Endoscopic Retrograde Pancreatography Research Articles

Blunt pancreatic trauma and pseudocyst: Management of major pancreatic duct injury

When there is no major pancreatic duct injury or the injury involves only the distal duct, percutaneous drainage should be considered the primary therapeutic procedure for traumatic pancreatic pseudocyst. If the pseudocyst does not then resolve, endoscopic retrograde pancreatography should be performed to prove proximal duct injury. When the major pancreatic duct is disrupted but not obstructed, pancreatic duct stenting may avert surgical resection. If the major duct is obstructed, surgical resection is required.

Pancreatic Panniculitis After Endoscopic Retrograde Pancreatography With Sphincterotomy

Fernández-Jorge, Beatriz1; García-Silva, Jésus M.D.1; Almagro, Manuel M.D.1; Ruzo, Jose Souto M.D.2; Rey, Enrique Carro M.D.3; Fonseca, Eduardo M.D.1 Author Information

Balloon-catheter endoscopic retrograde pancreatography-compression study for diagnosis of early-stage pancreatitis

Endoscopic retrograde pancreatography (ERP) is considered by many as the gold standard imaging method in the diagnosis of chronic pancreatitis (CP). However, conventional ERP usually has a limited ability to accurately diagnose early-stage CP, in which only the branch ducts are involved and the main pancreatic duct (MPD) is unaffected. To visualize precisely the branch ducts, we have developed a more sophisticated ERP method, called balloon ERP-compression study (balloon ERP-CS). In this procedure, a catheter equipped with a balloon at its tip is placed first into the MPD via the papilla with the aid of conventional ERP, followed by the removal of the endoscope, leaving the catheter behind. Then, the balloon is inflated, and the contrast medium is injected slowly. The balloon serves to block the back flow of the injected contrast medium from the MPD to the duodenum, enabling visualization of the branch ducts. The compression study affords further precise pancreatography of the corresponding area. Thus, balloon ERP-CS has now become an essential procedure for diagnosis of pancreatic lesions, including CP. So far (April 1984 to April 2005), we have performed the procedure in 1012 cases, for a total of 1562 examinations. In this study, we focus on the role of balloon ERP-CS in diagnosis of early-stage CP to elucidate its characteristic features in association with histological findings. This presentation will clarify the usefulness as well as the limitations of balloon ERP-CS for the diagnosis of CP, especially cases without the involvement of the MPD.

Possibility of diagnosing early-stage chronic pancreatitis by endoscopic retrograde pancreatography

It has been proposed that pathological lesions in chronic pancreatitis initially arise in the acini or fine ducts of the pancreas. To investigate the possibility of diagnosing early-stage chronic pancreatitis by endoscopic retrograde pancreatography (ERP), we reviewed pancreatographic findings of the pancreatic duct branches in patients with chronic pancreatitis. A total of 90 cases of chronic pancreatitis (calcified, n=52; noncalcified, n=38) were reassessed according to the imaging of the pancreatic duct branches by ERP. Degree of irregular dilatation of the pancreatic duct branches was classified into three grades: severe, moderate, and mild. We also reviewed pancreatographic findings of 57 patients with chronic pancreatitis who had undergone ERP on more than two occasions at intervals of at least 1 year. Severe irregular dilatation of the pancreatic duct branches was detected more frequently in cases of calcified chronic pancreatitis than in those of noncalcified chronic pancreatitis (P<0.01). Histology of the pancreas showing exclusively dilatation of the pancreatic duct branches without dilatation of the main pancreatic duct showed interlobular fibrosis without marked destruction of the acini. In serial pancreatography, segmental abnormalities of the pancreatic duct at the body or tail of the pancreas spread to the head of the pancreas in eight cases. Irregular dilatation of the pancreatic duct branches or segmental ductal changes in the pancreatic body or tail might indicate early-stage chronic pancreatitis.

