Dilatation Of Main Pancreatic Duct Research Articles

粘液の胆管内逆流により黄疸を来した膵管内乳頭粘液性腫瘍の1例

An 80-year-old-man was admitted because of acute cholecystitis, and PTGBD was performed. However, 6 days later, he presented with abdominal pain and jaundice. CT revealed a 30 mm-sized polycystic lesion at the pancreas head and the main pancreatic duct (MPD) dilated up to 8 mm in diameter. Duodenoscopy showed mucus discharge from the enlarged papilla of Vater. ERCP showed mucus in the dilated MPD regurgitated into the common bile duct (CBD) through the common channel. On EUS, there seemed to be a fistula between the CBD and the pancreatic cysts. Pancreaticoduodenectomy was performed. The resected specimen was histologically diagnosed as IPMN with high-grade dysplasia, and revealed no evidence of fistulization to the CBD. Thus, we concluded that mucus regurgitation into the CBD was likely to have caused jaundice in this case.

A Rare Pancreatic Tumor That Underwent a Change in Morphology and Histopathologic Features During Chemotherapy

Question: A 63-year-old man visited our hospital because of epigastric discomfort. He had no family history of pancreatic cancer, and abdominal examination was unremarkable. Serum levels of elastase 1 (1199 ng/dL; normal 100–400) and DUPAN2 (190 U/mL; normal <150) were elevated; however, serum levels of carcinoembryonic antigen, carbohydrate antigen 19-9, pancreatic polypeptide, gastrin, insulin, and vasoactive intestinal peptide were normal. Abdominal computed tomography (CT) showed a well-marginated round mass, 6 cm in diameter, in the pancreatic head, as well as a dilated caudal main pancreatic duct. Contrast-enhanced CT showed heterogeneous enhancement that was weak at the periphery of the tumor and almost absent in the center (Figure A). Diagnostic endoscopic ultrasound-guided fine-needle aspiration (FNA) showed trabecular growth patterns with acinar formations within a solid tumor. The tumor cells contained cytoplasmic periodic acid Schiff-positive zymogen granules and relatively large, eccentrically located nuclei. Immunohistochemistry showed strong expression of trypsin and chymotrypsin but no expression of chromogranin A or synaptophysin, suggesting acinar cell carcinoma. Because direct tumor invasion into the proper hepatic artery was suspected, we administered chemotherapy consisting of gemcitabine and S-1. After 4 courses, we observed a remarkable change in tumor morphology, including a clear demarcation of hypervascular and hypovascular areas (Figure B, white arrow). The tumor size was essentially unchanged. The disease was considered stable and stomach-preserving pancreaticoduodenectomy was performed. Macroscopically, a surgical specimen of the tumor had a mosaic-like pattern with partial necrosis (Figure C). Microscopically, the tumor had 2 distinct components (Figure D). The hypovascular area encompassed most of the tumor and comprised of acinar epithelial cells with prominent nucleoli and pale eosinophilic cytoplasm resembling the specimen obtained by FNA (Figure E). This area was positive for trypsin and chymotrypsin, but negative for chromogranin A and synaptophysin. The Ki-67 labeling index was approximately 20%. The hypervascular

Risk of misdiagnosis and overtreatment in patients with main pancreatic duct dilatation and suspected combined/main-duct intraductal papillary mucinous neoplasms

