Duodenal obstruction from chronic pancreatitis

The fibrosclerosing process of the pancreas in the chronic pancreatitis may constrict not only the pancreatic duct but also the bile duct, splenoportal venous system and duodenum. In our retrospective study we analysed 24 patients with duodenal obstruction associated with chronic pancreatitis. Duodenal obstruction was suspected whenever repeated vomiting occurred or large volumes of nasogastric aspirate were obtained. The diagnosis was confirmed by barium meal and endoscopic examination. Duodenal obstruction was relieved by gastrojejunostomy in eight patients, gastrojejunostomy and vagotomy in eight patients, gastroduodenostomy and vagotomy in two patients, vagotomy with Finney pyloroplasty in one patient, duodenoplasty with vagotomy in one patient and Whipple procedure in four patients. We concluded that vagotomy and gastroenterostomy are the procedures of choice. Bypass surgery is helpful to relieve the obstruction of the common bile duct and pancreatic duct. Whipple procedure should be reserved for the small duct form of chronic pancreatitis and for the cases in which there is high suspicion of malignancy.     

Chronic pancreatitis: nutrition and pain therapy

Therapy of chronic pancreatitis rests on five arms: Avoidance of alcohol, treatment of pain, replacement therapy for exocrine and endocrine insufficiency and adequate nutrition. Alcohol withdrawal improves pain and the patient's compliance. It also seems to retard the chronic inflammatory process. Therapy of pain depends on the pathomechanism of pain. There is a lack of prospective, controlled studies comparing various treatment regimens. Thus, treatment options are partly dependent on the experience of the physician taking care of the patient and include i.e. for pseudocysts: surgical vs percutaneous or endoscopic drainage; for stenosis of the main pancreatic duct close to the papilla: surgical vs endoscopic drainage (stents); for distal bile duct stenosis: endoscopic stents vs biliodigestive anastomosis vs pancreatic head resection; for pancreatic stones: extracorporal shock wave lithotripsy followed by endoscopic stone extraction vs surgery (pancreaticojejunostomy), finally for inflammatory tumor of the pancreatic head combined with pain with or without compression of the distal bile duct or duodenum: duodenum-preserving pancreatic head resection vs Whipple resection. Patients with pain resistant to medical treatment may be candidates for a transcutaneous blockade of the plexus coeliacus or for epidural nerve blockade before one choses a surgical procedure. Application of pancreatic enzymes does not seem to have a major beneficial effect on pancreatic pain. Modification of nutrition has become less restrictive. Thanks to improved substitution with acid resistant porcine pancreatic extracts with high lipase activity, fat restriction is no longer of paramount importance. However, supply with sufficient calories is still difficult due to pain, inadequate compliance and hypermetabolism.     

Heterotopic liver transplantation in rats: effect of intrahepatic islet isografts and split portal blood flow on liver integrity after auxiliary liver isotransplantation

BACKGROUND: Auxiliary heterotopic liver grafts atrophy in the absence of portal venous inflow; evidence suggests that an islet-derived hepatotrophic factor may exist in the portal drainage. Here we examine the effects of intrahepatic islet isografts in maintaining hepatocyte integrity in Wistar Furth rats with one of several types of arterialized auxiliary liver isografts. METHODS: In type 1 procedures the auxiliary liver was interposed into the recipient infrarenal vena cava and perfused through the graft portal vein with caval blood. In type 2 procedures the donor infrahepatic vena cava was anastomosed end-to-side to the recipient vena cava and the recipient portal vein was diverted to the graft portal vein. Both types of auxiliary grafts were arterialized; bile duct drainage was through the duodenum. Syngeneic islets were isolated and embolized into the portal veins of one half of the donor type 1 or native type 2 livers (1500 to 1700 islets). Finally, we performed six type 3 procedures in which a type 2 procedure was performed except that the portal blood flow was split so that the portal vein receiving the splenic, gastric, pancreatic, and duodenal drainage supplied the native liver and that the common mesenteric vein supplied the auxiliary graft with equivalent portal blood flow. Atrophy in heterotopic and native livers were compared for the three models after 3 months. RESULTS: Intrahepatic islets in type 1 auxiliary liver isografts without portal venous inflow did not prevent graft atrophy. Conversely, native livers deprived of portal venous inflow in our type 2 procedures, regardless of the presence of intrahepatic islet isografts, atrophied relative to auxiliary liver grafts in which portal venous inflow was provided by diverting the recipient's portal vein to the graft. In type 3 recipients atrophy was greater in the native livers than in the grafts. CONCLUSIONS: The results of our study suggest that islet-derived factors are not sufficient to prevent hepatocellular atrophy in auxiliary rat liver transplantation models and that a potent hepatotrophic factor may exist in the venous drainage of the bowel distal to the duodenum.     

