Flow Of Pancreatic Juice Research Articles

Endoscopic interventions in pancreatic strictures and stones-A structured approach.

Chronic pancreatitis (CP) is an irreversible disease of varied etiology characterized by destruction of pancreatic tissue and loss of both exocrine and endocrine function. Pain is the dominant and most common presenting symptom. The common cause for pain in CP is ductal hypertension due to obstruction of the flow of pancreatic juice in the main pancreatic duct either due to stones or stricture or a combination of both. With advances in technology and techniques, endoscopic retrograde cholangiography (ERCP) and stenting should be the first line of therapy for strictures of the main pancreatic duct (MPD). Small calculi in the MPD can be extracted by ERCP and balloon trawl. Extracorporeal shockwave lithotripsy (ESWL) remains the standard of care for large pancreatic calculi and aims to fragment the stones 3mm or less that can easily be extracted by a subsequent ERCP. Single operator pancreatoscopy with intraductal lithotripsy is a technique in evolution and can be tried when ESWL is not available or is unsuccessful in producing stone fragmentation.

Application of Mid-Pancreatectomy with End-to-End Anastomosis in Pancreatic Benign Tumors.

Mid-pancreatectomy combined with end-to-end anastomosis is a surgical procedure used to treat benign pancreatic tumors. It involves removing the tumor from the middle section of the pancreas and connecting the proximal and distal ends through an anastomosis. The traditional surgical approach for resecting the middle segment of the pancreas involves closing the proximal pancreas and creating a Roux-en-Y anastomosis with the jejunum. However, this approach carries a double risk of pancreatic stump fistula and pancreatico enteric anastomotic leak postoperatively. In this paper, a new procedure is described where stent tubes were placed into the proximal and distal sides of the pancreatic ducts after ensuring sufficient freedom from the proximal distal pancreas. The pancreatic parenchyma was then sutured continuously under direct vision to achieve pancreatic end-to-end anastomosis. This procedure helps preserve pancreatic function, reducing the risk of postoperative pancreatic insufficiency. However, due to the complexity and risks involved, thorough evaluation and preparation are necessary before surgery. We carefully assess the patient's history, serology, and imaging results to determine the feasibility and effectiveness of the procedure. During surgery, we consider the use of a suitable pancreatic duct stent to ensure the flow of pancreatic juice into the intestine through physiological pathways. Our goal is to remove the tumor while preserving as much normal pancreatic tissue as possible for the anastomosis. After the operation, it is crucial to monitor the patient's pancreatic function, paying close attention to blood glucose levels, drainage fluid volume, and amylase value of the pancreatic anastomosis. During the postoperative follow-up visit, the patient's pancreatic function was assessed, and there was no significant change in quality of life compared to before the surgery. This indicates that mid-pancreatectomy combined with end-to-end anastomosis is a safe and effective procedure for treating pancreatic benign neoplasms.

Comparison of Slab and Pencil Beam Labeling in Spin-labeled MR Imaging for Pancreatic Juice Flow Visualization.

The usefulness of a highly targeted pencil beam (PB) label was compared with the commonly used slab label for direct visualization of pancreaticobiliary reflux using the time-spatial labeling inversion pulse (time-SLIP) technique. Signal profiles of flow phantom images obtained with a 1.5T MRI were analyzed. Both labels had similar labeling capabilities, but the edge characteristics of the PB label were blunt. Next, sixty-eight patients were classified into two groups according to the angle of the pancreaticobiliary ducts, and the displacement of the pancreatic ducts in respiratory fluctuation was measured. The results were approximately 7 mm in both groups. The blunt edge characteristics of the PB label suggest that it is robust to respiratory fluctuations. The overall labeling ability of the PB is comparable to that of the slab. In the larger angle of pancreaticobiliary ducts, the PB label may be able to label the pancreatic duct more selectively.

