Pancreatic Duct Strictures Research Articles

Endoscopic Retrograde Cholangio-Pancreatography and Endoscopic Ultrasound in the Management of Paediatric Acute Recurrent Pancreatitis and Chronic Pancreatitis.

Objectives: To evaluate the role of ERCP (endoscopic retrograde cholangio-pancreatography) and EUS (endoscopic ultrasound) and to describe the efficacy and safety of these procedures in a paediatric cohort with chronic pancreatitis (CP) and acute recurrent pancreatitis (ARP). Methods: All patients (<18 years) undergoing an ERCP or EUS for ARP and CP between January 2008 and December 2022 were included. Data collection included indications for the procedure, technical success, adverse events and outcome data. Results: A total of 222 ERCPs were performed in 98 patients with CP and ARP (60% female, median age 10 years). The commonest indications were a main pancreatic duct stricture (PD) with or without a stone within the main PD. Successful cannulation was achieved in 98% of cases. Improved stricture resolution was demonstrated in 63% of patients. The overall adverse event rate for ERCP was low (n = 8/222, 3.6%). An improvement in abdominal pain was demonstrated in (75/98) 76% of patients. Their Body Mass Index also significantly improved post ERCP (15.5 ± 1.41 vs. 12.9 ± 1.16 kg/m2, p = 0.001). A total of 54 EUS procedures were undertaken in 48 individuals. Moreover, 35 individuals underwent a therapeutic EUS procedure, for which the commonest indication was the drainage of a pancreatic fluid collection. The overall complication rate was low (n = 2.4%) in all EUS cases. Conclusions: ERCP and EUS can be safely and effectively used in a paediatric population with indications analogous to an adult cohort.

Association of pancreatic atrophy patterns with intraductal extension of early pancreatic ductal adenocarcinoma: a multicenter retrospective study.

Focal pancreatic parenchymal atrophy (FPPA) and upstream pancreatic atrophy (UPA) may indicate the presence of early pancreatic cancer. In early pancreatic cancer, the tumor occasionally spreads laterally along the main pancreatic duct, presenting challenges in determining the extent of surgical resection. This study aimed to investigate the association of pancreatic atrophy pattern and intraductal cancer extension. Thirty-two patients with early-stage pancreatic cancer who underwent surgery at five participating centers were enrolled. Pancreatic atrophy was defined as the narrowing of parenchyma compared to the surrounding parenchyma and was classified as either FPPA (partial atrophy surrounding the pancreatic duct stenosis) or UPA (global atrophy caudal to the site of duct stenosis). Intraductal cancer extension was defined as an extension exceeding 10mm. Preoperative computed tomography revealed FPPA, UPA, and no parenchymal atrophy in 13, 13, and 6 patients. Cases with FPPA or UPA showed significantly longer cancer extensions than those without atrophy (P = 0.005 and P = 0.03, respectively). Intraductal cancer extension was present in all but one case of FPPA. 69% (9/13) of the cases with UPA showed intraductal cancer extension, whereas cases without atrophy showed no intraductal cancer extension. Importantly, two patients with FPPA or UPA showed positive resection margins during surgery and three patients with FPPA or UPA showed recurrence in the remnant pancreas. The presence of FPPA and UPA indicates lateral cancer extension in early-stage pancreatic cancer. Preoperative assessment of the pancreatic parenchyma may provide valuable insights for determining the extent of surgical resection.

Potential of Carbohydrate Antigen 19-9 and Serum Apolipoprotein A2-Isoforms in the Diagnosis of Stage 0 and IA Pancreatic Cancer.

