A novel technique for multiple pancreatectomies: removal of unicinate process of the pancreas combined with medial pancreatectomy

Preservation of normal pancreatic tissue in the surgical treatment of benign tumors of the pancreas offers advantages over more extended pancreatic resections. Removal of the uncinate process of the pancreas with the preservation of Wirsung's duct allows resection of a localized tumor within the uncinate process of the pancreas, maintains the flow of pancreatic juice into the duodenum, and preserves the dorsal part of the head of the gland. A pancreatic duct stent is particularly useful to identify the pancreatic duct (Wirsung's duct) intraoperatively to avoid injury which causes postoperative pancreatic leak. We have developed and employed a novel technique whereby tumors are completely excised, in combination with medial pancreatectomy, for the management of multiple mucin‐producing tumors of the pancreas localized in the uncinate process and in the body of the pancreas. The cut end of the head of the pancreas is closed by interrupted sutures. Reconstruction for the distal pancreas is effected with a Roux‐en‐Y pancreatico‐jejunostomy to the tail of the pancreas. Recovery was uncomplicated in our patient, with no endocrine or exocrine pancreatic insufficiency after 2‐year follow‐up.     

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)     

DOES A PATENT ACCESSORY PANCREATIC DUCT PREVENT ACUTE PANCREATITIS?

Background and Aim: The role of the accessory pancreatic duct (APD) in pancreatic pathophysiology has been unclear. We previously examined the patency of the APD in 291 control cases who had a normal pancreatogram in the head of the pancreas by dye‐injection endoscopic retrograde pancreatography (ERP). APD patency was 43% and was closely related with the shape of the terminal portion of the APD. The present study aimed to clarify the clinical implications of a patent APD. Methods: Based on the underlying data, the patency rate of the APD was estimated from the terminal shape of the APD on ERP in 167 patients with acute pancreatitis. Results: In patients with acute pancreatitis, stick‐type APD, spindle‐type APD, and cudgel‐type APD, which showed a high patency, were rare, and branch‐type APD and halfway‐type or no APD, which showed quite low patency, were frequent in acute pancreatitis patients. Accordingly, the estimated patency of the APD in acute pancreatitis patients was only 21%. There was no significant relationship between the estimated APD patency and etiology or severity of acute pancreatitis. Conclusions: The terminal shapes of the APD with low patency were frequent in acute pancreatitis patients, and estimated APD patency was only 21% in acute pancreatitis. A patent APD may function as a second drainage system to reduce the pressure in the main pancreatic duct and prevent acute pancreatitis.     

Patency of the accessory pancreatic duct evaluated by dye‐injection endoscopic retrograde pancreatography: Methods and clinical implication

The accessory pancreatic duct (APD) is sometimes developmentally obliterated near the duodenum. We evaluated patency of the APD by dye‐injection endoscopic retrograde pancreatography (ERP). We injected 2–3 mL contrast medium containing indigocarmine into the main pancreatic duct (MPD) via a selectively cannulated endoscopic catheter. Patency of the APD was evaluated by observing the excretion of dye from the minor duodenal papilla. Of the 291 control cases studied, 43% demonstrated a patent APD. Patency of the APD in patients with acute pancreatitis was only 17%, signi?cantly lower than that of controls (P < 0.01). Mean caliber of patent APD was 1.6 ± 0.5 mm, signi?cantly greater than the 1.1 ± 0.5 mm of non‐patent APD (P < 0.01). Regarding the terminal shape of the APD, spindle‐ and cudgel‐type APD were frequently patent (93% and 88%, respectively, (P < 0.01). With respect to APD course, long‐type APD showed most frequent patency (75%, P < 0.01). Dye‐injection ERP represents a simple and de?nitive method for examining APD function. A patent APD may prevent acute pancreatitis by reducing pressure in the MPD. Patency of the APD might be dependent on duct caliber, course, and terminal shape.     