Understanding bacterial infiltration of the pancreas through a deformable pancreatic duct

Tiny amount of bacteria are found in the pancreas in pancreatitis and cancer, which seemed involved in inflammation and carcinogenesis. However, bacterial infiltration from the duodenum is inhibited by the physical defense mechanisms such as bile flow and the sphincter of Oddi. To understand how the bacteria possibly infiltrate the pancreas through a deformable pancreatic duct, influenced by the periodic contractions of the sphincter of Oddi, a mathematical model of bacterial infiltration is developed that considered large deformation, fluid flow, and bacterial transport in a deformable pancreatic duct. In addition, the sphincter’s contraction wave is modeled by including its propagation from the pancreas toward the duodenum. Simulated structure of the deformed duct with the relaxed sphincter and simulated bile distribution agreed reasonably well with the literature, validating the model. Bacterial infiltration from the duodenum in a deformable pancreatic duct, following the sphincter’s contraction, is counteracted by a gradual peristalsis-like deformation of the pancreatic duct, due to an antegrade contraction wave propagation from the pancreas to the duodenum, Parametric sensitivity analysis demonstrated that bacterial infiltration is increased with lower bile and pancreatic juice flow rate, greater contraction amplitude and frequency, thinner wall thickness, and retrograde contraction wave propagation. Since contraction waves following retrograde propagation are increased in patients with common bile duct stones and pancreatitis, they may possibly be factors for continuum inflammation of pancreas. (224 words).

Using Spin-labeled MR Imaging to Depict Slow Pancreatic Juice Flow.

This study evaluated the dependence of the signal characteristics of time-spatial labeling inversion pulse (time-SLIP) on flow velocity and tag thickness to depict the pancreatic juice flow by analyzing signal profile using a tube phantom study. The tag edge property was evaluated by edge rise distance (ERD). For various slow flow velocities and tag thicknesses, the signal profile characteristics were evaluated using two indices: the tag center value (RTCV) reduction rate and the total signal value along the tube (TSVT). ERD, which was about 10% of the tag thickness, was higher for thicker tags, making slow flow detection difficult. TSVT was proportional to the thickness of the tag and was preserved irrespective of the flow velocity. RTCV became lower with higher flow velocity and decreased significantly with thinner tags. These results suggest that the visualization of pancreatic juice flow might improve stability by considering the appropriate tag thickness.

Investigation of pancreatic juice reflux mechanism in high confluence of pancreaticobiliary ducts and pancreaticobiliary maljunction (Development and validation of a mathematical model for pancreatic and bile juice flow based on fluid mechanics)

Investigation of pancreatic juice reflux mechanism in high confluence of pancreaticobiliary ducts and pancreaticobiliary maljunction (Development and validation of a mathematical model for pancreatic and bile juice flow based on fluid mechanics)

PH-taxis drives aerobic bacteria in duodenum to migrate into the pancreas with tumors

As oral or intestinal bacteria have been found in pancreatic cystic fluid and tumors, understanding bacterial migration from the duodenum into the pancreas via hepato-pancreatic duct is critical. Mathematical models of migration of aerobic bacteria from the duodenum to the pancreas with tumors were developed. Additionally, the bacterial distributions under the pH gradient and those under flow were measured in double-layer flow based microfluidic device and T-shaped cylinders. Migration of aerobic bacteria from the duodenum into pancreas is counteracted by bile and pancreatic juice flow but facilitated by pH-taxis from acidic duodenum fluid toward more favorable slightly alkaline pH in pancreatic juice. Additionally, the reduced flow velocity in cancer patients, due to compressed pancreatic duct by solid tumor, facilitates migration. Moreover, measured distribution of GFP E. coli under the pH gradient in a microfluidic device validated pH-tactic behaviors. Furthermore, Pseudomonas fluorescens in hydrochloride solution, but not in bicarbonate solution, migrated upstream against bicarbonate flow of > 20 μm/s, with an advancement at approximately 50 μm/s.

Pancreatobiliary Flow Dynamics: Association Between Bile and Pancreatic Juice Evaluated With Cine-Dynamic Magnetic Resonance Cholangiopancreatography Using Spatially Selective Inversion Recovery Pulse.