Usefulness of endoscopic ultrasound to diagnose the severity of chronic pancreatitis

Endoscopic ultrasonography (EUS) is considered the most sensitive imaging method for the diagnosis of chronic pancreatitis (CP). Several investigators have shown that EUS findings of CP correlate with the presence of CP on endoscopic retrograde pancreatography (ERP). In general, for diagnosing CP using EUS, the presence or absence of the following EUS criteria is determined: hyperechoic foci, hyperechoic strands, lobularity, shadowing calcifications, cysts, hyperechoic duct margins, visible side branches, main pancreatic duct dilatation, and main pancreatic duct irregularity. Using these criteria, we reviewed the number of EUS criteria required to diagnose early CP and whether each EUS criterion correlates with the severity of CP on ERP. CP is likely when more than three criteria (for "early CP") or more than five criteria (for "moderate CP") are present. Moreover, each EUS criterion has its own importance at each ERP classification level. However, the obtained images can be operator dependent, and interobserver variability may affect interpretation of CP by EUS. Therefore, we performed a quantitative computer analysis of parenchymal echogenicity and compared it with the EUS diagnosis of CP so that the diagnosis of CP on the basis of EUS criteria could be objectively supported by the quantitative analysis of EUS images. In conclusion, EUS can objectively distinguish between a normal pancreas and CP, and can be used to evaluate the severity of the CP. EUS is a useful modality for diagnosing CP and is relatively less invasive than other available modalities.

Fistule pancréatique post-traumatique : succès du traitement endoscopique par endoprothèse

The risk of complications and the severity of pancreatic trauma depend on the status of the main pancreatic duct. Endoscopic retrograde pancreatography (ERCP) has emerged as the technique of reference for assessing pancreatic ductal anatomy, and it also permits therapeutic intervention by the endoscopic placement of an endoprosthesis. We report a pancreatic fistula attributable to posttraumatic rupture of the main duct, undiagnosed before ERCP and successfully treated by endoscopic stent placement. ERCP has emerged as a tool for both diagnosis and treatment. Major traumatic pancreatic duct disruptions can be diagnosed more easily and managed successfully by endoscopic stent placement, thereby avoiding surgical morbidity. ERCP is impractical in emergency settings for many reasons. Magnetic resonance pancreatography may be useful for establishing the type and extent of pancreatic lesions and for selecting patients for endoscopic treatment.

EFFECTIVENESS OF CYTODIAGNOSIS WITH PANCREATIC DUCT LAVAGE FLUID FOR PANCREATIC DUCTAL CARCINOMA: NEW SAMPLING TECHNIQUE

Background: Pancreatic carcinoma is one of the most lethal cancers. Because pancreatic carcinoma is still very difficult to diagnose in its early stage, many of these patients will be considered unsuitable for surgery. If a cytological diagnosis is obtained at initial endoscopic retrograde cholangiopancreatography (ERCP), suitable treatment will be initiated without delay.Methods: To increase the number of exfoliated cells from the pancreatic duct, we devised a new technique, pancreatic duct lavage fluid (PDLF), following bronchoalveolar lavage fluid. The present paper reports the effectiveness of cytological examination using PDLF in the diagnosis of pancreatic carcinoma. We examined 18 pancreatic carcinoma cases. After the endoscopic retrograde pancreatography (ERP), PDLF was collected from a double‐lumen catheter inserted into the main pancreatic duct. Saline injected from the lumen for the injection, and PDLF was aspirated from the other lumen for the guidewire at the same time. The cytological examination was performed using PDLF.Results: Exfoliated cells were more frequently found in PDLF from all patients. In 15 cases (83%), cytological examination of PDLF revealed positive cytological results as the diagnosis of pancreatic carcinoma.Conclusion: Cytological examination using PDLF has a high sensitivity for detection of pancreatic carcinoma. The new examination, PDLF, is simple, safe and effective, so we expect PDLF to become widely popular.

