Narrow Duct Segment Distal to Choledochal Cyst

"Narrow segments" (or stenotic portions) of the common bile duct (CBD) distal to cysts in two patients (a 50-yr-old woman and a 25-yr-old man) with choledochal cyst (CholCyst) were studied macroscopically and histologically. The narrow segments of the ducts were patent and connected with the main pancreatic duct extraduodenally, whereas the CBD in controls were neither dilated nor stenotic, and joined the main pancreatic duct within the duodenal wall. These narrow segments were 1 cm long. In case 1, a minute orifice was found in the narrow segment of the duct macroscopically and was identified microscopically as a small duct from a pancreatic lobule. In case 2, a small pancreatic duct also joined the narrow segment of the duct. These small pancreatic ducts were derived from the ventral pancreas, based on distribution of PP-islets. Therefore, the narrow duct distal to the cyst in patients with CholCyst (or congenital biliary dilatation) was considered to be a branch of the ventral pancreatic duct.     

Branch Fusion Between the Ventral and Dorsal Pancreatic Duct

Abstract : Fusion of the dorsal and ventral pancreatic ducts exhibits various forms and one of them is branching fusion. Branch fusion was divided into 3 types according to ERP findings. Fusion of the upper branches of the ventral pancreatic duct with the dorsal pancreatic ducts was designated as being type 1. Fusion of the lower branch of the dorsal pancreatic duct with the ventral pancreatic duct in roundabout way was designated as being type 2. Fusion of the lower branch of the dorsal pancreatic duct with the ventral pancreatic duct in short way was designated as being type 3. We demonstrated the presence of branch fusion involving the branch of the dorsal pancreatic duct by histopathological examination and immunohistochemical examination using pancreatic polypeptide cells as an indicator in one patient with type 1 branch fusion and one with type 3 branch fusion who underwent a pancreatoduodenectomy. ERP showed chronic pancreatitis in 3 of 4 patients with type 1, 3 of 8 patients with type 2, and 7 of 18 patients with type 3 branch fusion, of whom 1, 2, and 4, respectively had non-alcoholic pancreatitis. The high incidence of pancreatitis suggested that branch fusion is the cause of pancreatitis. In addition, evaluation of ERP images revealed Santorini's duct originating from the ventral pancreatic duct in 5 patients with type 1 branch fusion, suggesting the presence of the ansa pancreatica proposed by Dawson. This finding may also be closely associated with the development of pancreatitis. (Dig Endosc 1994; 6 : 87–93)     

核磁共振胰胆管造影与内镜下逆行胰胆管造影在胰胆疾病诊断方面的对比研究

目的：探索核磁共振胰胆管造影（ＭＲＣＰ）检查在临床应用中的价值。方法：对１１０例胰胆管疾病患者选择性地行ＭＲＣＰ检查,并与内镜下逆行胰胆管造影（ＥＲＣＰ）检查作比较,结合内镜下治疗以及外科手术,以明确两者之间的相关性。ＥＲＣＰ和手术结果作为金标准。结果：１１０例患者ＭＲＣＰ图像质量均较高,对胆管扩张诊断的敏感性为８５．０６％（７８／８７）,对胆管下段狭窄伴扩张诊断的敏感性为９０％（１８／２０）。Ｍ     

Pancreatic Duct Stricture Caused by Islet Cell Tumors

We report three cases of pancreatic islet cell tumors causing stricture of the main pancreatic duct. The clinical presentation was consistent with episodes of acute pancreatitis or biliary colic. One patient in whom the diagnosis was delayed died of metastatic disease. Islet cell tumors are an important clinical entity that must be considered in the differential diagnosis of pancreatic duct strictures.     

