Nondilated Main Pancreatic Duct Research Articles

Somatostatin vs. Octreotide for Prevention of Postoperative Pancreatic Fistula The PREFIPS Randomized Clinical Trial A FRENCH 007 - ACHBT Study.

Pharmacological prevention of postoperative pancreatic fistula (POPF) after pancreatectomy is open to debate. The present study compares clinically significant POPF rates in patients randomized between somatostatin versus octreotide as prophylactic treatment. Multicentric randomized controlled open study in patient's candidate for pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) comparing somatostatin continuous intravenous infusion for 7 days versus octreotid 100μg, every 8 hours subcutaneous injection for 7 days, stratified by procedure (PD vs. DP) and size of the main pancreatic duct (>4mm) on grade B/C POPF rates at 90 days based on an intention-to-treat analysis. Of 763 eligible patients, 651 were randomized: 327 in the octreotide arm and 324 in the somatostatin arm, with comparable the stratification criteria - type of surgery and main pancreatic duct dilatation. Most patients had PD (n=480; 73.8%), on soft/normal pancreas (n=367; 63.2%) with a non-dilated main pancreatic duct (n=472; 72.5%), most often for pancreatic adenocarcinoma (n=311; 47.8%). Almost all patients had abdominal drainage (n=621; 96.1%) and 121 (19.5%) left the hospital with the drain in place (median length of stay=16d). A total of 153 patients (23.5%) developed a grade B/C POPF with no difference between both groups: 24.1%: somatostatin arm and 22.9%: octreotide arm (Chi-2 test, P=0.73, ITT analysis). Absence of statistically significant difference persisted after adjustment for stratification variables and in per-protocol analysis. Continuous intravenous somatostatin is not statistically different from subcutaneous octreotide in the prevention of grade B/C POPF after pancreatectomy.

Tomoelastography and Pancreatic Extracellular Volume Fraction Derived From MRI for Predicting Clinically Relevant Postoperative Pancreatic Fistula.

Pancreatic stiffness and extracellular volume fraction (ECV) are potential imaging biomarkers for pancreatic fibrosis. Clinically relevant postoperative fistula (CR-POPF) is one of the most severe complications after pancreaticoduodenectomy. Which imaging biomarker performs better for predicting the risk of CR-POPF remains unknown. To evaluate the diagnostic performance of ECV and tomoelastography-derived pancreatic stiffness for predicting the risk of CR-POPF in patients undergoing pancreaticoduodenectomy. Prospective. Eighty patients who underwent multiparametric pancreatic MRI before pancreaticoduodenectomy, among whom 16 developed CR-POPF and 64 did not. 3 T/tomoelastography and precontrast and postcontrast T1 mapping of the pancreas. Pancreatic stiffness was measured on the tomographic c-map, and pancreatic ECV was calculated from precontrast and postcontrast T1 maps. Pancreatic stiffness and ECV were compared with histological fibrosis grading (F0-F3). The optimal cutoff values for predicting CR-POPF were determined, and the correlation between CR-POPF and imaging parameters was evaluated. The Spearman's rank correlation and multivariate linear regression analysis was conducted. The receiver operating characteristic curve analysis and logistic regression analysis was performed. A double-sided P < 0.05 indicated a statistically significant difference. Pancreatic stiffness and ECV both showed a significantly positive correlation with histological pancreatic fibrosis (r = 0.73 and 0.56, respectively). Patients with advanced pancreatic fibrosis had significantly higher pancreatic stiffness and ECV compared to those with no/mild fibrosis. Pancreatic stiffness and ECV were also correlated with each other (r = 0.58). Lower pancreatic stiffness (<1.38 m/sec), lower ECV (<0.28), nondilated main pancreatic duct (<3 mm) and pathological diagnosis other than pancreatic ductal adenocarcinoma were associated with higher risk of CR-POPF at univariate analysis, and pancreatic stiffness was independently associated with CR-POPF at multivariate analysis (odds ratio: 18.59, 95% confidence interval: 4.45, 77.69). Pancreatic stiffness and ECV were associated with histological fibrosis grading, and pancreatic stiffness was an independent predictor for CR-POPF. 1 TECHNICAL EFFICACY STAGE: 5.

