Nondilated Ducts Research Articles

Is Intraductal Papillary Mucinous Neoplasm Really a Risk Factor of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis after Pancreatic Stenting?

To the Editor We read with great interest the article by Ito et al. (1). It is extremely impressive and it is important to know that a risk factor of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after intubation with a pancreatic stent in high-risk patients is an intraductal papillary mucinous neoplasm (IPMN). Although there are some previous reports on the prevention of PEP by a pancreatic stent (2, 3), the report by Ito et al. is of high value as it is the first report that clarified a risk factor of PEP after pancreatic duct stenting in patients at high risk in a multicenter setting. Herewith, we have the following questions: 1) Was there a bias of pancreatogram extent between patients with IPMN and those with other diseases? A pancreatogram for IPMN is generally obtained to ascertain communication between the IPMN and the pancreatic duct and to obtain pancreatic juice for cytology or biochemical examinations. Therefore, the extent of a pancreatogram in patients with IPMN may be stronger than that of patients with other diseases that could cause PEP. Meanwhile, we question the necessity of pancreatogram only to ascertain the communication between a cystic lesion and the main/branch pancreatic duct, because the communication is not necessarily revealed due to mucin. 2) What was the relationship between the opening of the orifice of the major papilla and the diameter of the MPD? Both would reflect viscosity of mucin. We think that the orifice would be open and that the diameter of MPD would be large if the mucin has a high viscosity. Therefore, we cannot understand that a small caliber stent would be occluded by mucin with high viscosity in a non-dilated duct at the pancreatic head as the authors discussed. 3) What was the frequency of guidewire mis-insertion into the pancreatic branch ducts which could lead to injury of the pancreatic duct and pancreatic parenchyma and PEP? We think it is important to know the frequency in a study on PEP. 4) What is the definition of difficult cannulation of the bile duct? This is critical information because difficult cannulation is related to PEP. As Ito et al. stated in their report, prospective randomized controlled trials for assessment of the efficacy of pancreatic stenting in patients at high risk or in patients with IPMN with as few limitations as possible are necessary.

Preoperative MRCP to detect choledocholithiasis in acute calculous cholecystitis

PurposeThere are risks of common bile duct (CBD) stones in acute cholecystitis, and there is a move among surgeons to identify choledocholithiasis before surgery. Magnetic resonance cholangiopancreaticography (MRCP) has the potential to accurately detect choledocholithiasis in patients with acute cholecystitis. The aim of this study was to evaluate the predictive values of MRCP and elevated biochemical predictors for choledocholithiasis in patients with acute cholecystitis.MethodsBetween September 2006 and August 2008, of 84 patients with acute cholecystitis based on the diagnosis criteria of the Tokyo guidelines, 57 had MRCP preoperatively. The predictive values of six biochemical predictors for choledocholithiasis were also evaluated.ResultsOf the 57 patients, seven (12.28%) had choledocholithiasis, of whom three had CBD stones in nondilated ducts. The smallest stone detected in a dilated CBD and nondilated duct was 3.19 and 4.55 mm in diameter, respectively. None of our patients whose MRCP showed a clear CBD returned with symptomatic choledocholithiasis during the follow-up period. All biochemical predictors and CBD diameter had limited positive predictive values.ConclusionsMagnetic resonance cholangiopancreaticography is a reliable evaluation technique for the detection of choledocholithiasis. It reduces the misdiagnosis of retained choledocholithiasis with normal biochemical predictors and prevents the risk of overlooking choledocholithiasis. No single predictor or combined markers have been found to be reliable for including/excluding the presence of choledocholithiasis.

