Pancreatic biopsy under visual control in conjunction with laparoscopy for diagnosis of pancreatic cancer

Two cases of histologically confirmed pancreatic cancer are reported. Histological diagnosis was obtained after pancreatic biopsy was carried out under visual control in conjunction with laparoscopy using pancreatic biopsy forceps designed by us. In Case 1, localized swelling of the pancreas was observed on abdominal ultrasonography (US) and computer tomography (CT) scan, and interruption of the main pancreatic duct was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP). In Case 2, a pancreatic tumor was detected by abdominal US and CT scan, but ERCP findings were only those of chronic pancreatitis.     

内镜下诊断与治疗慢性胰腺炎17例

目的 探讨内镜下诊断和治疗慢性胰腺炎的价值。方法 对17例慢性胰腺炎均行内镜下逆行胰胆管造影术(ERCP)，并对部分胰管狭窄患者施行塑料支架放置引流术(ERPD)或鼻胰管引流术(ENPD)，对部分胰管内结石行内镜下胰管括约肌切开术(EPS)并行网篮取石。结果 有8例胰管狭窄者放置塑料支架，平均引流时间为276d。5例胰管结石中2例行EPS后网篮取出结石，3例行鼻胰管引流术后手术取出。结论 ERCP可作为有条件医院检查慢性胰腺炎的常规手段，是治疗部分慢性胰腺炎安全有效的方法。     

联合应用CT、MRI增强扫描鉴别诊断胰腺癌与慢性胰腺炎

目的探讨联合应用MSCT和MRI增强扫描在胰腺癌与慢性胰腺炎鉴别诊断价值。方法选择经手术病理证实或临床随访证实的胰腺癌及慢性胰腺炎患者56例。所有患者在手术或随访前均同时行MSCT及MRI增强扫描。由高年资医生观察胰腺MSCT及MRI影像,对其影像学特征进行分析。总结胰腺癌及慢性胰腺炎的影像学特征,统计其在胰腺癌组与慢性胰腺炎组的统计学差异;统计MSCT、MRI及二者组合在胰腺癌和慢性胰腺炎的鉴别诊断上的统计学差异。结果胰腺体积增大、胰腺周围组织及大血管的侵犯、胰腺周围淋巴结肿大、动脉期强化不明显、胰胆管不规则扩张等多见于胰腺癌;病变内及病变周围囊肿、病变钙化、胰胆管平滑状扩张多见于慢性胰腺炎。以上征象在胰腺癌组与慢性胰腺炎组间均存在明显统计学差异（P〈0．05）。应用各种MSCT和MRI影像学方法综合鉴别诊断胰腺癌和慢性胰腺炎,其诊断准确度均优于任何以上单一影像学技术（P〈0．05）;而MSCT增强扫描和MRI增强扫描在胰腺癌和慢性胰腺炎的鉴别诊断上,诊断准确度未见明显差异（P〉0．05）。结论MSCT和MRI增强扫描联合应用在胰腺癌与慢性胰腺炎的鉴别诊断上,具有突出的临床应用价值。     

Angiographic evaluation of the abnormal endoscopic pancreatogram

Out of 1,269 pancreatograms, 122 were abnormal. Angiography was performed in these patients. Fifty-five were found to have pancreatic carcinoma. In the remaining 67 patients a false positive angiographic diagnosis of either chronic pancreatitis or pancreatic cancer was made in 11%. In one patient a hemangioma was diagnosed as a pancreatic cyst. The remaining 58 patients all had normal pancreatic angiograms in spite of gross ductal abnormality on endoscopic retrograde cholangiopancreatography (ERCP). All these patients were followed for an average of 19 months and showed no clinical evidence of pancreatic disease. It is suggested that angiography should be considered a complementary examination to ERCP and is particularly useful to exclude carcinoma when the pancreatogram is abnormal.     

多种MRI技术联合应用鉴别诊断胰腺癌与慢性胰腺炎

目的　评价联合应用多种MRI技术在鉴别诊断胰腺癌和慢性胰腺炎中的价值。方法　回顾分析 47例胰腺癌与 2 8例慢性胰腺炎的MRI表现。MRI技术包括 :平扫FSFLASHT1WI和TSET2 WI、MR胆胰管成像 (MRCP)及多时相动态增强扫描。测量肿块与正常胰腺信号值 ,计算对比噪声比 (CNR)。结果　平扫FSFLASHT1WI和TSET2 WI对胰头癌的敏感率为 5 9.4% ,对胰体癌为 86.7% ,对慢性胰腺炎为 78.6%。MRCP对胰头癌的敏感率为 90 .6% ,对胰体癌为 6.67% ,对慢性胰腺炎为 82 .1%。多时相动态增强扫描对胰头癌的敏感率为 78.1% ,对胰体癌为 93 .3 % ,对慢性胰腺炎为85 .7%。联合应用多种MRI技术对胰头癌的敏感率为 96.9% ,对胰体癌为 93 .3 % ,对慢性胰腺炎为 92 .9% (P <0 .0 1)。结论　多种MRI技术联合运用 ,是一项对胰腺癌和慢性胰腺炎进行鉴别诊断的准确有效的方法     

