Dynamic CT scanning of pancreatic duct after secretin provocation in pancreas divisum

Variations in pancreatic duct diameter at CT scanning and serum pancreatic amylase response following secretin administration were studied in 29 patients with pancreas divisum and unexplained upper abdominal pain. Eleven healthy individuals were used as controls. At endoscopie retrograde pancreatography (ERP) six patients had signs of marked and six moderate pancreatitis, whereas there were no pancreatitis changes in 17 of the patients. At CT scanning patients with marked pancreatitis (ERP) had significantly increased pancreatic duct diameter as compared to patients without signs of pancreatitis. The duct was visualized in 52% of all patients before and 71% after secretin stimulation the corresponding figures for healthy controls, being 18% both before and after secretin. In patients without signs of pancreatitis, it was demonstrated in 5/17 (29%) before and 11/17 (65%) after secretin, whereas it was seen in 10/12 (83%) pancreatitis patients both before and after the hormonal provocation. In five of the nonpancreatitis patients in whom the duct was measurable before and at all study intervals (10, 20, and 50 min) after secretin, there was a significant duct dilation response both at 10 min and when comparing the maximal duct diameter after secretin to the initial values. In contrast secretin did not affect the duct caliber in pancreatitis patients. Serum pancreatic amylase increased significantly after secretin administration to healthy controls and nonpancreatitis patients but was uninfluenced in the marked and moderate pancreatitis groups, respectively. However, when all pancreatitis patients were grouped together, the amylase levels were significantly elevated by secretin. In conclusion, secretin provocation caused duct dilation at CT scanning in pancreas divisum patients without signs of pancreatitis at ERP. In this group secretin also increased the number of patients with visualized pancreatic duct. However, in pancreas divisum patients with pancreatitis and in healthy controls no such findings were observed. Secretin stimulation increased samylase in a nonspecific way. If secretin at CT scanning causes dilation of the pancreatic duct compared to its initial measurable width or visualization of an initially not demonstrable duct in patients with unexplained upper abdominal pain, the presence of pancreas divisum without morphologically manifest pancreatitis should be considered.     

胆胰管良恶性梗阻的双支架联合引流

目的 探讨胆、胰管良恶性狭窄或梗阻时内镜双支架联合引流的操作技术及其临床疗效。方法 所有患者先行经内镜逆行胰胆管造影，了解胆、胰管狭窄或梗阻的部位、程度，并确定置入支架的外径及长度；然后胆、胰管分别置入导丝，并在导丝引导下按常规分别置入胆管和胰管引流支架。术后观察血清淀粉酶变化及黄疸、腹痛、腹泻等临床症状的改善情况。结果 14例胆、胰管并存狭窄或梗阻患者（壶腹癌5例、胰头癌4例、乳头部癌3例及胰头部慢性炎症2例）均一次操作成功，置入胆管塑料支架14根（12例1根，1例2根），置入金属支架1根；同时还置入胰管支架14根。术后2周、1个月及3个月黄疸消失率分别为50．0％、71．0％和93．0％，术后2周上腹痛缓解率为75．0％；7例腹泻患者，术后1个月5例症状消失，2例明显减轻。未发生与操作相关的早期并发症，术后3个月未发现支架移位及阻塞情况。结论 胆、胰管良恶性狭窄患者经内镜双支架联合引流是一种简便、安全、有效的治疗方法，既能解除黄疸，又能减压止痛，改善胰腺外分泌功能。     

Risk factors,predictors and prevention of pancreatic fistula formation after pancreatoduodenectomy

Background/Purpose

Although the operative mortality and morbidity associated with pancreatoduodenectomy (PD) has been decreasing, pancreatic fistula remains a potentially fatal complication. The aim of this study was to identify risk factors and predictors of pancreatic fistula formation, and ways to prevent this in a consecutive series of PD patients in a single institution.

Methods

The association between pancreatic fistula formation and various clinical parameters was investigated in 50 patients who underwent PD at Kochi Medical School from January 1991 through February 2006.

Results

The incidence of pancreatic fistula in these patients was 28%. Multivariate analysis identified three independent factors correlated with the occurrence of pancreatic fistula: (1) absence of fibrotic texture of the pancreas examined intraoperatively (relative risk [RR], 1.6; 95% confidence interval [CI], 1.2–2.0; P = 0.01); (2) serum amylase concentration greater than 195?U/l (1.69 times the normal upper limit) on the first postoperative day (RR, 2.4; 95% CI, 1.0–5.7; P = 0.01); and (3) not having early postoperative enteral nutrition (RR, 3.2; 95% CI, 1.2–9.0; P = 0.004).

