Nondilated Pancreatic Duct Research Articles

Endoscopic ultrasound-guided pancreatic duct stenting with a new plastic stent for nondilated pancreatic duct in pancreatic fistula after pancreaticoduodenectomy

A 76-years-old man who underwent pylorus-preserving pancreaticoduodenectomy for lower cholangiocarcinoma developed peritonitis with intra-abdominal abscess from anastomotic leakage. We have done a reoperation for surgical drainage and jejunostomy for intestinal decompression. After operation, pancreatic leakage from anastomosis of pancreatico-jejunum was detected using contrast medium from jejunostomy. We tried percutaneous drainage for abscess several times but could not treat pancreatic leakage completely over 6 months hospitalization. The pancreatic duct stenting from the intestine by balloon endoscopy was impossible because of adhesion. We tried antegrade stenting using endoscopic ultrasound-guided pancreatic drainage (EUS-PD). In EUS findings, we could identify main pancreatic duct with a diameter of 1.3 mm. It is too thin to insert the needle for EUS-PD. Therefore, we punctured it with a 22-gauge needle and succeeded pancreatography. Then, we inserted 0.018 inch guidewire, and it reached into the duct of pancreatic head. After expanding the puncture site by ultra-tapered dilator and standard dilation catheter step-wisely, the guidewire was exchanged to 0.025 inch hard-type guidewire. We placed a new 7 Fr plastic stent smoothly across the pancreatic duct (Through Pass Type IT, Gadelius Medical, Tokyo, Japan); the distal part was in the intestine, and the proximal part (pigtail) was in the gastric lumen. Pancreatic leakage was improved and patient was discharged. EUS-PD with newly developed tube stent may be considered as an effective therapy in selected patients with a pancreatic leakage after pancreatectomy.

Pancreatic Duct Holder and Mucosa Squeeze-out Technique for Duct-to-Mucosa Pancreatojejunostomy After Pancreatoduodenectomy: Propensity Score Matching Analysis.

Duct-to-mucosa pancreatojejunostomy after pancreatoduodenectomy can be technically difficult, particularly in cases with a non-dilated pancreatic duct. We devised a novel procedure employing a pancreatic duct holder and mucosa squeeze-out technique facilitating duct-to-mucosa anastomosis. We compared the perioperative outcomes of pancreatoduodenectomy with duct-to-mucosa pancreatojejunostomy between the novel and conventional procedures. Our pancreatic holder has a cone-shaped tip with a slit. The holder can expand the pancreatic duct and provides a good surgical field for anastomosis. A small incision for anastomosis is made on the jejunum, while the jejunum is grasped around the incision. Then, the jejunal mucosa becomes squeezed-out and everted. This mucosa squeeze-out technique facilitates suturing the full thickness of the jejunum. Propensity score matching yielded 113 cases each undergoing the novel and the conventional procedure, among 308 cases receiving pancreatoduodenectomy with duct-to-mucosa pancreatojejunostomy. The overall morbidity rate was significantly lower in the novel procedure group. The pancreatic fistula (ISGPF grade B/C) rate was significantly lower in the novel (5%) than in the conventional (13%) procedure group. For cases with a non-dilated pancreatic duct (≤3mm), the rate was significantly lower in the novel (10%) than in the conventional procedure group (24%). Multivariate analysis identified a non-dilated pancreatic duct, soft pancreas, and the conventional procedure as factors independently predicting the complication of pancreatic fistula formation. Our novel procedure facilitates duct-to-mucosa pancreatojejunostomy and decreases the pancreatic fistula rate. This procedure is simple, rational, and useful for achieving anastomosis, particularly in cases with a non-dilated pancreatic duct.