Treatment of a postoperative cervical chylous lymphocele by percutaneous sclerosing with povidone-iodine

The development of postoperative leaks of the thoracic duct after neck dissection or vascular surgery of the subclavian and vertebral artery is a well-known but rare complication. Usually, an injury of the duct manifests immediately after the operation with chylous drainage. Presentation as a postoperative lymphocele is rare. Operative treatment may be an option, but identification of the leak often is impossible, resulting in a high rate of failure. Percutaneous catheter drainage in combination with sclerosis with povidone-iodine has proved to be highly effective in obliterating pelvic lymphoceles but has not been reported in patients who have undergone vascular surgery in the neck. We present a case in which a povidone-iodine solution was used successfully in percutaneous sclerosis of a cervical lymphocele after transposition of the left subclavian artery to the left common carotid artery.     

The genetic analysis of cancer

A previously unreported pancreatic duct was found by Liu (1989) in Pekin ducks. This duct has now been consistently found in six breeds of domestic ducks and six species of wild ducks in China. For purposes of Nomina Anatomica Avium it is hereby called the 'first pancreatic duct' (Ductus pancreaticus primus) since it enters the duodenum at or near the flexure where the descending duodenum becomes the ascending duodenum. All other pancreatic ducts enter the duodenum later, closer to where it joins the jejunum. This first pancreatic duct drains the caudal extremity of the dorsal lobe of the pancreas and can be easily exteriorized for experimental purposes. Within the parenchyma of the dorsal lobe of the pancreas this duct communicates with the dorsal pancreatic duct. In the present study of the gross anatomy of the pancreatic lobes of domestic and wild Chinese ducks we describe and illustrate variations in position and number of all biliary and pancreatic ducts.     

Postsurgical bile leaks: endoscopic obliteration of the transpapillary pressure gradient is enough

OBJECTIVES: Bile leaks are a well documented complication of biliary surgery, occurring more frequently with laparoscopic procedures. Endoscopic therapy with a long biliary endoprosthesis traversing the site of the leak is effective. We have evaluated the hypothesis that equalizing biliary and duodenal pressures with a short transpapillary stent is an equally effective therapy for bile leaks. METHODS: Thirty one consecutive patients presenting over a 52-month period with postsurgical bile leaks were evaluated. Patients had been treated with long endoprostheses (stents or nasobiliary tubes), sphincterotomy, or short transpapillary stents. The success, complication rate, need for additional therapy, and hospitalization time of each therapeutic approach were determined. RESULTS: Endoscopic therapy was successful in all 25 patients in whom a bile leak could be documented. The clinical success, need for radiological drainage, length of hospitalization, and incidence of pancreatitis were similar for all methods of treatment. CONCLUSIONS: These results confirm that endoscopic therapy is highly successful in the treatment of postoperative bile leaks and suggest that the mechanism of healing is the equalization of bile duct and duodenal pressures, allowing flow of bile into the duodenum. The endoscopic placement of short transpapillary stents without sphincterotomy is a temporary, effective, and technically simple method of pressure equalization. This should be considered as the primary therapy for most postoperative bile leaks.     

Cast syndrome: the superior mesenteric artery syndrome

Cast syndrome, clinically known as superior mesenteric artery syndrome (SMAS), is gastric dilatation with partial or complete obstruction of the duodenum. Although rare, it is most frequently seen in orthopaedic patients who have had spinal surgery or who are in hip spica or body casts. Obstruction occurs when there is compression of the duodenum between the superior mesenteric artery anteriorly and the aorta and spinal column posteriorly. Obstruction can occur within days of surgery or casting or may not develop for several weeks. Treatment for SMAS varies from conservative nonoperative to operative procedures. Complications can be severe if symptoms are not quickly recognized and treatment instituted in a timely manner.     

ERCP and CT findings of ectopic drainage of the common bile duct into the duodenal bulb

OBJECTIVE: The purpose of this study was to evaluate ERCP and CT findings of ectopic drainage of the common bile duct into the duodenal bulb. CONCLUSION: Although rare, the diagnosis of ectopic drainage of the common bile duct into the duodenal bulb is important to prevent inadvertent damage during biliary tract or gastric surgery and to clarify the cause of chronic peptic ulcers.     