Conclusions

Soft texture of the pancreas and increased serum amylase the day after PD are both risk factors with predictive value for pancreatic fistula. The incidence of fistula formation is reduced by early postoperative enteral nutrition.

     

The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head

Pylorus‐preserving pancreatoduodenectomy (PPPD) was reintroduced in 1978. This pylorus‐preserving modification was designed to minimize complications related to gastric resection, such as early satiety, marginal ulceration, and bile reflux gastritis, as well as diarrhea and dumping. Since 1978, PPPD has been performed preferentially for benign and malignant diseases of the periampullary region and pancreatic head. Some groups have argued against PPPD for cancer of the pancreatic head, because the pylorus‐preserving procedure is likely to compromise the field of resection and does not allow lymph node dissection of the peripyloric and perigastric groups. However, comparative survival rates after PPPD have been the same as, or better than, those with classic pancreatoduodenectomy, showing the rationale for PPPD as a radical resection procedure for cancer of the pancreatic head. PPPD can be performed with low mortality. Delayed gastric emptying, which is the most common complication in the immediate postoperative period after PPPD, is always transient. Many investigators have shown that body weight and the majority of nutritional parameters are better than after PD. PPPD does not appear to cause any negative outcomes. We conclude that PPPD is the surgical procedure of choice for cancer of the head of the pancreas.     

Exocrine pancreatic function during the early recovery phase of acute pancreatitis

BACKGROUND:Exocrine pancreatic dysfunction has been reported in humans in the convalescent period after acute pancreatitis,but the data are scarce and conflicting.This study aimed to prospectively assess the exocrine pancreatic function in patients with acute pancreatitis at the time of their refeeding. METHODS:Fecal elastase-1 was determined on the day of refeeding in all consecutive acute pancreatitis patients with their first episode of the disease.They were 75 patients including 60(80.0%)patients with m...     

Experimental investigation of the role of the splenic vein in gastric venous obstruction after pylorus-preserving pancreatoduodenectomy in the dog

Summary Conclusion   This study showed that the splenic vein (SV) plays a major role in maintaining gastric blood flow after ligature of peripyloric vesels in the dog. Therefore, SV preservation or alternative venous drainage may be recommended to maintain sufficient gastric blood flow in pylorus-preserving pancreatoduodenectomy (PPPD). Background  In PPPD, we often encounter the problem of gastric venous drainage obstruction, if the splenic-portal vein confluence needs to be resected. This study investigated significance of venous drainage via the left gastric and splenic veins in gastric tissue blood flow. Methods  In seven mongrel dogs, gastric tissue blood flow was measured by both laser Doppler flowmetry (LDF) in the antrum and hydrogen gas clearance (HGC) in the antrum and body. Blood flow was measured after the following treatments:

Sonographic imaging of the pancreatic duct

The pancreatic duct or at least parts of this structure can be demonstrated today by sonography in 75–85% of all persons examined. In 84 persons we have now measured the caliber of the sonographically visualized pancreatic duct in the region of the proximal body of the pancreas with special attention to dependence on age. The diameter of Wirsung's duct ranged from 1 to 3 mm (mean 1.9 mm) and increased significantly from the fifth decade of life onwards. After intravenous injection of the hormone secretin, healthy persons usually show a distinct duct enlargement, which also depends on age. Nine persons aged 19 through 35 (median 28) years showed a dilatation of the main pancreatic duct by about 110% following secretion injection. Nine further probands, 50–74 (median 58) years old, had a dilatation of about 70%. Eighteen patients with confirmed chronic pancreatitis and a pancreatic duct diameter not exceeding 4 mm generally showed no duct enlargement after secretin stimulation. We believe that periductal fibrosis, which is common in chronic pancreatitis, is the most important reason for these results. The use of the sonographic secretin test in the diagnosis of chronic pancreatitis should be considered.     