The physiological flow patterns and the reciprocal relationship between pancreatic juice and bile excretion dynamics have not been clearly elucidated by imaging. To assess the physiological flow patterns of bile and pancreatic juice simultaneously in order to clarify the pancreatobiliary flow dynamics using cine-dynamic magnetic resonance cholangiopancreatography (MRCP) with a spatial selective inversion recovery (IR) pulse. Retrospective. A total of 85 patients with physiologically normal pancreatobiliary flow without ductal dilatation (normal group) and 19 patients with dilated pancreatic duct. A 3 T, fast spin echo sequence with IR pulse to nullify the signal of static pancreatic juice and bile. The frequency and secretion grade of the antegrade and reverse flow of the pancreatic juice and bile on cine-dynamic MRCP were visually evaluated. Additionally, the reciprocal relationship between pancreatic juice and bile flow was evaluated based on its flow patterns. Spearman's rank correlation coefficient analysis and the Kruskal-Wallis and Mann-Whitney U tests were used. P values of <0.05 were considered to indicate statistical significance. In the normal group, the antegrade pancreatic juice flow and no bile flow pattern was most frequently observed (29%), followed by the no pancreatic juice flow and no bile flow pattern (23%), the antegrade pancreatic juice flow and antegrade bile flow pattern (22%), and the no pancreatic juice flow and reverse bile flow pattern (9%). The flow of the pancreatic juice and bile were synchronized with each other in 47%, while they were not in 53%. In the dilated pancreatic duct group, the mean secretion grade of the antegrade bile and pancreatic juice flow was significantly lower than in the normal group. Cine-dynamic MRCP with a spatially selective IR pulse can visualize the variations of the physiological flow patterns of bile and pancreatic juice including 53% of unsynchronized patterns. 4 TECHNICAL EFFICACY: Stage 5.

USEFULNESS OF BIODEGRADABLE STENT IN THE PREVENTION OF PANCREATIC FISTULA AFTER PANCREATIC SURGERY

Abstract INTRODUCTION Postoperative pancreatic fistula (POPF) remains the most important cause of morbidity after cephalic pancreaticoduodenectomy (PD), affecting up to one third of cases. The aim of this paper is to present a prospective single-center study with 16 patients undergoing PD in whom a biodegradable stent was placed, analyzing morbidity and mortality, the presence of POPF and the correct position and degradation time of the stent. MATERIAL Y METHODS A duct-to-mucosa end-to-side anastomosis was performed for the pancreaticojejunal anastomosis and the biodegradable stent (“Archimedes”, amg International GmbH, Germany) was placed from the pancreatic duct to the jejunum (Figure 1). The stent has a helical shape that facilitates the flow of pancreatic juice. POPF was defined as drainage fluid amylase value of &amp;gt; 5000 U/L on the first day after surgery. RESULTS Only one patient developed POPF in the postoperative period and it was successfully treated with interventional radiology drainage and somatostatin analogues. There was no mortality at 30 days after PD. An abdominal radiograph was performed to asses well-positioning of the stent on postoperative day 7. To evaluate the degradation after three months we used the CT scan. A complete degradation was defined as &amp;lt; 25% of stent length or stent fragments visible at CT. Completed degradation occurred after 3 months in all cases. CONCLUSION The use of resorbable internal pancreatic stent could be a valid alternative to prevent the development of pancreatic fistula after a pancreaticoduodenectomy.

Value of pancreatic and biliary flow MR imaging in the evaluation of pancreaticobiliary disorders.

Researchers have examined the possibility of studying pancreatic and biliary flow and using to aid the pathological evaluation of pancreaticobiliary diseases. Recently, a new method using MR imaging (MRI) has been developed for the direct visualization of pancreatic juice flow, based on a spin labeling technique. This technique enables direct visualization of pancreatic or bile duct juice flow and has various clinical applications relating to pancreaticobiliary disease. This review discusses the principle of pancreatic and biliary flow MRI with spin labeling and typical application examples such as the evaluation of the exocrine function of the pancreas in cases of chronic pancreatitis and the visualization of pancreatic juice reflux into the bile duct. Moreover other application is also discussed.

Mechanism of pancreatic juice reflux in pancreaticobiliary maljunction: A fluid dynamics model experiment.