Can MRCP replace ERCP for the diagnosis of autoimmune pancreatitis?

Background  It is of utmost importance that autoimmune pancreatitis (AIP) be differentiated from pancreatic cancer. Irregular narrowing of the main pancreatic duct is a characteristic finding in AIP; it is useful for differentiating AIP from pancreatic cancer stenosis. This study evaluated the usefulness of magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of AIP and assessed whether MRCP could replace endoscopic retrograde cholangiopancreatography (ERCP) for diagnosing AIP. Methods  The MRCP and ERCP findings of 20 AIP patients were compared. Results  On MRCP, the narrowed portion of the main pancreatic duct was not visualized, while the noninvolved segments of the pancreatic duct were visualized. The degree of upstream dilatation of the proximal main pancreatic duct was milder in AIP than in pancreatic cancer patients. In the skipped type, only skipped narrowed lesions were not visualized. After steroid therapy for AIP, the nonvisualized main pancreatic duct became visualized. Conclusions  MRCP cannot replace ERCP for the diagnosis of AIP, since narrowing of the main pancreatic duct in AIP was not visualized on MRCP. MRCP findings of segmental or skipped nonvisualized main pancreatic duct accompanied by a less dilated upstream main pancreatic duct may suggest the presence of AIP. MRCP is useful for following AIP patients.     

Therapeutic pancreatic endoscopy

In view of increasingly accurate noninvasive diagnostic imaging modalities for pancreatic diseases, endoscopic retrograde cholangiopancreatography (ERCP) should be mainly restricted to therapeutic indications. Acute pancreatitis is still the most common complication of ERCP. Prevention measures should focus in particular on well-defined risk groups. Temporary pancreatic duct drainage, preferably using small-diameter endoprostheses, can reduce the incidence of post-ERCP pancreatitis in at-risk individuals. By contrast, pharmacological prevention does not appear to be effective. ERCP in conjunction with sphincter of Oddi manometry frequently reveals the diagnosis of undetermined causes of acute recurrent pancreatitis. Endoscopic sphincterotomy (EST) is the treatment of choice in patients with sphincter of Oddi dysfunction or papillary stenosis. For these indications, dual pancreaticobiliary sphincterotomy promises a lower early morbidity and a better long-term outcome than biliary EST alone. In patients with pancreatic divisum, the cannulation rate of the dorsal duct can be improved by methylene blue staining and/or stimulation of the pancreatic secretion. Papillotomy of the minor papilla with short-term stenting appears to be an effective and safe approach for associated acute recurrent pancreatitis. Large-scale trials indicate that the majority of symptomatic patients with chronic pancreatitis can be well managed in the long term by endoscopic interventions. There is still a lack of prospective randomized controlled trials on endotherapy for chronic pancreatitis; however, they are also lacking for the surgical approach. Endoscopic and/or endosonographically guided drainage has become the treatment of choice for the majority of symptomatic pancreatic pseudocysts. Transmural debridement of pancreatic abscesses and infected necroses is still investigational, but appears to offer a minimally invasive alternative to surgery in selected cases. Pancreatic endotherapy is technically demanding and potentially hazardous; these interventions should be restricted to high-volume centers with options for an interdisciplinary team approach. Methods that have not yet been established should be evaluated in carefully designed prospective trials.     

Computed tomography,ultrasonography, and endoscopic retrograde cholangiopancreatography in the diagnosis of pancreatic disease: A comparative study

A prospective study was performed comparing the sensitivity of computed tomography, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic disease. Forty patients with suspected pancreatic carcinoma, acute recurrent or chronic pancreatitis, and/ or jaundice were studied. CT was the most sensitive study in evaluation of pancreatitis. ERCP was most accurate in evaluation of pancreatic malignancy. Ultrasonography was the least sensitive method in detecting pancreatic disease and dilatation of the extrahepatic biliary ducts.     