Sp696 Switching it up. EUS-Guided Antegrade Clearance of Biliary Stones in “Duodenal Switch” Surgically Altered Anatomy

Sp696 Switching it up. EUS-Guided Antegrade Clearance of Biliary Stones in “Duodenal Switch” Surgically Altered Anatomy

Combining duodenoscopic sphincterotmy with laparoscopy to treat choledocholithiasis in a non-dilated common bile duct: a report of 106 cases

成都市第二人民医院于2001年2月至2009年2月有选择地施行腹腔镜胆囊切除术(LC)联合术中十二指肠镜下乳头切开取石术(LEST)一次性手术的方案治疗细径胆总管(横径2～8 mm)结石106例,效果较满意。

Percutaneous Biliary Drainage in Patients With Nondilated Intrahepatic Bile Ducts Compared With Patients With Dilated Intrahepatic Bile Ducts

The purpose of this article is to compare the technical success and guidance of percutaneous transhepatic biliary drainage (PTBD) in patients with nondilated and dilated bile duct systems using different techniques to supplement the conventional approach. Between 2006 and 2008, 71 patients (mean age, 66.6 years) underwent PTBD with 97 interventions. According to sonographic evaluation of bile duct morphology, patients were divided into two groups: 50 patients with dilated and 21 patients with nondilated bile ducts. In a retrospective analysis, both groups were compared for technical success, fluoroscopy time, complications, and medical indications. The use of interventional guidance (deviations from the standard protocol) in patients with nondilated bile ducts was recorded. The technical success rate was 90% in patients with dilated bile ducts versus 81% in patients with nondilated ducts, with no significant difference (p = 0.36). The greater complexity of the intervention in patients with nondilated bile ducts resulted in longer fluoroscopy times (p = 0.04). Complication rates were not different between the two groups. The main indication for PTBD was relief of a compressed biliary system in patients with dilated ducts and postoperative management of complications or prevention of tumor-associated bile duct obstruction in patients with nondilated ducts. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage were performed in 16 of 21 interventions for patients with nondilated bile ducts, resulting in a 100% success rate, versus a success rate of 60% in the five PTBDs of nondilated ducts performed in the conventional manner. T-drainage, additional CT-guided puncture, and temporary gallbladder drainage improve the technical success of PTBD when used in patients with nondilated bile ducts. With these measures, technical success and complication rates in patients with nondilated ducts are comparable to those for PTBD of dilated bile ducts.

Ultrasound of the Extrahepatic Bile Duct

Ultrasound is a pivotal study for evaluation of the biliary tree. In particular, the size of the extrahepatic bile duct is a critical measurement and has been a contentious issue since the early days of diagnostic ultrasound. This article reviews the history and ongoing issues regarding sonography of the normal-size duct and a variety of factors that may affect its size, including age, prior surgery, congenital abnormalities, anatomical variations, and medications. Other related sonographic issues are discussed including abnormal nondilated ducts and abnormal intraluminal contents such as sludge or air that make evaluation of the duct more difficult, particularly in patients with primary sclerosing cholangitis and prior liver transplantation. Ultimately, the luminal size of the extrahepatic duct should be considered as a single part of the entire assessment of the biliary tree that must also include the intrahepatic and pancreatic ducts, the pattern of dilatation (variable vs progressively dilated to a single point of obstruction), any wall thickening, intraluminal sludge, calculi or mass, and extraluminal compression. Clinical symptoms and abnormal laboratory values should prompt further evaluation despite a normal appearance of the bile duct, whereas pursuit of an isolated finding of an enlarged duct without supporting clinical data may not be warranted.

Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology

Magnetic resonance cholangio-pancreatography (MRCP), endoscopic ultrasonography (EUS), and endoscopic cholangio-pancreatography (ERCP) are the most frequently employed second-step procedures to detect biliary and pancreatic abnormalities in patients with acute recurrent pancreatitis (ARP) of unknown aetiology. MRCP and EUS both give a better view of the bilio-pancreatic ductal system after secretin stimulation (MRCP-S, EUS-S). EUS also serves to identify changes in the pancreatic parenchyma consistent with chronic pancreatitis, at an early stage. However, no studies have compared MRCP-S, EUS-S, and ERCP in the diagnosis of recurrent pancreatitis. To prospectively compare the diagnostic yield of MRCP-S, EUS-S, and ERCP in the evaluation of patients with acute recurrent pancreatitis with non-dilated ducts, of unknown aetiology. Forty-four consecutive patients with ARP were prospectively scheduled to undergo MRCP-S, EUS-S and ERCP, in accordance with a standard protocol approved by the institutional review board. Diagnoses such as biliary microlithiasis, congenital variants of the pancreatic ducts, chronic pancreatitis and sphincter of Oddi dysfunction were compared between the three procedures. The diagnosis of chronic pancreatitis was established according to ductal morphology by MRCP-S and ERCP, ductal and parenchymal morphology by EUS-S. The three procedures combined achieved a diagnosis that could have explained the recurrence of pancreatitis in 28/44 patients (63.6%). EUS-S recognized ductal and/or parenchymal abnormalities with the highest frequency (35/44 patients, 79.5%). Both MRCP-S and EUS-S were superior to ERCP for detecting pancreatic ductal abnormalities. EUS-S showed up pancreatic parenchymal changes in more than half the cases. Both EUS and MRCP secretin kinetics were concordant in identifying two cases with sphincter of Oddi dysfunction. The diagnostic yield of EUS-S in recurrent pancreatitis with non-dilated ducts and unknown aetiology was 13.6% and 16.7% higher than MRCP-S and ERCP respectively (although not significant), which both gave substantially similar diagnostic yields. In no case did ERCP alone find a diagnosis missed by the other two procedures. MRCP-S and EUS-S should both be used in the diagnostic work-up of idiopathic recurrent pancreatitis as complementary, first-line, techniques, instead of ERCP.

Microcatheter Use for Difficult Percutaneous Biliary Procedures

Percutaneous biliary drainage procedures in patients with nondilated ducts are demanding, resulting in lower success rates than in patients with bile duct dilatation. Pertinent clinical settings include patients with iatrogenic bile leaks, diffuse cholangiocarcinomas, and sclerosing cholangitis. We describe a method to facilitate these procedures with the combined use of a 2.7-Fr microcatheter and a 0.018-in. hydrophilic wire.

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.

MRCP-secretin test–guided management of idiopathic recurrent pancreatitis: long-term outcomes

In patients with recurrent pancreatitis of unknown etiology and nondilated ducts, accurate morphofunctional evaluation of the pancreaticobiliary ductal system and sphincter of Oddi function is important in the diagnostic workup. However, ERCP and sphincter of Oddi manometry may be nondiagnostic and postprocedure complications may be frequent. Our purpose was to assess the diagnostic accuracy of the magnetic resonance cholangiopancreatography with secretin test (MRCP-S) in patients with recurrent acute pancreatitis of unknown etiology. Accuracy was established on the basis of ERCP findings and a minimum of 24 months' clinical follow-up. Thirty-seven consecutive patients with intact gallbladder and a nondilated pancreaticobiliary ductal system with nonpathologic EUS findings entered a prospective MRCP-S-guided and ERCP-guided diagnostic and therapeutic study protocol. Patients were followed up for a mean of 31.3 months (range 26-38 months). MRCP-S identified some pancreatic outflow impairment, suggesting morphofunctional dysfunction of either the major or minor papilla, in 12 of 37 patients (32.4%). The addition of ERCP to MRCP-S did not substantially improve the diagnostic yield for the etiology of recurrent pancreatitis, and 13.6% of cases had mild postprocedure pancreatitis. The S-test was abnormal in 12 of 20 cases (60%) in whom some dysfunction of the sphincter of Oddi or minor papilla was assumed on the basis of follow-up findings. The outcome was successful after biliary or pancreatic sphincterotomy in all patients with an abnormal S-test result. Sensitivity, specificity, and positive and negative predictive values of the S-test for the diagnosis of pancreatic outflow impairment at the major or minor papilla were, respectively, 57.1%, 100%, 100%, and 64%. When the test showed an abnormal result, we were unable to distinguish between biliary and pancreatic segment dysfunction of the sphincter of Oddi. In idiopathic recurrent pancreatitis with nondilated ducts, the MRCP-S-guided approach gave diagnostic accuracy comparable to ERCP with regard to morphologic lesions, and it can be used as an alternative, avoiding ERCP-related complications in the diagnostic phase. An abnormal S-test result showed an excellent positive predictive value and somewhat disappointing negative predictive value for sphincter of Oddi or minor papilla dysfunction and for clinical success of therapeutic endoscopic approach.

Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy

To analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy. We retrospectively reviewed 172 consecutive patients who had undergone pancreatico-duodenectomy at Inha University Hospital between April 1996 and March 2006. We analyzed the pancreatic fistula rate according to the clinical characteristics, the pathologic and laboratory findings, and the anastomotic methods. The incidence of developing pancreatic fistulas in patients older than 60 years of age was 21.7% (25/115), while the incidence was 8.8% (5/57) for younger patients; the difference was significant (P=0.03). Patients with a dilated pancreatic duct had a lower rate of post-operative pancreatic fistulas than patients with a non-dilated duct (P=0.001). Other factors, including clinical features, anastomotic methods, and pathologic diagnosis, did not show any statistical difference. Our study demonstrated that pancreatic fistulas are related to age and a dilated pancreatic duct. The surgeon must take these risk factors into consideration when performing a pancreaticoduodenectomy.

Surgery of chronic pancreatitis

Chronic pancreatitis is a progressive disease of multiple etiologies. Surgery is frequently indicated for relief of debilitating pain as well as to address other complications, and three operations have proven effective. The pancreatico-duodenectomy (Whipple) procedure results in excellent long-term pain relief, but is associated with a low mortality rate and a persistent risk of early and late complications. The duodenum-preserving pancreatic head resection (DPPHR) introduced by Beger et al, and the local resection of the pancreatic head with longitudinal pancreatico-jejunostomy (LR-LPJ) devised by Frey, achieve the same high rate of pain relief long term but are associated with lower rates of perioperative complications and a decreased incidence of diabetes long term. All 3 operations address the head of the pancreas as the nidus of persistent inflammation, and all 3 achieve success with both dilated and nondilated duct disease. The LR-LPJ has a lower risk of perioperative problems and may be easier to perform.

A Novel Biodegradable Biliary Stent in the Normal Duct Hepaticojejunal Anastomosis: an 18-month Follow-up in a Large Animal Model

Creating a well-functioning hepaticojejunostomy (HJ) anastomosis with nondilated bile ducts remains a challenge. Our aim was to study the use in a large animal model of a novel, braided polylactide barium sulfate biodegradable biliary stent (BDBS) without external connection and with no need for later removal. Fifty swine were randomly operated on for Roux-Y HJ with or without BDBS in the anastomosis, and followed up (dynamic biligraphy, x-ray, serum determinations, anastomosis inner diameter, and histology) for 1.5, 3, 6, 12, and 18 months. During the follow-up, one nonstented animal died because of anastomotic leakage. In x-ray BDBS was seen in place until 1.5 months in all of the stented animals. In the nonstented animals HJ anastomosis inner diameter was decreased at 18 months [6.3 (5.0–7.0) mm vs 7.4 (7.0–9.0) mm, p = 0.05] and liver clearance reduced at 12 and 18 months compared to stented animals. Serum liver values and liver and bile duct histology did not differ between the groups. We conclude that this novel BDBS is easy to insert into the HJ anastomosis with nondilated ducts. It is nontoxic, dissolves safely, and may be associated with a larger and better draining anastomosis at 18-month follow-up. These results encourage us to proceed to clinical studies.

Diagnosing pancreatic cancer: the role of percutaneous biopsy and CT

To determine the sensitivity and complications of percutaneous biopsy of pancreatic masses, and whether typical computed tomography (CT) features of adenocarcinoma can reliably predict this diagnosis. A 5 year retrospective analysis of percutaneous core biopsies of pancreatic masses and their CT features was undertaken. Data were retrieved from surgical/pathology databases; medical records and CT reports and images. Three hundred and three patients underwent 372 biopsies; 56 of 87 patients had repeat biopsies. Malignancy was diagnosed in 276 patients, with ductal adenocarcinoma in 259 (85%). Final sensitivity of percutaneous biopsy for diagnosing pancreatic neoplasms was 90%; for repeat biopsy it was 87%. Complications occurred in 17 (4.6%) patients, in three of whom the complications were major (1%): one abscess, one duodenal perforation, one large retroperitoneal bleed. CT features typical of ductal adenocarcinoma were: hypovascular pancreatic mass with bile and/or pancreatic duct dilatation. Atypical CT features were: isodense or hypervascular mass, calcification, non-dilated ducts, cystic change, and extensive lymphadenopathy. Defining typical CT features of adenocarcinoma as true-positives, CT had a sensitivity of 68%, specificity of 95%, positive predictive value (PPV) of 98%, and negative predictive value of 41% for diagnosing pancreatic adenocarcinoma. Final sensitivity of percutaneous biopsy for establishing the diagnosis was 90%. CT features typical of pancreatic adenocarcinoma had high specificity and PPV. On some occasions, especially in frail patients with co-morbidity, it might be reasonable to assume a diagnosis of pancreatic cancer if CT features are typical, and biopsy only if CT shows atypical features.