Segmental/diffuse dilatation of the main pancreatic duct (MPD) is the typical feature of combined/main-duct intraductal papillary mucinous neoplasms (CMD-IPMNs). MPD dilation in IPMNs may be also expression of mucus hypersecretion/obstructive chronic pancreatitis (OCP). The aim of this study was to evaluate the presence and extension of MPD involvement by tumor/OCP and assess the risk of overtreatment. Retrospective analysis of suspected CMD-IPMNs resected between January 2009 and October 2014 were included. Pathologic correlations among MPD dilatation, IPMN, and OCP was searched. Overall, 93 patients were resected for suspected CMD-IPMNs. At pathology, CMD-IPMNs were found in 69 patients (74%). Branch-duct IPMNs (BD-IPMNs) were found in 8 cases (9%), pancreatic ductal adenocarcinoma (PDAC) in absence of IPMN in 9 (10%), cystic neuroendocrine tumor (NET G2) in 1 (1%), serous cystadenoma in 2 (2%), and OCP alone/mucinous metaplasia in 4 patients (4%). Overall, 18 patients (19%) underwent an overtreatment because unnecessary (2 BD-IPMNs, 2 serous cystadenomas, and 4 OCPs only) or too extensive resections (9 CMD-IPMNs and 1 PDAC with associated OCP). In these, total pancreatectomy was the most common procedure (67%). Median size of MPD in IPMN-involved area was 12 mm compared with 7 mm when only OCP was found (P < .05). There is a considerable risk of overtreatment in patients with a preoperative morphologic diagnosis of CMD-IPMNs. Partial pancreatectomy with margin examination should be performed instead of upfront total pancreatectomy. Radiologic observation can be considered in asymptomatic patients with "worrisome" MPD dilatation (5-9 mm) and lacking other high-risk stigmata.

What Is the Best Way to Identify Malignant Transformation Within Pancreatic IPMN: A Systematic Review and Meta-Analyses.

Objectives:Pancreatic intraductal papillary mucinous neoplasias (IPMNs) represent 25% of all cystic neoplasms and are precursor lesions for pancreatic ductal adenocarcinoma. This study aims to identify the best imaging modality for detecting malignant transformation in IPMN, the sensitivity and specificity of risk features on imaging, and the usefulness of tumor markers in serum and cyst fluid to predict malignancy in IPMN.Methods:Databases were searched from November 2006 to March 2014. Pooled sensitivity and specificity of diagnostic techniques/imaging features of suspected malignancy in IPMN using a hierarchical summary receiver operator characteristic (HSROC) approach were performed.Results:A total of 467 eligible studies were identified, of which 51 studies met the inclusion criteria and 37 of these were incorporated into meta-analyses. The pooled sensitivity and specificity for risk features predictive of malignancy on computed tomography/magnetic resonance imaging were 0.809 and 0.762 respectively, and on positron emission tomography were 0.968 and 0.911. Mural nodule, cyst size, and main pancreatic duct dilation found on imaging had pooled sensitivity for prediction of malignancy of 0.690, 0.682, and 0.614, respectively, and specificity of 0.798, 0.574, and 0.687. Raised serum carbohydrate antigen 19-9 (CA19-9) levels yielded sensitivity of 0.380 and specificity of 0903. Combining parameters yielded a sensitivity of 0.743 and specificity of 0.906.Conclusions:PET holds the most promise in identifying malignant transformation within an IPMN. Combining parameters increases sensitivity and specificity; the presence of mural nodule on imaging was the most sensitive whereas raised serum CA19-9 (>37 KU/l) was the most specific feature predictive of malignancy in IPMNs.

Integrated analysis of autoimmune pancreatitis by CT, MRCP and DWI

PurposeCT, MRCP and diffusion weighted imaging characteristics were discussed to improve the diagnostic accuracy of autoimmune pancreatitis. Materials and methods23 cases of confirmed autoimmune pancreatitis were retrospectively analyzed before treatments. 23 cases underwent CT unenhanced and enhanced scans, 21 cases underwent MRCP examination, and 11 cases underwent DWI examination. Pancreatic lesion, involvement of the pancreatic duct and bile duct, changes of adjacent artery and vein, and other organs lesions. CT values and ADC values of pancreas and lesion were measured. ResultsFocal type lesions were shown in 6 cases, diffuse type in14 cases, and both types in 3 cases. Diffuse pancreatic swelling was shown in 20 cases, and peripancreatic halo in 13 cases. Mean CT values of lesions: unenhanced scan 35.81 ± 6.23 HU, late arterial phase 75.80 ± 17.47 HU, venous phase 93.19 ± 14.06 HU, and equilibrium phase 90.00 ± 14.67HU. Delayed homogenous enhancement was shown in 17 cases. Tapered narrowing (12 cases) or multiple segmental pancreatic duct stenosis (8 cases) was detected, the absence of main pancreatic duct dilatation or less than 3.5 mm in 20 cases, and duct penetrating sign in 20 cases. Bile duct lesions were found in 20 cases. ADC values of lesions (0.99 ± 0.03 × 103 mm2/s) were significantly lower that of pancreas (1.47 ± 0.16 × 103 mm2/s). ConclusionCT and MRI integrated diagnosis was helpful for accurate diagnosis based on the distinctive imaging characteristics of autoimmune pancreatitis.