Advance ligation to facilitate pancreaticojejunostomy following pancreaticoduodenectomy by dilating the main pancreatic duct.

Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is technically challenging, particularly in cases of soft pancreas with a nondilated main pancreatic duct (MPD). We propose a novel procedure that involves ligating the pancreas in advance to allow for MPD dilation. We compared the data of 16 patients who underwent PD followed by PJ with advance ligation (AL) for soft pancreas with a nondilated MPD with that of 17 patients who underwent a conventional procedure (conventional group) without AL at a single institution between January 2015 and April 2017. MPD diameters were assessed using preoperative computed tomography and intraoperative ultrasonography. Pancreatic consistency was judged intraoperatively. The pancreatic parenchyma and MPD were ligated in advance to allow time for MPD dilation. After AL, we divided the pancreatic parenchyma. AL led to MPD dilation and facilitated PJ. There were significantly fewer complications in the AL group than in the conventional group (P=0.005). There were no cases of pancreatitis or death in either group. The mean procedural time for occluding the MPD was 43 min (range, 21-134 min). The median MPD dilation rate after AL was 1.6 (0.9-3.8). AL is a simple, safe, and useful procedure for facilitating PJ.

A deep pancreas is a novel predictor of pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct

BackgroundWe investigated the risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct. MethodsWe investigated a total of 354 patients who underwent pancreaticoduodenectomy. The diameter of the main pancreatic duct, the shortest distance from the body surface to the pancreas (the pancreatic depth), and the computed tomography attenuation index (the difference between the pancreatic and splenic computed tomography attenuation) were measured in preoperative computed tomography. ResultsOne hundred eighty-one (51.1%) patients had a nondilated main pancreatic duct, and 50 (27.6%) of the 181 patients with a nondilated main pancreatic duct developed a clinically relevant postoperative pancreatic fistula. Univariate analyses revealed that the calculated body mass index (≥21.8 kg/m2) (P = .004), deep pancreas (pancreatic depth ≥51.2 mm) (P = .001), and low computed tomography attenuation index (≤–3.8 Hounsfield units) (P = .02) were significant risk factors for clinically relevant postoperative pancreatic fistula. The multivariate logistic regression analysis revealed that deep pancreas (odds ratio 2.370; 95% confidence interval 1.0019–5.590; P = .049) was an independent risk factor for clinically relevant postoperative pancreatic fistula. Among patients with a nondilated main pancreatic duct, deep pancreas (in comparison to patients without deep pancreas) was associated with male sex (72.7% vs 54.9%; P = .016), higher body mass index (22.5 kg/m2 vs 19.6 kg/m2; P < .001), a history of diabetes mellitus (24.5% vs 8.5%; P = .006), a lower computed tomography attenuation index (–9.6 Hounsfield units vs –4.6 Hounsfield units; P = .007), a longer operative time (454 minutes vs 420 minutes; P = .007), and a higher volume of intraoperative blood loss (723 mL vs 500 mL; P < .001), respectively. ConclusionDeep pancreas may be an important parameter associated with significant risk factors for clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy in patients with a nondilated main pancreatic duct.

Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1465 patients

BackgroundPostoperative acute pancreatitis (POAP) after pancreaticoduodenectomy (PD) has been recently recognized as an independent complication that is associated with undesirable postoperative outcomes and often precedes other complications, yet predictive factors attributable to POAP after PD remain elusive. MethodsThe data from 1465 consecutive patients who underwent laparotomy or minimally invasive robotic PD from March 2010 to December 2018 were retrospectively reviewed. POAP was defined as an elevation of the serum amylase levels above the institution’s normal upper limit (100 U/L) on postoperative day (POD) 1. Univariate and multivariate analyses were performed to investigate the predictive factors for POAP after PD and the association between POAP and clinically relevant postoperative pancreatic fistulas (CR-POPFs). ResultsAmong the 1465 patients, 411 (28%) underwent minimally invasive robotic surgeries, and the overall POAP and CR-POPFs rates were 770 (53%) and 277 (19%), respectively. The female sex (OR 1.76), a normal bilirubin level (OR 1.55), the robotic surgery (OR 1.36), a main pancreatic duct (MPD) ≤3 mm (OR 5.69) and a high-risk nonadenocarcinoma pathology (cystic disease: OR 4.33; pNETs: OR 4.34; others: OR 2.74) were considered independent risk factors for POAP. A nondilated MPD was a predominant predictor for POAP, with 72.2% sensitivity and 71.8% specificity. POAP was also an independent predictive factor for CR-POPFs (OR 3.48). ConclusionA nondilated MPD, a high-risk pathology, the female sex, a normal bilirubin level and the robotic surgery were independent predictive factors for POAP after PD. Prevention and early treatment strategy changes can be made based on these preoperative predictive factors.

