多功能吸引器在免充气经口腔镜甲状腺癌中央区淋巴结清扫术中的应用

目的:总结在免充气经口腔前庭入路腔镜甲状腺癌切除术标准手术流程中应用新型多功能吸引器的安全性及便利性。方法:回顾分析2022年1月至2022年11月接受免充气经口腔前庭入路腔镜甲状腺癌切除术患者的临床资料，分析手术时间及术后并发症情况。结果:共纳入239例甲状腺乳头状癌患者，其中221例行单侧中央区淋巴结清扫术，手术时间平均(161.28±2.71)min; 18例行双侧中央区淋巴结清扫术，手术时间平均(192.33±10.66)min。术后2例患者出现切口感染，未发生永久性低钙血症、喉返神经损伤。结论:在标准免充气经口腔镜甲状腺癌中央区淋巴结清扫流程中应用多功能吸引器利于空间的建立，可协助暴露手术视野，加快烟雾排出。     

无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术对侧处理改进三步法（附视频）

随着腔镜技术的发展,腔镜甲状腺手术也得以广泛应用,目前腔镜甲状腺手术的常见入路有经胸乳、经口、经腋等,其中无充气腋窝入路腔镜甲状腺手术受到众多从事甲状腺外科医生的高度认可。该技术能够满足患者的美容需求,同时能够利用颈前肌肉的自然间隙进行手术达到微创的目的。虽然目前无充气腋窝入路腔镜甲状腺手术操作越来越成熟规范,但是在无充气单侧腋窝入路全腔镜甲状腺双侧叶全切除术（GUA-ETT）过程中,切除对侧叶时,如何避免气管的遮挡、顺利暴露对侧喉返神经并保证对侧中央区淋巴结清扫的彻底性等都是需要直接面对的困难。本中心针对单侧叶切除后行对侧叶全切除术及对侧中央区淋巴结清扫术,提出对侧处理改进三步法。为了更方便甲状腺外科医生掌握该技术,笔者就该GUA-ETT中对侧处理改进三步法的手术方法、技术特点、操作技巧及细节与操作重点、难点及操作经验进行详细阐述及分享。     

经胸经口联合入路腔镜甲状腺癌颈侧区淋巴结清扫术临床应用

背景与目的 目前,经胸乳入路腔镜甲状腺癌手术已广泛开展,但伴颈侧区淋巴结转移的患者能否在腔镜下完成彻底的淋巴结清扫,特别是Ⅵ和Ⅳ区的低位淋巴结清扫,一直存在争议。本研究总结分析笔者团队近年实施的经胸经口联合入路腔镜甲状腺癌的颈侧区淋巴结清扫患者的临床资料,探索采用该术式的必要性及安全性。方法 回顾分析2015年2月—2021年12月于厦门大学附属中山医院63例行腔镜甲状腺切除、中央区及颈侧区淋巴结清扫的甲状腺乳头状癌患者资料。其中,41例行经胸口联合入路手术（联合入路组）,包括12例行经胸甲状腺切除、中央区及颈侧区淋巴结清扫后再经口补充清扫Ⅵ和Ⅳ区淋巴结,另29例行经胸和经口手术步骤合理融合,不再单独补充清扫Ⅵ及Ⅳ区淋巴结;22例行单纯经胸入路腔镜甲状腺癌根治并颈侧区淋巴结清扫术（经胸入路组）。比较两组患者的相关临床指标。结果 两组患者的年龄、性别及肿瘤大小差异均无统计学意义（均P>0.05）。联合入路组的12例经口补充清扫颈侧区淋巴结的标本中有8例检出淋巴结,其中2例检出阳性淋巴结。联合入路组与经胸入路组获得的中央区淋巴结总数分别为（8.80±5.78）枚、（8.23±3.53）枚,颈侧区获得的淋巴结总数分别为（31.49±14.90）枚、（29.05±7.80）枚,差异均无统计学意义（P>0.05）。两组的手术时间、住院时间以及术后出血、喉返神经麻痹、甲状旁腺功能减低、副神经损伤、乳糜漏和Horner综合征等并发症发生率差异均无统计学意义（均P>0.05）。术后随访,联合入路组1例颈侧区淋巴结转移癌复发,经胸入路组1例手术清扫侧中央区淋巴结转移癌复发。结论 经胸经口联合入路腔镜甲状腺癌颈侧区淋巴结清扫术安全、有效,与单纯经胸入路疗效相当。但补充清扫中的阳性淋巴结提示,对于淋巴结转移较多的甲状腺癌患者经胸经口联合入路腔镜甲状腺癌颈侧区淋巴结清扫术可能有一定的价值。然而,本研究病例数量较少,随访时间相对较短,有待多中心、大样本量的对照研究及长期随访结果来进一步评估该方法的安全性、有效性和必要性。     