Pancreatic juice reflux to the common bile duct and gallbladder is observed in the pancreaticobiliary maljunction (PBM), and various pathological conditions occur in the biliary tract. However, the mechanism of pancreatic juice reflux has not been discussed yet. This study aimed to investigate the mechanism of this phenomenon from the perspective of the fluid dynamics theory. A fluid dynamics model of PBM without biliary dilatation having gallbladder function and of the pressure of sphincter of Oddi was developed. Water (as bile juice and pancreatic juice) was flowed to these models with a flow rate similar to that in humans. Pancreatic and bile juice flow and bile duct pressure were observed in three phases of gallbladder function. Moreover, the same experiment was performed in the PBM without biliary dilatation model without gallbladder. Pancreatic juice reflux could be observed when the gallbladder was passively expanded with the pressure in the bile duct lower than that in the sphincter of Oddi. However, pancreatic juice reflux was not observed in the model without gallbladder. Gallbladder function may be strongly involved in pancreatic juice reflux in PBM without biliary dilatation. Cholecystectomy may be able to stop the reflux of pancreatic juice.

Хирургическое лечения осложненных форм хронического панкреатита открытым стентированием панкреатического протока

Хирургическое лечение хронического панкреатита (ХП) – одна из наиболее сложных и не решенных до настоящего времени проблем хирургической панкреатологии. Целью научной работы являлось исследование эффективности открытого стентирования панкреатического протока с целью восстановление дренажной функции протоковой системы поджелудочной железы путем создания искусственного хода в паренхиме головки поджелудочной железы, соединяющего просвет главного панкреатического протока с просветом 12-перстной кишки. В ходе исследования был теоретически обоснован, разработан и внедрен в клиническую практику новый способ хирургического лечения ХП, позволяющий восстановить поступление панкреатического сока в двенадцатиперстную кишку и эффективно купирующий острый процесс в ПЖ, поддерживаемый панкреатической протоковой гипертензией – открытое стентирование панкреатического протока. Данная технология позволяет быстро купировать болевой синдром и воспалительный процесс в поджелудочной железе, восстановить пассаж панкреатического сока в двенадцатиперстную кишку, устранить трофологические нарушения, уменьшить количество и тяжесть послеоперационных осложнений, улучшить качество жизни пациентов, исключить развитие сахарного диабета непосредственно после операции.

Pancreaticobiliary maljunction (PBM) complicated with complete pancreas divisum

Abstract A rare pediatric case of pancreaticobiliary maljunction (PBM) with pancreas divisum is reported. The case showed extremely rare arrangement of the biliary tree and pancreatic duct; the common channel usually seen in PBM did not exist and the common bile duct was connected to the dorsal pancreatic duct via a dilated intermediary duct, in which a large protein plug had formed. The common bile duct was not dilated at all. All of these anomalies may have been caused by abnormal development of the ventral and dorsal pancreatic ducts at an early gestational age. We report a very rare pediatric case of pancreaticobiliary maljunction (PBM) complicated with pancreas divisum. In this case, the common bile duct showed a normal caliber and it was connected to the dorsal pancreatic duct through an intermediary dilated duct, which contained a protein plug that dammed up bile and pancreatic juice flow. This anomaly is very similar to type IIIc3 choledochal cyst, whose classification was addressed by Komi et al. (1), but it differed in the following point; in our case, the common bile duct did not connect to the duodenum through the ampulla of Vater (the common channel was absent) and bile was drained to the duodenum through Santorini duct. These quite rare anomalies might have been caused in the fetus by some kind of maldevelopment of the ventral and dorsal pancreatic ducts.

Postprandial changes in secretory flow of pancreatic juice in the main pancreatic duct: evaluation with cine-dynamic MRCP with a spatially selective inversion-recovery (IR) pulse.

To evaluate the influence of oral ingestion on the secretory flow dynamics of physiological pancreatic juice within the main pancreatic duct in healthy subjects by using cine-dynamic MRCP with spatially-selective inversion-recovery (IR) pulse non-invasively. Thirty-eight healthy subjects were investigated. MRCP with spatially-selective IR pulse was repeated every 15s for 5min to acquire a total of 20 images (cine-dynamic MRCP). A set of 20 MRCP images was repeatedly obtained before and after liquid oral ingestion every 7min (including 2-min interval) for 40min (a total of seven sets). Secretion grade of pancreatic juice on cine-dynamic MRCP was compared before and after oral ingestion using the nonparametric Wilcoxon signed-rank test. Median secretion grades of pancreatic juice at 5min (score = 2.15), 12min (score = 1.95) and 19min (score = 2.05) after ingestion were significantly higher than that before ingestion (score = 1.40) (P = 0.004, P = 0.032, P = 0.045, respectively). Secretion grade of pancreatic juice showed a maximum peak of 2.15 at 5min after ingestion. Thereafter, the secretion grade of pancreatic juice tended to gradually decline. Non-invasive cine-dynamic MRCP using spatially-selective IR pulse showed potential for evaluating postprandial changes in the secretory flow dynamics of pancreatic juice as a physiological reaction. • Secretion grade of pancreatic juice at cine-dynamic MRCP after ingestion was evaluated. • Secretion grade was significantly increased within 19min after liquid meal ingestion. • Secretion grade showed maximum peak of 2.15 at 5min after ingestion. • Postprandial changes in pancreatic juice flow can be assessed by cine-dynamic MRCP.