A Nondilated Main Pancreatic Duct Predicts Type 2 Autoimmune Pancreatitis: Comparative Study of Resected Pancreatic Head Masses

Background: Chronic pancreatitis (CP), pancreatic cancer (PCa), and autoimmune pancreatitis (AIP) often present as a pancreatic mass. Accurate diagnosis is not always possible; up to 8% of surgical procedures are performed in benign pancreatic masses presumed to be malignant. Objectives: We aimed to compare clinical and imaging characteristics of resected focal type 2 AIP, CP, and PCa and identify factors that could improve preoperative differential diagnosis. Methods: Charts from patients that underwent pancreatic resection under suspicion of PCa between 2000 and 2014 were reviewed. Clinical and imaging data were recorded. Subjects were grouped as type 2 AIP, CP, and PCa. Results: We included 79 cases; 41 men, mean age of 57.3 years/old ± 15.6 SD. Pathology report was type 2 AIP (20%), CP (10%), and PCa (70%). According to international consensus criteria for AIP 11 cases were deemed probable type 2 and 5 as unspecific pancreatic mass. A nondilated main pancreatic duct (MPD) was associated with AIP (OR 9.3; 95% CI 3.05–28.7), p < 0.001; obstructive jaundice (OR 28.5; 95% CI 8.18–79.5); and a dilated MPD (OR 5.21; 95% CI 1.9–14.6) suggested malignancy. Conclusions: In the setting of undetermined pancreatic focal mass, a nondilated MPD suggests the diagnosis of type 2 AIP.

Duct-penetrating method for pancreaticojejunostomy using a suture-assistance device around a non-dilated main pancreatic duct

Introduction and aims: We conceived a novel anastomotic technique (duct-penetrating method: DPM) using a specially prepared suture-assistance device (InnerSure Ace®). This suture placement allows appropriate suture bites around the duct without damaging the duct by lifting, pulling and pushing forces on the edge of the duct. Methods: We performed a duct-to-mucosa pancreaticojejunostomy in 44 patients using InnerSure Ace®. InnerSure Ace® is a forceps having two flexible members connected to each other at the tip, which makes a front loop. During the DPM, an atraumatic needle stabbed the cut surface of the pancreas in which the tip of the InnerSure Ace® was placed deeply into the MPD. The needle traveled along its arc and pierced both duct walls while incorporating pancreatic parenchyma with adequate depth and width around the MPD. When the needle passed through the front loop of the InnerSure Ace®, a paired thread was trapped while the instrument was withdrawn. Two suture threads were prepared by dividing the thread at the midpoint for approximation to the jejunum. Results: The average inner diameter of the duct was 1.9 ± 0.1 mm during surgery. More than 8 suture threads were placed in all patients. We encountered no grade C pancreatic fistulas and 8 patients (18.1%) with grade B fistulas. Conclusion: We achieved a safe and reliable pancreaticojejunostomy for a small-sized duct in a soft and fragile pancreas using the DPM with the InnerSure Ace®. Our anastomotic technique might become a unique clinical approach to pancreaticoenterostomy and/or duct-enterostomy.

Pancreatic Stiffness Quantified with MR Elastography: Relationship to Postoperative Pancreatic Fistula after Pancreaticoenteric Anastomosis.