慢性胰腺炎的超声内镜诊断

对３０例慢性胰腺炎作体表腹部超声（ＵＳ）。内镜逆行胰胆管造影（ＥＲＣＰ）和超声内镜（ＥＵＳ）对比检查。对胰管、胰实质回声、胰腺形态、胰石及囊肿等特征的研究表明：①ＥＵＳ能清楚地显示主胰管及其扩张程度、胶管狭窄部位、胰石和囊肿情况，ＥＵＳ对胰石和囊肿的发现率优于ＥＲＣＰ（Ｐ＜０．０１），ＥＵＳ对分枝胰管的显示率低于ＥＲＣＰ（Ｐ＜０．０１）；②ＥＵＳ显示扩张的主胰管与ＵＳ比较无差别（Ｐ＞０．０５），对狭窄的主胰管及分枝胰管的显示率和胰石的显示率均高于ＵＳ（Ｐ＜０．０１），对囊肿的显示二者无差别；③ＥＵＳ能对胰实质回声改变进行分型诊断；④年龄增长和ＥＵＳ非连续切面影响对慢性胰腺炎的诊断；⑤ＥＵＳ与ＵＳ和／或ＥＲＣＰ联合检查可提高慢性胰腺炎的正确诊断率．     

Ultrasound imaging in tropical pancreatitis.

Tropical pancreatitis differs in many respects from the chronic pancreatitis seen in Western countries. The present study was carried out to evaluate the role of ultrasonography in the diagnosis of tropical pancreatitis (TP) and to characterize the ultrasound findings in tropical pancreatitis. Patients referred with a suspected diagnosis of tropical pancreatitis formed the subjects for the study. Plain x-rays of the abdomen, ultrasonography, and endoscopic retrograde cholangio-pancreatography (ERCP) were carried out in all cases. Of the 25 cases, 17 patients had ERCP evidence of pancreatitis. Duct dilatation (82%) and demonstration of calculi were the most common ultrasound findings. Pancreatic atrophy (53%) was also a major feature of TP. Compared with ERCP, ultrasonography had a sensitivity of 94% and a specificity of 100%. Only one case with mild changes in ERCP was missed by ultrasonography. For the diagnosis and planning of surgery in TP, ultrasonography can replace ERCP. Even complications like cysts and malignancies are detected by ultrasonography.     

Pancreatic and biliary tract disorders in inflammatory bowel disease

Hepatobiliary disorders occur frequently in patients with IBD, with PSC and cholangiocarcinoma being the most clinically significant for endoscopists. Endoscopic therapy for PSC is effective in improving symptoms, biochemical parameters, and radiographic abnormalities. Endoscopic therapy may also confer survival benefit, but this has yet to be confirmed in randomized, controlled trials. Treatment should be restricted to those individuals with a rapid decline in liver function testing or those with recurrent cholangitis. Cholangiocarcinoma is a serious complication of PSC and carries an extremely poor prognosis. ERCP with brush cytology has a relatively low sensitivity and the diagnosis is usually made after the disease has become metastatic. Malignant biliary obstruction can be palliated by endoscopic stenting. Photodynamic therapy is a promising experimental technique that may confer symptomatic and survival benefit in patients with nonresectable, advanced cholangiocarcinoma. IBD patients also have an elevated risk for developing acute and chronic pancreatitis as well as pancreatic insufficiency. The majority of cases of acute pancreatitis are likely due to medication side effects and local structural complications of IBD. The remainder may possibly represent true extraintestinal manifestations of IBD. Chronic pancreatitis is frequently subclinical, but may be accompanied by clinically relevant exocrine insufficiency. ERCP is the test of choice for the diagnosis of chronic pancreatitis, but the role of endoscopy in the therapeutic management of IBD-associated chronic pancreatitis remains to be defined.     

磁共振不同脉冲序列成像对慢性胰腺炎与胰腺癌的诊断价值

慢性胰腺炎及胰腺癌的诊断及鉴别诊断一直是临床工作中的难点,本文回顾了磁共振技术在慢性胰腺炎与胰腺癌鉴别诊断方面的应用进展,描述了不同磁共振脉冲序列中正常胰腺组织的信号特点,以及慢性胰腺炎和胰腺癌的不同表现,比较了ERCP、CT、MRCP、MRI检查诊断慢性胰腺炎及胰腺癌的优势与不足。     