Small serotonin-positive pancreatic endocrine tumors caused obstruction of the main pancreatic duct

We report 2 cases of pancreatic endocrine tumors that caused obstruction of the main pancreatic duct (MPD). A 49-year-old asymptomatic man was referred to our institution because dilation of the MPD was revealed by abdominal ultrasonography (US). No tumor was detected by endoscopic ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). The diameter of the MPD was > 20 mm at the body, and no dilation was noted at the head. Although malignancy was not confirmed through cytology or imaging, pancreatic cancer was strongly suspected. Pancreaticoduo- denectomy was performed. Pathological and immunohistochemical examination revealed a 5 mm × 3 mm serotonin-positive endocrine tumor. Fibrosis was present around the MPD and seemed to cause stricture. A 32-year-old asymptomatic man had elevated serum amylase, and US demonstrated dilation of the MPD. No tumor was detected by CT and MRI. Pancreatic cancer was suspected due to stricture and dilation of the MPD. Pancreatectomy of middle part of pancreas was performed. Pathological and immunohistochemical examination revealed a serotonin-positive endocrine tumor sized 5 mm × 4 mm. We report 2 cases of serotonin-positive pancreatic endocrine tumors that caused stricture of the MPD in spite of the small size of the tumor.     

Prophylactic octreotide for postoperative pancreatic fistula in patients with pancreatoduodenectomy: Risk-stratified analysis

Background:Postoperative pancreatic fistula is one of the most critical complications following pancreatic surgery. This study aimed to evaluate the utility of selective prophylactic octreotide for patients at high risk of developing postoperative pancreatic fistula.Methods:From June 2019 to July 2020, 263 patients underwent pancreatoduodenectomy with pancreatojejunostomy at Samsung Medical Center. The individual fistula risk scores were calculated using a previously developed nomogram. The clinicopathological data of the patients were retrospectively reviewed.Results:There were 81 patients in the low-risk group and 182 patients in the high-risk group. No statistically significant differences were found in the rates of clinically relevant postoperative pancreatic fistula between octreotide group and the control group in all patients (15.0% vs 14.7%, P = .963) and in the high-risk group (16.1% vs 23.6%, P = .206). In risk factor analysis, postoperative octreotide was not an independent risk factor for clinically relevant pancreatic fistula in all patients and the high-risk group. Drain fluid amylase levels on the first postoperative day were significantly associated with clinically relevant postoperative pancreatic fistula, regardless of the individual risk.Conclusions:The selective use of octreotide, even in high-risk patients, showed no protective effect against pancreatic fistula. Therefore, the routine use of postoperative octreotide is not recommended.     

A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) can be associated with severe postoperative morbidity. This study aims to develop a preoperative POPF risk calculator that can be easily implemented in clinical routine.MethodsPatients undergoing PD were identified from a prospectively-maintained database. A total of 11 preoperative baseline and CT-based radiological parameters were used in a binominal logistic regression model. Parameters remaining predictive for grade B/C POPF were entered into the risk calculator and diagnostic accuracy measures and ROC curves were calculated for a training and a test patient cohort. The risk calculator was transformed into a simple nomogram.ResultsA total of 242 patients undergoing PD in the period from 2012 to 2018 were included. CT-imaging-based maximum main pancreatic duct (MPD) diameter (p = 0.047), CT-imaging-based pancreatic gland diameter at the anticipated resection margin (p = 0.002) and gender (p = 0.058) were the parameters most predictive for grade B/C POPF. Based on these parameters, a risk calculator was developed to identify patients at high risk of developing grade B/C POPF. In a training cohort of PD patients this risk calculator was associated with an AUC of 0.808 (95%CI 0.726–0.874) and an AUC of 0.756 (95%CI 0.669-0-830) in the independent test cohort. A nomogram applicable as a visual risk scale for quick assessment of POPF grade B/C risk was developed.ConclusionThe preoperative POPF risk calculator provides a simple tool to stratify patients planned for PD according to the risk of developing postoperative grade B/C POPF. The nomogram visual risk scale can be easily integrated into clinical routine and may be a valuable model to select patients for POPF-preventive therapy or as a stratification tool for clinical trials.     

Value of the p53 protein for diagnosing cancer in pancreatic cells obtained by endoscopic pancreatic duct brushing

OBJECTIVE: To investigate the value of the p53 protein for diagnosing cancer in pancreatic cells obtained by using endoscopic pancreatic duct brushing. METHODS: Immunohistochemical methods were used to assay the amount of p53 protein in cytological specimens. The results were compared with those obtained by hematoxylin and eosin (H&E) staining. RESULTS: Detection of the p53 protein by staining cytological specimens with H&E diagnosed pancreatic cancer with 53% sensitivity, 100% specificity and 70% accuracy. Using immunohistochemical methods, pancreatic cancer was diagnosed with 59% sensitivity, 100% specificity and 74% accuracy. The methods in combination produced a test with 71% sensitivity, 100% specificity and 81% accuracy. CONCLUSIONS: Hematoxylin and eosin staining combined with p53 protein detection in cells obtained by using endoscopic pancreatic duct brushing is a useful tool in the diagnosis of pancreatic cancer, and in the differentiation of benign and malignant pan­creatic disease.     