Purpose To describe the relationship between conventional magnetic resonance (MR) imaging parameters and MR elastography of the pancreas in association with pancreatic histologic features and occurrence of postoperative pancreatic fistula (POPF). Materials and Methods Patients who underwent preoperative MR imaging (MR elastography and diffusion-, T1-, and T2-weighted imaging) followed by pancreatectomy with pancreaticoenteric anastomosis were included. The relationships between preoperative MR imaging parameters, demographic data, and intraoperative factors with POPF risk were analyzed with logistic regression analyses. The correlation of MR imaging parameters with histologic characteristics was evaluated with multivariate regression analysis. Results A total of 112 patients (64 men, 48 women; median age, 58 years) were evaluated. Forty-two patients (37.5%) developed POPF and 20 (17.9%) developed high-grade POPF (grades B and C). Lower pancreatic stiffness (≤1.43 kPa; odds ratio [OR], 9.196; 95% confidence interval [CI]: 1.92, 43.98), nondilated main pancreatic duct (MPD) diameter (<3 mm; OR, 7.298; 95% CI: 1.51, 35.34), and larger stump area (≥211 mm2; OR, 9.210; 95% CI: 1.53, 55.26) were risk factors for POPF. Lower pancreatic stiffness (≤1.27 kPa; OR, 8.389; 95% CI: 1.88, 37.41) was the only independent predictor of high-grade POPF. Log-transformed pancreatic stiffness was independently associated with fibrosis (β = 0.060; 95% CI: 0.052, 0.068), acinar atrophy (β = 0.015; 95% CI: 0.003, 0.028), and lipomatosis (β = -0.016; 95% CI: -0.026, -0.006). Conclusion Preoperative MR assessment of pancreatic stiffness, MPD diameter, and stump area are important predictors of POPF.

Duct-penetrating method for pancreaticojejunostomy using a suture-assistance device: outcomes of early clinical study

Background: Suture placement around a non-dilated main pancreatic duct (MPD) in the soft pancreas has always been problematic and still requires experienced hands. We conceived a novel anastomotic technique (duct-penetrating method: DPM) using a specially prepared suture-assistance device (InnerSure Ace®). This suture placement allows appropriate suture bites around the duct without damaging the duct by lifting, pulling and pushing forces on the edge of the duct. Methods: We performed a duct-to-mucosa pancreaticojejunostomy in 44 patients using InnerSure Ace®. InnerSure Ace® is a forceps having two flexible members connected to each other at the tip, which makes a front loop. During the DPM, an atraumatic needle stabbed the cut surface of the pancreas in which the tip of the InnerSure Ace® was placed deeply into the MPD. The needle traveled along its arc and pierced both duct walls while incorporating pancreatic parenchyma with adequate depth and width around the MPD. When the needle passed through the front loop of the InnerSure Ace®, a paired thread was trapped while the instrument was withdrawn. Two suture threads were prepared by dividing the thread at the midpoint for approximation to the jejunum. Results: The average inner diameter of the duct was 1.9 ± 0.1 mm during surgery. More than 8 suture threads were placed in all patients. We encountered no grade C pancreatic fistulas and 8 patients (18.1%) with grade B fistulas. Conclusion: We achieved a safe and reliable pancreaticojejunostomy for a small-sized duct in a soft and fragile pancreas using the DPM with the InnerSure Ace®. Our anastomotic technique might become a unique clinical approach to pancreaticoenterostomy and/or duct- enterostomy. We are continuing to perform clinical investigations of the safety and utility of this novel technique using InnerSure Ace®.

Long-term Risk of Pancreatic Malignancy in Patients With Branch Duct Intraductal Papillary Mucinous Neoplasm in a Referral Center