Apolipoprotein A2-ATQ/AT (apoA2-ATQ/AT) is a new biomarker for diagnosing pancreatic cancer (PC). In this study, the value of blood carbohydrate antigen 19-9 (CA19-9) and apoA2-ATQ/AT levels in diagnosing stage 0 and IA PC was evaluated. During 2014-2021, 12 patients with stage 0 PC and 12 patients with IA PC (average age: 73.8 years) underwent resection at JA Onomichi General Hospital. In addition, the data of 200 healthy controls were collected from a community-based cohort study. Levels of two apoA2-isoforms were measured using enzyme-linked immunosorbent assay (ELISA) with specific antibodies to calculate the apoA2-i Index as a surrogate value for apoA2-ATQ/AT. The cutoff value for the apoA2-i Index was determined to be 62.9 μg/mL. CA19-9 levels were also measured through ELISA. Among all 24 patients with PC, the positivity rates for apoA2-i and CA19-9 were 33.3% and 25.0%, respectively. The positivity rates for apoA2-i and CA19-9 were 16.7% and 8.3% in patients with stage 0 PC and 50.0% and 41.7% in those with stage IA, respectively. For CA19-9-negative patients, the apoA2-i positivity rate was 9.1% in stage 0 and 42.9% in stage IA. The combined positivity rate for both markers was 16.7% in stage 0 and 66.7% in stage IA. Imaging findings in apoA2-i- and CA19-9-positive patients included pancreatic duct dilatation (87.5%/100%), duct stenosis (75.0%/50%), and atrophy (87.5%/66.7%). The imaging findings of this study suggest that apoA2-i may enhance the sensitivity for detecting CA19-9-negative stage 0 and IA PC, and complementary measurements with CA19-9 may be valuable for diagnosing early-stage PC. Therefore, minute PC with pancreatic duct dilation, duct stenosis, and atrophy may exhibit a high positivity rate, aiding differential diagnosis.

Diagnosis of pancreatic malignancies using an overnight-stored pancreatic juice cell block specimen

Background and aimsPancreatic juice cytology is useful for diagnosing pancreatic duct strictures and cystic lesions. However, some cases cannot be diagnosed using cytology. This study aimed to evaluate the utility of the overnight-stored pancreatic juice cell block (CB) method for diagnosing pancreatic disease. MethodsThis retrospective study included 32 patients who presented with pancreatic duct strictures or cystic lesions between 2018 and 2024. The sensitivity, specificity, and accuracy of the CB method and single/multiple pancreatic juice cytology were compared to evaluate the utility of the CB. ResultAn endoscopic nasopancreatic drainage tube was placed in the main pancreatic duct, and pancreatic juice was collected to create a CB specimen. The median amount of pancreatic juice collected was 180(30–200) mL, and the median number of cytological examinations was three(2–8). Of the 32 cases, 13 were malignant, and 19 were benign (non-malignant). The sensitivity was significantly higher for the CB method (62 %) than for single cytology(15 %, P = 0.0414), and there was no significant difference between CB and multiple cytology(54 %, P = 1.0). The specificity and accuracy were not significantly different between the CB method and single or multiple cytology. When multiple cytology and CB were combined, sensitivity improved to 77 %. The pathological findings of the CB specimens were similar to the surgical specimens, including immunohistochemistry. ConclusionThe overnight-stored pancreatic juice CB method was more effective than single cytology, with similar sensitivities to multiple cytology and can also be used for immunohistochemistry. The pancreatic juice CB method is useful for pancreatic juice assessment.

EUS-guided pancreatic duct drainage: a single-center observational study

Background and aimsPancreatic duct obstruction can cause pain and atrophy of the pancreatic parenchyma. Endoscopic drainage is the first-line treatment, usually by endoscopic retrograde cholangiopancreatography. However, in some patients, the classic transpapillary approach cannot be performed because of anatomical inability to access the papilla, rupture of the main pancreatic duct, intracanal stones that cannot be crossed or tight stenosis of the main pancreatic duct due to extrinsic compression by parenchymal calcifications. Endoscopic ultrasound-guided pancreatic duct drainage is an efficient and minimally invasive therapeutic alternative for these patients. We aimed to evaluate clinical success of endoscopic ultrasound-guided pancreatic duct drainage in our center. MethodsData of patients who underwent endoscopic ultrasound-guided pancreatic duct drainage in our center between 2016 and 2022 were retrospectively reviewed. Clinical success was defined as pain ≤2 on the pain Visual Analog Scale (VAS, 0-10) and no recurrence of obstructive pancreatitis after successful stent placement. If the indication to the procedure was chronic pancreatitis with painless weight loss, then clinical success was defined as weight stabilization or weight regain after the procedure. Results46 patients (mean age 58 years old, 69.6% male) were included. Indications of endoscopic ultrasound-guided pancreatic duct drainage were chronic pancreatitis in 69.6% of patients (78.1% due to alcohol abuse). Other indications included post-operative complications, rupture of pancreatic duct and pancreatic cancer. Technical success was achieved in 93.5% of patients. 40 patients had pancreaticogastrostomy and 3 patients pancreaticoduodenostomy. The mean hospital stay was 2 days. Clinical success was 93% in patients who achieved technical success. Remaining pain on the VAS > 2 occurred in 9.3% of patients and obstructive pancreatitis recurrence in 6.9%. Adverse event occurred in 5 patients (11.6%). 18 stent dysfunctions were observed, 16 stent migrations and 2 stent obstructions. No patient died from the procedure. ConclusionEndoscopic ultrasound-guided pancreatic duct drainage showed a high clinical success rate. It is therefore a good minimally invasive alternative to avoid pancreatic surgery in patients with symptomatic pancreatic duct stenosis of benign or malignant etiology who failed endoscopic retrograde cholangiopancreatography.