RISK FACTORS FOR PANCREATIC FISTULA. DOES IT HAVE A CLINICAL APPLICATION FOR EARLY IDENTIFICATION OF PATIENTS WITH HIGH RISK TO DEVELOP PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY?

Operative mortality rates after pancreaticoduodenectomy (PD) have decreased dramatically over the past 3 decades and recent series have reported very low mortality. Nevertheless pancreatic fistula remains the major cause of morbidity. A significant fraction of patients undergoing pancreaticoduodenectomy develop a postoperative pancreaticocutaneous leak. To analyze the clinical application of risk factors for pancreatic leakage after pancreaticoduodenectomy, we conducted a retrospective review of patients undergoing pancreaticoduodenectomy (PD). Methods: Thirty-seven patients who underwent PD at our hospital between January 2004 and July 2005 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, gastric cancer, and pancreatic metastases. Standard PD was performed for 3 cases and pylorus-preserving PD for 34 cases. A duct-to-mucosa pancreaticojejunostomy was performed in all patients and a transanastomotic stent was placed in patients with soft pancreas and non-dilated duct. Octreotide was not used after surgery. Four preoperative, two intraoperative, and five postoperative risk factors with potential to affect the incidence of pancreatic fistula were analyzed. The recent established definition of pancreatic fistula was used to make the fistula diagnostic - a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase. Results: Of the 37 patients, 11 (29.7%) were identified as having pancreatic leakage after operation. The hospital mortality in this series was 5.4% (2/37), and the mortality associated with pancreatic fistula was 0% (0/37). General risk factors including patient age, gender, history of jaundice, preoperative nutrition, and pathological diagnosis didn't have any relation with pancreatic fistula occurrence. Intraoperative risk factor, texture of the remnant pancreas, was not found to be significantly associated with pancreatic leakage. Blood loss, type of resection, and serum amylase level on postoperative day 1 did not have significantly relation with pancreatic fistula. The incidence of pancreatic leakage was 81.9% (9/11) in those patients with abdominal drain amylase level > 1000UI/dL on postoperative day 1, it was the only risk factor with significantly relation with pancreatic fistula (p < 0.05). Conclusion: Amylase level > 1000UI/dL in the abdominal drain on postoperative day 1 shows a significant relation with the occurrence of pancreatic fistula and seems to be an important factor for early identification of pancreatic fistula development after PD.

Risk Factors of Early Complications after Pancreaticoduodenectomy in 200 Consecutive Patients

Objective: To study the risk factors for early complications after pancreaticoduodenectomy (PD). Methods: Two hundred patients undergoing PD at our hospital between December 1996 and September 2002 were reviewed retrospectively. Standard PD was performed on 176 cases, standard PD with extended lymphadenectomy on 24 patients, whereas pylorus-preserving PD was not used. An end-toside combined with mucosa-to-mucosa pancreaticojejunostomy was performed on the patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy on the patients with a soft pancreas and a non-dilated duct. The risk factors with the potential to affect the incidence of complications were analyzed with SAS 8.12 software. Logistic regression was then used to determine the effect of multiple factors on early complications. Results: The overall rate of the major complications was 21% (42/200), with the failure of pancreaticojejunal anastomosis being the most frequently encountered. Age (odds ratio [OR] 2.162), diabetes mellitus (OR 4.086), total serum bilirubin level (OR 7.556), end-to-end pancreaticojejunostomy (OR 2.616), T tube through the choledochojejunostomy (OR 0.100), and blood transfusion over 1000 mL (OR 2.410) were the significant risk factors for the morbidity. Conclusion: The results from published series concerning morbidity after pancreaticoduodenectomy are not comparable because of lack of homogeneity between them. The knowledge of the complications rate in each particular department turns out essentially to provide the patient with tailored information about risks before surgery. Additionally, management of postoperative complications is essential for improving the results of this operation.