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreato-duodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.     

Clinical significance of the minor duodenal papilla and accessory pancreatic duct

The accessory pancreatic duct (APD) is the main drainage duct of the dorsal pancreatic bud in the embryo, entering the duodenum at the minor duodenal papilla (MIP). As development progresses, the duct of the dorsal bud undergoes varying degrees of atrophy at the duodenal end. In cases of patent APD, smooth-muscle fiber bundles derived from the duodenal proper muscular tunics surround the APD. The APD shows long and short patterns on pancreatography, and ductal fusion in the two types appears to differ embryologically. Patency of the APD in control cases, as determined by dye-injection endoscopic retrograde pancreatography, was 43%. Patency of the APD may depend on duct caliber, course, and terminal shape of the APD. A patent APD may prevent acute pancreatitis by reducing the pressure in the main pancreatic duct. Pancreas divisum is a common anatomical anomaly in which the ventral and dorsal pancreatic ducts do not unite embryologically. As the majority of exocrine flow is routed through the MIP in individuals with pancreas divisum, interrelationships between poor function of the MIP and increased flow of pancreatic juice caused by alcohol or diet may increase dorsal pancreatic duct pressure and lead to the development of pancreatitis. Wire-guided minor sphincterotomy, followed by dorsal duct stenting, is recommended for acute recurrent pancreatitis associated with pancreas divisum.     

Pancreatic carcinoma that completely obstructs the Wirsung duct without dilatation of the main pancreatic duct

BACKGROUND AND AIM: Pancreatic carcinomas in which the main pancreatic duct (MPD) is completely obstructed are almost always associated with dilatation of the upstream MPD. However, some carcinomas are not associated with MPD dilatation despite complete MPD obstruction. This paradoxical phenomenon has not been well documented. METHODS: The findings from endoscopic retrograde cholangiopancreatography in 207 cases of pancreatic head carcinomas were analyzed with special reference to this unique type of carcinoma. Twenty-five of the patients were found to exhibit no MPD dilatation on ultrasonography, computed tomography or magnetic resonance imaging. RESULTS: Pancreatography via the major papilla showed complete obstruction of the MPD (112 patients with MPD dilatation and 6 without), stenosis (70 and 10, respectively), or no abnormal findings (0 and 9, respectively). In all six patients with complete MPD obstruction but without upstream MPD dilatation, injection of the minor papilla revealed a non-dilated dorsal pancreatic duct. The size of the obstructive carcinomas with and without MPD dilatation was comparable. CONCLUSIONS: Some (3%) pancreatic head carcinomas are not associated with MPD dilatation despite complete obstruction of the Wirsung duct. In such cases, the Santorini duct drains the dorsal pancreatic duct, completely compensating for the obstructed Wirsung duct. Attention should be paid to this unique type of carcinoma in diagnosing pancreatic head carcinomas.     

Pylorus-preserving pancreatoduodenectomy for cancer treatment: Surgical procedure,indications, and analysis of outcomes

Factors determining the prognosis of cancer of the pancreatic head were analyzed in 100 patients who had undergone surgical treatment. So as to clarify the indications for pylorus-preserving pancreatoduodenectomy (PPPD), the prognosis was compared in two sets of such patients, 25 who had undergone PPPD and 25 who had undergone the Whipple procedure. Of these 50 patients, 20 (40%) also underwent portal vein resection and 29 (58%) were found to have lymph node metastasis. Curative resection was achieved in 33 of these 50 patients (66%) and the 5-year survival rate after the curative resection (42.0%) was significantly higher in these patients that in those given a non-curative resection (P <0.01). Further, the prognosis was better for patients who did not require a portal vein excision than for those who did (P<0.01), and for patients who showed no lymph node metastasis than for those with metastasis (P<0.01). The 5-year survival rate did not differ significantly between the PPPD group and the Whipple procedure group. These results indicate that PPPD can also be a useful procedure for treating malignant diseases.     