A case of pancreatic adenosquamous cell carcinoma with a pseudocyst following curative surgery

BackgroundPancreatic adenosquamous cell carcinoma (PASC) is a relatively rare histological type of pancreatic malignancy, and preoperative diagnosis is difficult because of its rarity. PASC accounts for 1–4% of all pancreatic cancers, and even after curative surgery, its prognosis is poorer than that of ordinary pancreatic adenocarcinoma. Pathologically, it shows glandular and squamous differentiation of cells. Complete resection is the only method to achieve a good long-term prognosis, and an increasing doubling time of PASC is considered to indicate early recurrence after surgery. Here, we report a rare case of PASC with an infected pancreatic cyst that was difficult to treat, along with a review of the literature.Case presentationA woman in her 80s with a history of breast cancer presented with pericardial pain. Computed tomography revealed a 20-mm hypovascular tumor in the body of the pancreas and a 27-mm pseudocyst. Endoscopic retrograde cholangiopancreatography showed a severe main pancreatic duct stenosis in the body of the pancreas that made cannulation impossible, and contrast media extravasation was due to pancreatic duct disruption in the pancreatic tail. Endoscopic fine-needle aspiration revealed that the tumor was a PASC. Because the patient had an infected pancreatic cyst, central intravenous nutrition and antibiotics were administered, which stabilized her general condition. She was diagnosed with resectable PASC and underwent distal pancreatectomy with lymphadenectomy. The postoperative course was uneventful. Immunohistochemical analysis of the resected specimen confirmed T2N0M0 stage IB. Systemic adjuvant chemotherapy with S-1 is ongoing.ConclusionAppropriate preoperative management and preoperative accurate staging (T2N0M0 stage IB) of PASC with curative surgery can ensure predictable outcomes.

A case of young male with recurrent acute pancreatitis caused by an intrapancreatic gastric duplication cyst

Gastric duplication cyst (GDC) is a rare gastrointestinal malformation that frequently occurs in the greater curvature of the gastric antrum or corpus. Herein, we reported a case of intrapancreatic GDC found as a result of recurring pancreatitis. A 15-year-old man experienced repeated episodes of acute pancreatitis and was found to have a cystic lesion in the pancreatic tail. Contrast-enhanced computed tomography revealed a 20-mm cystic lesion with an enhanced thick wall. Endoscopic ultrasonography revealed an anechoic cyst with a three-layered wall. Magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography (ERP) revealed a connection between the cyst and the main pancreatic duct (MPD), and the duplication of the MPD. ERP showed the pancreatic duct stenosis downstream of the cyst. Although preoperative diagnosis was difficult, distal pancreatectomy was performed to prevent recurrence of pancreatitis. Pathological examination revealed that the cystic lesion was circumferentially surrounded by the pancreatic parenchyma. The epithelial lining of the cyst was crypt epithelium containing the fundic or pyloric glands and surrounded by a smooth muscle layer. The final diagnosis was intrapancreatic GDC.

Distinctive Pathology Associated With Focal Stenosis of the Main Pancreatic Duct Secondary to Remote Trauma: A Long-term Complication of Seat Belt Pancreatitis.

The radiologic finding of focal stenosis of the main pancreatic duct is highly suggestive of pancreatic cancer. Even in the absence of a mass lesion, focal duct stenosis can lead to surgical resection of the affected portion of the pancreas. We present four patients with distinctive pathology associated with non-neoplastic focal stenosis of the main pancreatic duct. The pathology included stenosis of the pancreatic duct accompanied by wavy, acellular, serpentine-like fibrosis, chronic inflammation with foreign body-type giant cell reaction, and calcifications. In all cases, the pancreas toward the tail of the gland had obstructive changes including acinar drop-out and interlobular and intralobular fibrosis. Three of the four patients had a remote history of major motor vehicle accidents associated with severe abdominal trauma. These results emphasize that blunt trauma can injure the pancreas and that this injury can result in long-term complications, including focal stenosis of the main pancreatic duct. Pathologists should be aware of the distinct pathology associated with remote trauma and, when the pathology is present, should elicit the appropriate clinical history.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy.