Modified Blumgart pancreaticojejunostomy following pancreaticoduodenectomy

Background: Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) have not been compared in the literature. The aim of this study was to compare perioperative outcomes after Blumgart PJ and PG. Methods: Data of patients undergoing Blumgart PJ and PG were retrieved from our prospectively-collected database. Surgical parameters and risks were compared between these two groups. Results: A total of 436 patients undergoing PD were included. Blumgart PJ was associated with shorter operation time, less blood loss, shorter hospital stay after operation. There was no surgical mortality in the Blumgart PJ group, but 6.6% surgical mortalities in the PG group. Pancreatic leakage rate (grades B and C) was significantly lower after Blumgart PJ for overall patients (7.8% vs. 16.2%), as well as for those with soft pancreas parenchyma (10.2% vs. 24.0%), and for those with non-dilated pancreatic duct (7.3% vs. 39.6%). Post-PD bleeding (1.0% vs. 5.4%) and intraabdominal abscess (1.9% vs. 9.6%) were less common in the Blumgart PJ group. Conclusions: Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended as a fast, simple and safe alternative for pancreatic reconstruction after PD.

Targeted Transgastric Drainage of Isolated Pancreatic Duct Segments to Cure Persistent Pancreaticocutaneous Fistulas from Pancreatitis

Chronic pancreaticocutaneous fistulas can be difficult to treat. This article presents a snare-target technique for draining a nondilated pancreatic duct into the stomach, diverting pancreatic fluid away from the pancreaticocutaneous fistula to allow it to heal. Internal or internal/external transgastric pancreatic duct or fistula drains were placed in six patients. After an average of 4 months of drainage, all six patients experienced resolution of the cutaneous fistula. Two patients developed a pseudocyst but no recurrent fistula after drain removal, and the other four patients had no pseudocyst or fistula after an average 27-month follow-up (range, 6–74 mo).

Benign Parapapillary Choledochoduodenal Fistula Associated with Ampullary Carcinoma : Case Report and Literature Review

Parapapillary and periampullary choledochoduodenal fistulas (CDF) are rare conditions. We here report a case of benign parapapillary choledochoduodenal fistula associated with early ampullary carcinoma (pT1NoMo). A 54-year-old Jordanian man had recurrent cholangitis without clinical jaundice. He had marked elevation of the alkaline phosphatase (AP) and Gamma Glutamyl Transferase (GTT). Abdominal ultrasonography showed distension of the gallbladder with dilatation of the common bile duct (CBD). Duodenoscopy showed a swollen ampulla with no intraduodenal growth. Cannulation the orifice of the papilla of Vater failed. But endoscopic biopsy revealed adenocarcinoma. Magnetic resonance cholangiopancreatiocography showed a dilated bile duct with a filling defect in its most distal part. With the diagnosis of ampullary carcinoma, the patient underwent pylorus-preserving pancreatico-duodenectomy (PPPD). The gross and microscopic examination of the resected specimen showed a dilated CBD, a small-sized benign choledocho-duodenal fistula to the CBD above the tumor, and a non-dilated pancreatic duct that opened above the tumor. The small-sized fistula was missed by all used diagnostic procedures. This communication presents a unique case of association between ampullary carcinoma with benign small sized parapapillary CDF that caused cholangitis with marked elevation of AP and GTT but without clinical jaundice. The benign CDF may cause cholangitis and together with the high bilio-pancreatic junction may increase the risk of biliary cancer.

Clinical efficacy of endoscopic pancreatic drainage for pain relief with malignant pancreatic duct obstruction.

This study was conducted to investigate the efficacy of pancreatic drainage for pain relief in advanced pancreatic cancer. Seventy-one patients with pancreatic carcinoma were divided into two groups: dilated and non-dilated pancreatic ducts. All patients underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary stenting and pancreatic stenting. Visual Analog Scale (VAS) scores, pain remission rates and survival time were evaluated during follow-up. The post-ERCP VAS score of the dilated group was lower than that of the non-dilated group at 1 and 3 months post-ERCP. There was no difference at 6 months. The pain remission rate in the dilated duct group was significantly higher than that in non-dilated duct group in 1 and 3 months post-ERCP. The median survival times were 8.17 and 8.22 months respectively. Endoscopic pancreatic drainage can relieve pain of advanced pancreatic cancer accompanied by safe dilation of the pancreatic duct.