改良无充气经锁骨下入路腔镜甲状腺手术治疗甲状腺乳头状癌70例疗效分析

目的 探讨改良无充气经锁骨下入路腔镜甲状腺手术治疗甲状腺乳头状癌的可行性和安全性。方法 回顾性分析2021年1～7月在浙江大学医学院附属邵逸夫医院头颈外科接受改良无充气经锁骨下入路腔镜甲状腺手术的70例甲状腺乳头状癌病人的临床资料。记录手术时间、中央区完全显露率、住院时间、清扫淋巴结数目及术后并发症。采用门诊随访方式，随访截止时间为2022年1月。结果 所有病例均顺利在腔镜下完成手术，无中转开放手术。甲状腺乳头状癌最大直径为6（2~30 ）mm，中央区淋巴结获取数目为4（0~19）枚。中央区完全显露率为92.8%（65/70）。手术时间为95（65~145）min，术后住院时间为4（2~5 ）d。暂时性喉返神经损伤1例，皮下积液1例，局部红肿2例，均经保守治疗痊愈。无术后出血发生。随访过程中无肿瘤残留或复发。结论 改良无充气经锁骨下入路腔镜甲状腺手术治疗甲状腺乳头状癌安全可行，中央区淋巴结清扫彻底，切口隐蔽性好，有临床运用价值。     

自制Trocar套管在经口腔前庭入路腔镜甲状腺手术中的应用

目的:评价自制Trocar辅助套管在经口腔前庭入路腔镜甲状腺手术中操作空间维持的效果及临床价值.方法:2019年4月至2021年3月在Trocar套管辅助下完成16例腔镜甲状腺癌根治术(辅助组),行单侧甲状腺腺叶及峡部切除+同侧中央区淋巴结清扫术,与同期14例非套管辅助的常规组进行对比.结果:两组手术时间、淋巴结清扫数...     

经颏下前庭腔镜甲状腺手术的历史、优点和不足

甲状腺疾病以青年女性多见，传统的手术瘢痕可能影响患者美观，不能完全满足患者的美容需求。随着外科手术技术的进步，腔镜甲状腺手术迅猛发展。经口腔前庭入路实现体表无瘢痕，是安全、可行的，但有一些不可避免的局限性，如术后下巴水肿、麻木不适等。经颏下前庭腔镜甲状腺手术作为一种全新入路的甲状腺手术，它具备与经口腔前庭入路一样的由上而下的视角优势，能够可靠彻底清扫中央区（特别是Ⅶ区）淋巴结，允许较大的标本取出，扩大了手术的适应证，最大限度地减少了皮瓣剥离，避免了下巴疼痛和麻木不适。经颏下前庭腔镜甲状腺手术是甲状腺外科治疗理念的创新，在保证手术质量、治愈疾病的前提下，实现微创和美观的效果。笔者通过回顾经颏下前庭腔镜甲状腺手术的历史和自身经验，总结了该入路的优缺点。     

经胸乳入路腔镜手术治疗女性单侧甲状腺微小乳头状癌的临床价值

目的:探讨经胸乳入路腔镜技术在女性单侧甲状腺微小乳头状癌手术中的应用价值。方法:回顾分析2019年1月至2020年7月收治的50例女性甲状腺微小乳头状癌患者的临床资料,根据术式分为腔镜组(n=25)与开放组(n=25)。对比分析两组手术时间、中央区淋巴结清扫数量、术后引流量、置管时间、术后美容效果、术后并发症等。结果:两组中央区淋巴结清扫数量、术后引流量、置管时间、术后并发症发生率差异无统计学意义(P>0.05);腔镜组手术时间长于开放组,患者对切口满意度更高,两组差异有统计学意义(P<0.05)。结论:全腔镜技术与开放甲状腺手术在甲状腺微小乳头状癌根治术中的疗效相当,但腔镜手术美容效果更好,对美容要求高且颈侧无肿大淋巴结的甲状腺微小乳头状癌患者可作为首选术式。     

