Anatomical Preservation of Pancreatic Ducts in Partial Pancreatectomy: A Case Report of Canine Insulinoma.

Endoscopic minor papilla interventions in patients without pancreas divisum

Management of Chronic Pancreatitis

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.

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).

7241 Endoscopic therapy in chronic pancreatitis through the minor papilla in non-divisum patients.

Chronic pancreatitis: long-term surgical results of pancreatic duct drainage, pancreatic resection, and near-total pancreatectomy and islet autotransplantation.

Objective To explore the clinical application value of central pancreatectomy in the treatment of benign and low-grade pancreatic malignant neoplasms. Methods Clinical data of 23 patients (9 males, 14 females, age range: 16-59 years old, median age: 46 years old), who underwent central pancreatectomy and were diagnosed as benign or low-grade malignant neoplasms by postoperative pathological examinations in Department of General Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University from January 2006 to December 2011 were retrospectively analyzed. Five cases were insulinomas, 4 cases were solid pseudopapillary tumors, 4 cases were mucinous cystadenomas, 3 cases were serous cystadenomas, 3 cases were intraductal papillary mucinous tumors, 2 cases were pancreatic cysts, 1 case was nonfunctioning endocrine tumor and 1 case was hemangioma. The informed consents of all patients were obtained and the ethical committee approval was received. All patients received central pancreatectomy under tracheal intubation general anesthesia. The pancreas was transected about 1 cm away from both sides of neoplasm. The proximal end of pancreas was closed by U shape-suture or mattress-suture, and the main pancreatic duct was ligatured separately. The distal end of pancreas was anastomosed with stomach or jejunum. The volume of intraoperative blood loss, blood transfusion, operation length, postoperative blood glucose level and pancreatic fistula were observed. The patients were followed up after operation about tumor recurrence, quality of life and blood glucose level. Results The median volume of intraoperative blood loss was 159 ml(50-400 ml). One case received blood transfusion during operation. The median operation length was 225 min(149-386 min). No severe complication was observed in all patients. Elevated blood glucose level was found in 1 case after operation and remitted after symptomatic treatment. Pancreatic fistula was found in 11 cases(48%) with 10 cases of grade A pancreatic fistula and 1 case of grade B pancreatic fistula. The patients with grade A pancreatic fistula were self-cured without any treatment. The patient with grade B pancreatic fistula was cured by peritoneal lavage and anti-infective treatment. The postoperative follow-up length was 6 months to 5 years with the median of 23 months. One case was lost to follow-up, the other 22 cases survived without tumor recurrence. One case suffered from elevated blood glucose level 6 months after operation. The patient received oral hypoglycemic agents for 1 year and then stopped, the blood glucose level was kept normal. Three cases failed to regain body weight within half a year after operation, but no symptoms of dyspepsia were observed and no exogenous pancreaticenzyme replacement was used. Conclusion Central pancreatectomy is a safe and reasonable procedure for patients with benign or low-grade pancreatic malignant neoplasms. Key words: Pancreatectomy; Pancreatic neoplasms; Pancreatic fistula; Hyperglycemia; Neoplasm recurrence, local

Relationship Between the Radiological Anatomy and Patency of the Accessory Pancreatic Duct: Dye-Injection ERP Study

It is extremely rare to encounter tumors arising exclusively in the minor duodenal papilla. We report a 60-year-old male patient with a polypoid type of adenocarcinoma of the minor papilla. Preoperative examinations, including computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP), suggested pancreas divisum and showed a series of stones in the dorsal pancreatic duct. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy (SSpPD). On histology, an adenocarcinoma was located in the minor papilla, which was limited to the mucosa, without invasion of the duodenum, sphincter muscles of the minor papilla, or the underlying pancreas. The carcinoma cells, together with dysplastic and hyperplastic epithelium of the pancreatic duct, extended peripherally within the pancreatic duct. No cystic dilatation of the pancreatic duct was observed. The ventral pancreatic duct was short and narrow; there was evidence of chronic pancreatitis in the dorsal pancreas, whereas the ventral pancreas was almost normal, suggesting the existence of pancreas divisum. Although it is well known that adenocarcinoma of the duodenal papilla is sometimes accompanied by intraepithelial spread in the pancreatic duct, an adenocarcinoma arising in the minor papilla in this case with pancreas divisum was more extended than our thoughts.

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%-50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re-sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus-preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function.