Pasireotide for Postoperative Pancreatic Fistula

BackgroundPostoperative pancreatic fistula is a major contributor to complications and death associated with pancreatic resection. Pasireotide, a somatostatin analogue that has a longer half-life than octreotide and a broader binding profile, decreases pancreatic exocrine secretions and may prevent postoperative pancreatic fistula.MethodsWe conducted a single-center, randomized, double-blind trial of perioperative subcutaneous pasireotide in patients undergoing either pancreaticoduodenectomy or distal pancreatectomy. We randomly assigned 300 patients to receive 900 μg of subcutaneous pasireotide (152 patients) or placebo (148 patients) twice daily beginning preoperatively on the morning of the operation and continuing for 7 days (14 doses). Randomization was stratified according to the type of resection and whether the pancreatic duct was dilated at the site of transection. The primary end point was the development of pancreatic fistula, leak, or abscess of grade 3 or higher (i.e., requiring drainage).ResultsThe primary end point occurred in 45 of the 300 patients (15%). The rate of grade 3 or higher postoperative pancreatic fistula, leak, or abscess was significantly lower among patients who received pasireotide than among patients who received placebo (9% vs. 21%; relative risk, 0.44; 95% confidence interval [CI], 0.24 to 0.78; P=0.006). This finding was consistent among 220 patients who underwent pancreaticoduodenectomy (10% vs. 21%; relative risk, 0.49; 95% CI, 0.25 to 0.95) and 80 patients who underwent distal pancreatectomy (7% vs. 23%; relative risk, 0.32; 95% CI, 0.10 to 0.99), as well as among 136 patients with a dilated pancreatic duct (2% vs. 15%; relative risk, 0.11; 95% CI, 0.02 to 0.60) and 164 patients with a nondilated pancreatic duct (15% vs. 27%; relative risk, 0.55; 95% CI, 0.29 to 1.01).ConclusionsPerioperative treatment with pasireotide decreased the rate of clinically significant postoperative pancreatic fistula, leak, or abscess. (Funded by Novartis Pharmaceuticals; ClinicalTrials.gov number, NCT00994110.)

Do All Fingers Point Towards Malignancy? Story of a Great Masquerader

Purpose: A 49-year-old man presented with dark urine, epigastric discomfort, and 20-pound weight loss in 3 months. Past medical and family history was unremarkable. He denied alcohol use. On examination, he was afebrile and hemodynamically stable, but was diffusely jaundiced with moderate epigastric tenderness. Total bilirubin/direct bilirubin was 29.3/15 mg/dL, AST/ALT 341/311 U/L, alkaline phosphotase/GGT 1928/944 IU/L, CA-19-9 >1500. Ultrasound revealed a 20-mm common bile duct (CBD) and gallbladder sludge. A computed tomography (CT) revealed severe dilation of intra- and extrahepatic bile ducts with tapering into the head of pancreas (HOP), and mild prominence of the HOP without obvious mass lesions. Differential diagnosis of malignancy and autoimmune pancreatitis/cholangiopathy were considered. Endoscopic ultrasound (EUS) revealed dilated CBD (19 mm) and dilated cystic duct (CD) 10 mm with low insertion. A single, round, hyperechoic defect (15 mm) with acoustic shadowing was noted in the distal CD causing extrinsic compression of the CBD at the level of HOP without any evidence of HOP mass lesion. Endoscopic retrograde cholangiopancreatography (ERCP) revealed non-dilated pancreatic duct and 15-mm oval filling defect in the CD causing distal CBD compression. After a biliary sphincterotomy and selective cannulation of CD, a large stone was removed using a basket. Post-procedure there was a significant improvement in liver function tests and CA 19-9 down-trended and eventually normalized in 6 weeks. Discussion: Obstructive jaundice, weight loss, and high levels of CA 19-9 along with radiologic findings of CBD narrowing are highly suggestive of pancreatobiliary malignancy. However, benign disorders such as cholelithiasis, choledocholithiasis, and autoimmune process should be considered in the differential diagnosis. This case represents typical presentation of Mirizzi's syndrome type 1B. EUS is a valuable tool for accurate diagnosis of distal biliary pathology. ERCP with stone extraction from the cystic duct is safe and effective. Elevated levels of CA 19-9 usually point to a neoplastic phenomenon; however, one must thoroughly rule out benign causes.Figure: ERCP image: cystic duct filling defect.

