Tubular adenoma of the main pancreatic duct.

We report a case of tubular adenoma of the duct of Wirsung with focal villous changes. To our knowledge, this is the 13th reported case of this uncommon neoplasm and the first with a primarily tubular histologic pattern. The patient presented with abdominal pain and diarrhea and was found on endoscopic retrograde cholangiopancreaticography to have a mass in the head of the pancreas, which was confirmed by endoscopic ultrasound. Clinical and pathological features of the 12 previously reported cases are reviewed. Intraoperative testing failed to rule out adenocarcinoma which, in addition to difficulties presented by local anatomic relationships of the tumor, supports wide surgical resection as the preferred surgical solution.     

Delayed occlusion of the pancreatic duct

Seventy six delayed occlusions of the main pancreatic duct were fulfilled during the period from 1978 to 1985. No severe complications or lethal outcomes due to performing a delayed occlusion of the duct were noted.     

Cystic duct directly joining the main pancreatic duct

A unique anomaly of the direct union between the cystic duct and the main pancreatic duct is presented. A 19-year-old man with a history of repeated epigastralgia underwent endoscopic retrograde cholangiopancreaticography that showed a direct union between the cystic duct and the main pancreatic duct. No pancreaticobiliary maljunction was noticed. Cholecystectomy accompanied by resection of the long cystic duct was performed. The excised gallbladder showed cholesterolosis, chronic cholecystitis, and hyperplasia of the pseudopyloric glands microscopically. The patient has been well for 3 years since surgery.     

Experimental pancreatic duct occlusion with polyurethane

Pancreatic transplantation requires an effective method to manage exocrine secretion. A new technique to eliminate the exocrine function of the pancreas by obstruction of the duct with polyurethane was investigated in terms of function, outcome and morphology. Polyurethane is an alcoholic solution of block copolymers with the property of polymerizing within 5-10 min. In this study the in-situ pancreatic tail model in dogs was utilized, the pancreatic duct was cannulated and injected with 2-3 ml of polyurethane. As a result, complete atrophy and fibrosclerosis of the exocrine tissue was obtained leaving islets well vascularized and functioning for the entire experimental periods. All animals remained normoglycemic and showed normal K-values. Amylase levels were found to be maximally elevated at 24 h and returned to normal within 2 weeks after duct occlusion. Insulin, glucagon and somatostatin levels remained normal. Because of its ability to effect a complete occlusion of the pancreatic ducts with subsequent atrophy of the exocrine gland and without notable disturbance of endocrine function, we feel that polyurethane solution is superior to previously used materials for this purpose.     

Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial

OBJECTIVE: To determine whether temporary occlusion of the main pancreatic duct with human fibrin glue decreases the incidence of intra-abdominal complications after pancreatoduodenectomy (PD) or distal pancreatectomy (DP). SUMMARY BACKGROUND DATA: To the authors' knowledge, there are no randomized studies comparing outcomes after pancreatic resection with or without main pancreatic duct occlusion by injection of fibrin glue. Of three nonrandomized studies, two reported no fistulas after intracanal injection and ductal occlusion with fibrin glue after PD with immediate pancreatodigestive anastomosis, while another study reported no protective effect of glue injection. METHODS: This prospective, randomized, single-blinded, multicenter study, conducted between January 1995 and January 1999, included 182 consecutive patients undergoing PD followed by immediate pancreatic anastomosis or DP, whether for benign or malignant tumor or for chronic pancreatitis. One hundred two underwent pancreatic resection followed by ductal occlusion with fibrin glue (made slowly resorbable by the addition of aprotinin); 80 underwent resection without ductal occlusion. The main end point was the number of patients with one or more of the following intra-abdominal complications: pancreatic or other digestive tract fistula, intra-abdominal collections (infected or not), acute pancreatitis, or intra-abdominal or digestive tract hemorrhage. Severity factors included postoperative mortality, repeat operations, and length of hospital stay. RESULTS: The two groups were similar in pre- and intraoperative characteristics except that there were significantly more patients in the ductal occlusion group who were receiving octreotide, who had reinforcement of their anastomosis by fibrin glue, and who had fibrotic pancreatic stumps. However, the rate of patients with one or more intra-abdominal complications, and notably with pancreatic fistula, did not differ significantly between the two groups. There was still no significant difference found after statistical adjustment for these patient characteristic discrepancies, confirming the inefficacy of fibrin glue. The rate of intra-abdominal complications was significantly higher in the presence of a normal, nonfibrotic pancreatic stump and main pancreatic duct diameter less than 3 mm, whereas reinforcement of the anastomosis with fibrin glue or use of octreotide did not influence outcome. In multivariate analysis, however, normal pancreatic parenchyma was the only independent risk factor for intra-abdominal complications. No significant differences were found in the severity of complications between the two groups. CONCLUSIONS: Ductal occlusion by intracanal injection of fibrin glue decreases neither the rate nor the severity of intra-abdominal complications after pancreatic resection.     

Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modified puestow procedure.

OBJECTIVE: This study evaluated the effect of operative drainage of the main pancreatic duct (MPD) on functional derangements associated with chronic pancreatitis (CP). SUMMARY BACKGROUND DATA: The author previously reported delayed functional impairment in an evaluation of the impact of operative drainage in patients with CP. The author now reports on a prospective study of 143 patients with this diagnosis. METHODS: Each patient underwent 1) ERCP, 2) the Bentiromide PABA, 3) 72-hour fecal fat test, 4) oral glucose tolerance test (OGTT) and 5) fat meal (LIPOMUL)--stimulated pancreatic polypeptide release (PP). All patients were stratified as mild/moderate (M/M) or severe CP on the basis of a 5-point system that was developed by the author. Patients were studied at 16-month intervals. RESULTS: All 143 patients underwent initial and follow-up evaluations in a mean follow-up of 47.3 months; 83 of 143 patients had M/M grade at initial evaluation. Eighty-seven patients underwent (MPD) decompression to relieve abdominal pain. In a separate prospective 17 patients with a diagnosis of CP, a grade of M/M and non-disabling abdominal pain were randomized to operative or non-operative treatment; 9 of these randomized patients were operated upon and 8 were not. No patient improved their grade during follow-up; 47 of 83 M/M patients had operative drainage and 36 did not. This grade was preserved in 41 of 47 (87%) operated patients but in only 8 of the 36 non-operated patients (22%). In the randomized trial, seven of nine operated patients retained their functional status in follow-up, whereas only two of eight patients (25%) randomized to non-operation preserved their functional grade. CONCLUSIONS: These data in this large study as well as among a previous randomized sample, support a policy of early operative drainage before the development of irreversible functional impairment in patients with chronic pancreatitis and associated dilation of the main pancreatic duct.     

Pancreatic leak after left pancreatectomy is reduced following main pancreatic duct ligation