Comparison of Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Pancreatography (ERP) for the Prediction of Pancreatic Exocrine Insufficiency (PEI)

Comparison of Endoscopic Ultrasound (EUS) and Endoscopic Retrograde Pancreatography (ERP) for the Prediction of Pancreatic Exocrine Insufficiency (PEI)

Double-Balloon Enteroscopy To Complete Gastroscopy through a Redundant Ileo-Colonic Interposition

Double-balloon enteroscopy (DBE) provides access to regions of small intestine that can't be reached by standard techniques. DBE can also reach other areas that are inaccessible to standard endoscopy. DBE has been used to complete colonoscopy in difficult cases, for endoscopic retrograde pancreatography though Roux-en-Y anastomoses, to reach excluded stomach after Roux-en-Y bypass surgery, and to access bypassed or blind loops of small intestine. We used DBE to reach the stomach of a patient with a redundant intestinal interposition after standard endoscopy was not successful. Case: A 61 year old man presented with recurrent acute gastrointestinal hemorrhage. Lye ingestion at age 16 led to esophageal strictures, and ileo-colonic interposition for esophageal replacement. Recurrent stricturing and dysfunction led to a revision surgery, with part of the interposition. Symptomatic dysfunction of the interposition led to multiple upper endoscopies over the years, but none of these had reached the stomach. The interposition had become redundant, creating a series of sigmoid loops proximal to the stomach. When he presented with acute gastrointestinal hemorrhage, upper endoscopy was performed to identify the bleeding source. Multiple attempts were made by different endoscopists, using gastroscopes and colonoscopes, but on each procedure, an area of angulation and looping was reached at 50 cm, beyond which advancement was not possible. The stomach was never reached, and a bleeding source was not seen. The Fujinon EN-450T5 double-balloon enteroscope and overtube system were then used for upper endoscopy. The balloons helped to shorten redundant loops, and the overtube was used to limit looping. The enteroscopy identified an esophago-enteric anastomosis at 18 cm, an enterocolonic anastomosis at 50 cm, a colo-gastric anastomosis at 80 cm from the mouth, and a partial gastrectomy with two limbs of small intestine attached to the stomach. Both limbs of small intestine were intubated for over 20 cm. There was diffuse hemorrhagic gastritis, without other obvious bleeding sites. The interposition of intestinal segments to replace the esophagus can create redundant intestinal loops making it difficult to reach the stomach or duodenum using standard endoscopy. The overtube and shortening maneuvers used for double-balloon enteroscopy may be useful to gain endoscopic access to regions that are made inaccessible to standard endoscopy by esophageal replacement surgery.

Feasibility of Visualization and Biopsy of Donor Duodenum by Double-balloon Enteroscopy Technique in a Recipient of Simultaneous Enteric-drained Pancreas-kidney Transplant: Case Report