A Case Report of Anomalous Pancreaticobiliary Duct Connection with Choledocholithiasis and Acute Pancreatitis

Abstract: A 25-year-old man was admitted to hospital with epigastric pain. He had had a history of episodic abdominal pain since early childhood. An anomalous pancreaticobiliary duct connection was seen by endoscopic retrograde cholangiopancreatography. In many cases, this type of abnormality is caused by an anomaly in the ventral pancreas. In this case, however, the common bile duct, with calculi, was joined to the pancreatic duct which did not arise from the ventral pancreas but from the dorsal pancreas. The pancreatic duct arising from the ventral pancreas was absent in this case. The patient underwent a prophylactic cholecystectomy, a transduodenal sphincteroplasty, a choledocholithotomy, a partial resection of the common bile duct, and a hepaticojejunostomy, performed by a Roux-en-Y anastomosis. His postoperative recovery was satisfactory. An anomalous pancreatobiliary duct connection allows pancreatic juices and bile to mix. This is considered to be an etiological factor in pancreatitis and choledocholithiasis.     

Endoscopic Management of Pancreatic Duct Leak Complicated by Retrogastric Abscess

A patient was diagnosed with a large retrogastric ahscess associated with a postsurgical pancreatic duct leak refractory to somatostatin (Sandostatin) and external drains. She was managed entirety by endoscopic means consisting of transgastric ahscess decompression, irrigation via a nasocystic tube, total parenteral nutrition, and a 7-Fr pancreatic duct stent to facilitate healing of the pancreatic duct leak. Thirty days after placement, the pancreatic duct stent was removed and pancreatogram revealed closure. Fifty-one days after transgastric decompression of the abscess, near complete closure of the cavity was accomplished and the patient returned to a regular diet. One year later, the patient continues to do well.     

Percutaneous Pancreatography for Treatment of Complicated Pancreatic Duct Strictures

Background: Percutaneous transhepatic cholangiography was developed over 30 years ago for the diagnosis of biliary disorders. It has become an accepted interventional technique for management of biliary tract diseases, especially in patients who have failed attempted endoscopic retrograde pancreatography or have altered anatomy that makes the biliary tree endoscopically inaccessible. The correlative procedure, which we term ‘percutaneous pancreatography’ (PP), has only been described once in the literature. Case Presentations: We report the outcome of 4 patients undergoing PP for management of difficult pancreatic duct strictures. In all patients, PP was used to provide access and therapy of otherwise endoscopically impassable pancreatic duct strictures. PP-guided pancreatic stent duct placement was performed and allowed for subsequent successful endoscopie management of complex, benign pancreatic duct obstructions. Conclusions: PP is a useful modality for management of otherwise endoscopically impassable pancreatic duct Strictures.     

外科手术治疗胰管结石23例临床回顾

目的 探讨外科手术治疗胰管结石的疗效及手术方式的合理选择.方法 回顾性分析2003年1月～2010年1月间在我院收治的23例胰管结石病人的临床资料.结果 16例患者行胰管切开取石加胰管空肠Roux-en-Y吻合术(Partington手术),5例行胰十二指肠切除术,2例行胰体尾切除加脾切除术.无严重手术并发症及手术死亡...     

Obstructing Pseudocyst of the Duct of Santorini in Pancreas Divisum

Pancreas divisum is a pancreatic duct anomaly that occurs due to failure of fusion of the dorsal and ventral ducts. While recognition of this anomaly is increasing due to more aggressive endoscopic retrograde cholangiopancreatography, its significance remains unclear. A patient with chronic pancreatitis and a history of alcohol abuse was noted to have pancreas divisum. At surgical exploration, intraoperative pancreatography revealed an obstructing pseudocyst of the duct of Santorini. Extended sphincteroplasty and cystduodenostomy as well as Roux-en-Y pancreatojejunostomy were necessary to insure adequate accessory duct drainage. Surgical therapy of pancreas divisum in chronic pancreatitis should be designed to correct existing pancreatic duct obstruction.     