Chronic pancreatitis sparing the annular pancreas

Figure Legend: This magnetic resonance cholangiopancreatogram (MRCP) belongs to a 55-year old woman who presented with recurrent episodes of epigastric pain radiating to the back. She had a previous history of cholecystectomy. On the MRCP, an annular pancreas was identified. The pancreatic parenchyma in the body and tail was atrophic. There was dilatation of the main pancreatic duct and the side branches giving it a ‘chain of lakes’ appearance (arrowheads) in the body. The pancreatic duct in the region of the tail showed irregular dilatation. Multiple calculi were seen in the duct. The duct and parenchyma at the annulus (arrow), however, appeared unaffected by the disease process, which was confirmed by inspection and palpation at the time of surgery. A lateral pancreaticojejunostomy was performed, following which the patient has been asymptomatic for one year. Histopathological examination of themultiple biopsies taken from the diseased pancreatic duct showed features of chronic pancreatitis. Although annular pancreas generally presents in childhood with duodenal obstruction, it may manifest later in life with abdominal pain, vomiting, obstructive jaundice and pancreatitis (acute or chronic). Chronic pancreatitis in a patient with annular pancreas affects the annulus and spares the body and tail of the pancreas. This is usually attributed to an obstruction to flow in the annular duct. In this case, however, the annulus was entirely free of any disease. Despite a thorough literature search for a similar pattern of chronic pancreatitis in an adult with annular pancreas, no published report could be found.

Clinical and radiologic characteristics of pancreatic head carcinoma without main pancreatic duct dilatation: using dual-phase contrast-enhanced CT scan

PurposeThe purpose was to evaluate characteristics of pancreatic cancer without main pancreatic duct (MPD) dilatation on dual-phase computed tomographic (CT) scans. Materials and methodsWe studied 16 patients with pancreatic head cancer without accompanying MPD dilatation and 39 patients with MPD dilatation ResultsElevation of serum amylase level and peripancreatic fluid collection were more frequently seen in the MPD(−). Common bile duct dilatation and atrophy of the upstream pancreatic parenchyma were more frequently seen in MPD(+). ConclusionPancreatic cancers without MPD dilatation were more frequently related to acute pancreatitis and had fewer secondary signs. Thus, early diagnosis of pancreatic cancer with these characteristics could be difficult.

Assessment value of secretin-enhanced magnetic resonance cholangiopancreatography in the pancreatic duct of 88 patients with chronic pancreatitis

