Lateral Pancreaticojejunostomy in a Rare Case of Chronic Calcific Pancreatitis With Peripancreatic Pseudocyst in an 18-Year-Old Male: A Case Report.

Another name for the Puestow surgery is a lateral pancreaticojejunostomy. The primary pancreatic duct, which runs from the head to the tail of the organ, is opened, exposing the pancreas. In order to allow the pancreas to empty straight into the intestines, the opening of the pancreatic duct is subsequently joined to a tiny intestinal loop. For more than 50 years, this process has been used to effectively relieve pain caused by chronic pancreatitis. This technique has a very low mortality rate and a low rate of surgical complications, and a high success rate. The gradual fibrosis of the pancreas resulting in the loss of exocrine and endocrine function is known as chronic pancreatitis. Intense pain is the disease's most typical symptom. It is unclear what causes the discomfort in chronic pancreatitis. Nonetheless, a large number of these patients have dilated ducts that are made up of intervening structures and saccular dilations, a condition known as the "chain of lakes" phenomenon. Radiological investigations can be used for diagnosis in these patients. Lateral pancreaticojejunostomy is the most effective treatment option for these individuals. Preservation of endocrine and exocrine pancreatic function is another benefit of lateral pancreaticojejunostomy. With lateral pancreaticojejunostomy, chronic fibrocalcific pancreatitis that manifests as pancreatic ductal dilatation and persistent discomfort can be effectively treated. Excellent early outcomes have been observed in terms of pain alleviation as well as post-operative morbidity and mortality; however, the patient's overall outcome and long-term follow-up have not been as well defined.

Early Diagnosis and Surgical Management of Tropical Chronic Pancreatitis in a Tertiary Care Rural Hospital: A Case Report.

Tropical chronic pancreatitis represents a variant of chronic calcific non-alcoholic pancreatitis, typically found in adolescents and young adults, predominantly in developing nations. This condition usually presents as a classic triad of recurrent and severe abdominal pain, diabetes, and steatorrhea. As the disease progresses and diabetes develops, it is called fibrocalculous pancreatic diabetes. A defining characteristic of this ailment is the presence of pancreatic calculi, leading to duct dilation. Key features of this condition include an early onset in youth, intraductal calculi, an aggressive disease course, and a heightened susceptibility to pancreatic cancer. Diagnostic tools such as ultrasound, CT, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography aid in identifying the disease. Timely diagnosis and treatment significantly reduce mortality and morbidity. Our patient, a young female, presented solely with recurrent episodes of abdominal pain resembling pancreatitis, along with a normal biological profile and an absence of readily apparent symptoms. She received a diagnosis of tropical chronic pancreatitis and underwent the Partington-Rochelle procedure for surgical decompression of the main pancreatic duct.

A Multicenter, Randomized, Double-Blinded, Clinical Trial Comparing Cattell-Warren and Blumgart Anastomoses Following Partial Pancreatoduodenectomy: PANasta Trial.

Whether a Blumgart anastomosis (BA) is superior to Cattell-Warren anastomosis (CWA) in terms of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy. Importance: Complications driven by POPF following pancreatic cancer resection may hinder adjuvant therapy, shortening survival. BA may reduce complications compared to CWA, improving the use of adjuvant therapy and prolonging survival. Methods: A multicenter double-blind, controlled trial of patients undergoing resection for suspected pancreatic head cancer, randomized during surgery to a BA or CWA, stratified by pancreatic consistency and duct diameter. The primary end point was POPF, and secondary outcome measures were adjuvant therapy use, specified surgical complications, quality of life, and survival from the date of randomization. For a 10% POPF reduction, 416 patients were required, 208 per arm (two-sided α = 0·05; power = 80%). Results: Z-score at planned interim analysis was 0.474 so recruitment was held to 238 patients; 236 patients were analyzed (112 BA and 124 CWA). No significant differences in POPF were observed between BA and CWA, odds ratio (95% confidence interval [CI]) 1·04 (0.58-1.88), P = 0.887, nor in serious adverse events. Adjuvant therapy was delivered to 98 (62%) of 159 eligible patients with any malignancy; statistically unrelated to arm or postoperative complications. Twelve-month overall survival, hazard ratio (95% CI), did not differ between anastomoses; BA 0.787 (0.713-0.868) and CWA 0.854 (0.792-0.921), P = 0.266, nor for the 58 patients with complications, median (IQR), 0.83 (0.74-0.91) compared to 101 patients without complications 0.82 (0.76-0.89) (P = 0.977). Conclusions: PANasta represents the most robust analysis of BA versus CWA to date.