Altered expression levels of occludin, claudin-1 and myosin light chain kinase in the common bile duct of pediatric patients with pancreaticobiliary maljunction.

BackgroundIn pancreaticobiliary maljunction (PBM), the sphincter of Oddi can not control bile and pancreatic juice flow, which may lead to two-way reflux of bile and pancreatic juice, thus causing chronic inflammation, thickening, fibrosis and metaplasia of the common bile duct wall. These pathophysiological changes have been linked to disruption of the epithelium barrier in the common bile duct. We hypothesized that the expression of tight junction-associated proteins may be dysregulated in the common bile duct in PBM. In the current study, we sought to analyze the expression of tight junction-associated proteins in the common bile duct epithelium of pediatric patients with PBM.MethodsSpecimens of the common bile duct were collected from 12 pediatric patients with PBM and 10 non-PBM controls. The expression of the tight junction-associated proteins occludin and claudin-1 in the epithelium was examined by immunohistochemistry. The Image-Pro Plus v. 6.0 image analysis software was used to calculate the mean qualifying score (MQS) of imunostained sections of common bile duct epithelium. Total protein extracts of common bile duct were analyzed by Western blotting assays to examine expression of occludin, claudin-1 and myosin light chain kinase (MLCK). Spearman correlation analysis was used to analyze the relation between MLCK and occludin, MLCK and claudin-1.ResultsImmunostained sections of the common bile duct epithelium showed significantly higher MQS in pediatric patients than controls for occludin (44.11 ± 13.82 vs. 11.30 ± 9.58, P = 0.0034) and claudin-1 (63.44 ± 23.59 vs. 46.10 ± 7.84, P = 0.0384). Western blotting also showed significantly higher expression of occludin, claudin-1 and MLCK in the common bile duct of patients than of controls (P = 0.0023, 0.0015, 0.0488). Spearman correlation analysis showed that MLCK expression correlated positively with the expression of occludin (rs = 0.61538, P = 0.0032) and claudin-1 (rs = 0.7972, P = 0.0019).ConclusionsOccludin and claudin-1 are up-regulated in the common bile duct epithelium of pediatric PBM patients. MLCK may be involved in the process of up-regulation of the tight junction-associated proteins in PBM.

Strategy to Treat Pancreatic Fistula Using Comprehensive Endoscopic Procedures Together with Percutaneous Methods

Objective: Pancreatic fistula (PF) is an early complication after pancreatoduodenectomy. PF occurs because of disruption to the pancreatodigestive tract anastomosis with stricture or occlusion. A strategy to treat PF using interventional methods is proposed. Methods: We treated a total of 6 patients with PF by endoscopic ultrasound (EUS)-guided or percutaneous pancreatic duct drainage. In this paper, these patients are reviewed based on the applied treatment for PF. Results: At the time of introduction to our department, all the patients, except for one, had a percutaneous drainage tube implanted prior to surgery. In 2 patients undergoing pancreatojejunostomy within 3 months of the previous surgery, percutaneous introduction of a guidewire into the anastomosed jejunum, via the disrupted anastomosis, through the percutaneous fistula and the implantation of a percutaneous jejunal tube for 6 weeks was an effective PF treatment. There were 4 patients (3 pancreatojejunostomy, 1 pancreatogastrostomy) with more than 3 months of PF, with an occluded anastomosis and the pancreatic juice flow had to be rerouted by making another pancreatodigestive tract anastomosis using percutaneous or EUS-guided puncture of the pancreatic duct. Conclusions: The optimal treatment for PF is considered to be the recanalization of the stricture or occluded anastomosis, or rerouting of the pancreatic juice flow by making another anastomosis. Considering our experiences in the treatment of PF, EUS-guided puncture of the pancreatic duct near the occluded anastomosis using a convex-type EUS endoscopy is the most preferable method to treat PF. In patients for whom it is difficult to introduce the endoscope into the afferent loop in the pancreatojejunostomy, various methods, including percutaneous approaches, are feasible to treat PF.