Objective To investigate effect of secretin-enhanced magnetic resonance cholangiopancreatography (S-MRCP) on visualization improvement of main and branch pancreatic duct and its diagnostic value of grading chronic pancreatitis (CP). Methods The 3.0 T magnetic resonance (MR) imaging data of 88 subjects (23 health volunteers and 65 CP patients) were prospectively analyzed. All the subjects received coronal T2-weighted sequences scan, thick slab 2-dimensional MRCP sequences scan, routine pancreas plain scan and enhanced scan before and after 0.1 mL/kg secretin intravenous injection. Sixty-five CP patients were grouped according to Cambridge classification and also according to normal and abnormal of duodenal filling (DF). The images of main pancreatic duct (MPD), branch pancreatic duct (BPD) and DF were compared before and after secretin injection. The result was compared with that of endoscopic retrograde cholangio pancreatography (ERCP) which was the gold standard. One-way analysis of variance test was performed for comparison between healthy control group and CP group. Chi-square test was used for comparison between normal DF group and abnormal DF group. The consistence between the diagnostic results of MRCP, S-MRCP and the results of ERCP were analyzed by Kappa test. Results Compare with MRCP, after secretin injection the indexes of MPD, the sensitivity, specificity, positive predictive value and negative predictive value of BPD were all improved, and the rates of misdiagnosis and missed diagnosis all decreased. Using ERCP as gold standard of CP grade diagnosis, the consistence of S-MRCP in CP grade diagnosis increased more significantly (Kappa=0.77, P=0.000 1) compared with that of MRCP (Kappa=0.55, P=0.000 1). Among 43 normal DF cases, the number of MPD dilatation, filling defect and branch duct in pancreatic head was 28, 23 and 30, respectively; among 22 abnormal DF cases which was 20, 19 and 21, respectively, and the differences were statistically significant (χ2=5.01, 3.91, 6.88 and 4.26, all P<0.05). Taking 4 min as the cutoff value of peak time, the sensitivity and specificity of which in CP diagnosis were 86.0% and 100.0%, respectively. Conclusion S-MRCP improves the visualization of MPD and BPD, and also increases the accuracy of CP grade diagnosis. Key words: Cholangiopancreatography, magnetic resonance; Cholangiopancreatography, endoscopic retrograde; Pancreatitis, chronic

Follicular pancreatitis: a distinct form of chronic pancreatitis—an additional mimic of pancreatic neoplasms

Follicular pancreatitis is a recently described variant of chronic pancreatitis characterized clinically by the formation of a discrete pancreatic mass and histologically by the presence of florid lymphoid aggregates with reactive germinal centers. Our aim was to study the clinical and histologic features of follicular pancreatitis, as well as to critically examine potential overlap with autoimmune pancreatitis. Immunohistochemistry for Bcl-2, CD21, κ and λ light chains as well as IgG4 and IgG were performed. We found a total of 6 patients (male-female ratio, 2:1; mean age, 57 years) who fulfilled the diagnosis of follicular pancreatitis in our institutions. Four had an incidental diagnosis, while two presented with abdominal pain, fatigue, and elevated liver enzymes. On imaging, 3 patients had a discrete solid mass, whereas 2 cases showed a dilated main pancreatic duct, mimicking an intraductal pancreatic mucinous neoplasm on imaging. One patient had a lesion in the intra-pancreatic portion of the common bile duct. On histopathology, all cases showed numerous lymphoid follicles with Bcl-2-negative germinal centers either in a periductal or in a more diffuse (periductal and intra-parenchymal) fashion, but without attendant storiform fibrosis, obliterative phlebitis, or granulocytic epithelial lesions. IgG4-to-IgG ratio was <40% in 5 cases. A comparison cohort revealed germinal centers in 25% of type 1 autoimmune pancreatitis and 2% of type 2 autoimmune pancreatitis cases, but none were periductal in location. In conclusion, follicular pancreatitis, an under-recognized mimic of pancreatic neoplasms is characterized by intrapancreatic lymphoid follicles with reactive germinal centers.

Cystic Lesions of the Pancreas: Observe or Operate.

Cystic Lesions of the Pancreas: Observe or Operate.