Robotic lateral pancreatico-jejunostomy for chronic pancreatitis Puestow procedure.

Chronic pancreatitis is a benign inflammatory disorder, which can lead to severe and persistent symptoms. Patients with recurrent episodes of abdominal pain often require endoscopic treatments, which are frequently associated with inadequate symptom relief. In selected patients, surgical treatment allows for a greater long-term pain reduction.As one of the first teams reporting this approach, we present a didactical video with a stepwise technique to perform a robotic Puestow procedure.This technical report details a robotic approach to complete a latero-lateral pancreatojejunostomy in patients with symptomatic chronic pancreatitis with dilated main pancreatic duct.The robotic approach has shown to be an effective treatment with postoperative relief of ductal hypertension and successful long-term outcomes in patients with symptomatic chronic pancreatitis. A properly executed operation following precise surgical steps is critical for the success of the procedure.

Pancreatico-Jejunostomy On Isolated Loop After Pancreatico-Duodenectomy: Is It Worthwhile?

BACKGROUND: Postoperative morbidity remains a significant problem after pancreatico-duodenectomy. The management of pancreatic stump continues to be a challenge, and many technical solutions have been developed over the years. In this study, we report the results obtained with the use of an isolated loop for pancreatico-jejunostomy in patients with soft pancreas and small pancreatic duct diameter. METHODS: Clinical data of patients submitted to pancreatico-duodenectomy in a period of sixteen years (2005-2020) were extracted from a prospective database. Patients with soft pancreas, main duct diameter < 2 mm and reconstruction by pancreatico-jejunostomy on single loop or isolated loop were selected. Primary end-point was the incidence of clinically relevant fistulas in the two groups of patients. Secondary endpoint was the length of postoperative hospital stay. A propensity score matching analysis was used for the statistics. RESULTS: Two hundred and twenty-one patients with the above characteristics were found in the database. One hundred and twelve of these received a single-loop reconstruction and 109 an isolated loop reconstruction. Incidence of clinically relevant fistulas was higher in the first group (41% vs 27%; p = 0.023). Postoperative hospital stay was significantly shorter in the second group (21 days vs 15; p < 0.001). These results were confirmed at the propensity score matching. CONCLUSION: In patients with soft pancreatic texture and small main duct diameter, pancreatico-jejunostomy on isolated loop is associated with a lower incidence of clinically relevant fistulas than after classic reconstruction. The duration of postoperative hospital stay was significantly reduced, with consequent reduction of cost.

Surgical management of 10 years delayed recurrent acute pancreatitis post Whipple procedure for chronic pancreatitis: A case report.

INTRODUCTION: In patients who underwent pancreatoduodenectomy for management of Chronic pancreatitis, early and late anastomotic failure can occur [1]. Nevertheless, taking into consideration that most pancreatic head resections are performed for malignant disease with poor prognosis, long term pancreatico-jejunal anastomotic durability has not been well examined; similarly, the management of its stenosis has not been well assessed [1]. CASE: Here we present a case of a 69 years old male patient with history of chronic alcoholic pancreatitis and ampullary fibrosis managed by pancreatico-duodenectomy presenting for 10 years delayed onset of recurrent acute pancreatitis with signs of pancreatico-jejunal anastomotic stenosis, managed surgically with revision of pancreatico-jejunal anastomosis. CONCLUSION: Our case report might hold strongly for bringing up a purposeful approach, and be an insight to take into consideration in approaching pancreatic anastomosis, especially when pancreatic resections are utilized for treating benign pathologies.

Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience.

BACKGROUND AND AIM: Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions. METHODS: It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted. RESULTS: We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8 days (range 2-10). During the follow-up interval, no leak recurrences were observed. CONCLUSIONS: Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.

Prognostic factors for long-term survival after pancreaticoduodenectomy for periampullary adenocarcinoma. A retrospective cohort study.