Risk factors of pancreatic leakage after pancreaticoduodenectomy

To analyze the risk factors for pancreatic leakage after pancreaticoduodenectomy (PD) and to evaluate whether duct-to-mucosa pancreaticojejunostomy could reduce the risk of pancreatic leakage. Sixty-two patients who underwent PD at our hospital between January 2000 and November 2003 were reviewed retrospectively. The primary diseases of the patients included pancreas cancer, ampullary cancer, bile duct cancer, islet cell cancer, duodenal cancer, chronic pancreatitis, pancreatic cystadenoma, and gastric cancer. Standard PD was performed for 25 cases, PD with extended lymphadenectomy for 27 cases, pylorus-preserving PD for 10 cases. A duct-to-mucosa pancreaticojejunostomy was performed for patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy for patients with a soft pancreas and a non-dilated duct. Patients were divided into two groups according to the incidence of postoperative pancreaticojejunal anastomotic leakage: 10 cases with leakage and 52 cases without leakage. Seven preoperative and six intraoperative risk factors with the potential to affect the incidence of pancreatic leakage were analyzed with SPSS10.0 software. Logistic regression was then used to determine the effect of multiple factors on pancreatic leakage. Of the 62 patients, 10 (16.13%) were identified as having pancreatic leakage after operation. Other major postoperative complications included delayed gastric emptying (eight patients), abdominal bleeding (four patients), abdominal abscess (three patients) and wound infection (two patients). The overall surgical morbidity was 43.5% (27/62). The hospital mortality in this series was 4.84% (3/62), and the mortality associated with pancreatic fistula was 10% (1/10). Sixteen cases underwent duct-to-mucosa pancreaticojejunostomy and 1 case (1/16, 6.25%) developed postoperative pancreatic leakage, 46 cases underwent invagination pancreaticojejunostomy and 9 cases (9/46, 19.6%) developed postoperative pancreatic leakage. General risk factors including patient age, gender, history of jaundice, preoperative nutrition, pathological diagnosis and the length of postoperative stay were similar in the two groups. There was no statistical difference in the incidence of pancreatic leakage between the patients who received the prophylactic use of octreotide after surgery and the patients who did not undergo somatostatin therapy. Moreover, multivariate logistic regression analysis showed that none of the above factors seemed to be associated with pancreatic fistula. Two intraoperative risk factors, pancreatic duct size and texture of the remnant pancreas, were found to be significantly associated with pancreatic leakage. The incidence of pancreatic leakage was 4.88% in patients with a pancreatic duct size greater than or equal to 3 mm and was 38.1% in those with ducts smaller than 3 mm (P = 0.002). The pancreatic leakage rate was 2.94% in patients with a hard pancreas and was 32.1% in those with a soft pancreas (P = 0.004). Operative time, blood loss and type of resection were similar in the two patient groups. The incidence of pancreatic leakage was 6.25% (1/16) in patients with duct-to-mucosa anastomosis, and was 19.6% (9/46) in those with traditional invagination anastomosis. Although the difference of pancreatic leakage between the two groups was obvious, no statistical significance was found. This may be due to the small number of patients with duct-to-mucosa anastomosis. By further analyzing with multivariate logistic regression, both pancreatic duct size and texture of the remnant pancreas were demonstrated to be independent risk factors (P = 0.007 and 0.017, OR = 11.87 and 15.45). Although anastomotic technique was not a significant factor, pancreatic leakage rate was much less in cases that underwent duct-to-mucosa pancreaticojejunostomy. Pancreatic duct size and texture of the remnant pancreas are risk factors influencing pancreatic leakage after PD. Duct-to-mucosa pancreaticojejunostomy, as a safe and useful anastomotic technique, can reduce pancreatic leakage rate after PD.

Wall stent-enhanced lateral pancreaticojejunostomy for small-duct pancreatitis.