Hemodynamic Instability Secondary to Inferior Vena Cava Compression: A Rare Complication of Massive Walled-off Pancreatic Necrosis

Severe acute pancreatitis has significant morbidity and mortality and is often complicated by pancreatic necrosis. Walled-off pancreatic necrosis (WOPN) may form as a sequelae of acute pancreatitis over the following weeks. Most uncomplicated acute pancreatic fluid collections are managed conservatively unless symptomatic or infected. We present a rare complication of WOPN causing IVC compression leading to shock requiring emergent intervention.Figure 1A 56 year old male with a history of alcoholism presented with right lower quadrant abdominal pain and a significant elevation of amylase and lipase. Initial CT scan showed moderate necrosis at the head of the pancreas with a moderate fluid collection in the right half of the abdominal cavity. MRCP showed a dilated main pancreatic duct proximally with distal tapering towards the tail of the pancreas and stone in the main pancreatic duct. Despite a week of conservative treatment with fluids, bowel rest and pain control, the patient continued to have worsening abdominal pain. A repeat CT scan showed an interval increase in fluid collection compared to prior exam. At this time, endoscopic intervention was deferred as pancreatic necrosis was not walled off. However, the patient developed progressively worsening abdominal distention over the following week followed by sudden onset respiratory distress and hemodynamic instability on 18th day from initial presentation. The patient was transferred to the intensive care unit and CT scan showed a massive walled-off pancreatic necrosis causing compression of inferior vena (image 1 a & b) and right hydronephrosis (image1c) with large amount of necrotic fluid in right retronephric space displacing right kidney anteriorly. An emergent CT guided percutaneous drainage was performed with significant improvement in fluid collection (image 2) and patient's vital signs and respiratory distress over next 24hours. Fluid output from percutaneous drain slowly decreased over next few days as the patient continued to recover. Compression of IVC by a large walled-off pancreatic necrosis is a rare potential cause of hemodynamic instability in a patient with severe acute pancreatitis.

Impact of Intraoperative Pancreatoscopy with Intraductal Biopsies on Surgical Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas

Because of its known malignant potential, precise histologic diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN) during intraoperative pancreatoscopy (IOP) is essential for complete surgical resection. The impact of IOP on perioperative IPMN patient management was reviewed over 20 years of practice at Cliniques universitaires Saint-Luc, Brussels, Belgium. Among 86 IPMN patients treated by pancreatectomy between 1991 and 2013, 21 patients had a dilated main pancreatic duct enabling IOP and were retrospectively reviewed. The IOP was performed using an ultrathin flexible endoscope and biopsy forceps, and specimens of all suspicious lesions underwent frozen section examination. Complete IOP with intraductal biopsies was easily and safely performed in 21 patients, revealing 8 occult IPMN lesions. In 5 cases (23.8%), initially planned surgical resection was modified secondary to IOP: 3 for carcinoma in situ and 2 for invasive carcinoma. The postoperative morbidity rate at 3 months was 25.0% (5 of 20); 1 patient died from septic shock postoperatively and was excluded. Median follow-up was 93 months (range 13 to 248 months). Nineteen of 21 patients were still alive and free of disease at last follow-up (90.5%); there was 1 patient with invasive carcinoma at initial pathology (pT3 N1) who died of pulmonary recurrence 21 months after surgery. Intraoperative pancreatoscopy of the main pancreatic duct combined with intraductal biopsies plays a significant role in the surgical management of IPMN patients and should be used in all patients presenting a sufficiently dilated main pancreatic duct.

Risk factors for postoperative recurrence of intraductal papillary mucinous neoplasms of the pancreas based on a long-term follow-up study: proposals for follow-up strategies.

The aim of this study was to examine the associations between postoperative clinicopathological features of intraductal papillary mucinous neoplasm (IPMN) and recurrence over a long follow-up period. We retrospectively assessed 153 IPMN patients who underwent resection. The resected tumors showed low/intermediate-grade dysplasia (LGD/IGD), high-grade dysplasia (HGD), T1a (stromal invasion ≤5 mm), and invasive intraductal papillary mucinous carcinoma (IPMC), in 54.9%, 22.2%, 4.6%, and 18.3% of patients, respectively. The median follow-up period after surgery was 46.4 (6.0-216.3) months, with an overall recurrence rate of 17.0%; the recurrence rates by histological type were 6.0%, 5.9%, 42.9%, and 57.1% for LGD/IGD, HGD, T1a, and invasive IPMC, respectively. Multivariate analysis revealed that recurrences related with tumor location, mural nodule size, presence of invasive cancer, lymph node metastasis, IPMN in the remnant pancreas, and main pancreatic duct dilatation after surgery. Recurrence occurred within the remnant pancreas in all LGD-T1a patients and as extrapancreatic metastasis in all patients with invasive IPMC. Of the total recurrences, 15.4% occurred over 5 years postoperatively. The postoperative follow-up protocol for patients with LGD-T1a should be similar to non-resected IPMN, and that for invasive IPMC should be the same as for pancreatic ductal adenocarcinoma patients.