BACKGROUND: Periampullary adenocarcinoma (PAAC) had a poor prognosis, and pancreaticoduodenectomy (PD) remains the only potentially curative treatment. The study aimed to identify the impact of different clinicopathological factors on long-term survival following PD for PAAC. PATIENTS AND METHODS: This study is a retrospective cohort study for the patients who underwent PD for pathologically proven PAAC from January 2010 to January 2019. Statistical analysis was done using Cox regression multivariate analyses for independent risk factors for survival. RESULT: There were 137 patients with PAAC who underwent PD, 79 patients (57.7%) underwent pylorus-preserving PD. Pancreatico-jejunostomy was done in 108 patients (78.8%). The primary analysis showed that risk factors for poor long-term survival include patients with co-morbidities like hypertension or ischemic heart disease, Carbohydrate Antigen 19-9 > 400U/ml, tumor size > 3 cm, poor tumor differentiation, positive lymph nodes invasion, lymphovascular invasion, and Perineural invasion. Multivariate analysis demonstrated that large tumor size > 3 cm (HR: 0.177, 95%CI: 0.084-0.374, P = 0.002), poorly differentiated tumor (HR: 0.059, 95%CI: 0.020-0.0174, P = 0.016), and perineural invasion in the pathological study (HR: 0.101, 95%CI: 0.046-0.224, P = 0.006) were independent risk factors for poor 5-years survival. The prognosis was better in ampullary adenocarcinoma (5-year survival was 42.1%) than pancreatic adenocarcinoma (5-year survival was 24.3%). The 1, 3, 5 and 7-year overall survival rates were 84.5%, 57.4%, 35.9% and 20.1% respectively. CONCLUSION: It seems from the current study that Tumor size > 3 cm, poor tumor differentiation, and Perineural invasion were independent predictors of poor survival in patients with PAAC.

Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome.

BACKGROUND: The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. METHODS: We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. RESULTS: Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. CONCLUSION: PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.

Modified Puestow Procedure for Chronic Pancreatitis in a Child Due to Annular Pancreas and Duodenal Duplication: A Case Report.

An 18-year-old woman with annular pancreas and duodenal duplication presented with recurrent acute pancreatitis and underwent a resection of duodenal duplication. However, the patient experienced recurrent abdominal pain after resection. Abdominal computed tomography and magnetic resonance imaging showed a dilatation of the peripheral pancreatic duct and stenosis and malformation of both the Wirsung's and Santorini's duct due to multiple stones. The modified puestow procedure was performed. The main pancreatic ducts in the body and tail were opened, and the intrapancreatic common bile duct was preserved. A Roux-en-Y pancreatico-jejunostomy was performed for reconstructing the pancreaticobiliary system after removing the ductal protein plug. The patient experienced no abdominal pain, no significant elevation of the serum amylase and lipase levels, and no stone formation during the 2 years of follow-up. This procedure is considered to be beneficial for pediatric patients with chronic pancreatitis due to annular pancreas and duodenal duplication.

EUS-guided pancreatic drainage: A steep learning curve.

BACKGROUND AND OBJECTIVE: EUS-guided pancreatic drainage (EUS-PD) is an efficacious, acceptable risk option for patients with pancreatic duct obstruction who fail conventional ERCP. The aim of this study was to define the learning curve (LC) for EUS-PD. METHODS: Consecutive patients undergoing EUS-PD by a single operator were included from a dedicated registry. Demographics, procedural info, adverse events, and follow-up data were collected. Nonlinear regression and cumulative sum (CUSUM) analyses were conducted for the LC. RESULTS: Fifty-six patients were included (54% of male, with a mean age of 58 years). Technical success was achieved in 47 patients (84%). Stent placement was antegrade in 36 patients (77%) and retrograde in 11 (23%). Clinical success was achieved in 46/47 (98%) patients who achieved technical success. Adverse events were seen in 13 patients (6 of whom did not achieve technical success) and included bleeding requiring embolization (n = 5), bleeding treated with clips peri-procedurally (n = 1), pancreatitis (n = 5), and a pancreatic fluid collection drained via EUS-drainage (n = 2). The median procedural time was 80 min (range 49-159 min). The CUSUM chart showed that 80-min procedural time was achieved at the 27th procedure. Durations further reduced 40th procedure onward, reaching a plateau indicating proficiency (nonlinear regression P < 0.0001). CONCLUSION: Endoscopists experienced in EUS-PD are expected to achieve a reduction in procedural time over successive cases, with efficiency reached at 80 min and a learning rate of 27 cases. Continued improvement is demonstrated with additional experience, with plateau indicating mastery suggested at the 40th case. EUS-PD is probably one of the hardest therapeutic endosonographic procedures to learn.

Laparoscopic pancreatic neck transection and double pancreatico-jejunostomy, an alternative surgical approach to chronic pancreatitis.