慢性胰腺炎胰管支架治疗(附30例病例分析)

目的 探讨内镜下胰管支架置入术治疗慢性胰腺炎的疗效和并发症.方法 回顾性分析2005年3月～2010年3月在我院诊断的30例慢性胰腺炎患者,均在内镜逆行性胰胆管造影(ERCP)术后行胰管括约肌小切口,并置入胰管塑料支架.术后随访观察临床症状及生化检查等变化情况.结果 30例患者共放置胰管支架51例次,除2例支架自行脱落...     

The Value of Pancreatic Pseudocyst Amylase Concentration in the Detection of Pseudocyst Communication with the Pancreatic Duct

The aims of the study were to compare the results of endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous cystopancreatography (PCP) in the detection of the communication between the pancreatic pseudocyst and the pancreatic duct, and to assess the reliability of the increased amylase concentration in the pseudocyst content as an indicator of the existence of communication between the pancreatic pseudocyst and the pancreatic duct system. Forty-three patients were included in the study. Pseudocystic fluid content was obtained by percutaneous aspiration. Twenty-four patients had pseudocyst amylase concentrations above 64 Wolgemuth units (WU), and 19 patients had less than 64 WU. The communication between pseudocyst and the pancreatic duct was determined in 22 patients by ERCP and in 13 patients by PCP, all in the group with increased pseudocyst amylase concentration. Due to high sensitivity and specificity of pseudocyst amylase concentration for the existence of pseudocyst communication with the pancreatic duct, we conclude that guided percutaneous aspiration of the pancreatic pseudocyst with the determination of amylase concentration in the fluid can replace ERCP as a method of choice for the detection of pseudocyst communication with the pancreatic duct.     

Saline Infusion Through the Pancreatic Duct Leads to Changes in Calcium Homeostasis Similar to Those Observed in Acute Pancreatitis

This work focuses on studying the early events associated with pancreatic damage after retrograde infusion through the pancreatic duct in rats. We have analyzed changes in calcium homeostasis and secretory response in pancreatic acini from rats with taurocholate-induced acute pancreatitis. Moreover, in order to test whether pancreatic duct manipulation can trigger damage inside pancreatic acinar cells, we have studied both parameters in acini from animals infused with saline. Our study demonstrates that taurocholate causes evident damage to acinar cells, impairing both calcium homeostasis and secretory response to CCK. In saline, a significant decrease in calcium cytosolic response to CCK was observed. Calcium disturbances similar to those observed in acute pancreatitis appear before secretion blockade and inflammation processes in saline treated rats. These results could be interesting since pancreatitis is associated to clinical procedures that require duct manipulation such as endoscopic retrograde cholangiopancreatography.     

Extracorporeal Shock Wave Lithotripsy of Pancreatic Duct Stones

Chronic calcifying pancreatitis presents a major clinical problem, often requiring extensive surgery. Extracorporeal shock wave lithotripsy (ESWL) offers a new therapeutic option. We applied ESWL after endoscopic sphincterotomy of the pancreatic orifice in eight patients with impacted pancreatic duct stones. An electromagnetic lithotriptor (Siemens Lithostar, Erlangen, FRG) was used. Patients were treated in prone position under fluoroscopic control. A mean of 6,813 shock waves (range 1,500-10,000) was delivered in one or two sessions. Disintegration of stones was achieved in 6/8 patients, initial relief of pain in 7/8 patients, and total clearance of the pancreatic duct in 3/8 patients. One patient had an exacerbation of her pancreatitis one day after ESWL, which resolved rapidly with medical treatment. No other complications were observed. Four of five patients with fragmented stones had no abdominal complaints at follow-up (mean 17 months, range 3-27). Three patients in whom ESWL was not completely successful (two without and one with partial fragmentation) underwent an operation according to Puestow. Two of them still have abdominal complaints after surgery. From these data, we conclude that ESWL of pancreatic duct stones is a promising new alternative for surgery, when endoscopic stone extraction fails.     