BACKGROUND: Although much is known about the long-term outcome of patients undergoing left (distal) pancreatectomy for malignancy, comparatively little is known about the optimal management strategy for the residual transected pancreatic parenchyma and the divided pancreatic duct. Clinicopathological and operative factors that may contribute to postoperative pancreatic leak were evaluated. METHODS: A retrospective review of the medical records of 126 patients who underwent left pancreatectomy between June 1990 and December 1999 at the University of Texas M. D. Anderson Cancer Center was performed. RESULTS: Indications for left pancreatectomy included pancreatic neoplasms (n = 42; 33.3 per cent), en bloc resection for management of retroperitoneal sarcoma (n = 21; 16.7 per cent), gastric adenocarcinoma (n = 14; 11.1 per cent), renal cell carcinoma (n = 11; 8.7 per cent) and other tumours or benign conditions (n = 38; 30.2 per cent). Pancreatic parenchymal closure was accomplished by a hand-sewn technique, mechanical stapling, or a combination of the two in 83, 20 and 15 patients respectively. No form of parenchymal closure was used in eight patients. Identification of the pancreatic duct and suture ligation was performed in 73 patients (57.9 per cent). Twenty-five patients (19.8 per cent) developed a pancreatic leak. For subgroups having duct ligation or no duct ligation, pancreatic leak rates were 9.6 per cent (seven of 73 patients) and 34.0 per cent (18 of 53 patients) respectively (P < 0.001). Multivariate analysis including clinicopathological and operative factors indicated that failure to ligate the pancreatic duct was the only feature associated with an increased risk for pancreatic leak (odds ratio 5.0 (95 per cent confidence interval 2.0 to 10.0); P = 0.001). CONCLUSION: Pancreatic leak remains a common complication after left pancreatectomy. The incidence of leak is reduced significantly when the pancreatic duct is identified and directly ligated during left pancreatectomy.     

胰头后侧径路切开主胰管取石术

目的 探讨胰头部主胰管结石(PHDS)取石手术的这一临床难题。方法 总结3例PHDS病人的医疗教训,设计并施行了经十二指肠降部及胰头后侧径路切开胰头部主胰管的取石手术(PPRS手术)。结果 施行PPRS手术的首例患者术后无并发症治愈。结论 PPRS手术是治疗PHDS病人的一种简易、方便、安全的手术,但应根据共存于病人的其它病理情况,组合施行其它手术,如胰体、尾部主胰管明显增粗,则尚需行胰-空肠Roux-Y吻合术等。     

Development and critical evaluation of pancreatic duct occlusion

The three original aims of pancreatic duct occlusion (PDO) were first the reduction of early complications after Whipple's operation in chronic pancreatitis and carcinoma as well as segmental pancreas transplantation, second to finish the inflammation in cases of chronic pancreatitis and third to protect the B-cell function in remained or transplanted pancreas. We have compared PDO by Tissucol and Ethibloc with non-occluded pancreases up to 3 years after Whipple's operation in patients with chronic pancreatitis and carcinoma and in patients with autologous segmental pancreas transplantation. In concluding the results one can say that PDO is of high value with regard to early complications in patients with pancreas carcinoma. In these patients and in autologous pancreas transplantation the PDO by Tissucol seems to have more protective effect on B-cell function than the other approaches. In patients with chronic pancreatitis and Whipple's operation the PDO was without value neither for early complications, these are very low anyhow, nor B-cell function.     

The anatomical relationship between the retropancreatic part of the bile duct and the main pancreatic duct.

The main pancreatic duct lies posteriorly within the head of the pancreas and adjacent to the retropancreatic part of the common bile duct. In 17 out of 25 (68%) autopsy specimens which were studied, the two ducts ran within 5 mm of each other for a mean distance of 3.9 cm. The pancreatitis which sometimes develops as a complication of instrumentation of the bile duct could be a result of damage to the main pancreatic duct.     

Pancreatico-enterostomy for isolated main pancreatic duct disruption

BACKGROUND: We present our experiences with isolated main pancreatic duct injuries due to blunt trauma, managed by pancreatico-enterostomies. METHODS: This is a retrospective study of seven patients, one female and six males who presented between 1997 and 2005, whose ages ranged from 10 to 54 years. Three were due to motor vehicle accidents, two due to blunt assault, one pedestrian vehicle accident and one go-cart accident. Four presented acutely and were managed surgically within 24h; two were delayed by 3 days and one by 14 days. Six had pre-operative CT scans; one had an ERCP confirming ductal transection by contrast extravasation. RESULTS: Five pancreatico-gastrostomies and two pancreatico-jejenostomies were performed. Three patients complicated; one by biliary cutaneous fistula after a left hepatic segmentectomy, one with an amylase-rich low output fistula and one with haematemesis, for which no cause could be identified. All complications were managed conservatively. Post-operative follow-up ranged between 4 and 20 weeks. No deaths occurred. CONCLUSION: In a stable patient, pancreatico-enterostomy for an isolated main pancreatic duct injury appears to be a viable option and simpler to perform than distal pancreatectomy with splenic preservation. Furthermore, it has the advantage of pancreatic tissue and spleen preservation and a low fistula rate. The authors believe pancreatico-gastrostomy to be the easier to perform.     