A Not-So-Groovy Masquerader: A Case Report of Groove Pancreatitis

Background: Groove pancreatitis is an uncommon and under-recognized form of focal chronic pancreatitis of the area between the pancreatic head and duodenum due to obstruction of pancreatic juice flow in the minor duct. This disease entity creates a diagnostic challenge as clinical, radiographic, and gross pathologic features can mimic pancreatic adenocarcinoma. Case: A 54-year-old male former-smoker with a history of chronic alcohol consumption presented initially with refractory pyrosis and nausea. Esophagogastroduodenoscopy (EGD) demonstrated duodenal wall thickening and a CT scan of his abdomen revealed duodenitis and inflammation of the pancreatic head with fat stranding. He re-presented three years later with worsening epigastric pain and a 60 pound weight loss. Repeat CT scan revealed an infiltrating heterogeneously enhancing process between the descending duodenum and pancreatic head (Figure 1). Magnetic resonance cholangiopancreatography (MRCP) revealed a 2.7 x 2.3 x 2.3cm mass with soft tissue infiltration and narrowing of the distal common bile duct (CBD) concerning for possible malignancy. CA 19-9 and liver function tests were within normal limits. Continued abdominal pain, intolerance to oral intake, persistent nausea and vomiting, and continued weight loss lead to endoscopic ultrasound (EUS). This demonstrated diffuse pancreatic head and genu parenchymal abnormalities, a 10mm CBD, and enlarged peripancreatic lymph nodes. Repeat MRCP on subsequent admission again revealed focal groove-centric changes of acute and chronic pancreatitis with duodenal wall thickening. EGD/EUS with duodenal biopsies demonstrated focal duodenitis with prominent Brunner glands and fine needle aspiration of the mass revealed cellular atypia and chronic inflammation consistent with chronic pancreatitis and a diagnosis of groove pancreatitis was established.Figure 1Discussion: Groove pancreatitis poses a diagnostic challenge due to its malignancy-like presentation and clinical course. Many of the described risk factors and classical findings of groove pancreatitis were present in our patient including chronic tobacco and alcohol use, severe weight loss secondary to duodenal stenosis, sheet-like mass lesion in the periduodenal space, and prolonged time to diagnosis. However, his clinical course demonstrates the complex nature of this disease process, the close resemblance to pancreatic malignancy, and the difficulty in differentiating these two conditions to arrive at a diagnosis.

In the Groove: A Case Series of Groove Pancreatitis

Background: Groove pancreatitis is an uncommon and under-recognized form of focal chronic pancreatitis of the “sliding plane” between the pancreatic head and duodenum due to obstruction of pancreatic juice flow through the minor duct. This process creates clinical, radiographic, and gross pathologic features that can mimic pancreatic adenocarcinoma. Presentation: We present a series of three male patients ultimately diagnosed with groove pancreatitis. Case 1: A 45 year-old smoker with a history of chronic alcohol ingestion and multiple prior admissions for acute pancreatitis with pancreatic pseudocysts and changes of chronic pancreatitis on imaging. On his seventh admission for pancreatitis, CT scan demonstrated a “double duct sign,” signs of gastric outlet obstruction (GOO), and duodenal thickening which an endoscope was unable to traverse. He subsequently went for pancreaticoduodenectomy and pathology demonstrated chronic pancreatitis, Brunner gland hyperplasia, and no evidence of malignancy. Case 2: A 56 year-old former smoker with severe vascular disease presented with generalized weakness and melena. A CT scan revealed a prominent pancreatic head and a hypodense duodenal mass. Symptomatic GOO lead to pancreaticoduodenectomy and pathology revealed extensive scaring of the pancreatic head and duodenal musculature with numerous cysts, some of which had ruptured suggesting duct malformation. Case 3: A 66 year-old former smoker presented with one year of intermittent bloating, post-prandial abdominal pain, early satiety, nausea, vomiting, and a 20 pound weight loss. Imaging revealed GOO from a duodenal mass and a cystic lesion in the pancreatic head. Endoscopy revealed a large circumferential polypoid mass in the duodenal bulb. Biopsy of this revealed prominent Brunner glands without malignancy. He was treated with gastrojejunostomy leaving the inflammatory mass behind. To date his symptoms have improved and all repeat biopsies were negative for malignancy. Discussion: This case series exemplifies the risk factors and classical findings of groove pancreatitis such as smoking history, duodenal stenosis, “pseudotumor” appearance of the periduodenal space, and Brunner gland hypertrophy. The variations in presentation as demonstrated above can lead to an intricate and diagnostically challenging work-up to rule out malignancy. We also highlight a patient successfully treated without surgical removal of the affected pancreas and duodenum.

