Intraoperative Cholangiopancreatography Research Articles

Significance of imaging modalities for preoperative evaluation of the pancreaticobiliary system in surgery for pediatric choledochal cyst.

Roles of magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), drip infusion cholangiography with computed tomography (DIC-CT), and intraoperative cholangiopancreatography (IOCP) in visualizing pancreaticobiliary anatomy for pediatric choledocal cyst (CC) operations were examined. From 1980-2013, 117 pediatric CC patients (median age, 3years) underwent hepaticojejunostomy at our institution, with imaging modalities of ERCP (n = 81 over 34years), MRCP, DIC-CT, and IOCP (n = 45, 20, and 45 cases over the last 12years). First, visualization rates for pancreaticobiliary maljunction (PBM), common bile duct (CBD), pancreatic duct (PD), and intrahepatic bile duct (IHBD) were investigated. Sensitivity, specificity, and accuracy for detecting hepatic duct stricture were then compared between MRCP and IOCP. Visualization rates of PBM, CBD, PD, and IHBD were 57%, 100%, 64%, and 100% for MRCP; 82%, 77%, 95%, and 32% for ERCP; 25%, 75%, 21%, and 85% for DIC-CT; and 87%, 100%, 87%, and 100% for IOCP, respectively. Combination of MRCP and IOCP achieved rates of 89%, 100%, 91%, and 100%, respectively. Sensitivity, specificity, and accuracy for detecting stenosis were 86%, 68%, and 71% for MRCP, and 100%, 89%, and 91% for IOCP, respectively. Combining MRCP and IOCP can provide satisfactory pancreaticobiliary anatomical information for surgical planning for pediatric CC, with hepatic duct strictures evaluated more accurately by IOCP.

The Predictivity of Serum Biochemical Markers in Acute Biliary Pancreatitis

Background and Aim. There are no accurate methods of differentiating acute biliary pancreatitis. Obstructions of biliary ducts, idiopathic pancreatitis may be related with biliary origin which needs identification for acute treatment. We searched for the predictivity of biochemical markers in early acute biliary pancreatitis. Patients and Methods. Serum levels of AST (Aspartate Transaminase),ALT (Alanine Transaminase), ALP (Alkaline Phosphatase), GGT (Gamma Glutamyl Transferase), total bilirubin, direct bilirubin, LDH (Lactate Dehydrogenase), amylase, lipase, CRP (C-Reactive Protein) and WBC (White Blood Cell) were measured in 157 patients with acute pancreatitis. Biliary and nonbiliary pancreatitis were differentiated by Magnetic Resonance Cholangiopancreatography (MRCP), Endoscopic Retrograde Cholangiopancreatography (ERCP), Intraoperative Cholangiopancreatography (IOC). Cut-off points of admission biochemical markers with sensitivity, specifity, positive predictive value and negative predictive value were determined after identification of significant variables. Receiver Operator Curves were plotted for each biochemical marker. Results. Serum Alkaline Phosphatase, total bilirubin, direct bilirubin, amylase and lipase levels were significantly higher in biliary pancreatitis with a positive predictive value of 80.8%, 83.9%, 81.6%, 78.8%, 79.7%. Conclusion. Increased Alkaline Phosphatase,total bilirubin, direct bilirubin, amylase and lipase levels may be used in prediction of biliary pancreatitis.

Recurrent pancreatitis caused by pancreatobiliary anomalies in children with annular pancreas

Annular pancreas (AP) is usually associated with duodenal obstruction in neonates. Pancreatitis with AP occurs frequently in adults but is rare in children. This article describes pancreatitis in children with AP and pancreatobiliary anomalies and its surgical treatment. Six children who underwent duodenal bypass for AP subsequently developed recurrent pancreatitis. Three had trisomy 21. Duodenoduodenostomy had been performed in 5 patients and gastrojejunostomy in 1 patient for neonatal duodenal obstruction. We reviewed overall management, imaging, and surgical treatment in these children. All children subsequently complained of recurrent abdominal pain. Pancreatitis developed in 6 children, and magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) revealed associated pancreatobiliary anomalies such as pancreas divisum, pancreatobiliary malunion, choledochocele, and intraluminal duodenal diverticulum. In 5 cases, surgery for recurrent or chronic pancreatitis was performed. The range of follow-up was 11 to 54 months, and all children who underwent surgery had excellent results. Children with AP occasionally require reoperation for recurrent pancreatitis because of associate pancreatobiliary anomalies. Magnetic resonance cholangiopancreatography and ERCP provide excellent images of pancreatobiliary anomalies. Intraoperative cholangiopancreatography is also essential for accurate depiction of the ductal structure and selection of the appropriate surgical procedure.

Pancreas divisum in pancreaticobiliary maljunction in children

Pancreaticobiliary maljunction (PBM) is defined as a congenital anomaly in which the main pancreatic and common bile ducts are joined outside the duodenal wall and forms the long common channel. Although PBM and pancreas divisum are congenital anomalies causing pancreatitides, distinct data about the incidence of pancreas divisum in pediatric PBM has not been reported to date. The present study was designed to reveal the incidence and clinical features of pancreas divisum in cases of PBM. The configurations of pancreatic ducts of 78 pediatric cases of PBM were assessed by endoscopic retrograde cholangiopancreatography (ERCP) and/or intraoperative cholangiopancreatography. Additional cannulation of the minor papilla was performed when the entire length of the main pancreatic duct was not detected with cannulation of the major papilla alone. Clear pancreatography was obtained in 71 cases out of 78 cases of PBM. Abnormal fusion of the pancreatic duct was detected in 1 case (1.4%) with complete pancreas divisum. This case was asymptomatic preoperatively and for 10 years postoperatively. Pancreas divisum exists in 1.4% of PBM. Although pancreas divisum is one of the pathogenesis of pancreatitis in PBM, is rarely associated with PBM and not always causes pancreatitis.

Choledochal cysts and multilocular cysts of the pancreas

Choledochal cyst is a rare congenital anomaly of the biliary system that may be associated with other abnormalities of the hepatobiliary tract. We report a case of an 11-year-old boy in whom the preoperative evaluation revealed a choledochal cyst and intraoperative cholangiopancreatography showed a cystic mass in the pancreas. Examination of the choledocho-pancreatico-duodenectomy specimen showed a multilocular cyst in the pancreas in addition to a segmental dilation of the common bile duct. The findings in our case adds pancreatic cyst to the spectrum of abnormalities associated with choledochal cyst and may also support the theory that choledochal cyst is the predominant abnormality in a widespread spectrum of the pancreatobiliary duct dysplasia.