Objective To analyze the curative effect and prognosis of pancreatic ductal stone treated by pancreatectomy, pancreatic duct drainage or combined procedures. Methods The clinical data of 296 pancreatic ductal stone patients who received surgical treatment in First Affiliated Hospital of the Army Medical University between January 2008 and June 2017 were retrospectively analyzed. The cases were divided into pancreatectomy group (162 cases), pancreatic duct drainage group (104 cases) and combined procedures group (30 cases) according to their surgical procedures. The clinical characteristics and short-term and long-term outcomes of surgical treatment between the three groups were analyzed. Kaplan-Meier method was used to estimate the survival rate of no recurrence of pain after operation. Log-rank test and Cox-proportional hazard model were used to analyze the influencing factors on the recurrent pain free survival after surgery. Results The ratio of male patients was highest in pancreatectomy group, and the incidence of pancreatic exocrine insufficiency was highest in pancreatic duct drainage group. Of 296 patients, Ⅰ type pancreatic stone was most in pancreatectomy group and combined procedures group (80.2%, 70.0%), and Ⅲ type pancreatic stone was most in pancreatic duct drainage group(46.2%). Medium size pancreatic stone was most in pancreatectomy group (52.5%), and medium and large size pancreatic stone was most in pancreatic duct drainage group (80.8%). Obvious pancreatic atrophy was most in pancreatic duct drainage group.Pancreatic head swelling, bile ductal dilation or compression, combined with pancreatic or surrounding organ complications were most in pancreatectomy, and all the differences were statistically significant (all P<0.05). In the short-term effect, the overall rate of pain relief was 99.3%, and there was no statistical difference among three groups. Pancreatic duct drainage group was superior to the other two groups in terms of operative time, bleeding volume, postoperative hospitalization days and postoperative complications (all P<0.05), but the total incidence of residual stones after operation in drainage group (64.8%) was higher than that in the other two groups, and the difference was statistically significant (all P<0.05). In the long-term effect, there were no significant differences in pain recurrence, stone recurrence reoperation, postoperative pancreatic function, body weight and quality of life recovery among the three groups. The 1-year, 3-year and 5-year no recurrent pain after operation was 89.0%, 79.2% and 68.9%, respectively. Univariate and multivariate analysis showed that the course of CP ≥5 years(HR=2.113, 95% CI 1.160-3.848, P=0.014) and postoperative long-term alcohol consumption (HR=1.971, 95% CI 1.073-3.620, P=0.029) were independent risk factors affecting pain recurrence after surgery. Conclusions Surgery is still an important means for the treatment of pancreatic ductal stone. The short-term and long-term effect of pancreatectomy, pancreatic duct drainage and combined procedures for pancreatic ductal stones are definitely effective. However, none of the three methods can prevent the continued loss of pancreatic function in some patients. According to the preoperative clinical features, surgery strategy should be formulated individually, and the postoperative health guidance and follow-up should be emphasized, which can help to improve the prognosis of the patients with pancreatic ductal stones. Key words: Pancreatitis, chronic; Calculi; Surgical procedures, operative; Treatment outcome; Prognosis

Can histopathology be the “Gold Standard” for diagnosing autoimmune pancreatitis?

This study aimed to assess the prevalence of tumor recurrence/persistence and determine the appropriate frequency and interval of follow-up neck ultrasonography (US) in papillary thyroid microcarcinoma (PTMC) patients who underwent hemithyroidectomy and long-term follow-up US. From January 2005 to December 2006, 179 patients underwent a hemithyroidectomy for the treatment of PTMC and at least 1 postoperative US surveillances. The postoperative follow-up US was performed by 2 radiologists for all patients. Based on the US and histopathologic results, tumor recurrence/persistence was determined. Of the 179 patients, the following results were determined after hemithyroidectomy: all patients exhibited T1 stage, while nodal metastasis to the ipsilateral level VI node (n = 27) and ipsilateral multifocality (n = 16) were found. Tumor recurrence was found in 5 (2.8%) of 179 and tumor persistence in 2 (1.1%) of 179. In the tumor recurrence cases, all patients underwent US-guided fine-needle aspiration for the newly detected thyroid nodule because of suspicious features on postoperative follow-up US (8-, 24-, 36-, 87-, and 96-month intervals). Differences were observed in the number of follow-up US sessions (mean, 5.2; range, 1-13) and in the interval period to the last follow-up (mean, 80.7 months; range, 8-138 months). Among the patients, 82 (45.8%) had a more than 120-month interval to the last follow-up US after hemithyroidectomy. In conclusion, the PTMC tumor recurrence rate was low, indicating that only 1 or 2 sessions of postoperative US follow-up may be sufficient to detect tumor recurrence within the first 10 years after hemithyroidectomy in PTMC patients.

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice in establishing the nature and the site of common bile and pancreatic duct disease and related complications. It was used in 668 Jordanian patients who presented with biliary or pancreatic disease and unexplained upper abdominal pain. Common bile duct (CBD) stones, postsurgical traumatic CBD strictures, papillary stenosis and malignant strictures were the most common findings in this study. The incidence of malignant strictures was less and the postsurgical CBD injuries, mainly CBD complete ligation, were more than what was reported by others. This procedure was also valuable in the investigation of unexplained upper abdominal pain and pancreatic disease.

Distal pancreatectomy: another indication for prophylactic pancreatic stenting?