甲状腺微小乳头状癌全乳晕腔镜手术与开放手术的疗效比较

目的:对比全乳晕腔镜手术与开放手术治疗甲状腺微小乳头状癌的临床疗效。方法:选择2019年1月至2021年1月收治的200例甲状腺微小乳头状癌患者作为研究对象,根据手术方法分为两组,100例开放手术患者纳入开放组,100例全乳晕入路腔镜手术患者纳入腔镜组。对比分析两组中央区淋巴结清扫数量、术中出血量、术后心率、术后切口疼痛视觉模拟评分、术后住院时间、术后并发症发生率及手术前后血钙水平。结果:两组中央区淋巴结清扫数量差异无统计学意义(P0.05)。两组术后6 h血清钙均低于入院时,且开放组低于腔镜组,差异有统计学意义(P0.05),腔镜组术中出血量、术后心率、术后6 h与24 h疼痛评分、术后住院时间、并发症发生率均低于开放组,差异有统计学意义(P0.05)。结论:全乳晕入路腔镜甲状腺手术治疗微小乳头状癌可减少出血量与术后并发症,减轻手术操作对甲状旁腺、返喉神经的刺激与损伤,可作为甲状腺微小乳头状癌的优选术式。     

经口腔前庭入路非充气腔镜甲状腺乳头状癌手术的安全性及可行性研究

目的探讨无充气经口腔前庭入路腔镜甲状腺乳头状癌手术的安全性及可行性。方法回顾性分析2020年11月至2021年6月在浙江大学医学院附属邵逸夫医院头颈外科接受无充气拉钩悬吊法经口腔前庭入路腔镜甲状腺手术的39例甲状腺乳头状癌患者的临床资料。结果 39例患者均在腔镜下顺利完成手术, 无中转开放手术, 平均手术时间为(142±35)min, 术后平均住院时间为(4.1±0.8)d。甲状腺乳头状癌平均最大直径为(8.5±4.5)mm, 平均清扫的中央区淋巴结数目为(7.7±5.9)枚。术后发生暂时性甲状旁腺功能减退2例, 1个月均恢复正常;皮下积液1例, 经皮置管引流后治疗痊愈;下唇及颏部皮肤麻木3例, 6个月症状得到改善。随访过程中无肿瘤局部残留或复发。结论无充气拉钩悬吊法经口腔前庭入路腔镜甲状腺手术治疗甲状腺乳头状癌安全可行。     

经口腔前庭入路腔镜甲状腺癌根治手术的临床体会

目的探讨经口腔前庭入路腔镜甲状腺癌根治术临床应用的可行性及安全性。方法查询我院实施经口腔前庭入路腔镜甲状腺癌根治手术的临床资料,包括一般资料、手术方式、手术时间、出血量、并发症、住院时间、手术转归和术后病理结果等指标,综合分析该术式的可行性及安全性。结果 2016年11月～2018年11月我科共实施经口腔前庭入路腔镜甲状腺癌根治手术36例,其中女性27例,男性9例,中位年龄27岁(22～32岁);所有患者均成功实施口腔前庭入路甲状腺癌根治手术(甲状腺腺叶及峡部切除+患侧中央区淋巴结清扫术),无中转病例;平均手术时间150 min(120～180 min);术中平均出血量35 mL(20～75mL);术后均无伤口感染、出血、声音嘶哑、饮水呛咳、手足抽搐等并发症发生;1例术中刺穿颏下皮肤,所有病例术后均出现不同程度的口唇和颏下肿胀,术后7天均基本消退;术后病理结果 36例均为甲状腺乳头状癌,中央区淋巴结平均数目5.5枚(3～11枚);术后3个月复查体表及口腔前庭均无疤痕,患者对美容效果满意。结论选择合适的病例行经口腔前庭入路腔镜甲状腺癌根治术安全可行,在美容效果和中央区淋巴结清扫彻底性上有优势。     

Transsphenoidal surgery for pituitary tumors from microsurgery to the endoscopic surgery: single surgeon's experience