The purpose of this study was to see if a small (<7 mm) pancreatic duct could be dilated to an acceptable diameter, allowing lateral pancreaticojejunostomy to decompress the pancreatic duct and relieve pain, while preserving pancreatic endocrine and exocrine function. Patients with chronic pancreatitis who had a small main pancreatic duct underwent progressive trans-ampullary dilation of the duct and subsequent placement of an expandable metallic wall stent (wallstent; Boston Scientific Microvasive Division, Natick, Mass). Approximately 14 days later, a lateral pancreaticojejunostomy was done. A 400-bed university referral center hospital in an urban setting. Thirty-five patients were selected from a large group with chronic pancreatitis. Thirty-one had pancreas divisum. All patients had undergone transendoscopic sphincterotomies and stenting before being accepted into the study. All had endoscopic retrograde cholangiopancreatography-proven chronic pancreatitis, and all ducts were observed to be 7 mm or smaller. Patients were selected after endoscopic sphincterotomy and stenting failed. Progressive transendoscopic duct dilation with plastic stents was carried out, and a 10-mm expandable metallic wall stent was placed prior to surgical decompression. Lateral pancreaticojejunostomy was performed. Patients were observed for pain relief, postoperative symptoms, analgesic use, glucose intolerance, and quality of life. All patients were seen or contacted by telephone, and their results were recorded. There were no operative deaths, but 26% of patients had complications. Seventy-one percent of patients reported that their pain was better than preoperatively. Three patients had subsequent pancreatic surgery. No new cases of diabetes occurred except in the 2 patients who underwent total pancreatectomy. In general, most patients feel that their lives were improved by the procedure. A quarter of the patients no longer take narcotics, and many have been able to resume a relatively normal lifestyle. Although this procedure is not a panacea for all patients with chronic pancreatitis and a nondilated duct, it is a reasonable alternative to resection.

The use of MRCP in the detection of pancreatic injuries after blunt trauma.

From January 2000 to November 2001, five consecutive, hemodynamically stable trauma patients (age range 8-69 years, mean age 34 years) with parenchymal injuries were evaluated by magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP). One patient also underwent a MRCP-facilitated secretin test. MRI depicted pancreatic laceration in two patients, ductal disruption and a post-traumatic intraparenchymal pseudocyst in one, migrating pancreatic fluid collection in the mediastinal space with disruption in another, and main pancreatic duct rupture and dilatation in the patient evaluated with MRCP following secretin administration. MRI with MRCP is an effective noninvasive test for detecting and managing pancreatic injuries after blunt trauma. Secretin administration improves ductal visualization, particularly of nondilated ducts. Finally, MRI was useful in the follow-up studies of parenchymal damage and minor ductal injuries, providing high-quality images of the pancreatic duct and biliary tract.

New pancreatic duct-invagination anastomosis using ultrasonic dissection for nonfibrotic pancreas with a nondilated duct.

Nonfibrotic pancreases with a nondilated duct are susceptible to pancreatic fistula or leakage following pancreaticoduodenectomy. We developed a novel pancreatic duct-invagination anastomosis using an ultrasonic dissector and applied this technique to 14 consecutive pancreaticoduodenectomies and 1 segmental pancreatectomy for otherwise normal pancreases. With the aid of an ultrasonic dissector, even branch pancreatic ducts were skeletonized, ligated securely, and divided during pancreatic transection. Moreover, the main duct was exposed (> 1 cm) easily by ultrasonic dissection and a small-caliber pancreatic tube was inserted into the duct on the stump. Subsequently, pancreatic duct invagination could be easily done through a 10 G intravenous catheter passed through the gastrointestinal tract. The main duct was anchored to the adjacent serosa, but any pancreatic parenchymal sutures, possibly leading to internal laceration and/or parenchymal ischemia particularly in soft nonfibrotic pancreases, were avoidable during the procedures. All the anastomoses were done within 10 minutes. Only 1 patient (6.7%)developed pancreatic fistula, which resolved spontaneously in 21 days postoperatively. Neither anastomotic leakage nor remnant pancreatitis was seen in this series. Although a prospective, randomized study is needed, this technique may contribute to reduced morbidity after pancreaticoduodenectomy for a nonfibrotic pancreas with a nondilated main duct.