Little is known about the development of branch duct intraductal papillary mucinous neoplasms (BD-IPMNs). We evaluated long-term outcomes of a large cohort of patients with BD-IPMNs to determine risk of malignancy and define a subset of low-risk BD-IPMNs. We performed a retrospective analysis of data from 577 patients with suspected or presumed BD-IPMN under surveillance at the Massachusetts General Hospital. Patients underwent cross-sectional imaging analysis at 3 months or later after their initial diagnosis. The diagnosis of BD-IPMN was based on the presence of unilocular or multilocular cysts of the pancreas and a non-dilated main pancreatic duct (<5 mm). We collected demographic, clinical, and pathology data. Cysts were characterized at the time of diagnosis and during the follow-up period. Follow-up duration was time between initial cyst diagnosis and date of last visit or death for patients without development of pancreatic cancer, date of surgery for patients with histologically confirmed malignancy, or date of first discovery of malignancy by imaging analysis for patients with unresectable tumors or who underwent neoadjuvant treatment before surgery. The primary outcome was risk of malignancy, with a focus on patients followed for 5 years or more, compared with that of the US population, based on standardized incidence ratio. Of the 577 patients studied, 479 (83%) were asymptomatic at diagnosis and 363 (63%) underwent endoscopic ultrasound at least once. The median follow-up time was 82 months (range, 6-329 months) for the entire study cohort; 363 patients (63%) underwent surveillance for more than 5 years, and 121 (21%) for more than 10 years. Malignancies (high-grade dysplasia or invasive neoplasm) developed after 5 years in 20 of 363 patients (5.5%), and invasive cancer developed in 16 of 363 patients (4.4%). The standardized incidence ratio for patients with BD-IPMNs without worrisome features of malignancy at 5 years was 18.8 (95% confidence interval, 9.7-32.8; P < .001). One hundred and eight patients had cysts ≤1.5 cm for more than 5 years of follow-up; only 1ofthese patients (0.9%) developed a distinct ductal adenocarcinoma. By contrast, among the 255 patients with cysts >1.5 cm, 19 (7.5%) developed malignancy (P= .01). In a retrospective analysis of patients with BD-IPMNs under surveillance, their overall risk of malignancy, almost 8%, lasted for 10 years or more, supporting continued surveillance after 5 years. Cysts that remain ≤1.5 cm for more than 5 years might be considered low-risk for progression to malignancy.

1111 Modified Eus-Guided Rendezvous Drainage of an Obstructed Non-Dilated Main Pancreatic Duct (MPD) Due to Chronic Pancreatitis

1111 Modified Eus-Guided Rendezvous Drainage of an Obstructed Non-Dilated Main Pancreatic Duct (MPD) Due to Chronic Pancreatitis

Salvage anastomosis for postoperative chronic pancreatic fistula.

Salvage anastomosis for postoperative chronic pancreatic fistula is challenging, and its safety and surgical outcomes remain unclear. Four patients with postoperative chronic pancreatic fistulas who underwent surgical interventions in our institute were retrospectively reviewed. A re-pancreatojejunostomy was performed in two patients with a disruption of the pancreatojejunostomy and a dilated main pancreatic duct of the remnant pancreas. A fistulojejunostomy was performed in the remaining two patients with a duct disruption after necrosectomy for necrotic severe acute pancreatitis and non-dilated main pancreatic duct. The median duration from the onset of the pancreatic fistula to the surgical intervention was 4.5months (range 4-6months). The median operation time was 151min (range 38-257min) and the median blood loss was 200mL (range 5-350mL). According to the Clavien-Dindo classification, one patient had grade 0, two patients had grade I, and one patient had grade II (wound infections). The median length of hospital stay was 22days (range 21-28days). There were no recurrences of pancreatic fistulas. Salvage anastomosis according to the simple radiologic classification for postoperative chronic pancreatic fistulas is a safe and effective procedure.

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.

A Simple and Dependable Technique for Pancreatic-Enteric Anastomosis with a Soft Pancreas and Nondilated Duct

Background: Pancreatic anastomotic leakаgе is one of the most serious complications following pancreaticoduodenectomy (PD). The most significant riskfactors for pancreatic leakage are pancreatic texture, main pancreatic duct (MPD) size and anastomotic technique. Herewith we describe our technical modifications for single-layer pancreaticojejunostomy (PJ) with a soft pancreas and nondilated MPD for reconstruction after PD. Methods: We report our early experience using this technique in 52 patients who underwent PD between May 2009 and December 2012. Results: Overall postoperative mortality rate was1.92%. Postoperative morbidity rate was 32.69%, with major complications occurring in three patients (5.77%). Pancreatic leak was diagnosed in sixpatients (11.54%). Three patients with pancreatic fistulae (PF) of Grades A and B were managed conservatively, whereas three other patients with PF of Grade C required relaparotomy. Conclusions: According to our early experience with this modified technique for PJ, usage of horizontal mattress sutures, “everting” of MPD and incorporation of its wall into a single layer pancreatic-enteric anastomosis result in a low pancreatic anastomotic leakagerate after PD. This technique for PJ with a soft pancreas and nondilated ductensures ideal preconditions for anastomosis healing. They consist of an excellent blood supply, an anatomical position with tension-free approximation and unobstructed pancreatic juice flow from the pancreas into the jejunal loop.