Histologic examination of the tissue sample is the only definitive way of diagnosing pancreatic rejection. Percutaneous pancreas biopsy under imaging control is the method of choice for obtaining tissue sample. Adequate sample is obtained, however, in 73–89% of biopsy attempts (1, 2). Even when laparoscopic biopsy is performed the success rate is 90% (3). It was shown that the duodenal histology predicts the initial diagnosis of rejection of the pancreas, being less accurate for monitoring recovery from rejection (4). It was also reported that rejection process might occur independently in either organ (5). Duodenal biopsy was reported in recipients of pancreatic transplants with bladder drainage. In case of enteric drainage, which at present is the most commonly employed technique, duodenal biopsies were reported only in special circumstances, either through temporal venting enterostomy (6) or when the donor duodenum was anastomosed to recipient's duodenum, so access with a “classic” duodenoscope was possible (7). Therefore an enteroscopic approach to visualize directly the transplanted duodenum and obtain tissue samples might be of clinical importance. Double–balloon enteroscopy (push-and-pull enteroscopy) is a new method that allows visualization, biopsy and carrying out endoscopic interventions in the small bowel (8). This method uses two balloons, one attached to the tip of the endoscope and another at the distal end of an overtube. Inflation of the second balloon to grip intestinal wall allows insertion of the endoscope without forming redundant loops. To our knowledge up till now there have been no reports on the use of this technique in recipients of pancreas transplant. Our patient is a 32-year-old female who underwent simultaneous pancreas kidney transplantation (SPK) for type 1 diabetes mellitus of 17 years duration and end-stage renal disease, treated by hemodialysis. The transplanted duodenal segment was attached to the recipient‘s jejunum in a side-to-side manner, approximately 40 cm below the Treitz' ligament. Immunosuppressive regimen included daclizumab and thymoglobulin for induction, and mycophenolate mofetil, tacrolimus, and short-term steroids for maintenance treatment. The immediate postoperative course was complicated by a mild bleeding from the gastrointestinal tract treated by intravenous proton-pump inhibitor, and non-ST-segment-elevation myocardial infarction which was accompanied by pulmonary edema. The patient was temporarily intubated and mechanically ventilated, and responded well to furosemide. On the 15th postoperative day, she complained of a sudden, severe upper abdominal pain for which no apparent cause could be determined. A decision was made, therefore, to perform enteroscopy. Endoscopy was performed with propofol sedation, using Fujinon EN-450T5 enteroscope. Extreme care was taken to minimize threading on of the small bowel. Endoscopic image of the esophagus and stomach was normal. Mucous membrane of sewn-in duodenum with it's papilla and anastomosis had normal appearance (Fig. 1). Biopsies of the graft duodenal mucosa only showed mild infiltration with mononuclear cells. The postendoscopy course was uneventful. The pain subsided spontaneously on the next day. She was discharged home on the 21st postoperative day with both grafts functioning well.FIGURE 1.: Entrance to the transplanted duodenum. Major duodenal papilla (left) and suture line (right) can be seen.In conclusion, double-balloon enteroscopy is feasible in recipients of pancreatic transplants with enteric drainage. This method makes possible to directly visualize duodenal graft and tissue biopsy. It might be employed to look for and possibly intervene at bleeding from the enteric anastomoses, and in special cases for endoscopic retrograde pancreatography of the graft. Its safety must be, however, carefully evaluated as threading on small bowel might potentially be damaging to anastomosed blood vessels supplying transplanted pancreas. Marek Durlik Department of Gastroenterological and Transplantation Surgery Central Clinical Hospital of Ministry of Internal Affairs and Administration Warsaw, Poland Wojciech Kosmala Janusz Milewski Department of Internal Medicine and Gastroenterology Central Clinical Hospital of Ministry of Internal Affairs and Administration Warsaw, Poland Agnieszka Serwacka Department of Internal Medicine and Nephrology Central Clinical Hospital of Ministry of Internal Affairs and Administration Warsaw, Poland Grażyna Rydzewska Andrzej Rydzewski Institute of Experimental and Clinical Medicine Polish Academy of Sciences Warsaw, Poland

Long-term results of endoscopic stent in the management of blunt major pancreatic duct injury

Pancreatic stents can be used to treat a variety of acute and chronic pancreatic lesions. Sporadic successful trials in trauma patients have been reported. To our knowledge, however, a series with long-term follow-up has not previously been reported. We treated six patients in a 6-year period and report the long-term results. From February 1999 to February 2005, six blunt-trauma patients with major pancreatic duct disruption were treated with pancreatic duct stent at a single trauma center. Assessment of injury severity and diagnosis were based on abdominal computed tomography (CT) and proved by endoscopic retrograde pancreatography (ERP), with chart review used to establish mechanism of injury, timing of ERP, and stent placement, as well as the long-term outcome. Three of the six injuries were classified AAST grade III and three were grade IV; the interval to ERP with stent placement ranged from 8 hours to 22 days after the injury. One patient developed sepsis and died. One patient's stent could be removed early (52 days post-stenting) with mild ductal stricture, whereas the other four were complicated by severe ductal stricture that required repeated and prolonged stenting treatment. Removal of the stents was only possible in three of these four cases (at 12, 19, and 39 months, respectively), with stent dislodgment in the pancreatic duct occurring in another. Stent therapy may avoid surgery in the acute trauma stage, and may be preserved as another choice for acute grade IV pancreatic injury. However, variant outcome and long-term ductal stricture reveal that the role of pancreatic duct stent is uncertain and may not be suitable for acute grade III pancreatic injury. However, it needs more clinical data to define the value in the acute blunt pancreatic duct injury.