Performing simple and safe dunking pancreaticojejunostomy using mattress sutures in pure laparoscopic pancreaticoduodenectomy

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic pancreatic resection, laparoscopic pancreaticoduodenectomy still presents major technical difficulties, such as when performing pancreatic-enteric anastomosis. Laparoscopic dunking pancreaticojejunostomy using mattress sutures was performed in 15 consecutive patients with a soft pancreas and a nondilated pancreatic duct between October 2011 and December 2012. According to the International Study Group on Pancreatic Fistula criteria, 3 patients developed PF (grade A), whereas the remaining 12 patients did not. Dunking pancreaticojejunostomy using mattress sutures is considered to be a feasible and safe method for performing pure laparoscopic pancreaticoduodenectomy.

Endoscopic ultrasound‐guided rendezvous procedure for unidentifiable papilla and non‐dilated pancreatic duct (with video)

Video S1 Endoscopic ultrasound-guided rendezvous procedure for non-dilated pancreatic duct of the head of the pancreas. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Risk Factors of Pancreatic Fistula after Pancreaticoduodenectomy – Patients with Low Drain Amylase Level on Postoperative Day 1 are Safe from Developing Pancreatic Fistula

Based on the criteria of International Study Group on Pancreatic Fistula (ISGPF), the risk factors for grade B/C pancreatic fistula (PF) after pancreaticoduodenectomy (PD) were analyzed in this study. Between October 2006 and August 2010, 114 consecutive patients underwent PD at National Hospital Organization Osaka National Hospital. We compared the clinicopathological features between patients with grade B/C PF and those with PF-free/grade A PF. We also examined the relationship between PF formation and the drain amylase level on post-operative day (POD) 1 and POD 3. Eighteen patients (15.8%) developed grade B/C P. Of these patients, four patients underwent reoperation. The mortality rate in patients with grade B/C PF was 5.6%(1/18). The non-dilated pancreatic duct (≤ 3mm) was the only independent risk factor for grade B/C PF by a multivariate analysis (p=0.026). There were 45 patients who showed low (≤ three times serum amylase level)drain amylase level on POD 1 and none of them developed PF. Although our study demonstrated that the non-dilated pancreatic duct is significantly correlated with the increased incidence of grade B/CPE patients with low amylase level of drainage fluid on POD 1 are thought to be safe from developing PE.

Wire-Guided Endoscopic Snare Retrieval of Proximally Migrated Pancreatic Stents after Endoscopic Papillectomy for Ampullary Adenoma

With the increasing use of pancreatic duct (PD) stents after endoscopic papillectomy (EP), complications such as proximal migration of the stent have become increasingly prevalent. A PD stent that migrates within a nondilated PD may be difficult to remove endoscopically. We performed endoscopic retrieval of proximally migrated PD stents after EP in 5 patients. Endoscopic retrieval was performed immediately after EP in one patient, the next day in 3 patients, and 2 weeks later in one patient. Wire-guided endoscopic retrieval was attempted in 4 patients, and the migrated stents were removed successfully in these 4 patients. No significant procedure-related complications occurred, other than mild pancreatitis in a single patient. In one patient, endoscopic retrieval performed immediately after EP failed when using the conventional method, and the migrated stent was removed using a minisnare without a guidewire the next day; this patient developed severe pancreatitis. Wire-guided endoscopic snare retrieval seems to be a safe and effective method for removing proximally migrated PD stents after EP.