Clinical implications of 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).With the growth,the duct of the dorsal bud undergoes varying degrees of atrophy at the duodenal end.Patency of the APD in 291 control cases was 43% as determined by dye-injection endoscopic retrograde pancreatography.Patency of the APD in 46 patients with acute pancreatitis was only 17%,which was significantly lower than in control cases (P < 0.01).The terminal shape of the APD was correlated with APD patency.Based on the data about correlation between the terminal shape of the APD and its patency,the estimated APD patency in 167 patients with acute pancreatitis was 21%,which was signif icantly lower than in control cases (P < 0.01).A patent APD may function as a second drainage system for the main pancreatic duct to reduce the pressure in the main pancreatic duct and prevent acute pancreatitis.Pancreatographic f indings of 91 patients with pancreaticobiliary maljunction (PBM) were divided into a normal duct group (80 patients) and a dorsal pancreatic duct (DPD) dominant group (11 patients).While 48 patients (60%) with biliary carcinoma (gallbladder carcinoma,n=42;bile duct carcinoma,n=6) were identified in PBM with a normal pancreatic duct system,only two cases of gallbladder carcinoma (18%) occurred in DPD-dominant patients (P < 0.05).Concentration of amylase in the bile of DPD dominance was signifi cantly lower than that of normal pancreatic duct system (75 403.5 ± 82 015.4 IU/L vs 278 157.0 ± 207 395.0 IU/L,P < 0.05).In PBM with DPD dominance,most pancreatic juice in the upper DPD is drained into the duodenum via the MIP,and reflux of pancreatic juice to the biliary tract might be reduced,resulting in less frequency of associated biliary carcinoma.     

Patency of the accessory pancreatic duct in relation to its course and shape: a dye-injection endoscopic retrograde pancreatography study

Objective: The accessory pancreatic duct (APD) exhibits several appearances on pancreatography. We examined the patency of the APD by dye-injection endoscopic retrograde pancreatography (ERP), and studied the relationship between patency and duct course and shape.
Methods: There were 213 patients with satisfactory imaging of the entire normal APD who also underwent dye-injection ERP. The length and maximum diameter of the APD and the length of the main pancreatic duct (MPD) from its orifice to the junction with the APD were measured.
Results: The caliber of the patent APD was 1.6 ± 0.6 mm. This was significantly larger than the caliber (1.1 ± 0.4 mm) of the nonpatent APD (   p < 0.01  ). The length of the MPD from its orifice to the junction with the patent APD was 32.7 ± 12.5 mm. This was significantly longer than the length to the junction with the nonpatent APD (22.5 ± 8.1 mm) (   p < 0.01  ). The APD was classified according to duct course: long type, intermediate type, short type, or ansa type. Patency was most common in the long type APD (74.5%). The terminal shape of the APD was also used to classify the ducts: stick type, branch type, saccular type, cudgel type, or spindle type. Patency was most frequently observed in the spindle and cudgel type ducts.
Conclusions: Patency of the APD might be dependent on duct caliber, course, and terminal shape of the duct.     

Study of patency of minor duodenal papilla--comparison between pigment method combined with pH sensor and pancreatographic method]

We investigated the patency of minor duodenal papilla in 25 cases that had presented normal pancreatogram by using the endoscopic retrograde pancreatographic (ERP) method and a pH sensor-combined indigo carmine pigment method. The pigment method allowed us to classify the function of minor papilla into three types according to pancreatic juice excretion pre- and post-secretin administration (Type I), excretion after secretin administration (Type II), and no excretion even after secretin administration (Type III). Twelve cases belonged to Type I, 4 cases to Type II and 9 cases to Type III. By ERP method, terminal shapes of the Santorini's duct were classified as stick type, cystic type and branch type. 19 cases were considered stick type, 2 cases cystic type and 4 cases branch type. Eighteen cases were identified as patent minor papilla under ERP method. There were two cases alleged to be patent under the ERP but without pancreatic juice excretion. Therefore, the necessity of pigment method was confirmed for investigation of the function of minor papilla.     

Modes of spread in early ampullary cancer in terms of establishing proper indications for endoscopic papillectomy