Chronic pancreatitis is a benign inflammatory process that results symptoms pertaining to loss of endocrine and exocrine function. Pain poses a great challenge in the management of CP and intractable pain represents the main indication for surgical intervention. Surgical options for CP ranges from pancreatic resection to pure drainage procedures. Herein, we present the case of 68 year-old female with recurrent abdominal pain due to chronic pancreatitis, who underwent successful laparoscopic pancreatic neck transection and double pancreatico-jejunostomy (duct-to-mucosa). Pre-operative imaging revealed a uniformly dilated pancreatic duct with encrusted pancreatic stone in the pancreatic head near the ampulla of Vater, with no inflammatory mass. Pre-operative laboratory work-ups were all normal. Pancreas texture was noted to be intermediate to soft. During pancreatic neck transection, there was spontaneous deviation of distal stump laterally leaving an ample space to accommodate jejunal loop. PD measured 8 mm. The standard duct to mucosa double layer simple interrupted suture was used for PJ anastomosis. There were no significant intra-operative events. No transfusion was required. Total operation time was 297 minutes, and it took 129 minutes for laparoscopic PJ completion. Immediate post-operative course was unremarkable. This case suggests laparoscopic double PJ can be an alternative surgical approach to reduce the pancreatic duct pressure in chronic pancreatitis. Based on accumulating experiences, long-term outcome also needs to be investigated to address potential role of this technique.

Fish-Mouth Closure of the Pancreatic Stump and Parachuting of the Pancreatic End with Double U Trans-Pancreatic Sutures for Pancreatico-Jejunostomy.

PURPOSE: Leakage of pancreatico-jejunal anastomosis (PJ) remains the primary cause of morbidity and mortality after Whipple's operation. To reduce the occurrence thereof, the present author recently began to apply a modification of the Blumgart method of anastomosis after Whipple's operation (hereinafter referred to as Lee's method), with very good results. MATERIALS AND METHODS: The modified method and technique utilizes fish-mouth closure of a beveled pancreatic stump and parachuting of the pancreatic end with double U trans-pancreatic sutures (symmetric horizontal mattress-type sutures between the full thickness of the pancreas and the jejunal limb) after duct-to-mucosa pancreatico-jejunostomy. RESULTS: Eleven cases of pylorus preserving Whipple's operation have been performed without a clinically significant postoperative pancreatic fistula. CONCLUSION: This new method (Lee's method) may dramatically reduce the occurrence of postoperative pancreatic fistula after Whipple's operation.

Stented Pancreatico-duodenectomy: Does it lead to decreased pancreatic fistula rates? A prospective randomized study.

OBJECTIVE: To compare clinically relevant pancreatic fistula rates in patients with stented versus non-stented pancreatico-jejunostomies. METHODS: The randomised comparative clinical trial was conducted at Civil Hospital, Karachi, from September 2009 to August 2015, and comprised patients presenting to the Surgical Unit 4 with a diagnosis of resectable periampullary carcinoma, carcinoma of head of pancreas, duodenal carcinoma involving the second part, and distal cholangiocarcinomas. Pancreatic fistula or leakage was defined as amylase-rich fluid lasting over 5 days, collected from the peripancreatic drains on day 1, 3 and 7 postoperatively, and the rate of clinically relevant fistulas was taken as primary study endpoint. RESULTS: There were 102 patients with a male to female ratio of 2.4:1. The overall mean age was 53.16±12.11 years (range: 30-80 years). Of the total, 53(51.9%) patients had pancreatic duct stent and 49(48%) did not. Clinically relevant pancreatic leak was seen in 13(12.7%) patients of whom 8(61.5%) were stented (p=0.46), 9(69.2%) patients had soft pancreatic texture (p=0.54) and 7(53.8%) had pancreatic duct <3mm (p=0.11). CONCLUSIONS: Pancreatic fistula rates between stented and non-stented anastomosis did not show any significant difference.

Pancreatico-jejunostomy decreases post-operative pancreatic fistula incidence and severity after central pancreatectomy.