Intraductal papillary mucinous neoplasm of the pancreas spontaneously ruptured into the peritoneal cavity.

A 72-year-old female was pointed out to have a dilated main pancreatic duct of the pancreatic body and tail and fluid collection around the spleen by ultrasonography performed for annual medical check. She did not have any sign of abdominal and/or back pain, and had no history of abdominal bruising. Computed tomography demonstrated the main pancreatic duct dilatation that was 12 mm in size, and the accumulation of fluid around the pancreatic tail and the spleen. The dilated main pancreatic duct was apparently continuouswith the extrapancreatic fluid (Fig. 1). Magnetic resonance cholangiopancreatography also revealed distal pancreatic duct dilatation and communicating fluid collection around the spleen (Fig. 2). Endoscopic ultrasonography revealed the distal pancreatic duct dilatation and mural nodules with 5 mm in size. Based on these findings, main duct type intraductal papillary mucinous neoplasmwith pseudomyxoma peritonei caused by spontaneous rupture into the peritoneal cavity was highly suspected. At laparotomy, yellow-tan gelatinous material was encountered around the pancreas tail and the spleen (Fig. 3). Additionally, lavage cytology at Douglas’ pouch was positive for mucus, although no cancer cells were observed in the specimen. Therefore, we considered that, microscopically, mucus spread diffusely to entire abdominal cavity. After removal of the extrapancreatic mucus, distal pancreatectomy and splenectomy were performed. Intraperitoneal lavage using 10 000 ml of dextran fluid was also performed. Macroscopically, the resected specimen revealed a 15 mm orifice and mucus outpouring at the pancreas tail (Fig. 4). Pathologically, the tumor was diagnosed as minimally invasive intraductal papillary mucinous carcinoma without lymph node metastasis. After surgery, she received adjuvant chemotherapy with S-1 and survived for 1 year without any sign of recurrence. Figure 1.

Pancreaticogastrostomy in pure laparoscopic pancreaticoduodenectomy—A novel pancreatic-gastric anastomosis technique -

BackgroundAlthough many surgical procedures are now routinely performed laparoscopically, pure laparoscopic pancreaticoduodenectomy (LPD) is not commonly performed because of the technical difficulty of pancreatic resection and the associated reconstruction procedures. Several pancreatic-enteric anastomosis techniques for LPD have been reported, but most are adaptations of open procedures. To accomplish pure LPD, we consider it necessary to establish new pancreatic-enteric anastomosis techniques that are specifically developed for LPD and are safe and feasible to perform.ResultsOne patient developed a postoperative pancreatic fistula (International Study Group of Pancreatic Fistula criteria, grade B) and subsequent postoperative delayed gastric emptying (International Study Group of Pancreatic Surgery criteria, grade C). No other major complications occurred. We developed a novel pancreatic-gastric anastomosis technique that enabled us to safely perform pure LPD. The main pancreatic duct was stented with a 4-Fr polyvinyl catheter during pancreatic resection. A small hole was created in the posterior wall of the stomach and was bluntly dilated. A 5-cm incision was made in the anterior stomach, and the pancreatic drainage tube was passed into the stomach through the hole in the posterior wall. The remnant pancreas was pulled into the stomach, and was easily positioned and secured in place with only four to six sutures between the pancreatic capsule and the gastric mucosa. We used this technique to perform pure LPD in five patients between December 2012 and July 2013.ConclusionsOur new technique is technically easy and provides secure fixation between the gastric wall and the pancreas. This technique does not require main pancreatic duct dilatation, and the risk of intra-abdominal abscess formation due to postoperative pancreatic fistula may be minimized. Although this technique requires further investigation as it may increase the risk of delayed gastric emptying, it may be a useful method of performing pancreaticogastrostomy in pure LPD.Trial registrationISRCTN16761283. Registered 16 January 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12893-015-0061-x) contains supplementary material, which is available to authorized users.