Transgastric pancreatography and EUS-guided drainage of the pancreatic duct

Background/Purpose

Endoscopic transpapillary drainage of the retained pancreatic duct in symptomatic patients with chronic pancreatitis is considered an established treatment option. The aim of this study was to investigate, as an alternative, endoscopic ultrasound (EUS)-guided transgastric pancreatography and drainage of the pancreatic duct, in terms of their feasibility and outcome.

Methods

All consecutive symptomatic patients with failure of the traditional approach to catheterize and drain the pancreatic duct, over a 3-year time period, were enrolled in this prospective, observational single-center study (case series). Feasibility was characterized by success rate, outcome by complication rate (frequency of bleeding or perforation), mortality, and follow-up.

Results

Twelve patients underwent 14 interventions (sex ratio, M/F, 10?:?4; age range, 43–77 years) from November 2002 to October 2005. The main indication was retention of the pancreatic duct associated with pain, in particular: (i) papilla not reachable because of prior gastrointestinal surgery (n = 5); and (ii) not possible to introduce the catheter through the papilla in chronic pancreatitis or “pancreas divisum” (n = 7). Pancreatography was successful in all patients (normal finding with no therapeutic consequence, n = 1 [after pancreaticojejunostomy]), whereas drainage of the pancreatic duct was achieved in 9 patients (69%; attempts, n = 13). The transgastric route was used in 5 patients and the transpapillary route (rendezvous technique with endoscopic retrograde cholangiopancreatography [ERCP]) in 4. There was a complication rate of 42.9%, comprising postinterventional pain (n = 4; 28.6%); bleeding (n = 1); and perforation because of retriever problems (n = 1). The postinterventional pancreatitis rate was 0% and mortality was 0%. The follow-up investigation (range, 4 weeks ? 3 years) revealed that 4 patients (28.6%) subsequently underwent surgical intervention, because of duodenal stenosis (n = 1; 7.1%), suspicious tumor growth (n = 1; 7.1%), and insufficient drainage of the pancreatic duct (n = 2; 14.3%). In 2 subjects (14.3%), endoscopic reinterventions became necessary, which were subsequently successful. There were the following technical problems: 1) Too dense stenosis (n = 3); 2) inadequate equipment (insufficient infeed of the endoscopic tool because of its bending), in each case.

Conclusions

Transgastric pancreatography and EUS-guided drainage of the pancreatic duct are reasonable and feasible alternative options for diagnostic and therapeutic management for selected indications (chronic pancreatitis; anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy), with an acceptable periinterventional risk, which broaden the therapeutic spectrum and may avoid surgery but need further evaluation and follow-up investigation.

     

Pancreatic and bile duct obstruction exacerbates rat caerulein-induced pancreatitis: a new experimental model of acute hemorrhagic pancreatitis

Background Pancreatic duct obstruction induces edematous but not hemorrhagic pancreatitis even when combined with maximal secretory stimulation. The aim of the present study was to test the hypothesis that pancreatic and bile duct obstruction exacerbates edematous pancreatitis induced by supramaximal secretory stimulation by caerulein. Methods In in vivo studies using rats, biliopancreatic duct ligation was combined with supramaximal stimulation of caerulein, and pancreatic histology, serum amylase level, pancreatic edema, and intrapancreatic trypsin activation were evaluated. In in vitro studies, the pancreatic acini were isolated from the rats with biliopancreatic duct ligation, and amylase secretion, intracellular trypsin activation, and acinar cell fragility were evaluated. Results Biliopancreatic duct ligation exacerbated caerulein-induced pancreatitis from edematous to hemorrhagic only when the obstruction preceded caerulein administration. The amylase secretion from the acini was inhibited, and intracellular trypsin activation and the acinar cell fragility on the supramaximal stimulation with cholecystokinin in vitro were enhanced by the preceding in vivo biliopancreatic duct obstruction. Conclusions Preceding biliopancreatic duct obstruction exacerbates caerulein-induced pancreatitis. Enhancement of intracellular trypsin activation is possibly involved in this mechanism.     

坏死性胰腺炎合并胰管断裂的诊治进展

坏死性胰腺炎是胰管断裂最常见的病因,可引起胰腺液体积聚反复发作、胰瘘等严重并发症。目前,坏死性胰腺炎患者合并胰管断裂是否需要早期常规诊断、首选的干预方式、最佳的干预时机等问题仍无定论。本文就坏死性胰腺炎合并胰管断裂的诊治进展作一综述。