We reviewed results of the surgical outcome of pituitary tumors treated via the transsphenoidal approach between January, 1994 and January, 2010 at our institution. This data included 100 patients (124 procedures) treated through the sublabial transsphenoidal approach and 45 patients (54 procedures) treated through the endoscopic endonasal (bilateral nostrils) transsphenoidal approach performed by a single surgeon. The extent of tumor removal was significantly improved with endoscopic surgery; adjuvant gamma knife radiosurgery was needed for 65% of patients undergoing microsurgery vs. 30% for patients who had endoscopic surgery (p<0.0001). Patients who underwent endoscopic surgery had less intraoperative blood loss (mean volume: 100 mL for microsurgery patients vs. 30 mL for endoscopic surgery patients, p<0.0001), less pain, and less need for postoperative hormone replacement therapy (19% for microsurgery patients vs. 6% for endoscopic surgery patients; p<0.05). CSF leakage and meningitis were experienced in one microsurgery patient (1%) and one endoscopic surgery patient (2.2%). Endoscopic surgery is a reasonable alternative to microsurgery and our experience supports the concept that an otolaryngologist/neurosurgeon team skilled in endoscopic techniques and pituitary surgery can safely make the transition from microsurgery to endoscopic surgery.     

Surgical management of chronic fistula after sleeve gastrectomy

BackgroundThere is no clear definition of the chronic leak after sleeve gastrectomy. There are several endoscopic approaches, including endoprothese, endoscopic clips, endoscopic sealing glue, or balloon dilation. In case of failure of the endoscopic treatment, a definitive surgical approach can be attempted. The objective was to evaluate the surgical treatment of chronic leak after sleeve gastrectomy.MethodsFrom November 2010 through March 2012, 8 patients with chronic gastric fistula after laparoscopic sleeve gastrectomy had definitive surgical repair. The initial intervention, the diagnosis and management of the fistula, and the endoscopic approach were carefully reviewed.ResultsFive patients had their original laparoscopic sleeve gastrectomies performed at another hospital, while 3 had laparoscopic sleeve gastrectomy at our institution. The mean period of time from the diagnosis of the fistula to definitive surgical treatment was 14.4 months (range 5–44 months). Seven patients initially had surgical drainage by laparoscopy (5) and by laparotomy (2), with concomitant feeding jejunostomy in 6 patients. The endoscopic treatment consisted of endoprothese in 4 patients, endoscopic sealing glue in 2 patients, and sequential approach with glue and prosthesis in 2 other patients. One patient was treated exclusively by endoscopic approach with no surgical drainage.The surgical procedures performed for chronic fistula were gastrojejunal lateral anastomosis (4), Roux-en-Y gastric bypass (2), and gastrectomy with esojejunal anastomosis (2). Four patients presented with postoperative fistula, with a mean healing time of 32 days (range 22–63 days). No mortality was recorded.ConclusionIn chronic forms of fistulas with no improvements by endoscopic approach, the surgical treatment can be a solution. It remains a difficult procedure with a high percentage of leakage, but this type of fistula is more easily tolerated by the patient and heals faster.     

Comparative study of thyroidectomies

Background: We have performed endoscopic thyroidectomy by an anterior chest approach and by an axillary approach. In this study, we evaluate the efficacy of these two types of endoscopic procedures and conventional open surgery. Methods: Each procedure was performed in 15 patients. The degree of surgical invasiveness and the nature of patients' complaints after surgery were compared using results of the operation and a questionnaire. Results: Although the mean operating time for the endoscopic procedure was significantly longer than for open surgery, there was no postoperative pain difference in the three groups. Three months after surgery, the incidence of swallowing discomfort was higher in the open surgery group than in endoscopic surgery group. All of the patients treated using the axillary approach were satisfied with the cosmetic results. However, three patients (20%) treated using the anterior chest approach and 11 patients (73%; p < 0.01) who underwent open surgery complained about the cosmetic results. Conclusions: The incidence of postoperative complaints after endoscopic surgery is significantly lower than after open surgery. Patients treated using the axillary approach can obtain cosmetic results superior to those achieved with other procedures.     