External Pancreatic Duct Stent Decreases Pancreatic Fistula Rate After Pancreaticoduodenectomy

Pancreatic fistula (PF) is a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). The aim of this multicenter prospective randomized trial was to compare the results of PD with an external drainage stent versus no stent. Between 2006 and 2009, 158 patients who underwent PD were randomized intraoperatively to either receive an external stent inserted across the anastomosis to drain the pancreatic duct (n = 77) or no stent (n = 81). The criteria of inclusion were soft pancreas and a diameter of wirsung <3 mm. The primary study end point was PF rate defined as amylase-rich fluid (amylase concentration >3 times the upper limit of normal serum amylase level) collected from the peripancreatic drains after postoperative day 3. CT scan was routinely done on day 7. The 2 groups were comparable concerning demographic data, underlying pathologies, presenting symptoms, presence of comorbid illness, and proportion of patients with preoperative biliary drainage. Mortality, morbidity, and PF rates were 3.8%, 51.8%, and 34.2%, respectively. Stented group had a significantly lower overall PF (26% vs. 42%; P = 0.034), morbidity (41.5% vs. 61.7%; P = 0.01), and delayed gastric emptying (7.8% vs. 27.2%; P = 0.001) rates compared with nonstented group. Radiologic or surgical intervention for PF was required in 9 patients in the stented group and 12 patients in the nonstented group. There were no significant differences in mortality rate (3.7% vs. 3.9%; P = 0.37) and in hospital stay (22 days vs. 26 days; P = 0.11). External drainage of pancreatic duct with a stent reduced. PF and overall morbidity rates after PD in high risk patients (soft pancreatic texture and a nondilated pancreatic duct).

IPMN Natural History: A Story Very Much Still Evolving

Purpose: First described in 1982, intraductal papillary mucinous neoplasm (IPMN) has been recognized with increasing frequency in patients with and without symptoms referable to the pancreas. The literature on IPMN has been fast accumulating, including an international consensus guidelines publication in 2006. However, much remains to be learned about the natural history of this entity as evidenced by the case report below: In 2000, a 79-year-old white nonsmoker, tea-totaler asymptomatic woman sought medical attention because of the new diagnosis of ovarian cancer in her older sister. Her CA 19-9 was 200 (nl <37), leading to a CT showing small pancreatic cysts. For the ensuing 3 years, CA 19-9 fluctuated between 116 and 444. Because of the CA 19-9, patient was seen at our institution in 2003 when her CA 19-9 was 129. Since then, multiple MRCP, CT pancreas protocol, EUS examinations, and one ERCP were performed at annual interval. In 2008, a secretin MRCP was compared to her first MRCP in 2003, demonstrating no change. Seen were multiple sub-centimeter cysts throughout the pancreas, some of which were connected to a nondilated pancreatic duct, consistent with side branch IPMN. Because of the stability of these lesions and the patient's age, these lesions were reported by Radiology as being of doubtful clinical significance. However, a repeat MRCP 13 months later showed a new 2 cm mass at the head of the pancreas. EUS-guided biopsy showed adenocarcinoma. The patient described herein lacked all of the features commonly thought of as high-risk predictors for progression to high grade dysplasia or malignancy. Specifically, she had side branch IPMN, with pancreatic duct diameter <10 mm, cysts <10 mm, and no internal cystic nodules. Yet, her pancreas underwent a malignant transformation, contrary to published reports of majority (84%) having no change within a 5-year follow-up and no carcinoma. The possibility therefore exists that the so-called low risk group of patients with side-branch IPMN are quite heterogeneous, with some capable of developing adenocarcinoma. Until the risk factor profile for this subgroup is defined, clinical management of patients with IPMN will require individualized flexibility and IPMN natural history is still very much an evolving story.