167例老年胰腺癌特点及与糖尿病、慢性胰腺炎的关系分析

目的 :分析 16 7例老年胰腺癌的临床特征 ,探讨胰腺癌与糖尿病、慢性胰腺炎之间的关系。方法 :对 16 7例胰腺癌和16 7例对照组进行回顾性对比分析 ,计算其相对危险度 (RR) ,评价胰腺癌与糖尿病、慢性胰腺炎的关系。结果 :(1)胰腺癌的临床表现以腹痛、黄疸、消瘦、腹胀和上腹不适为主 ,男性多见。无一例是早期胰腺癌。 (2 )在胰腺癌组中 2年内确诊糖尿病有4 5例 (2 6 .95 % ) ,对照组中有 4例 (2 .4 0 % ) ,两组有显著差异 (P <0 .0 1)。胰腺癌组中糖尿病病史两年以上有 12例 (7.19% ) ,对照组中有 14例 (8.38% ) ,两组无显著差异 (P >0 .0 5 )。 (3)胰腺癌组和对照组分别检出慢性胰腺炎 6例和 1例 ,两组无显著差异 (P >0 .0 5 )。结论 :老年人胰腺癌确诊相对较晚 ,常伴有糖尿病的发生 ,但糖尿病不是胰腺癌的危险因素 ,糖尿病是胰腺癌的继发性结果。慢性胰腺炎与胰腺癌发生无相关性。老年人出现血糖异常须警惕胰腺癌的发生。     

超声内镜对胰腺疾病的诊断

本文报告超声内镜（ＥＵＳ）对５０例胰腺癌及３０例慢性胰腺炎的诊断，并与ＵＳ、ＥＲＣＰ和ＣＴ进行了对比研究。结果表明：①ＥＵＳ对胰腺癌的显示率达１００％，诊断正确率达９４％，高于ＵＳ、ＣＴ和ＥＲＣＰ。②ＥＵＳ对胰腺癌术前被膜浸润、胰后方组织浸润、淋巴结转移和门脉浸润的诊断正确率分别为７２％、７４％、７６％和８０％。③ＥＵＳ显示主胰管与ＥＲＣＰ，相近．对胰石和囊肿的发现率优于ＥＲＣＰ。④ＥＵＳ能对胰实质回声改变进行分型诊断。⑤ＥＵＳ与ＵＳ和／或ＥＲＣＰ联合检查可提高慢性胰腺炎的正确诊断率。     

Therapeutic pancreatic endoscopy

Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) has established itself as a valuable tool for the treatment of a variety of biliary tract disorders. Fueled by an ever-increasing demand for minimally invasive therapy, pancreatic endoscopy was the logical frontier for expansion of therapeutic ERCP. Endoscopic treatment of benign pancreatic disorders can be a cost-effective alternative to more invasive radiological or surgical methods. Conditions such as acute and chronic pancreatitis, pancreatic calculi, and pseudocysts can in many cases be managed endoscopically. This review summarizes the current state of the art in therapeutic pancreatic endoscopy.     

Contrast-enhanced endoscopic ultrasound in the diagnosis of autoimmune pancreatitis

Autoimmune pancreatitis is a rare condition which can mimic pancreatic carcinoma. We report the cases of 10 patients with autoimmune pancreatitis investigated in two different centers using contrast-enhanced endosonography. In these patients, contrast-enhanced endosonography showed a unique vascularization pattern which makes it easy to discriminate between autoimmune pancreatitis and lesions caused by pancreatic cancer. Lesions caused by autoimmune pancreatitis and the surrounding pancreas typically showed hypervascularization, whereas lesions caused by pancreatic cancer were hypovascularized. This was true for all patients with the exception of one who showed a normal vascularization pattern in comparison with normal patients and no signs of hypovascularization. Final diagnosis was achieved either by transcutaneous biopsy or a combination of endoscopic fine-needle aspiration with IgG4 immunostaining of the sample. All patients were followed up over a period of at least 12 months to rule out pancreatic carcinoma.     

Clinical course of alcoholic pancreatitis

AIM: To study a natural course of alcoholic pancreatitis (AP). MATERIAL AND METHODS: Follow-up clinical, laboratory and radiation examinations were made of 170 patients with alcoholic pancreatitis. Exocrine secretion of the pancreas was assessed by secretin-pancreozymin test. Morphological signs of pancreatitis were studied in patients who had died of pancreatic cancer. RESULTS: In 24% of patients AP manifested with acute attack. In 76% it was preceded with weak clinical symptoms. AP ran was complicated with pseudotumorous pancreatitis, calcinosis and pancreatic pseudocysts. Pancreatic secretion was suppressed in 87% patients though clinically it was evident only in 12% cases. Autopsy cases of pancreatic cancer carried morphological markers of chronic pancreatitis. CONCLUSION: Various clinical forms of AP represent stages of its development: early symptoms, recurrences, complications and decompensated failure of the pancreatic function. The presence of pancreatitis in patients with pancreatic cancer causes difficulties in differential diagnosis between these diseases.     

