Frey procedure

Case contributed by Dr Matt A. Morgan

Presentation

Patient with a history of chronic pancreatitis who underwent a procedure to treat it. He is now being scanned for an unrelated issue.

Patient Data

Age: 65-70Y
Gender: Male
CT

All three planes show an afferent loop of jejunum pulled up and laid across long axis of the pancreas. The long axis of the main pancreatic duct is longitudinally incised and anastomosed to the long axis mobilized jejunal loop, allowing a route for pancreatic enzymes to escape from the pancreatic duct strictures causing repeat episodes of acute on chronic pancreatitis.

In addition to opening the pancreatic duct in the body, portions of fibrotic pancreatic head have also been removed, and the loop of jejunum carried into the region of the pancreatic head.

CT

Axial and sagittal annotated images show the afferent loop of jejunum (red arrow) meeting up with the incised pancreas (yellow arrow).

Case Discussion

Acute-on-chronic pancreatitis is a common problem.  Stricturing and parenchymal changes in chronic pancreatitis lead to a decreased ability to get pancreatic enzymes out of the pancreas and into the small bowel, which leads to further pancreatitis... a circular problem.

One method to treat this is the Puestow procedure, in which a side-to-side pancreaticojejunostomy is created by mobilizing a loop of jejunum, longitudinally incising the main pancreatic duct, and then using the loop of jejunum to create an afferent limb of a side-to-side pancreaticojejunostomy.

The Frey procedure additionally "cores" out portions of the fibrotic pancreatic head, intending to relieve pressure on the upstream main pancreatic duct (as well as remove nonfunctional pancreatic tissue).

The Whipple procedure (pancreaticoduodenectomy) is also used in some centers to treat chronic pancreatitis located primarily in the pancreatic head. This is performed on a case-by-case basis due to the potential for greater functional impairment with the Whipple procedure than with side-to-side pancreaticojejunostomy (mostly related to the gastrojejunostomy and additional hepaticojejunostomy).

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Case information

rID: 32217
Case created: 19th Nov 2014
Last edited: 10th Sep 2015
Inclusion in quiz mode: Included

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