Evaluation of the Guidelines for Management of Pancreatic Branch-Duct Intraductal Papillary Mucinous Neoplasm

The 2006 Sendai Consensus Guidelines recommend surgical resection for all suspected branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) greater than 3 cm irrespective of symptoms, and those less than 3 cm with worrisome features. We aimed to evaluate the surgical characteristics of these guidelines retrospectively in pathologically confirmed cases of BD-IPMN. IPMNs resected at our institution (1995-2006) were classified as main-duct predominant or branch-duct (BD) predominant based on preoperative imaging and postoperative histology. Resected BD-IPMNs were classified histologically: low risk (adenoma, borderline) and high risk (carcinoma in situ or invasive cancer). Clinical data (presence of symptoms, mural nodule, dilated pancreatic duct, and cyst size) were correlated with pathology. Between 1995 and 2006, there were 204 patients who underwent surgical resection of pancreatic cysts. Sixty-one patients had IPMN including 31 with BD-IPMN. A total of 74.2% (23 of 31) of BD-IPMNs would have been recommended for surgical resection including 69.2% (18 of 26) of low-risk lesions and 100% (5 of 5) of high-risk lesions. All 8 cases of BD-IPMN that would have been recommended for nonsurgical management were low-risk lesions. The positive predictive value of the guidelines is 21.7% (95% confidence interval, 9.7%-41.9%). The negative predictive value is 100% (95% confidence interval, 67.6%-100.0%). Between 2000 and 2007, 351 patients with likely BD-IPMN were evaluated but not resected. Implementation of the Consensus Guidelines to our single-institution, referral-based, surgical BD-IPMN population would have recommended resection of all histologically high-risk lesions. All lesions recommended for nonsurgical management were histologically low-risk lesions. For presumed BD-IPMNs less than 3 cm, the application of the Consensus Guidelines may reduce the resection rate for low-risk lesions.

Duct-to-mucosa pancreaticojejunostomies with a hard pancreas and dilated pancreatic duct and duct-to-mucosa pancreaticojejunostomies with a soft pancreas and non-dilated duct

Background. We performed duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa in 55 patients, and here compare the clinical results between duct-to-mucosa pancreaticojejunostomies with a non-dilated pancreatic duct and those with a dilated duct. Patients and methods. In the period 1999 to 2005, 55 patients (27 F, 28 M; mean age 63.4 years) underwent duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa. A non-dilated pancreatic duct was observe in 29 patients in group A and a dilated pancreatic duct in 26 patients in group B. Clinical characteristics (age, gender, benign or malignant condition, presence of diabetes mellitus, anastomotic time) were analyzed in both groups and postoperative complications were compared between groups. Results. In a comparison of clinical characteristics, all factors were similar between groups. In group A, the postoperative complication occurred in 4 (wound infection in 2, pulmonary embolism in 1, gastric ulcer in 1) of 29 patients (13.8%), and in group B in 1 (pneumothorax) of 26 patients (3.8%). No pancreatic leakage was observed in either group. The difference between group A and group B in the rate of postoperative complication was not statistically significant. Conclusions. There was no statistical difference in the rate of postoperative complications, including pancreatic leakage, between duct-to-mucosa pancreaticojejunostomies with a dilated pancreatic duct and those with a non-dilated duct. We consider that the diameter of the pancreatic duct is irrelevant to results of duct-to-mucosa pancreaticojejunostomy.

Pancreatic endoscopic ultrasound-assisted rendezvous procedure to facilitate drainage of nondilated pancreatic ducts

Pancreatic endoscopic ultrasound-assisted rendezvous procedure to facilitate drainage of nondilated pancreatic ducts

Does drainage fluid amylase reflect pancreatic leakage after pancreaticoduodenectomy?