Background: Endoscopic papillectomy for adenomas of the ampulla of Vater has been reported and is gaining acceptance as an alternative to surgery in the treatment of early ampullary cancer. However, whether endoscopic treatment is justified as a treatment of choice for early ampullary cancer remains controversial. The aim of the present study was to elucidate the possibility of endoscopic papillectomy as a treatment of early ampullary cancer from the review of pathology of cases treated by surgical resection. Patients and methods: Twenty‐three cases of early ampullary cancer (m—tumor limited to the mucosa of the ampulla 14; od—tumor that invades Oddi's sphincter, 9) treated by surgical resection from January 1984 to March 2003 were investigated as to the following: (i) macroscopic type, maximum size, and histological type of tumor; (ii) main location and extension of tumor; (iii) prevalence of extension into the lower bile duct or pancreatic duct, and relationship between ductal infiltration and macroscopic type, maximum size, main location, or depth of invasion of tumor; (iv) lymphatic permeation, vascular invasion, and lymph node metastasis; and (v) prognosis. Results: All cases were classified macroscopically as exposed‐tumor type or non‐exposed‐tumor type without ulceration. Extension into the lower bile duct or the pancreatic duct was observed in 43% of the cases. There was no correlation between ductal infiltration and macroscopic type, maximum tumor size, main tumor location, or tumor depth. No lymphatic permeation, vascular invasion, or lymph node metastasis were proven in cases with ampullary cancer confined to the mucosa. In the nine cases with involvement of Oddi's sphincter, lymphatic permeation and lymph node metastasis were observed in two cases and one case, respectively. Conclusion: Endoscopic treatment for early ampullary cancer confined to the mucosa without spread to the bile duct or pancreatic duct is justified as a treatment of choice if detailed histological examination of the resected specimen indicated no invasion beyond its margin.     

Size,location and patency of the minor duodenal papilla as determined by dye‐injection endoscopic retrograde pancreatography

Background: The accessory pancreatic duct (APD) sometimes is developmentally obliterated near the duodenum. We evaluated patency of the minor duodenal papilla by dye‐injection endoscopic retrograde pancreatography to determine whether patency was related to papillary size and location. Methods: We injected 2–3 mL of contrast material containing indigocarmine into the main pancreatic duct via an endoscopic catheter in 104 patients. It was endoscopically observed whether dye was extruded from the minor papilla. Size of the minor papilla and distance from the orifice of the major duodenal papilla to the apex of the minor papilla were measured endoscopically with measuring forceps. Results: The APD was patent in 56 of 104 cases (54%). Size of the minor papilla varied considerably from 3 to 6 mm, but showed no correlation with patency. Half of the patients with chronic pancreatitis (6/13) had the minor papilla larger than 6 mm. In cases where the terminal APD had a cudgel or tapering‐off configuration, the minor papilla was larger than in cases where the duct had a stick shape. The minor papilla was patent in 9 out of 10 cases (90%) when it was near the major papilla (≤ 1.5 cm). Frequency of a patent minor papilla was 16 out of 33 (48%) when it existed 1.5 to 2.0 cm from the major papilla, and 31 out of 61 (51%) when the distance was more than 2.0 cm. Conclusions: The minor papilla was more frequently patent when it was close to the major papilla (P < 0.05).     

Factors affecting the yield of percutaneous cholangioscopic biopsy in patients with bile duct cancer

Background: This study analyzed the factors associated with the yield of percutaneous transhepatic cholangioscopic biopsies in patients with bile duct cancer. Methods: One‐hundred‐and‐sixteen patients who had received percutaneous transhepatic cholangioscopy and who had been confirmed as having bile duct cancer were enrolled in this study. Multiple targeted biopsies were taken under direct cholangioscopic view. Results: When the location of the tumor was divided into intrahepatic duct (IHD), hilar duct and common bile duct (CBD), the biopsy yield was significantly higher in IHD cancer (93.7%) than in cases of hilar cancer (69.6%) (P < 0.05). After a bile duct cancer had been classified as a nodular type (n = 31), papillary type (n = 27) or infiltrative type (n = 58) cancer upon cholangioscopic findings, the biopsy yields from nodular (96.8%) or papillary types (96.3%) were significantly higher than from infiltrative types (58.6%; P < 0.01). The positive rate for malignant cells was not influenced by the presence of tumor vessels or the number of biopsy samples taken. However, the sensitivity of the combination of cholangioscopic biopsy and tumor vessel in overall bile duct cancer, especially in the infiltrative type, was significantly increased when it was compared with that of cholangioscopic biopsies (P < 0.01) or tumor vessels alone (P < 0.01). Conclusions: Cholangioscopic biopsy provides a high positive yield of malignant cells in those patients with IHD, nodular‐type and papillary‐type cancers. The cholangioscopic classification of bile duct tumors might thus provide important clues to predict biopsy yield.     