Gallstone-linked Tubular Stenosis of the Common Bile Duct

The transpancreatic segment of the distal common bile duct can be extrinsically stenosed by a pure gallstone-linked pancreatic disorder. It has a specific roentgen configuration--long, tubular and smooth. In two instances it was associated with severe suppurative complications. Precholedochotomy cholangiography is required to identify such long segment benign tubular stenosis of the distal common bile duct as an indication for management alternatives and as a guide to judicious common bile duct exploration.     

Coexistent Ampullary Squamous Cell Carcinoma with Adenocarcinoma of the Pancreatic Duct

Primary squamous cell carcinoma (SCC) of ampulla has seldom been reported. However, metastatic SCC to ampulla of Vater is well known. We report a case of primary SCC of ampulla of Vater coexistent with well-differentiated adenocarcinoma of the distal pancreatic duct. A 50-year-old female presented with evidence of obstructive jaundice. Endoscopic retrograde cholangio-pancreatography revealed bulging papilla with ulcero-infiltrative growth at the ampulla of Vater. An initial endoscopic biopsy of the ampullary mass showed a well-differentiated SCC. The patient underwent Whipple''s operation. Thorough sampling of the dilated portion of the pancreatic duct showed presence of well-differentiated adenocarcinoma of the distal pancreatic duct. Immunohistochemical study with synaptophysin and chromogranin was done with negative result, ruling out neuroendocrine differentiation. Also, a detailed clinical, endoscopic and radiological examination was carried out, that excluded the presence of primary SCC elsewhere.     

Temporary Pancreatic Duct Stenting to Prevent Pancreatitis Induced by Endoscopic Sphincter Dilation

Abstract: To investigate whether prophylactic temporary stenting of the main pancreatic duct would decrease the incidence of pancreatitis after endoscopic sphincter dilation (ESD), we conducted this procedure subsequent to ESD in 13 patients who had common bile duct stones. After ESD and extraction of stones, a stent was placed into the pancreatic duct across the papilla of Vater. The stent was removed endoscopically three days later. Stents were successfully placed in 12 (92.3%) patients. In 11 of the patients, there was no significant elevation of serum amylase values before and after the procedure. The remaining patient, whose stent was identified as occluded, demonstrated elevated serum amylase values. However, there were no other procedure-related complications. Although our report was only limited to 12 cases, our results suggest that temporary pancreatic stenting may help prevent postprocedual pancreatitis. (Dig Endosc 1999; 11:32–36)     

Pancreatogram of Unfused Pancreatic Duct Systems

Abstract: The aim of this study was to indirectly evaluate functional aspects of the accessory papilla, by measuring the diameter of the dorsal duct in non-fusion (pancreas divisum). In 56 patients with definite non-fusion, the diameter of the duct on ERCP was measured with a caliper rule, in the ventral duct (V1, V2), in the head of the dorsal duct (Dh1, Dh2), the body (Dbl, Db2), and the tail (Dt1, Dt2). The controls were 61 consecutive patients with a normally fused pancreatic duct system. The mean value ± SD were V1:2.0±1.1, V2:1.7±0.8, Dh1:2.5±0.6, Dh2:2.6±0.8, Dbl:2.7±0.8, Db2: 2.1 ±0.5, Dt1: 1.7±0.5, Dt2: 0.9±0.2 in the non-fusion group. The values in the control group were 3.4±0.9, 3.0±0.8, 1.0±0.3, 1.3±0.4, 2.6±0.6, 2.3±0.6, 1.6 ± 0.3, 0.9 ± 0.2, respectively. Results showed that the diameter of the pancreatic duct was significantly related to the age of the patient in the body and tail of the non-fusion group but not in the controls (p<0.05). The diameter of the ventral duct in the control group was related to the age but not in the non-fusion group (p<0.0001). In non-fusion group, mean values of V1 and V2 was smaller (p<0.02), and Dh1 and Dh2 were larger (p<0.05) than those in the controls. While there were no significant differences in the mean values of Db1, Db2, Dt1, and Dt2 in both groups. These results may indicate a more prominent influences of age to the caliber changes of pancretic duct when non-fusion existed.     