Pancreatitis After a Primary and Secondary Excision of Congenital Choledochal Cysts

Pancreatitis has been reported long after total choledochal cyst excision. The aim of this study was to determine if the disease process of postoperative pancreatitis differs between a primary and secondary cyst excision in a long-term follow-up. Among 53 postoperative patients who underwent a total cyst excision and were followed up, 44 patients underwent a primary cyst excision (primary excision group), while 9 patients underwent a secondary cyst excision after a previous cyst-duodenostomy for internal drainage (secondary excision group). The long-term clinical course, including the pancreatographic findings after a total cyst excision, was compared. In the primary excision group, six patients had mild pancreatitis. Endoscopic retrograde pancreatography demonstrated ductal dilatation that was limited to the common channel in two patients, concurrent with the ventral duct in three, and extended the duct of Santorini in three. Conservative treatments were carried out in three patients, and endoscopic irrigation in one patient with protein plugs in the ventral duct. A resection of the choledochal remnant in the pancreas was performed in two patients with choledochal remnant-associated pancreatitis. From the secondary excision group, 5 of the 9 patients had chronic pancreatitis. Endoscopic retrograde pancreatography showed entire pancreatic ductal dilatation. Two of these patients underwent duodenal papilloplasty at the same time as secondary surgery; however, the disease progressively worsened. In patients undergoing a secondary total excision after internal drainage, it is difficult to half the ongoing aggravating process in pancreatitis.

Endoscopic transpapillary nasopancreatic drainage alone to treat pancreatic ascites and pleural effusion

Pancreatic ascites and pleural effusion are uncommon sequelae of pancreatitis and are associated with significant morbidity and mortality. Endoscopic decompression of the pancreatic duct through transpapillary stent or nasopancreatic drain (NPD) has shown encouraging results but the experience is limited. The aim of the present study was to evaluate the efficacy of endoscopic transpapillary nasopancreatic drainage in patients with pancreatic ascites and pleural effusion. Over a period of 9 years, 10 patients (eight male) with pancreatic ascites and/or pleural effusion with pancreatic duct disruption documented on pancreatogram were studied. After informed consent, endoscopic transpapillary NPD was placed. The end-points were resolution of ascites and/or pleural effusion or need for surgery. Of 10 patients (age range: 13 months-46 years), four patients had only ascites, four had only pleural effusion and two had both ascites and pleural effusion. Ascites and/or pleural effusion resolved in all the patients within 4 weeks of placement of NPD. The healing of ductal disruption was demonstrated by nasopancreatogram as early as 2 weeks and NPD could be removed without necessitating another endoscopy. No major complications related to NPD placement were noted. There was no recurrence of pancreatic ascites and/or pleural effusion at a mean follow up of 39 months. Pancreatic ascites and pleural effusion can be effectively treated by endoscopic retrograde pancreatography and transpapillary NPD placement.

Screening for Early Pancreatic Neoplasia in High-Risk Individuals: A Prospective Controlled Study

Individuals with a strong family history of pancreatic cancer and persons with Peutz-Jeghers syndrome (PJS) have an increased risk for pancreatic cancer. This study screened for early pancreatic neoplasia and compared the pancreatic abnormalities in high-risk individuals and control subjects. High-risk individuals with PJS or a strong family history of pancreatic cancer were prospectively evaluated with baseline and 12-month computed tomography (CT) scan and endoscopic ultrasonography (EUS). If EUS was abnormal, EUS-fine-needle aspiration and endoscopic retrograde cholangiopancreatography (ERCP) were performed. Surgery was offered to patients with potentially neoplastic lesions. Radiologic findings and pathologic diagnoses were compared. Patients undergoing EUS and/or ERCP for benign non-pancreatic indications were concurrently enrolled as control subjects. Seventy-eight high-risk patients (72 from familial pancreatic cancer kindreds, 6 PJS) and 149 control patients were studied. To date, 8 patients with pancreatic neoplasia have been confirmed by surgery or fine-needle aspiration (10% yield of screening); 6 patients had 8 benign intraductal papillary mucinous neoplasms (IPMNs), 1 had an IPMN that progressed to invasive ductal adenocarcinoma, and 1 had pancreatic intraepithelial neoplasia. EUS and CT also diagnosed 3 patients with 5 extrapancreatic neoplasms. At EUS and ERCP abnormalities suggestive of chronic pancreatitis were more common in high-risk patients than in control subjects. Screening EUS and CT diagnosed significant asymptomatic pancreatic and extrapancreatic neoplasms in high-risk individuals. IPMN should be considered a part of the phenotype of familial pancreatic cancer. Abnormalities suggestive of chronic pancreatitis are identified more commonly at EUS and ERCP in high-risk individuals.