Cancer arising in choledochal cyst and management

Biliary cancer develops in 20-30% of the patients with choledochal cyst and pancreatobiliary malunion. Some bile acid fractions and refluxed pancreatic enxymes into the bile duct is probably responsible for carcinogenesis. Cancer often develops in the extrahepatic bile duct and gallbladder, and rarely in the intrahepatic duct. In cystic dilatation, cancer often occurs in the common bile duct, while in diffuse or non-dilated type it occurs in the gallbladder. Cancer usually occurs in younger patients than does biliary cancer in general population, and the average age is in the 40s. The risk of malignancy in cysts with internal drainage is higher than that in primary cysts, and early removal of the retained cyst should be performed as quickly as possible. Although the prognosis of biliary cancer is usually dismal, aggressive procedures are recently gaining better results than that by conventional methods. The prevention of cancer is the procedure of choice by early excision. Removal of the whole extrahepatic bile duct is necessary, even in case of malunion with no biliary dilatation. Cancer rarely arises in the intrahepatic duct after excisional surgery, due to long standing biliary stricture. Wide anastomosis with ductoplasty should be essential. Cancer also occurs in the remnant duct. Excision of the distal duct in the pancreas is also necessary.     

Value of endoscopy in the treatment of chronic pancreatitis]

Endoscopic treatment in patients with chronic pancreatitis involves several features: sphincterotomy of the wirsung, dilatation, insertion of a prosthesis, cystoenterostomy, cystowirsungostomy. Extracorporal lithotrity is often associated. Endoscopic treatment appears to give satisfactory short-term results in cases with pain, pseudocyst or pancreatic fistula. Morbidity is low. The optimum duration of endoscopic drainage via the prosthesis is still a question of debate and the long-term efficacy remains to be demonstrated. Endoscopic treatment is indicated in patients with a definitive or temporary surgical risk or may be indicated for all symptomatic patients. In this case, endoscopic treatment would be used as a therapeutic test. Stenosis of the main bile duct is not at present a good indication for endoscopic treatment as this stenosis is resistant to balloon dilatation and prosthesis calibration.     

Factors associated with elevated rates of adverse outcomes after cyclodestructive procedures versus drainage device procedures

OBJECTIVE: To identify factors associated with an increased risk of adverse outcomes after cyclodestructive or drainage device procedures. DESIGN: Retrospective, cohort analysis. PARTICIPANTS: A total of 5570 Medicare patients who were older than 65 years of age and who underwent cyclodestructive or drainage device procedures in 1994 participated. INTERVENTION: The authors identified cyclodestructive and drainage device procedures from claims to the Health Care Finance Administration (HCFA) by International Classification of Diseases (ICD-9) procedure codes, Current Procedural Terminology procedure codes, and HCFA Common Procedural Classification System codes. The authors analyzed adverse outcome rates using hierarchical logistic regression. Race, age group, gender, length of observed follow-up, state in which surgery took place, ocular procedures performed before and at the same time as the index surgery, and ocular diagnosis were included as covariates in the model. MAIN OUTCOME MEASURES: The authors defined an adverse outcome as the occurrence after the index surgery of at least one of the following: repeat cyclodestructive or drainage device procedure, retinal hole-tear repair, retinal detachment repair, surgery for endophthalmitis, vitrectomy, enucleation, evisceration, surgery for ocular hypotony, and/or extrusion or revision of drainage device. Adverse outcomes were also defined without the inclusion of repeat cyclodestructive or drainage device procedures. RESULTS: When repeat cyclodestructive or drainage device procedures were not included in the definition of an adverse outcome, eyes with a drainage device procedure were 3.8 times more likely to have an adverse outcome than eyes with a cyclodestructive procedure (odds ratio [OR], 3.8; 95% confidence interval [CI], 3.07, 4.67). Subjects with concurrent corneal transplant had increased odds of an adverse outcome compared to subjects without a concurrent corneal transplant (OR, 2.00; 95% CI, 1.27, 3.15). When the definition of an adverse outcome included repeat cyclodestructive or drainage device procedures, the odds of an adverse outcome were similar for both cyclodestructive and drainage device procedures (OR, 0.94; 95% CI, 0.79, 1.13). CONCLUSIONS: Cyclodestructive procedures need to be repeated more frequently than drainage device procedures. However, if the patient has a drainage device procedure, then that patient is more likely to have other types of adverse ophthalmic events than if he or she had a cyclodestructive procedure. Because the average follow-up of subjects in this study is 5 months (range, 0-12 months), outcomes that might take longer to manifest themselves would be excluded from this study.     