BACKGROUNDS: Central pancreatectomy (CP) is an alternative to pancreaticoduodenectomy and distal pancreatectomy in benign tumours of pancreatic isthmus management. It is known for a high post-operative pancreatic fistula (POPF) rate. The purpose of this study was to compare POPF incidence between pancreatico-jejunostomy (PJ) and pancreatico-gastrostomy (PG). METHODS: Fifty-eight patients (mean age 53.9 ± 1.9 years) who underwent a CP in four French University Hospitals from 1988 to 2011 were analysed. The distal pancreatic remnant was either anastomosed to the stomach (44.8%, n = 25) or to a Roux-en-Y jejunal loop (55.2%, n = 35) with routine external drainage allowing a systematic search for POPF. POPF severity was classified according to the International Study Group on Pancreatic Fistula (ISGPF) and Clavien-Dindo classifications. RESULTS: The groups were similar on sex ratio, mean age, ASA score, pancreas texture, operative time and operative blood loss. Mean follow-up was 36.2 ± 3.9 months. POPF were significantly more frequent after PG (76.9 versus 37.5%, P = 0.003). PG was associated with significantly higher grade of POPF both when graded with ISGPF classification (P = 0.012) and Clavien-Dindo classification (P = 0.044). There was no significant difference in post-operative bleeding (0.918) and delayed gastric emptying (0.877) between the two groups. Hospital length of stay was increased after PG (23.6 ± 3.5 days versus 16.5 ± 1.9 days, P = 0.071). There was no significant difference in incidence of long-term exocrine (3.8 versus 19.2%, P = 0.134) and endocrine (7.7 versus 9.4%, P = 0.575) pancreatic insufficiencies. CONCLUSION: PG was associated with a significantly higher POPF incidence and severity in CP. We recommend performing PJ especially in older patients to improve CP outcomes.

Surgical management of the pancreatic stump following pancreato-duodenectomy.

Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.

Quality of Life after Frey's Procedure in Patients with Chronic Pancreatitis.

INTRODUCTION: Chronic pancreatitis is a debilitating disease, associated with excruciating abdominal pain, exocrine and endocrine pancreatic insufficiency. Different types of surgical techniques have been described for the management of complications of this disease. The most common procedure which has been adopted for improving the quality of life of the patients with chronic pancreatitis is Frey's Procedure. It is an organ preserving procedure in which the main pancreatic duct is drained by lateral pancreatico-jejunostomy along with coring of the head of the pancreas. AIM: In this study, we have assessed the outcome of Frey's procedure in terms of quality of life in patients with chronic pancreatitis. MATERIALS AND METHODS: This was a prospective observational study done at a tertiary care center in West Bengal, India. The study period was from 2010 to 2014. All the patients who have undergone Frey's Procedure during the study duration and with the postoperative histopathology of chronic pancreatitis were included in this study. The preoperative and postoperative pain and quality of life assessment was done using VAS score (0-100) and EORTC QLQ-C30 (Version 3) respectively. The statistical analysis was performed with the help of Epi Info (TM) 3.5.3. RESULTS: A total of 35 patients with chronic pancreatitis underwent Frey's procedure during the study period. The mean age (mean ± s.e) of the 33 patients included in the study was 38.48±5.55 years with a range of 29-49 years. The mean preoperative Physical Functional Domain (PFD), Physical Domain (PD), Emotional Domain (ED), Social Domain (SD) and general health raw score with standard errors were 32.06±0.40, 37.86±0.36, 15.18±0.32, 8.63±0.31 and 4.48±0.26 respectively. ANOVA showed that there was significant differences in PFD, PD, ED, SD and GH values during different time period of follow up (p<0.0001) and as per Critical Difference the postoperative values of PFD, PD, ED and SD decreased while postoperative value of GH increased significantly in different months compared to the preoperative values. CONCLUSION: We conclude that Frey's procedure is a low risk surgery, which significantly improves the quality of life of the patients with chronic pancreatitis in all the domains and can be recommended as a surgical therapy for such patients.

Anterior Roux-en-Y Pancreatico-jejunostomy for Pancreatic Trauma.

Isolated pancreatic laceration is a rare injury. The typical mechanism by which it occurs is overstretching of the pancreas across the vertebral column during blunt abdominal trauma. The management depends on the location and extent of the injury. Disruption of the pancreatic duct usually requires operative treatment. Operative options for pancreatic laceration at the neck include distal pancreatectomy or suturing of the cephalic remnant and Roux-en-Y pancreatico-jejunostomy on the left remnant. We are reporting two cases of isolated pancreatic injury with disruption of the pancreatic duct but preserved posterior surface of the pancreas. These patients were managed by performing anterior Roux-en-Y pancreatico-jejunostomy at the lacerated area. Both the patients had successful outcome with removal of drains by 6(th) postoperative day. Anterior Roux-en-Y pancreatico-jejunostomy in this particular scenario is easy, less time consuming, and has the advantage of preserving the pancreas and the spleen.