Pancreatic head resection and Roux-en-Y pancreaticojejunostomy for the treatment of the focal form of congenital hyperinsulinism

Abstract

Purpose: To determine the outcome of patients who underwent pancreatic head resection and Roux-en-Y pancreaticojejunostomy to the remaining normal pancreatic body and tail for the treatment of a focal lesion in the pancreatic head causing congenital hyperinsulinism (HI).

Methods: One hundred thirty-eight patients underwent pancreatic resection for focal HI between 1998 and 2010. Twenty-three patients in the group underwent pancreatic head resection and Roux-en-Y pancreaticojejunostomy.

Results: There were 13 females and 10 males. Median age and weight at surgery were 8 weeks and 5.8 kg, respectively. Twenty-one patients had a near-total pancreatic head resection, and 2 patients had a pylorus-preserving Whipple procedure. The pancreaticojejunostomy anastomosis was performed with interrupted fine monofilament sutures such that the transected end of the pancreatic body was tucked within the end of the Roux-en-Y jejunal limb. Median hospital stay was 22 days. All patients were cured of HI.

Conclusion: We conclude that pancreatic head resection with Roux-en-Y pancreaticojejunostomy is a safe and effective procedure for the treatment of the HI patient with a large focal lesion in the pancreatic head that is not amenable to local resection alone.

Fig. 1

¹⁸Fluoro-l-DOPA positron emission tomography scan merged with a computed tomography (¹⁸F-PET/CT) showing a large focal lesion in the head of the pancreas. SMV: superior mesenteric vein.

Fig. 2

¹⁸F-PET/CT scan showing diffuse disease. Note the homogeneous distribution of the contrast throughout the pancreatic head (small white arrow) body and tail (long white arrows). LK: left kidney; RK: right kidney.

Fig. 3

Surgical technique. A, Focal lesion in the head of the pancreas that has octopus-like tentacles that extend into the normal tissue. B, Near-total pancreatic head resection. The common bile duct is skeletonized and the duodenal vasculature is preserved. A very small portion of the pancreatic head (<5%) is left between the common bile duct and the duodenal wall, along the superior pancreaticoduodenal artery. C, Pancreaticojejunostomy. In babies, the pancreatic duct is not visible even under 4× loupe magnification. Fine interrupted 5–0 monofilament stitches are placed from the end of the Roux-en-Y jejunal limb (full thickness) to the capsule of the pancreas just beyond the cut edge so that the cut end of the pancreatic body is tucked into the jejunal lumen. The posterior aspect of the anastomosis is performed first, with all sutures placed first and then tied serially leaving the knots on the inside of the anastomosis. The anterior aspect is performed in the same manner, but leaving the knots on the outside.