Initial experience with a gasless unilateral axillo-breast or axillary approach endoscopic thyroidectomy for papillary thyroid microcarcinoma: comparison with conventional open thyroidectomy

The efficacy of various endoscopic thyroidectomy has not been determined for papillary thyroid microcarcinoma (PTMC). We compared 31 consecutive patients with PTMC who underwent endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach, and the 36 PTMC patients who underwent conventional open thyroid lobectomy from August 2005 to December 2008. There were more female patients (P=0.004) in the endoscopic group, and the mean age of endoscopic group was younger than that of the open thyroidectomy group (P=0.006). The entire endoscopic thyroidectomy was successfully completed in all the patients. The operative time was longer for those undergoing endoscopic thyroidectomy (P<0.001). The complication rate did not differ between the 2 groups. The cosmetic satisfaction, as evaluated by questionnaire, was greater in the endoscopic group (P<0.001). Endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach for selected cases of PTMC is a feasible, safe, and cosmetically superior procedure.     

3-D endoscope using a single CCD camera and pneumatic vibration mechanism

Background

During endoscopic surgical procedures, surgeons must manipulate an endoscope inside the body cavity to observe a surgical area while estimating the distance between that area and the surgical instruments by reference to a monitor on which the movement and size of the surgical instruments are displayed in 2-D endoscopic images. Therefore, there is a risk of the endoscope or instruments physically damaging body tissues. To overcome this problem, we developed a Ø5-mm, 3-D endoscope using a single 1/10-inch CCD camera and pneumatic vibration mechanism.

Methods

The 3-D endoscope proposed in this paper consists of an outer and inner sleeve, a 1/10-inch CCD camera attached to its distal end, and a pneumatic vibration mechanism attached to its proximal end. This endoscope can acquire left and right endoscopic images for stereovision in synchrony with the periodical motion generated by the vibration mechanism. We measured the displacement at the proximal and distal end of the 3-D endoscope simultaneously, and evaluated the feasibility of its use in vivo.

Results

The displacement at the distal end of the endoscope to which the CCD camera is attached was approximately ±0.25 mm. The timing when the displacement of the CCD camera was at maximal amplitude coincided with the timing when the displacement of its proximal end was at maximal amplitude. In the in vivo experiment, this 3-D endoscope can provide clear 3-D images of the surgical area.

Conclusions

The developed 3-D endoscope that uses a single CCD camera and pneumatic vibration mechanism can successfully visualize internal organs inside the body even though the CCD camera is moved by the vibration. Therefore, the risk of damage to fragile body tissues can be significantly decreased.     

Endoscopic biopsies of lesions associated with a thickened pituitary stalk

Background

Lesions associated with a thickened pituitary stalk (TPS lesions) revealed by magnetic resonance imaging have a diverse pathology. Accordingly, for clinical decision-making, it is necessary to make a diagnosis based on histopathological examination of the TPS lesions. The objectives of this study were to review endoscopic biopsies of TPS lesions and to assess the surgical strategy for treating these lesions.

Methods

Eleven patients (four males and seven females) aged from 6 to 75 years underwent endoscopic biopsy of a TPS lesion between 2006 and 2011 at University of Niigata. The relationships of the extent of lesions with surgical approaches were retrospectively examined.

Results

Among the 11 patients, a biopsy was performed via an endoscopic transsphenoidal approach for five with intrasellar lesions; via an endoscopic extended transsphenoidal approach for two with localized TPS lesions; and via an endoscopic intraventricular approach for four with the lesion protruding from the infundibulum. Histopathological examinations of all the lesions confirmed diagnoses of germinoma in four patients, hypophysitis in three, Langerhans cell histiocytosis in two, craniopharyngioma in one, and cancer metastasis in one. None of the 11 patients had further deterioration of pituitary function postoperatively.

Conclusions

Endoscopic biopsy of TPS lesions is a less invasive alternative to open biopsy requiring transcranial surgery. The endoscopic transsphenoidal approach is most suitable for biopsies of TPS lesions associated with intrasellar lesions. Otherwise, the endoscopic intraventricular approach seems reasonable for intraventricular lesions protruding from the infundibulum, and the endoscopic extended transsphenoidal approach appears appropriate for localized TPS lesions.     