Three-Dimensional Computed Tomography Pancreatography of an Annular Pancreas with Special Reference to Embryogenesis

Several hypotheses have been proposed to explain the embryogenesis of an annular pancreas. Three-dimensional (3D) imaging of the annular pancreas may be useful to elucidate the embryogenesis. The aim of this case report is to clarify the pancreatic ducts in the annular pancreas by 3D computed tomography pancreatography (3D-CTP), stereographically. Three-dimensional CTP under endoscopic retrograde pancreatography using a balloon catheter was performed with a helical CT scanner. Three-dimensional images of the pancreatic duct were obtained with simple threshold, shaped surface display. Wirsung duct that surrounds the ventral side of the descending portion of the duodenum and Santorini duct that surrounds the dorsal side of the descending portion of the duodenum were reconstructed by 3D-CTP, stereographically, and the presence of an annular pancreas was confirmed. These findings suggest that the formation of the annular pancreas in the current case may be attributable not only to abnormal development of the right lobe of the ventral pancreatic bud, but also to overgrowth of the dorsal pancreatic bud toward the ventral aspect of the duodenum or excessive rotation of the duodenum following fusion of the ventral bud to the dorsal bud. Three-dimensional CTP is expected to contribute usefully toward clarifying the embryogenesis of an annular pancreas.

An audit of cystic duct closure in laparoscopic cholecystectomies

Cystic duct leak is an infrequent but potentially serious complication of laparoscopic cholecystectomy. The aims of this audit were to assess the efficacy of locking absorbable clips for closing the cystic duct and to compare the results with those for simple clips used previously. The records for all laparoscopic cholecystectomies performed in one hospital over a 5-year period were reviewed. The results were compared using Fisher's exact test. Of 518 laparoscopic cholecystectomies attempted, 24 were excluded. There was no difference in age or sex ratio between the two groups. Cystic duct leaks were identified either on endoscopic retrograde choloangio pancreatography or at laparotomy. No cystic duct leak occurred in any of the 344 locking clip cases, as compared with 3 leaks in the 146 (2%) simple clip cases (p < 0.03). Locking clips are a safe and effective method for cystic duct closure. They are associated with a reduced cystic duct leak rate, as compared with that for simple clips.

Hyperechoic Abnormalities of Pancreatic Parenchyma On EUS in Patient with Normal Pancreatic Duct On ERP: Are They True Or Fake?

Background and Aim: Traditionally, the gold standard for the diagnosis of chronic pancreatitis (CP) has been either endoscopic retrograde pancreatography (ERP) and/or pancreatic function test. Recently, endoscopic ultrasonography (EUS) is considered a useful modality for the diagnosis of CP because of its ability to place the transducer in close proximity to the pancreas. Among patients with CP, EUS may reveal abnormal parenchyma in the form of hyperechoic changes, such as echogenic strands and hyperechoic foci. However, since these findings sometimes identified in patient with normal pancreatic duct on ERP, it will be confused whether it may diagnose early CP or not. The aim of this study was to investigate the implication of hyperechoic abnormalities on EUS in normal ERP. Patients and Methods: One hundred ten patients who were undergone both EUS and ERP within 2 months were enrolled, excluding in patient with pancreatic cancer, IPMN and lower biliary ductal cancer. CP was defined using the Cambridge classification of ERP findings. On EUS images, fine-reticular pattern as normal pancreatic parenchyma, and hyperechoic foci/strand as hyperechoic abnormalities were evaluated. Results: Normal/abnormal pancreatic duct on ERP was identified in 86 (78.2%) /24 (21.8%) patients, respectively. Fine-reticular pattern on EUS was seen in 76 (76/86: 88.3%)/3 (12/24: 50%) patients who had normal/abnormal ERP (p < 0.01). On the other, in 43 patients who had no EUS abnormalities, all patients (100%) were identified fine reticular pattern. Moreover, in 22 patients who had no fine-reticular pattern on EUS, all patients (100%) were identified parenchymal abnormalities. These results strongly suggested fine-reticular pattern indicated normal pancreatic parenchyma. On the basis of above findings, EUS abnormalities on normal ERP were investigated. Hyperechoic abnormalities on EUS were seen in 46 (53.7%) patients with normal ERP. In these 46 patients, fine-reticular pattern on EUS was seen in 36 patients, and none of them have become definite CP in the follow-up period. Conclusion: Hyperechoic EUS abnormalities (foci/strands) were not necessarily mean that presence of early chronic pancreatitis. Fine-reticular pattern is useful for differentiation whether hyperechoic abnormalities are true or fake.