Treatment of the pancreatic stump after pancreaticoduodenectomy. Wirsung duct occlusion versus pancreaticojejunostomy

AIM: The aim of the study is to compare the results obtained using two different techniques of reconstruction after pancreaticoduodenectomy: pancreaticojejunostomy and pancreatic remnant duct occlusion. METHODS: The authors describe a retrospective study performed in 44 nonselected patients submitted to pancreaticoduodenectomy from 2000 to 2004. They have been divided into 2 groups. Patient characteristics were comparable in both groups. The first group (22 patients) received pancreaticojejunostomy. The second group (22 patients) received duct occlusion with sclerosing glue. Intraoperative finding (operative time, estimated blood loss) and postoperative morbidity and mortality were evaluated. Endocrine and exocrine function were analyzed at 3 and 12 months after surgery. RESULTS: Results showed no differences in median blood loss, duration operation and hospital day. Morbidity and mortality were higher in duct occlusion group; pancreatic fistula was more frequent after duct occlusion, but less dangerous than one from pancreaticojejeunostomy. Also exocrine function was better in anastomosis group and the incidence of diabetes mellitus was higher in patients with duct occlusion. CONCLUSION: Pacreaticojejunostomy is the procedure of choice, while duct occlusion should be performed in friable stump with small pancreatic duct (higher risk of pancreatic fistula).     

医源性胆胰结合部损伤

医源性胆胰结合部损伤指在治疗和检验过程中引起胆总管、主胰管汇合部位的损伤,虽然发生率较低,但其处理不当时常给患者带来极大痛苦,甚至危及患者生命。为此,本文阐述了引起医源性胆胰结合部损伤的原因、早期诊断及防治措施。一、医源性胆胰结合部损伤的原因开腹下胆总管探查术和内镜括约肌切开术(EST)是导致胆胰结合部损伤的两大主要医源性因素。①开腹下胆总管探查术:主要是胆总管探查术时Bakes探条的暴力性操作引起胆胰汇合部损伤,特别是近年来纷纷开展胆道手术的基层医院,在胆总管下端通过受阻时,未经术中胆道造影或胆道镜检查,采用…     

Choledochal cyst and benign stenosis of the main pancreatic duct

We report here the first case of choledochal cyst associated with a benign stenosis of the cephalic part of the main pancreatic duct. The pancreatic ductal stenosis was associated with a protein plug located upstream of the stenosis. Preoperatively, it was not possible to rule out a localized intraductal pancreatic tumor, and a pylorus-preserving pancreaticoduodenectomy was performed. This association has not been described previously, and gives new insights into the pathogenesis of acute pancreatitis associated with choledochal cyst. Received: August 8, 2000 / Accepted: October 12, 2000     

The delayed duct occlusion technique of human pancreatic transplantation

This is a report on a consecutive series of 50 primary human pancreatic transplants performed between 1980 and March 1989. All patients suffered from end-stage diabetic nephropathy, thus all received a kidney graft simultaneously. The basic technique consisted of intraperitoneal placement of a duct-occluded pancreas segment. The main technical and non-immunological complications included primary non-function (10%) because of ischemic damage or technical error, graft pancreatitis (4%), arterial thrombosis (6%) and venous thrombosis (16%). Five patients (10%) died in the later course with functioning transplant, and 10 transplants (20%) were lost due to acute or chronic rejection, 7 of them in the pre-cyclosporin era. The technical modifications introduced during these years to overcome complications consisted of temporary percutaneous drainage of the exocrine secretion for function control, delayed occlusion of the ductal system with polyurethane, and continuous heparin perfusion of the graft in the postoperative period by means of an arterial catheter.     