甲状腺腔镜术式与常规术式对人体细胞免疫影响的实验研究

目的:比较经胸前径路腔镜甲状腺手术与常规手术对机体细胞免疫功能的影响,以期对腔镜治疗甲状腺恶性肿瘤的可行性提供理论依据。方法:选择2007年7月至12月我科治疗的40例甲状腺结节患者,20例行经胸前径路腔镜甲状腺手术(ET组),20例行常规手术(CT组),两组分别于术前及术后第1、3、5天抽血,并用流式细胞仪测定自然杀伤细胞(NK细胞)数量;CD3+、CD4+、CD8+T淋巴细胞百分比及CD4+/CD8+比值。结果:ET组和CT组NK细胞术后第1天均升高,与术前相比有显著差异(P<0.05),术后第3天ET组NK细胞明显减少,术后第5天开始恢复,均与术前有显著差异(P<0.05);CT组术后第3天也出现下降趋势,至术后第5天下降更明显,与术前有显著差异(P<0.05)。ET组和CT组的CD3+、CD4+T淋巴细胞、CD4+/CD8+比值术后第1天均下降,与术前有显著差异(P<0.05),其中CT组的CD3+、CD4+T淋巴细胞百分比下降更为明显,与ET组相比差异有统计学意义(P<0.05)。ET组CD3+T淋巴细胞百分比在术后第3天恢复至正常水平,而CT组仍显著降低,与术前及与ET组相比均有显著差异(P<0.05)。结论:经胸前径路腔镜甲状腺手术与常规手术均在术后早期抑制了机体的细胞免疫功能,但与常规手术相比,腔镜手术后恢复至正常水平的时间更快,说明其引起的创伤应激导致的免疫抑制作用较小。     

Endoscopic aqueductoplasty through a tailored craniocervical approach

OBJECT: Neuroendoscopy has an essential role in the management of occlusive hydrocephalus due to a membranous obstruction of the sylvian aqueduct. Well-known endoscopic methods include endoscopic third ventriculostomy (ETV) and endoscopic aqueductoplasty through a frontal burr hole. Building on their experience in the endoscopic management of hydrocephalus, the authors realized that not all of their patients with aqueductal obstruction were eligible for the aforementioned lines of treatment. Certain anatomical situations made it impossible to perform ETV or endoscopic aqueductoplasty through a frontal burr hole. Long-term complications of the shunt system led the authors to seek an alternative form of treatment for these patients. In this study, they present a new endoscopic approach to performing aqueductoplasty through the fourth ventricle. METHODS: Endoscopic aqueductoplasty was performed in five patients by using a tailored craniocervical approach. In all patients a caudally located membranous obstruction of the sylvian aqueduct was present, and the authors were able to relieve the membranous obstruction in all patients without complications. All patients experienced improvement, which was demonstrated clinically and on imaging studies. CONCLUSIONS: Caudal endoscopic aqueductoplasty is a safe and effective method of treatment in the management of a caudally located membranous obstruction of the sylvian aqueduct. This should be considered as an alternative endoscopic method when other endoscopic solutions are not suitable.     

Fusion variations of pancreatic ducts in patients with anomalous arrangement of pancreaticobiliary ductal system

Fusion variations of the pancreatic ducts were studied to elucidate the significance of such variations. We classified structural fusion anomalies of the main and accessory pancreatic ducts on endoscopic retrograde cholangio-pancreatography (ERCP) in 37 patients with anomalous arrangement of the pancreaticobiliary ductal system (AAPB). The fusion variations of the pancreatic ducts were classified into five types: common, ansa pancreatica, branch fusion, looped, and separated. These fusion variations, except for common type, were found in 68% of the 37 patients with AAPB on ERCP. Fusion variations of the pancreatic ducts were very frequent (93%) in the 30 patients with congenital cystic dilatation of the common bile duct (CCD). The branch confluence fashion, in which the terminal bile duct communicated with a pancreatic duct branch, was found only in patients with cystic dilatation cyst of the CCD, and it appeared that cystic dilatation cyst of CCD might differ from spindle or cylindrical cyst originating from embryonic formation of an anomalous confluence. It was also suggested that in patients with fusion variations of the pancreatic ducts, the flow of pancreatic juice might be disordered, leading to the development of acute pancreatitis or pancreatic dysfunction. Consequently, it appears to be necessary to carefully examine patients with AAPB for the presence or absence of any fusion variations of the pancreatic ducts and to observe such patients with long-term monitoring by ERCP, and computed temography, and with pancreatic function tests. Received for publication on Jan. 7, 1998; accepted on April 28, 1998