The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

Treatment of Difficult Pancreatic Duct Strictures Using a Cystotome: A Single-Center Experience

Background/Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the useful treatment for treating diseases that cause pancreatic duct stenosis. However, if the stenosis is severe, accessories other than the guide wire cannot pass through. This makes the ERCP procedure difficult. At this time, cystotome, a type of diathermic dilator seems to be an option. In this paper, we would like to discuss the experience of treatment procedures using cystotome.Methods: Patients who underwent ERCP at a single tertiary hospital from November 2019 to October 2022 were analyzed retrospectively. Among them, cystotome was used in eight procedures in seven patients who passed the guide wire but failed to pass the stenosis.Results: Technical success was achieved in all eight times. All the balloon catheter smoothly passed through the stenosis after cystotome was performed. In the second ERCP, it was a functional success for the balloon catheter to pass through stenosis without further treatment. This was achieved in 6 out of 8 (75.0%). In the case of complications, only one of the total successful procedures developed mild pancreatitis, which led to additional hospitalization for about two days after the procedure, and improved after conservative treatment.Conclusions: Based on this, cystotome seems to be a good option as an alternative treatment to severe stenosis of the pancreatic duct.

Self-expanding metallic stent for refractory pancreatic duct stricture in chronic pancreatitis: A prospective follow-up study.

In chronic pancreatitis, fully covered self-expanding metal stents (FCSEMS) are used to treat refractory pancreatic duct strictures. However, the FCSEMS design, effectiveness, safety, optimal stent indwelling time and patient selection remain unclear. This study aimed at evaluating technical success, clinical success and adverse events with FCSEMS in patients with symptomatic pancreatic duct stricture. The prospective study was conducted between May 2017 and May 2021 at a tertiary care center for chronic pancreatitis with refractory pancreatic duct stricture using controlled radial expansion (CRE) endoscopic retrograde cholangiopancreatography (ERCP) with FCSEMS (Niti-S, Bumpy stent, Taewoong Medical, Gimpo-Si, South Korea). During the study period, a total of 11 patients underwent ERCP with FCSEMS for refractory pancreatic duct stricture. The mean age (± standard deviation, [SD]) was 32.36 ± 10.98years and nine patients (81%) were male. Technical and clinical success rates were 100% and 90.9%, respectively. All patients had a history of prior pancreatic endotherapy. The median (inter quartile range, [IQR]) stent indwell time was seven (6-10) months. The median visual analogue scale (VAS) pain score pre and post-FCSEMS was 8 (5-8) and 1 (0-2), respectively (p-value 0.003). Median (IQR) follow-up after stent removal was 48 (40-60) months. One patient (9%) developed de novo main pancreatic duct (MPD) stricture, which was asymptomatic. None of the patients had cholangitis, pancreatitis, perforation, proximal migration or stent fracture. The FCSEMS treatment appears to be safe, feasible and possibly an effective option for patients who have not responded to endoscopic plastic stenting.

Gastroenterological manifestations of IgG4 associated disease. Literature review, clinical case

IgG4‑associated disease is a disorder with an unknown etiology and multi‑organ damage caused by a specific inflammatory process, characterized by periductal inflammatory infiltrate mainly by CD4+‑T lymphocytes, IgG4+‑plasma cells, storiform fibrosis, atrophy of acinar tissue, which often results in pancreatic duct stenosis. A great number of target organs are involved in the pathological process, one primary localization of the pathological process without damage to other organs is observed in only 10 — 20% of patients. Mostly affected are middle‑aged and elderly men. The pathological process is stipulated by a pronounced tissue infiltration with lymphocytes and plasma cells, followed by fibrosis development. The clinical picture varies widely, depending on the combination of affected target organs. The long‑term prognosis of the disease has not been sufficiently studied due to the small number of observations, the variety of clinical forms and the variability of treatment approaches. IgG4‑associated lesions have been described for localization in pancreas, biliary tract and gallbladder, liver, esophagus, stomach and intestines, retroperitoneal space, mammary glands and thyroid and prostate glands, salivary and lacrimal glands, kidneys and ureters, lymph nodes, skin and bones. The article presents a review of current literature on gastroenterological lesions in IgG4 associated diseases, as well as a clinical case of a patient with IgG4‑autoimmune pancreatitis type 1, IgG4‑sclerosing cholangitis, autoimmune hepatitis type 1 complicated by 3 type diabetes mellitus. The diagnosis of an IgG4‑associated disease in gastroenterological practice causes some difficulties. However, the timely diagnosis and administration of adequate treatment can significantly improve the quality of life of the patient and prevent the development of complications.