Role of Endoscopic Ultrasound and Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Diagnosing Metastasis to the Pancreas: A Tertiary Center Experience

Background: Metastasis to the pancreas (MP) is a rare entity that is difficult to identify by imaging alone. Few reports have described endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (FNA) findings. Herein, we try to describe the EUS and EUS-FNA characteristics of MP. Methods: This retrospective study compared 28 patients with MP (13 males; mean age: 60.1 8 12.6 years) and 60 control patients (30 males; 62.7 8 11.5 years) with pancreatic ductal adenocarcinoma (PDAC). All lesions were characterized by EUS, and MP was diagnosed by EUS-FNA (n = 16), surgery (n = 6) or both (n = 6). Results: Multivariate logistic regression revealed that the presence of regular borders (p = 0.004; OR: 8.81, 95% CI: 1.97–39.4), the absence of retention cysts (p = 0.045; OR: 12.5, 95% CI: 1.06–147.0), and the absence of main pancreatic duct (MPD) dilation (p = 0.003; OR: 8.18, 95% CI: 2.04–32.8) were predictors of MP rather than PDAC. The EUS-FNA sampling adequacy was 95.4% (21/22), and the cor- rect diagnosis was obtained in 95.2% (20/21) of cases when K-ras mutation analysis and/or immunostaining were added. Conclusion: The presence of regular borders, the absence of retention cysts and the presence of nondilated MPD on EUS indicate MP rather than PDAC. This diagnosis can be accurately confirmed by EUS-FNA with immunostaining and/or K-ras analysis.

Invasive ductal carcinoma of the pancreas tail with noninvasive growth through the nondilated main pancreatic duct and macroscopically cystic invasive carcinomatous glands

Noninvasive growth forming macroscopically dilated cystic pancreatic ducts is a fundamental feature of intraductal papillary mucinous neoplasm (IPMN), from which invasive carcinomas can arise. However, some invasive ductal carcinomas of the pancreas also show a macroscopically cystic feature. We experienced 2 cases of invasive ductal carcinoma of the pancreas tail with noninvasive growth through the main pancreatic duct without dilation at the body side, and with collection of macroscopically cystic carcinomatous glands infiltrating at the spleen side, which resembled some IPMNs and/or IPMN-derived invasive carcinomas. These cases were different from IPMN in that they lacked macroscopic dilatation of the pancreatic ducts, and the macroscopically dilated cystic carcinomatous glands were invasive but not intraductal. The intraductal component of the carcinomas showed papillary growth of neoplastic epithelia with atypia consistent with PanIN-3. Both intraductal and invasive components predominantly showed gastric mucin phenotype (MUC5AC+, MUC6 focally +, MUC2- or MUC2+ in scattered small number of cells). Recognition of these pancreatic carcinoma cases is important in the following 2 points: (1) The presence of such cases should always be kept in mind as differential diagnosis of IPMN or IPMN-derived invasive carcinoma in imaging and pathologic diagnoses. (2) The histogenesis of these cases might be placed in the intermediate between 2 major histogenetic pathways of pancreatic carcinoma, that is, one from microscopic precursors called PanIN and the other from macroscopic precursors of IPMN. These cases can be regarded as invasive carcinomas derived from semimacroscopic extension of the intraductal lesion of the main pancreatic duct.

Pain management in chronic pancreatitis: A treatment algorithm

Abdominal pain is common and frequently debilitating in patients with chronic pancreatitis. Medical therapy includes abstinence from tobacco and alcohol and the use of analgesics and adjunctive agents. In many patients, a trial of non-enteric-coated pancreatic enzymes and/or antioxidants may be tried. Endoscopic or surgical therapy requires careful patient selection based on a detailed analysis of pancreatic ductal anatomy. Those with a non-dilated main pancreatic duct have limited endoscopic and surgical alternatives. The presence of a dilated main pancreatic duct makes endoscopic or surgical therapy possible, which may include ductal decompression or pancreatic resection, or both. Randomised trials suggest surgical therapy is more durable and effective than endoscopic therapy. Less commonly employed options include EUS-guided coeliac plexus block, thoracoscopic splanchnicectomy, or total pancreatectomy with auto islet cell transplantation. These are used rarely when all other options have failed and only in very carefully selected patients.