Oral Endothelium Corneum Gigeriae Galli Therapy for Pancreatic Duct Stones: A Prospective Cohort Study

Background:Pancreatic duct stones obstruct the pancreatic ducts and aggravate clinical symptoms of chronic pancreatitis. Only isolated case reports have shown that some drugs may be useful in dissolving pancreatic duct stones. Endothelium corneum gigeriae galli is a Chinese medicine widely used to cure multifarious lithiasis and maldigestion. This study aimed to evaluate the efficacy of endothelium corneum gigeriae galli oral therapy in the dissolution of stones and evaluate the improvement of clinical symptoms in patients with pancreatic duct stones.Methods:Sixty-eight patients with pancreatic duct stones were randomly divided into the endothelium corneum gigeriae galli and control groups. Endothelium corneum gigeriae galli was given orally to the endothelium corneum gigeriae galli group, and the placebo was given to the control group. Both groups were reviewed by computed tomography and magnetic resonance imaging; abdominal pain, exocrine and endocrine pancreatic function, and the nutritional status of patients were measured after the study.Results:The dissolution rate of the endothelium corneum gigeriae galli group was significantly higher than that of the control group (P = .002). The abdominal pain of the endothelium corneum gigeriae galli group was relieved more significantly compared to that of the control group (P < .001). The exocrine and endocrine pancreatic function of the endothelium corneum gigeriae galli group improved more significantly than that of the control group (P < .001). The nutritional status of the endothelium corneum gigeriae galli group was significantly higher than that of the control group (P = .003).Conclusion:Overall, oral endothelium corneum gigeriae galli treatment could dissolve pancreatic duct stones, relieve abdominal pain, improve exocrine and endocrine pancreatic functions, and control the deterioration of nutritional status. Endothelium corneum gigeriae galli treatment should be useful in pancreatic duct stones therapy.     

Endoscopic Approach to Pancreatic Duct Calculi and Obstructive Pancreatitis

Twelve patients with chronic pancreatitis and obstructing pancreatic calculi underwent endoscopic retrograde cholangiopancreatography and attempted pancreatic stone extraction. This procedure, utilizing conventional stone baskets and balloons, as well as extracorporeal or laser lithotripsy in a subset, was ultimately successful in 11 of 12 patients. Nine of the 10 patients with relapsing pancreatitis have not had a symptomatic flare at a mean follow-up of 17 months. In contrast, neither of the patients who presented with chronic pain had convincing symptomatic improvement. The authors conclude that endoscopic removal of pancreatic duct calculi deserves further investigation in the treatment of relapsing attacks of chronic pancreatitis.     

Clinical Evaluation of Brushing Cytology and Biopsy of the Pancreatic Duct in Patients with Mucin Producing Tumor of the Pancreas

Abstract: A cytological study of pure pancreatic juice obtained endoscopically after brushing the lesion of the pancreatic duct urns performed in 10 patients with mucin producing tumors of the pancreas. In 6 of these 10 patients, biopsies from the lesion in the pancreatic duct were also carried out endoscopically. The brushing cytology in all 6 patients with mucin producing carcinoma of the pancreas, except for the sidebranch type, showed cellular atypism and the cytological diagnoses were Class IV or Class V. The results of the brushing cytology in the patients assumed clinically benign were Class I ? Class III. Biopsy results in 4 patients with mucin producing carcinoma of the pancreas indicated that one of them had adenocarcinoma, and the other 3 had atypical hyperplasia which suggests the existence of malignancy. In the patient with adenoma, diagnosis of the biopsy specimen revealed hyperplasia only. It was concluded that cytology and biopsy of lesions in the pancreatic duct are a valuable way of assessing mucin producing tumors of the pancreas before surgery.