Functional, biological, and radiological evaluation of the pancreaticojejunal anastomosis 1 year after pancreatoduodenectomy: a prospective study

PurposeThis prospective study aimed to analyze the functional, biological, and radiological aspects of the pancreatic anastomosis 1 year after pancreatoduodenectomy (PD).MethodsFrom 2016 to 2019, patients with PD indication were screened. Questionnaires about pancreas insufficiency, fecal elastase tests, and magnetic resonance imaging (MRI) were performed before and 1 year after PD.ResultsTwenty patients were prospectively included. The only difference between pre- and postoperative questionnaires was constipation (less frequent 1 year after PD). Median pre- and postoperative fecal elastase levels were 96 μg/g (IQR 15–196, normal value > 200) and 15 μg/g (IQR 15–26, p = 0.042). There were no significant differences in terms of main pancreatic duct (MPD) size (4, IQR 3–5 vs. 4 mm, IQR 3–5, p = 0.892), border regularity, stenosis, visibility, image improvement, and secondary pancreatic duct dilation before and after secretin injection. All patients but one (2 refused and 2 were lost to follow-up, 15/16, 94%) had a patent pancreaticojejunal anastomosis on 1-year MRI.ConclusionAlthough median 1-year fecal elastase was significantly lower than preoperatively, suggesting that exocrine secretion was altered, the anatomical outcome as assessed by MRI was excellent showing high patency rate (15/16, 94%) at 1 year. This emphasizes the difference between anatomy and function.

Clinical Profile, Etiology and Role of Endotherapy in Chronic Calcific Pancreatitis: An Experience from North India.

Background: In recent years, we have witnessed an evolving landscape in the management of chronic pancreatitis (CP). Endoscopy plays a pivotal role in CP management. Because the management of CP is problematic, we aimed to review and evaluate the role of endoscopy in the management of CP. Methods: This study was carried out in patients with painful chronic calcific pancreatitis who were admitted to the Department of Gastroenterology at the Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar. This was an observational prospective study. We included 67 patients with painful chronic calcific pancreatitis and pancreatic duct abnormalities (stones, strictures, or ductal variations) in our study. These patients had to access exocrine and endocrine status before any therapeutic measures. All the patients underwent endoscopic retrograde cholangiopancreatography (ERCP) as a therapeutic measure. After ERCP, the patients were followed up for 2 years to assess improvement in pain (visual analog scale score reduction), endocrine status (HBA1C reduction), or exocrine status (Fecal elastase reduction). Results: 67 patients were included in the study. Among them males were 32 (47.8%), females were 35(52.5%) and the age distribution studied were as in the age group of 15-30 years, patients were 23 (34.3%), in 30-45 years, there was 20 (29.9%), in age group of 45-60 year, patients were 20 (29.9%), and in the age group of 60-75 years, the patients were 4 (6%). Etiology was sought in all patients; alcohol-related CP was seen in three patients (4.5%), genetic in 11 (16.4%), IgG4 in one (1.5%), pancreatic divisum in 6 (9.0%), hyperparathyroidism in on1e (1.5%), and idiopathic in 45 (67.2%). All patients underwent ERCP for their symptoms to reduce ductal pressure, which is postulated as one of the hypotheses for pain in CP. Pancreatic duct (PD) clearance was attempted in all patients (complete in 42 [62.7%], partial in 17 [25.4%], and failed in 8 [11.9%]). These patients were followed for a period of two years after endotherapy, and the important predictors for pain reduction were single PD stones, disease in the head and body, and non-stricturing disease. Conclusion: Endotherapy offers a high rate of success in selected patients, clearance being better in distal disease and CP without PD strictures, suggesting early disease usually gets cleared very easily.