MERITS and DEMERITS OF METALLIC STENT FOR TREATMENT OF PANCREATIC DUCT STRICTURES IN PATIENTS WITH CHRONIC PANCREATITIS

We inserted a metallic stent into the strictures of the main pancreatic duct in two patients with calcified chronic pancreatitis and severe abdominal pain not to be relieved using narcotics. One patient was a 39‐year‐ old male, and the other was 49‐year‐old male. Their etiology of chronic pancreatitis was alcoholism. We inserted a Strecker stent, 7 mm in diameter and 6 cm in length, for achieving long‐term patency than plastic stent. In one patient, the stent was obstructed half a year after the first treatment and pancreatic calculi recurred with abdominal pain. After endoscopic extraction of pancreatic stone and balloon dilatation of the stent was performed three times, a plastic stent was inserted in the metallic stent twice. Even if he was performed nerve block twice, he was administered narcotics for treatment of continuous abdominal pain. In the other patient, the stent was obstructed 1.5 years after insertion and pancreatic calculi recurred with abdominal pain. He was treated with extracorporeal shock‐wave lithotripsy for pancreatic stone, abdominal pain continued. He underwent pylorus preserving pancreato‐duodenectomy 6 years after the first stenting, because the obstructed metallic stent could not be removed. Metallic stent should not be chosen for treatment of pancreatic duct stricture.     

Transpapillary incision of refractory circumscript pancreatic duct stricture using wire-guided snare forceps

Endoscopic therapy of pancreatic duct(PD)strictures using balloon dilation and pancreatic duct stent(PS) placement has been reported to improve the severity of abdominal pain in selected patients with chronic pancreatitis(CP).However,some strictures are refractory and require frequent PS exchange to control symptoms.We describe two cases of successful endoscopic PD incision for difficult PD stricture using a wireguided snare.The snare is partially opened within the strictured pancreatic duct while applying ...     

Endoscopic biliary imaging and clinicopathological features of cystic duct cancer

Background Cystic duct cancer fulfilling Farrar’s criteria is relatively rare, but tumors whose origin is estimated to be in the cystic duct exist. The clinical features of such “broadly defined” cystic duct cancer have not been clarified. Methods The endoscopic retrograde cholangiography (ERC) findings, intraductal ultrasonography (IDUS) findings, histological findings, and prognoses of 11 cases of cystic duct cancers resected at our institution (group C) were retrospectively analyzed. As a control group, 55 cases of middle or lower bile duct cancer (group B) were used (in 20 of the 55 cases of group B, tumors extended to the cystic duct intraluminally (group B-C (+)). Results (1) ERC findings of group C as compared with those of group B-C (+) were as follows: (a) unilateral bile duct narrowing (spoon-like appearance): 55% versus 5% (P < 0.01); (b) bilateral bile duct narrowing (apple-core-like appearance): 27% versus 95% (P < 0.001). (2) IDUS was unable to visualize the cysticocholedochal junction (negative “confluence sign”) more often in group C (67%) than in group B-C (+) (13%) (P < 0.01). (3) Histologically, tumors extended to the gallbladder and the bile duct in 36% and 91% of the cases in group C, respectively. (4) The median survival time of the two groups was 21 and 28 months, respectively. Conclusions Cystic duct cancers frequently extended to the bile duct. The spoon-like appearance by ERC and the negative confluence sign by IDUS were characteristic findings.     

Clinical and radiological findings in dominance of Santorini's duct

BACKGROUND/AIMS: Few studies on Santorini's duct dominance, in which the ventral pancreatic duct is narrower than and anastomoses with Santorini's duct have been performed. We examined clinical and radiological findings in cases characterized by dominance of Santorini's duct. METHODS: We reviewed 3,800 cases of endoscopic retrograde cholangiopancreatography. Clinical and pancreatographic findings including caliber, course, terminal shape, and patency of Santorini's duct were examined in cases of Santorini's duct dominance. RESULTS: Twenty-nine cases were diagnosed as Santorini's duct dominant. Chronic pancreatitis, acute relapsing pancreatitis, pancreatic-type pain, and hyperamylasemia not associated with obvious pancreatitis were observed in 3, 1, 5, and 6 cases, respectively. Cholangiopancreatographic findings indicated congenital choledochal cyst (n = 2), branch fusion between the ventral and dorsal pancreatic ducts (n = 23), and normal pancreatic duct system characterized by a straight course through the body and tail to join the ventral pancreatic duct in the neck portion of the pancreas (n = 4). Regarding terminal shapes of Santorini's duct, cudgel type (n = 9) and spindle type (n = 8), which showed frequent patency, were observed significantly more frequently than in controls. Patency of Santorini's duct was observed in 90% (17/19). CONCLUSIONS: Many Santorini's duct-dominant cases exhibited branch fusion between the ventral and dorsal pancreatic ducts. Although Santorini's duct functions well in most cases in which it is dominant, pancreatitis or pancreatic-type pain occurs in half of such cases due to relative impairment of function of the minor duodenal papilla.     