This study tried to determine if drainage fluid amylase reflects pancreatic leakage after pancreaticoduodenectomy and to determine the factors affecting the drainage amylase level. Patients undergoing pancreaticoduodenectomy were recruited. The drainage amylase was measured from postoperative day (POD) 1 to POD 7. Direct evidence of pancreatic leakage was provided by upper gastrointestinal studies using a water-soluble contrast medium and methylene blue dye in the pancreaticogastrostomy group or by pancreaticography with injected contrast medium via an exteriorized pancreatic stent in the pancreaticojejunostomy group on POD 7. A total of 37 patients were recruited. The drainage amylase level was higher than the normal serum amylase (>or= 190 U/L) in more than half of the cases on the initial POD 2 specimen, with a median of 745 U/L on POD 1 and 663 U/L on POD 2. The drainage amylase level was more than three times the normal serum amylase level (>or= 190 x 3 U/L) in 56.8% on POD 1, in 51.4% on POD 2, and in nearly one-third on POD 7 (29.7%). However, no pancreatic leakage occurred in any of the patients with a drainage amylase of >or= 190 U/L. Only one case of pancreatic leakage with a small amount of drainage fluid (10 ml) and low amylase level (74 U/L), was noted. Soft pancreatic parenchyma and a nondilated pancreatic duct were significantly associated with higher drainage amylase levels. In conclusion, biochemical leakage defined by amylase-rich drainage fluid might have no clinical significance and was not necessarily clinical pancreatic leakage following pancreaticoduodenectomy.

Differential diagnosis of periampullary carcinomas at MR imaging.

Periampullary carcinomas arise within 2 cm of the major duodenal papilla and comprise carcinomas of the ampulla, distal common bile duct, pancreas, and duodenum. Their clinical features and anatomic locations are similar, as are the therapeutic approaches; however, their long-term outcomes vary. Magnetic resonance (MR) images of 89 pathologically proved periampullary carcinomas (29 ampullary carcinomas, 27 distal common bile duct carcinomas, 21 pancreatic carcinomas, six duodenal carcinomas, and six unclassified carcinomas) were reviewed. Ampullary carcinoma manifests as a small mass, periductal thickening, or bulging of the duodenal papilla. Pancreatic carcinoma is characterized by a discrete parenchymal mass, which enhances poorly on dynamic gadolinium-enhanced images. Sometimes, two proximal and two distal pancreatic and biliary ducts appear as four separate ducts (the four-segment sign). Dilatation of side branches of the pancreatic ducts is frequently seen in pancreatic carcinoma but not in other periampullary carcinomas. Distal bile duct carcinoma manifests as luminal obliteration and wall thickening or as an intraductal polypoid mass. A dilated proximal bile duct, a nondilated distal bile duct, and a dilated or nondilated pancreatic duct may form the three-segment sign. MR cholangiopancreatography and sectional MR imaging are useful in determining the origins of periampullary carcinomas.

Duct-to-mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy.

The aim of this retrospective study was to analyze the risk factors for pancreatic anastomotic leakage after pancreatoduodenectomy (PD) and to determine whether duct-to-mucosa pancreaticojejunostomy is superior to the total external tube drainage technique. Between 1990 and 1999, 161 patients underwent PD with end-to-side pancreaticojejunostomy at our institution. Fourteen preoperative and ten intraoperative risk factors for pancreaticojejunal anastomotic leakage were analyzed. Pancreaticojejunal anastomotic leakage was identified in 11% (17/161) of the patients. No preoperative parameters were found to have a significant association with the risk of pancreatic leakage. Three intraoperative parameters were identified as significant by means of univariate analysis: anastomotic technique, pancreatic duct size and texture of the remnant pancreas. A duct-to-mucosa pancreaticojejunostomy with total external tube drainage (3% vs. 15%, p = 0.018). A pancreas without duct dilatation of soft pancreas was more likely to develop pancreatic leakage than one with duct dilatation or atrophy. A multivariate analysis revealed that only anastomotic technique turned out to be an independent risk factor (Odds ratio: 4.15, CI: 1.1-27.4). Sub-analysis of patients with soft pancreas and non-dilated pancreatic duct further supported the finding that the duct-to-mucosa pancreaticojejunostomy technique is safer for patients at high risk. Results indicate that the status of the remnant pancreas and the pancreaticojejunostomy technique are the substantial risk factors for pancreatic leakage after pancreatoduodenecomy. Duct-to-mucosa pancreaticojejunostomy might well be the procedure of choice.