Role of Endoscopic Ultrasonography in Follow-Up of Branch Duct Type Intraductal Papillary-Mucinous Neoplasms of the Pancreas

Background/Aim: The aim of this study was to elucidate the role of endoscopic ultrasonography (EUS) in follow-up of the patients with branch duct type intraductal papillary-mucinous neoplasms of the pancreas (IPMNs). Methods: Sixty-five patients (forty-seven men and eighteen women) with branch duct type IPMNs were selected for follow-up and examined by EUS two or more times (mean, 3 times). Patients who had apparent mural nodules were excluded from follow-up study. All patients underwent initial endoscopic retrograde pancreatography (ERP), magnetic retrograde cholangiopancreatography (MRCP), and computed tomography (CT). Serial changes of the maximum cystic diameter and the presence of mural nodule were studied during the observation periods ranged from 19 to 172 months (mean, 87 months). Results: Six (9%) of 65 patients exhibited obvious progression of cystic dilatation. New apparent mural nodules were detected in 6 cases (9%) during the observation periods. These obvious changes were observed after a 19 to 114 months follow-up period (mean, 80 months). Of six patients with mural nodules, four cases underwent surgery after follow-up study, and the pathologic diagnosis was adenoma in two and non-invasive carcinoma in two. Mural nodules were accurately diagnosed in 6 cases (100%) by EUS, whereas in one (17%) by CT and in 0 (0%) by MRCP. Six patients with cystic size enlargement were followed up without surgical resection. None of the remaining 53 patients (82%) showed increases in cystic diameter and new apparent mural nodules. Conclusions: Mural nodule is an important factor affecting the follow-up, and most of branch duct type IPMNs without apparent mural nodules remained unchanged. EUS is the most sensitive method to detect mural nodules in follow-up of branch duct type IPMNs.

Pancreatic ERCP

Like biliary endoscopy, pancreatic endoscopic retrograde pancreatography (ERCP) has evolved from being a diagnostic procedure to a therapeutic one. The advent of magnetic resonance cholangiopancreatography and endoscopic ultrasonography have limited the need for anatomic definition and transpapillary tissue sampling, respectively. This review is therefore limited to studies published during the past year concerned either with efforts to limit the incidence of post-ERCP pancreatitis or with critical reviews of therapeutic pancreatography, including the treatment of strictures, stones, and ductal disruption.

Clinicopathological features and medical management of intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMN) are a clinicopathological entity that is being diagnosed with increasing frequency. However, the best approach to medical management of IPMN needs to be clarified. The aim of the present study was to identify preoperative features that may be predictors of malignant IPMN, and to define the medical management of IPMN of the pancreas. A total of 23 patients who underwent surgical resection for IPMN of the pancreas at Kochi Medical School between 1982 and 2004 were examined. Multivariate Cox regression analysis was used to identify factors independently associated with IPM carcinoma. Among the 23 patients, 12 had IPMN adenoma, three had borderline IPMN, four had IPMN with carcinoma in situ, and four had IPMN with invasive carcinoma. In multivariate analysis, elevated serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were found to be preoperative predictors of malignant IPMN. These results suggest that the following IPMN of the pancreas should be resected: (i) IPMN of the pancreas situated in the main duct; (ii) IPMN located in the branch duct if the size of the cystic lesion is >30 mm and the mural nodules are >5 mm in height by endoscopic ultrasound (EUS); and (iii) the diameter of the main pancreatic duct is >10 mm by endoscopic retrograde pancreatography (ERP). Careful observation of patients with branch-type IPMN with small cysts and/or without mural nodules is recommended as a management strategy. The present study reinforces the need for immediate surgical resection of malignant IPMN and suggests indicators for IPMN that should assist physicians in making decisions on treatment options.