Isolated main pancreatic duct injuries spectrum and management

BACKGROUND: We present our experience with the rare injury of isolated major pancreatic duct disruption. METHODS: From 1997 to 2003, 3 females and 13 males whose age ranged from 4 to 46 years were identified. Stabs caused 2 and blunt trauma 14 injuries. Nine presented acutely. Delay occurred in 7 patients, 6 with pseudocysts and 1 with infected pancreatic necrosis. RESULTS: Nine cases were managed in the acute phase: 6 by splenic-preserving distal pancreatectomy and 2 by distal pancreatico-enteric anastomosis; 1 was drained. A small pseudocyst and transient pancreatic fistula were the only complications. The 6 cases with pseudocysts were managed endoscopically. Five were stented and 1 was drained without stent. Four had resolution. Two had stent cyst migration. One required a pancreaticojejunostomy and another distal pancreatectomy. One patient died of infected pancreatic necrosis. Long-term outcome could not be assessed. CONCLUSION: In the acute situation, resection or distal pancreatico-enteric anastomoses are attainable with low morbidity. Endoscopic pseudocyst management options are feasible, with good short-term resolution. Giant cysts may be better managed operatively.     

Histopathological study of invasive ductal carcinoma (IDC) of the pancreas without associated cancerous occlusion of the main pancreatic duct

BACKGROUND/PURPOSE: [corrected] Invasive ductal carcinoma (IDC) of the pancreas may be associated with cancerous occlusion of the main pancreatic duct (MPD) in its growth process, but at quite low a frequency; there are patients who do not develop this occlusion. METHODS: This study examined the histological features of surgical specimens from 8 patients with IDC without MPD occlusion, in comparison to 32 patients with IDC with this occlusion (controls). The pancreatic duct was identified by confirming the presence of mural elastic fibers on the wall of the pancreatic duct. Immunohistochemical staining was done with Ki-67 antibody. RESULTS: The frequency of IDC without MPD occlusion was very low (5.0% [2/40] patients at Kurume University and 3.1% [4/126] patients at Juntendo University). The number of intraductal carcinoma components was 1.5 +/- 1.1 per specimen in the IDCs without occlusion and 5.9 +/- 2.4 in the controls (P < 0.001). The Ki-67 labeling index was 18.0 +/- 11.7% in the IDCs without occlusion and 30.0 +/- 12.1% in the controls (P < 0.05). The number of intraductal carcinoma components and the Ki-67 labeling index were significantly lower in the IDCs without occlusion than in the controls. CONCLUSIONS: Our findings suggested that these two types of IDC could have different biological features.     

Malignant islet cell tumor projecting into the main pancreatic duct

We report herein a rare case of islet cell tumor showing a unique growth pattern in a patient who developed repeated acute pancreatitis as the tumor's initial symptom. Preoperative imaging examinations showed dilatation of the main pancreatic duct (MPD) and cysts around the pancreatic tail. A distal pancreatectomy with splenectomy was performed because the pancreatitis was localized in the distal pancreas and was not controlled by various drug therapies. Grossly, the tumor consisted of two component parts: a markedly infiltrative part in the pancreatic parenchyma, and a papillary elevated part in the MPD. The MPD was obstructed by the tumor spreading widely along the distal MPD. Microscopically, the tumor was composed entirely of islet cell tumors (nonfunctioning), with several foci of venous and lymphatic involvement. Based on its growth behavior, we assumed that the tumor may have arisen from the MPD or from islet cells closely adjacent to the MPD. The patient's postoperative course was uneventful and he is doing well 2 years after the operation. We discuss the growth pattern of the tumor and the cause of the pancreatitis. Received: March 30, 2000 / Accepted: July 12, 2000