Abdominal ultrasonogram of autoimmune pancreatitis: Five cases of pancreatic lesions accompanied by Sjögren syndrome

The concept of autoimmune pancreatitis has recently been established, and ultrasonographic findings we obtained from five cases consistent with autoimmune pancreatitis are reported here. Case 1, a 77-year-old man, was admitted complaining of loss of body weight. Serum hepatobiliary enzymes and γ-globulin levels were elevated, and antinuclear antibody was positive, Abdominal ultrasonography showed dilatation of the intrahepatic bile duct, wall thickening of the common bile duct and hypoechoic swelling of the pancreatic head and body. ERCP revealed multiple stenosis of the intra-and extra-hepatic bile ducts, and diffuse irregular narrowing of the main pancreatic duct. The patient complained of thirst, and the minor salivary gland was examined histologically. Our diagnosis was Sjögren syndrome accompanied by sclerosing cholangitis and a pancreatic lesion. Obstructive jaundice also developed, and PTCD was therefore performed. Both the pancreatic swelling and multiple stenosis of the bile duct improved after steroids were administered. Case 2, a 71-year-old man, was admitted with jaundice. Abdominal ultrasonography showed hypoechoic swelling of the pancreas. ERCP showed stenosis of the common bile duct in the pancreatic head region and diffuse irregular narrowing of the main pancreatic duct. Histological examination of the minor salivary gland suggested Sjögren syndrome. Steroids were therefore administered because the presence of both hyper-γ-globulinemia and positive antinuclear antibody suggested involvement of the autoimmune mechanism. Steroid therapy improved the jaundice as well as the findings from the cholangiograms and pancreatograms. We also encountered three similar cases, all consistent with the concept of autoimmune pancreatitis. The ultrasonographic findings of the pancreatic lesion (1) showed them as homogeneous and markedly hypoechoic areas and, (2) visualized the main pancreatic duct in the lesion, which facilitated a differential diagnosis of the neoplastic lesions. (3) Steroid therapy effectively decreased the hypoechoic area; in some cases, however, a hypoechoic area remained around the main pancreatic duct.     

Chemical pancreatectomy treats chronic pancreatitis while preserving endocrine function in preclinical models

Chronic pancreatitis affects over 250,000 people in the US and millions worldwide. It is associated with chronic debilitating pain, pancreatic exocrine failure, and high risk of pancreatic cancer and usually progresses to diabetes. Treatment options are limited and ineffective. We developed a new potential therapy, wherein a pancreatic ductal infusion of 1%–2% acetic acid in mice and nonhuman primates resulted in a nonregenerative, near-complete ablation of the exocrine pancreas, with complete preservation of the islets. Pancreatic ductal infusion of acetic acid in a mouse model of chronic pancreatitis led to resolution of chronic inflammation and pancreatitis-associated pain. Furthermore, acetic acid–treated animals showed improved glucose tolerance and insulin secretion. The loss of exocrine tissue in this procedure would not typically require further management in patients with chronic pancreatitis because they usually have pancreatic exocrine failure requiring dietary enzyme supplements. Thus, this procedure, which should be readily translatable to humans through an endoscopic retrograde cholangiopancreatography (ERCP), may offer a potential innovative nonsurgical therapy for chronic pancreatitis that relieves pain and prevents the progression of pancreatic diabetes.     

Mucinous cystic neoplasms of the pancreas

Mucinous cystic neoplasms of the pancreas (MCNP) are rare tumors with presentation and findings that differ in most cases from pancreatic pseudocysts. A simple pancreatic cystic lesion in a younger-aged patient with a history of pancreatitis and endoscopic retrograde cholangiopancreatography (ERCP) demonstration of ductal communication with the cyst strongly suggests the diagnosis of a benign pseudocyst. MCNP may have extensive areas without an epithelial lining, adding histologic sampling error to the potential for confusing these two entities. Pancreatic pseudocysts are benign lesions treated by enteric drainage procedures, while MCNP have significant malignant potential, and resection is advised. Even when clinical presentation and imaging are persuasive for a benign cyst, MCNP of the pancreas should be considered in planning, evaluation, and treatment.