PWE-211 Evaluation of clinical and radiological features that predict malignant transformation in small cystic lesions of the pancreas

<h3>Introduction</h3> Cystic lesions of the pancreas (CLP) are being detected with increasing frequency. Current methods of stratifying risk of malignant transformation are imperfect. The aim of this study was therefore to determine the incidence of high-risk lesions and define clinical and radiological features that predict malignancy in a large cohort of patients with CLP managed by surgery or surveillance. <h3>Method</h3> A retrospective cohort study from January 2000 to December 2013 of patients over 18 years of age with a confirmed CLP evaluated in a tertiary referral hepatobiliary centre. <h3>Results</h3> Of the 1,090 patients diagnosed with a CLP during the study period, 768 patients were included in the study. A total of 141 patients were referred for immediate pancreatic resection, 570 entered surveillance while 57 had a malignant CLP which was unresectable at diagnosis (N=47) or were unfit for surgery (N=10). In those who underwent immediate resection, malignancy was present in 38% (54/141). During follow-up 2% (10/570) of those entering a surveillance programme underwent malignant transformation, although most instances were after discharge from active surveillance. Only two patients in the surveillance cohort underwent surgery, of which only one case was curative. Clinical and radiological features associated with a high-risk CLP included older age, associated symptoms, presence of a solid component or a dilated main pancreatic duct. Larger size did not correlate consistently with malignant transformation, particularly in IPMNs where the median size of benign lesions was larger than malignant IPMNs (30mm (range: 11–130) vs. 23mm (range: 15–56)). <h3>Conclusion</h3> The sensitivity of diagnostic tests leading to immediate surgery for high risk CLP (malignant or mucinous CLP) was 92%, with a specificity of just 5%. Surveillance of CLP without high-risk features was associated with a low incidence of cancer development. This study supports the stratification of CLP based on worrisome clinical and radiological features. <h3>Disclosure of interest</h3> None Declared.

Papillary-like main pancreatic duct invaginated pancreaticojejunostomy versus duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized trial

Development of a postoperative pancreatic fistula (POPF) is the single most significant complication of pancreatic anastomosis, which is a key procedure in pancreaticoduodenectomy. We previously reported a new papillary-like pancreaticojejunostomy, and a retrospective study showed a benefit in reducing the incidence of grade B/C POPF compared with duct-to-mucosa pancreaticojejunostomy. The aim of this study was to reassess whether the new pancreaticojejunostomy would decrease the POPF rate. A prospective, randomized, controlled trial (NCT01731821 registered at http://ClinicalTrials.gov) involving 308 patients who underwent pancreaticoduodenectomy was conducted. The overall POPF rate was significantly lower in the papillary-like group compared with the duct-to-mucosa group (14/155 [9.0%] vs 31/153 [20.3%]; P = .005), and the grade B/C POPF rate of the papillary-like group was significantly decreased compared with the duct-to-mucosa group. Multivariable analyses identified higher body mass index (odds ratio [OR], 3.520; P = .000), longer operative time (OR, 2.587; P = .041), soft texture and nondilated main pancreatic duct (OR, 0.365; P = .014), and the duct-to-mucosa pancreaticojejunostomy (OR, 0.405; P = .013) as significant risk factors for POPF. Further stratified analyses showed that, for patients with soft texture and nondilated main pancreatic duct, the POPF rate in the papillary-like group (9.6%) was significantly lower than that in the duct-to-mucosa group (27.3%). However, for patients with hard texture or dilated main pancreatic duct, there was no difference between the 2 groups (7.8% vs 8.6%; P > 0.999). The new papillary-like pancreaticojejunostomy may provide a better option for patients with soft texture and nondilated main pancreatic duct.