Comparison of MRCP and ERCP in the evaluation of common bile duct and pancreatic duct pathologies.

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging modality that has high diagnostic accuracy for a wide range of bile duct and pancreatic duct pathologies. Endoscopic retrograde cholangiopancreatography (ERCP) is still the gold standard for the exploration of the biliopancreatic region. The aim of the study was to compare the diagnostic accuracy of MRCP with that of ERCP in the diagnosis of bile duct and pancreatic duct pathologies. A total of 60 patients with common bile duct (CBD) and pancreatic duct pathologies detected on MRCP were subsequently evaluated by ERCP in this observational study. A comparison of MRCP findings with ERCP was made. MRCP had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 88.1%, 94.4%, 97.3%, 72.7%, and 90%, respectively, in diagnosing choledocholithiasis in comparison to ERCP. For CBD dilation, the sensitivity was 90.91%, specificity was 93.75% and the PPV, NPV, and accuracy were 97.56%, 78.95%, and 91.67%, respectively, for MRCP. In CBD stricture, MRCP showed a sensitivity, specificity, PPV, NPV, and accuracy of 83.33%, 97.92%, 90.91%, 95.92%, and 95%, respectively. In pancreatic duct dilatation, the sensitivity, specificity, PPV, NPV, and accuracy were all 100%. Pancreatic duct stricture showed a sensitivity, specificity, PPV, NPV, and accuracy of 80%, 98%, 88.89%, 96.08%, and 95%, respectively. For the diagnosis of periampullary carcinoma, the sensitivity, specificity, PPV, NPV, and accuracy rate of MRCP were 80%, 98%, 88.89%, 96.08%, and 95%, respectively. No significant difference was found between MRCP and ERCP in diagnosing those six pathologies.

Dilation of pancreatic duct strictures with a percutaneous transluminal angioplasty catheter

Dilation of pancreatic duct strictures with a percutaneous transluminal angioplasty catheter

Total pancreatectomy with remnant stomach preservation in a patient with a history of proximal gastrectomy and interposed jejunal reconstruction with right gastroepiploic conduit preservation: a case report

BackgroundPancreatic head resection following proximal gastrectomy jeopardizes the blood flow of the remnant stomach owing to right gastroepiploic conduit sacrifice, thereby necessitating total gastrectomy. However, owing to its high invasiveness, concomitant remnant total gastrectomy with pancreatectomy should be avoided as much as possible. Herein, we describe our experience of total pancreatectomy with right gastroepiploic conduit preservation in a patient with a history of proximal gastrectomy and reconstruction by jejunum interposition.Case presentationA 78-year-old woman with a history of gastric cancer was followed up at our institute for multiple intraductal papillary mucinous neoplasm, and main pancreatic duct stricture in the pancreatic head was newly detected. The cystic lesion was extended to the pancreatic body. Proximal gastrectomy and reconstruction by jejunal interposition were previously performed, and the mesenteric stalk of the interposed jejunum was approached through the retrocolic route. We planned total pancreatectomy with right gastroepiploic conduit preservation. Following adhesiolysis, the interposed jejunum and its mesentery lying in front of the pancreas were isolated. The arterial arcade from the common hepatic artery to the right gastroepiploic artery was detached from the pancreas. Furthermore, the right gastroepiploic vein was isolated from the pancreas. The pancreatic body and tail were pulled up in front of the remnant stomach, and the splenic artery and vein were resected. The pancreatic body and tail were pulled out to the right side, and the pancreatic head was divided from the pancreatic nerve plexus to the portal vein. The jejunal limb for entero-biliary anastomosis was passed through the hole behind the superior mesenteric artery and vein, and gastrointestinal anastomosis using the antecolic route and Braun anastomosis were performed.ConclusionsTo avoid remnant total gastrectomy, right gastroepiploic conduit preservation is an optional procedure for pancreatic head resection in patients who have undergone proximal gastrectomy with reconstruction by jejunal interposition.

Pancreatic duct strictures.

Pancreatic duct strictures.

Successful retrieval of a fractured migrated pancreatic stent using an endoscopic tapered sheath for severe pancreatic duct stenosis.

Successful retrieval of a fractured migrated pancreatic stent using an endoscopic tapered sheath for severe pancreatic duct stenosis.