经内镜逆行胰胆管造影术中不同取石器械对胆总管结石的疗效及安全性分析

目的 比较经内镜逆行胰胆管造影术（ERCP）中不同取石器械取石的效果及安全性。方法 回顾性分析2015年1月—2018年8月在南京市江宁医院及池州市人民医院行ERCP取石治疗的178例胆总管结石患者资料。患者先使用扩张气囊充分扩张乳头口，再行取石。根据取石器械不同，分为单纯气囊组（54例），单纯网篮组（60例）及网篮联合气囊组（64例），比较各组一次性结石清除率、术后24 h血淀粉酶水平及并发症发生率。结果 单纯气囊组、单纯网篮组及网篮联合气囊组一次性结石清除率分别为96.3%（52/54）、95.0%（57/60）、95.3%（61/64），3组比较差异无统计学意义（χ2=0.120,P=0.942）。3组术后24 h血淀粉酶水平分别为180.5（85.2,410.5）U/L、129.0（59.0,287.0）U/L、100.0（58.2,166.2）U/L，差异有统计学意义（H=9.655，P=0.008）。ERCP术后高淀粉酶血症、出血、术后胰腺炎发生率3组比较差异均无统计学意义（P均＞0.05）。3组均无穿孔发生，但网篮组发生结石嵌顿1例。结论 在使用扩张气囊充分扩张乳头口的情况下，ERCP取石可优先选用气囊取石，其具有较高的取石成功率，并发症发生率无显著升高，且不会发生取石器械嵌顿。     

Pancreatic stenting for the preservation of pancreatic function in chronic pancreatitis with stricture

Background: Although many reports have documented pain relief achieved by pancreatic stenting, the effect of stenting on pancreatic function is less clear. In addition, the effects of stent caliber and patency have not been considered in most previous studies. Pain and pancreatic function after stenting of the main pancreatic duct (MPD) were examined. Methods: Records of 24 patients with chronic pancreatitis who had an MPD stricture treated with a 10‐Fr stent from June 1996 to June 2002 were reviewed. The average age was 57.0 ± 1 years, and the male : female ratio was 7 : 1. Eleven patients had diabetes mellitus. Stent patency, pancreatic pain and pancreatic endocrine and exocrine function were examined before stenting and 6 months after stenting. Stenting was continued for 1 year or more, with repeated stent exchange every 3 months. Results: The stent became occluded in 29% of cases, migration occurred in 15% of cases, and the 50% patency time was 125 days. Pancreatic pain was relieved by stenting in all cases. The diameter of the MPD, the Bentiromide test value, weight and body mass index were improved. Conclusion: Stenting relieves blockage of the main pancreatic duct and provides both pain relief and preservation of residual pancreatic function.     

Clinical significance of the accessory pancreatic duct

BACKGROUND/AIMS: The accessory pancreatic duct is the smaller and less constant pancreatic duct in comparison with the main pancreatic duct. We investigated the patency of the accessory pancreatic duct and its role in pancreatic pathophysiology. METHODOLOGY: Dye-injection endoscopic retrograde pancreatography was performed in 411 patients. In patients in whom the main pancreatic duct could be selectively cannulated, contrast medium with indigo carmine was injected through the catheter. Excretion of the dye from the minor duodenal papilla was observed endoscopically. RESULTS: Patency of the accessory pancreatic duct was 43% of the 291 control cases. In the 46 patients with acute pancreatitis, 8 (17%) had a patent accessory pancreatic duct. The difference in patency between this group and the normal group was significant (p < 0.01). Especially, patency of the accessory pancreatic duct was only 8% of the 13 patients with acute biliary pancreatitis. In the patients with pancreaticobiliary maljunction, biliary carcinoma occurred in 72% of patients with a nonpatent accessory pancreatic duct, but in contrast, it occurred only in 30% of those with a patent accessory pancreatic duct. This difference was significant (p < 0.05). Lower amylase level in the bile of patients with pancreaticobiliary maljunction with a patent accessory pancreatic duct was frequently observed than those with a nonpatent accessory pancreatic duct. CONCLUSIONS: A patent accessory pancreatic duct may prevent acute pancreatitis by lowering the pressure in the main pancreatic duct. In cases of pancreaticobiliary maljunction with a patent accessory pancreatic duct, the incidence of carcinogenesis of the bile duct might be lower, as the reflux of the pancreatic juice to the bile duct might be reduced by the flow of the pancreatic juice into the duodenum through the accessory pancreatic duct.     