Preoperative pancreatic duct stenting in patients undergoing laparoscopic pancreatic surgery – a preliminary report.

Laparoscopic surgery is becoming an approved technique in pancreatic surgery. It offers some advantages over an open approach due to shorter hospital stay and decreased complication rate. Regardless the technique the most significant problem of pancreatic surgery is postoperative pancreatic fistula. There are numerous methods attempted at reduction of its incidence. One of the possibilities is preoperative pancreatic duct stenting. It aims at decreasing the pressure in the pancreatic duct, which is supposed to facilitate pancreatic juice flow to the duodenum. The aim of the study was to determine the role of preoperative pancreatic duct stenting in pancreatic surgery. Nineteen patients undergoing laparoscopic pancreatic resection were enrolled into the study. Prior to the surgery, all of the patients were submitted for the Endoscopic Retrograde Choleangiopancreatography (ERCP) with pancreatic duct stenting. Following the subsequent laparoscopic pancreatic resection, all patients were monitored to detect the pancreatic fistula appearance. The pancreatic stent was removed 6-8 weeks after the surgery. With an exception of two patients, all other patients underwent successful ERCP with pancreatic duct stenting before the surgery. In one case the placement of the prosthesis failed due to a tortuous pancreatic duct. Five patients had an episode of acute pancreatitis including two severe courses as a complication of preoperative ERCP. One of the patient died due to severe GI bleeding 2 weeks after stenting. Among the procedures there were 15 distal pancreatectomies, two enucleations of the tumor localized in the uncinate process and in the body of the pancreas and one central pancreatectomy. The median time of surgery duration was 186 minutes (90-300; ±56). No conversions to an open approach were necessary. Likewise, there was neither any major complications reported in a postoperative course nor incidence of pancreatic fistula in any of the patients undergoing surgery. Preoperative pancreatic duct stenting can decrease the incidence of pancreatic fistula. However, a number of serious complications exceed the potential benefit of this method.

Direct visualization of pancreatic juice flow using unenhanced MRI with spin labeling can be aid in diagnosing chronic pancreatitis.

The purpose of this study is to prospectively assess whether direct visualization of pancreatic juice flow using an unenhanced MRI technique with spin labeling can aid in the diagnosis of chronic pancreatitis. Ten healthy volunteers and 50 patients who were categorized as having no chronic pancreatitis (n = 11), early chronic pancreatitis (n = 7), or established chronic pancreatitis (n = 32) underwent MRI, including direct pancreatic juice visualization using a flow-out technique with a time-spatial labeling inversion pulse, comprising a nonselective inversion recovery pulse immediately followed by a spatially selective inversion labeling pulse. The mean velocities and volumes of pancreatic juice excretion were also obtained. Variance tests were used to evaluate the clinical groups with respect to the appearance rate and mean velocity; the Kruskal-Wallis test was used for volume. There were no significant differences between healthy volunteers and patients with no chronic pancreatitis. The appearance rate, mean velocity, and volume of pancreatic juice excretion tended to decrease with the degree of chronic pancreatitis. Although the difference in these values was statistically significant between the healthy group and the established chronic pancreatitis group, the values of the early group and other groups were not statistically significant. There was a significant correlation between the appearance rate of pancreatic juice and the clinical groups (τ = -0.4376, p = 0.0015). The measurement of directly visualized pancreatic juice flow may aid in establishing the diagnosis of chronic pancreatitis.