic duct with side-to-side Roux-en-Y jejunal anastomosis
- Provides pain relief in 70–80% of patients with dilated duct disease
- Does not address pancreatic head mass — consider Frey or Beger procedure if head is dominant
- Preserves pancreatic parenchyma and endocrine/exocrine function
Common Curveballs
The main pancreatic duct is not dilated (< 3 mm) but the patient has debilitating pain from chronic pancreatitis
Lateral PJ (Puestow) requires a dilated duct to be technically feasible. For small-duct disease, options include total pancreatectomy with islet autotransplantation (TPIAT), distal pancreatectomy for tail-dominant disease, or continued medical management with nerve block (celiac plexus block/neurolysis).
CT shows a pancreatic head mass in a patient with known chronic pancreatitis
This could be an inflammatory mass or pancreatic cancer arising in the setting of chronic pancreatitis. EUS with FNA is essential. If cancer cannot be excluded, proceed with pancreaticoduodenectomy. A Puestow alone would be inadequate if there is an underlying malignancy.
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