Distinctive expression of CD133 between intraductal papillary neoplasms of the bile duct and bile duct adenocarcinomas

Aim: Intraductal papillary neoplasm of the bile duct (IPNB), a novel entity of biliary disease, is recently advocated as the counterpart of pancreatic intraductal papillary mucinous neoplasm (IPMN) because both are in common with a large amount of mucin production and papillary growth. Based on our recent finding that expression of CD133, a cancer stem cell marker, is lacking in pancreatic IPMN, we herein focused on CD133 expression of IPNB in comparison with intrahepatic cholangiocellular carcinoma (IHCCC) or hilar bile duct cancer (HBDC). Methods: Expression of CD133 protein was immunohistochemically determined in patients with IPNB (n = 7), IHCCC (n = 16) or HBDC (n = 8). In addition, morphological and immunohistochemical mucin expression patterns were characterized in IPNB, and clinicopathological features including prognosis were compared between IPNB and other biliary tumors. Results: The IPNB group included significantly more females than the other two groups, and had a longer survival time. While no CD133 expression was observed in IPNB tumor, 16.4% of cancer cells in IHCCC and 17.2% of cells in HBDC expressed CD133. Among seven patients with IPNB, six (86%) were morphologically the pancreatobiliary type and four of six showed mucin expression pattern of the typical pancreatobiliary type (MUC1+/MUC2‐/MUC5AC+). Conclusion: Loss of CD133 expression supports the hypothesis that IPNB is a counterpart of pancreatic IPMN with a differing carcinogenesis from conventional bile duct adenocarcinomas.     

Stent-induced symptomatic pancreatic duct stricture after endoscopic prophylactic pancreatic duct stent placement for the normal pancreas

Background/ObjectivesStent-induced pancreatic duct stricture (SI-PDS) is a complication associated with pancreatic stent placement. However, symptomatic SI-PDS associated with prophylactic pancreatic duct stents has not been sufficiently investigated.MethodsWe examined the incidence and characteristics of symptomatic SI-PDS in patients who underwent pancreatic duct stent placement to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) between April 2007 and March 2017.ResultsWe examined 124 patients with normal pancreases consisting of 75 men and 49 women with a median age of 67.5 years [interquartile range (IQR): 61–74 years]. The median main pancreatic duct (MPD) diameter was 3.3 mm (IQR: 2.6–4.1 mm). The median duration of stent placement was 7 days (IQR: 3–14 days). Spontaneous dislodgment stents were placed in 43.5% of cases (54/124). The diameter of the stent was 5 Fr in 93.5% of cases (116/124) and 7 Fr in 6.5% of cases (8/124). Symptomatic SI-PDS was observed in 2.4% (3/124) of patients overall: 6.5% of patients with an MPD diameter of <3 mm and 0% of patients with an MPD diameter of ≥3 mm. Univariate analysis revealed that an MPD diameter <3 mm was a significant factor for symptomatic SI-PDS (p = 0.048). All cases of symptomatic SI-PDS improved with endoscopic treatment.ConclusionsSymptomatic SI-PDS occurred in 2.4% of patients who underwent prophylactic pancreatic duct stent placement for normal pancreases. Patients with an MPD diameter of <3 mm may be susceptible to symptomatic SI-PDS.     

Usefulness of selective endoscopic retrograde pancreatography (selective ERP) and endoscopic pancreatic biopsy (EPB) in the diagnosis of mucin-producing tumor of the pancreas]

Selective ERP and EPB were employed in the diagnosis of mucin-producing tumor (MPT) of the pancreas and their usefulness was evaluated. Thirty five cases of MPTs were subdivided into three subtypes, i.e., 1) main duct type, 2) branch duct type and 3) peripheral type (mucinous cystadenoma/cystadenocarcinoma). Selective ERP was proved to be useful in demonstrating precise and whole pancreatograms, especially in revealing multiple lesions, when compared with standard ERP. Selective ERP could demonstrate communication between cystic tumors of the peripheral type and the pancreatic duct in seven (88%) of eight cases of the peripheral type, which suggests high frequency of the communication in the peripheral type. For preoperative tissue diagnosis, EPB was shown to be a useful method to yield sufficient tissue materials for histopathological evaluation and may be used as an adjunction method to diagnose the intraductal extent of the tumorous lesion.