Pancreaticogastrostomy for High‐risk Gland After Pancreaticoduodenectomy: An Eligible Choice? Letter to the Editor

We read with interest the paper published by Dr. Niedergethmann and colleagues [1]. In this study, through ‘‘riskadapted pancreatic anastomosis,’’ the rate of pancreatic fistula (PF) after pancreaticoduodenectomy (PD) has been reduced. We give the authors particular credit for controlling the many variables involved in the performance of a pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) and congratulate the authors on their work. In this study, PG revealed a PF rate of 7% and PJ accounted for 19% of PF. Patients with high-risk glands received perioperative octreotide until postoperative day 5 and a high dose of pantoprazole. Patients with standard anastomosis received neither octreotide nor high-dose pantoprazole. A meta-analysis of seven identified randomized controlled trials reporting comparisons between the octreotide group and without octreotide group, perioperative octreotide is associated with a significant reduction in the incidence of PF after elective pancreatic surgery [2]. My first question is whether a lower rate of PF after patients receiving PG was conducted by octreotide and pantoprazole. During January 2004 to December 2006, the rate of PF after patients receiving duct-to-mucosa PJ was 22%, but patients receiving duct-to-mucosa PJ showed a lower rate of PF (13%) during January 2007 to December 2008. I find this hard to explain only by RAP. My second question is whether it might be influenced by a learning curve of PG in your institution. A randomized, controlled trial by Bassi et al. reported a total of 151 patients with soft remnant who were randomized to receive PG or duct-to-mucosa PJ. Compared with duct-to-mucosa PJ, PG did not show any significant differences in the PF (13 vs. 16%) [3]. Another randomized, controlled trial by Bassi et al. reported 144 patients with soft residual tissue who were assigned randomly to receive a duct-to-mucosa PJ or a PJ; however, the two methods revealed no significant difference in regards to the PF (13 vs. 16%) [4]. Recently, a number of techniques of managing the soft pancreatic remnant have been studied in relation to the PF. Peng et al. have described a new technique of binding PJ after PD in their randomized, controlled trial. They reported a 0% incidence of PF, which is the lowest ever published in the literature [5]. Subsequently, in a series report, 45 consecutive patients with soft pancreas and nondilated main pancreatic duct underwent a binding PJ, and only four patients (8.9%) developed a PF [6]. An easier method reported by Hakamada et al. for performing a PJ for the soft pancreas using a fast-absorbable suture, PF was noted in 3% of the patients in the duct-to-mucosa contact method group [7]. The surgeon is an important factor for the prevention of PF. The reconstruction of pancreatic digestive continuity after PD performed with fine sutures, minimal handling, and a good blood supply is likely to yield a favorable result. Therefore, we suggested that a meticulous level of surgical skill and perioperative octreotide may be associated with a significant reduction in the incidence of PF. Y. S. Hu D. K. Feng (&) Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, 17 Changle Western Road, Xi’an 710032, Shanxi Province, China e-mail: doukefeng2010@126.com

Peng’s Binding Pancreaticojejunostomy After Pancreaticoduodenectomy: A French Prospective Study

BackgroundPancreatic fistula (PF) is the single most important complication after pancreaticoduodenectomy. Recently, a 0% rate of PF was reported using a binding pancreaticojejunostomy with intussusception of the pancreatic stump. The aim of this study was to assess the safety of this new binding pancreaticojejunostomy in condition most susceptible to PF, i.e. soft pancreas and non-dilated main pancreatic duct. MethodsForty-five consecutive patients with soft pancreas and non-dilated main pancreatic duct underwent a binding pancreaticojejunostomy. Post-operative PF was defined according to the International Study Group of Pancreatic Fistula. ResultsFour patients (8.9%) developed a PF. In one case, PF developed on post-operative day 3 due to a technical deficiency. In the three other cases, pancreatic fistula developed after the tenth post-operative day; all the patients had local and/or general co-morbidities before PF occurrence. ConclusionsBinding pancreaticojejunostomy according to Peng is a safe and secure technique that improves the rate of pancreatic fistula, especially in case of soft texture of the pancreas remnant. However, a 0% rate seems to be hard to achieve because other abdominal and general complications are frequent and can lead to secondary leakage of the pancreatic anastomosis.