Cystic form of paraduodenal pancreatitis (cystic dystrophy in heterotopic pancreas (CDHP)): a potential link with minor papilla abnormalities? A study in a large series.

To analyze the association between cystic dystrophy in the heterotopic pancreas (CDHP) and minor papilla abnormalities. Seventy-six patients with CDHP were retrospectively included over 14 years. Two radiologists searched for MDCT signs of CDHP (cysts and thickened intestinal wall, inflammatory changes), and minor papilla abnormalities (Santorini duct dilatation, luminal calcifications of the minor papilla). Other pancreatic abnormalities (parenchymal calcifications, main pancreatic duct dilatation) or bile duct dilatation were also analysed. CDHP was mostly located in the second part of the duodenum (71/76, 93.5 %). Median duodenal wall thickness was 20 mm (range 10-46). There were multiple cysts in 86 % (65/76, median = 3), measuring 2-60 mm. No cysts were identified in four patients (5 %). Inflammatory changes were found in 87 % (66/76). Minor papilla abnormalities were found in 37 % (28/76) and calcifications in the minor papilla without calcifications in the major papilla were only observed in three patients (4 %). Abnormalities of the pancreas and main bile duct dilatation were identified in 78 % (59/76) and 38 % (29/76). Previously described CT features were seen in most patients with CDHP. However, minor papilla abnormalities were seen in a minority of patients and, therefore, do not seem to be a predisposing factor for CDHP. Imaging features suggesting a CDHP diagnosis are confirmed in a large series. Minor papilla abnormalities do not seem to be a predisposing factor for CDHP. Most patients did not have any isolated minor papilla abnormalities.

Missed pancreatic ductal adenocarcinoma: Assessment of early imaging findings on prediagnostic magnetic resonance imaging

ObjectiveTo investigate the early imaging findings and growth rate of pancreatic ductal adenocarcinoma (PDAC), and to assess whether MR imaging detects early PDAC better than CT. Materials and methodsThe institutional review board approved this retrospective study and waived the requirement for informed consent. Twenty-two patients were included, and two radiologists, by consensus, assessed the presence of focal lesions, interruption of the main pancreatic duct (MPD), MPD dilatation, and pancreatitis, volume doubling time (VDT) of PDAC on prediagnostic MR imaging. Two other observers independently reviewed three image sets (CT images, unenhanced MR images, and unenhanced and contrast-enhanced MR images) for the detection of early PDAC. Paired Wilcoxon signed rank test and receiver operating characteristic (ROC) curve analysis were used for statistical analyses. ResultsIn 20 (90.9%) patients, prediagnostic MR exams showed abnormality, and all of them showed focal lesions on the first abnormal prediagnostic MR exams. Thirteen lesions (65%) showed no MPD interruption and one lesion (5%) was accompanied by pancreatitis. The mean VDT of PDAC was 151.7 days (range, 18.3–417.8 days). Diagnostic performance of unenhanced MR images (Az, 0.971–0.989) and combined unenhanced and contrast-enhanced MR images (Az, 0.956–0.963) was significantly better than that of CT images (Az, 0.565–0.583; p<0.01) for both observers, ConclusionThe most common early imaging finding of PDAC on prediagnostic MR exams was a focal lesion with no MPD interruption with a mean volume doubling time of five months. MR imaging was superior to CT for the detection of early PDAC.

1037 Serum Human Telomerase Reverse Transcriptase Messenger RNA As a Novel Marker for Pancreatic Ductal Adenocarcinoma

1037 Serum Human Telomerase Reverse Transcriptase Messenger RNA As a Novel Marker for Pancreatic Ductal Adenocarcinoma