Endoscopic therapy of pancreas divisum

Pancreas divisum is the most frequent congenital ductal anomaly of the pancreas: it occurs in 5-10% of the population. In the majority of patients, this congenital anomaly is of no clinical importance. In a certain subset of patients, however, pancreas divisum is clinically important as a cause of abdominal pain, acute recurrent pancreatitis or chronic obstructive pancreatitis. The authors, experience on endoscopic drainage of the minor papilla is reported. In the history of patient 1., three episodes of recurrent pancreatitis and permanent upper abdominal pain were explored. ERP revealed a pancreas divisum and a mild irregularity and dilation of the dorsal pancreatic duct. A 7 F stent (length: 6 cm) was implanted in the dorsal pancreatic duct following a papillotomy on the stenotic minor papilla. A repeated Lundh test revealed a 58% improvement in the exocrine pancreatic function. No recurrence of pancreatitis has been observed in spite of the moderate continuous abdominal pain. In patient 2., ERP demonstrated a pancreas divisum and a severely dilated dorsal pancreatic duct as causes of the previous permanent abdominal pain. An 8 F stent (length: 5 cm) was inserted through the minor papilla without endoscopic sphincterotomy. A significant improvement in exocrine pancreatic function (70%) ensued. No abdominal pain has since been observed. In conclusion, dorsal pancreatic duct stenting (mainly in cases involving a dilated pancreatic duct) seems to have a beneficial effect in patients with both recurrent acute pancreatitis or chronic obstructive pancreatitis evoked by pancreas divisum.     

Laparo-endoscopic "rendezvous": a new technique in the choledocholithiasis treatment

BACKGROUND/AIMS: Endoscopic sphincterotomy for common bile duct stone clearance during laparoscopic cholecystectomy may fail due to difficulties in cannulating the papilla major. In this study we propose a new technique that facilitates the cannulation of the papilla and the common bile duct stone clearance during a standard laparoscopic cholecystectomy. Its clearance percentage, complication rate and post-operative stay have been evaluated and compared with standardized procedures such as open surgery and endoscopic sphincterotomy before laparoscopic cholecystectomy. METHODOLOGY: In a group of 16 patients presenting with cholelithiasis and common bile duct stones or papillitis, the sphincterotome was driven across the papilla into the choledochus by a Dormia basket passed in the duodenum through the cystic duct during laparoscopic cholecystectomy. Measures of outcome were clearance rate, mortality, morbidity and hospital stay. Furthermore, data obtained from this sample of patients were compared with those from another two groups of 16 patients in which choledocholithiasis was managed either by endoscopic sphincterotomy performed before laparoscopic cholecystectomy or by open cholecystectomy and trans-duodenal sphincterotomy. RESULTS: The rate of cannulation of the papilla and of the common bile duct stone clearance was 100% when the combined endo-laparoscopic approach was used in 15 patients with endoscopic sphincterotomy (93,7%) and in 15 patients with open sphincterotomy (93,7%), cholecystectomy was successful in every case. The groups were statistically similar with regard to complications; none of the patients required blood transfusion. The mean post operative stay was 95.2 hours (range 48-240) for the first group, 350.1 hours (range 192-1680) for the second and 69.7 hours (range 24-132) for the third. CONCLUSION: The laparo-endoscopic rendezvous, though still in evolution, is an efficacious method which can be used during the laparoscopic strategy of common bile duct clearance.     

Retrograde pancreatography. Technical tips and spectrum of pathology

ERP is an important technique in the diagnosis of diseases involving the pancreatic ducts, in determining therapeutic strategy, and in assessing the results of surgical bypass procedures. ERP facilitates the diagnosis of the majority of pancreatic tumors at a stage when they normally present to the clinician. It assists the diagnosis of small tumors in the ampullary region at an early stage when other tests are negative. In cases of obscure recurrent pancreatitis, ERP may identify a mechanical cause (e.g., stone, stricture). ERP is useful in the diagnosis of CCP only in the precalcified stage. If histologic confirmation already has been obtained at surgery, ERCP is not required. Compared with noninvasive techniques, ERP provides additional information: It enables a concomitant examination of the gastroduodenal tract and opacification of the bile ducts; additional procedures may be performed, such as intraductal cytologic brushings, biochemical and cytologic analysis of pancreatic juice, endoscopic manometry, and pancreatoscopy. The diagnostic yield is increased if these procedures are performed during ERCP. Because ERP outlines the ductal anatomy, it is of great value in assessing therapeutic strategy. In cases of acute recurrent pancreatitis or chronic pancreatitis, ERP provides an important baseline for performing procedures such as ductal drainage and therefore reduces the inappropriate use of exploratory laparotomy. In cases of necrotic pancreatitis or pancreatic trauma, ERP enables accurate localization of a pancreatic fistula and facilitates any subsequent surgical procedure. Finally, ERP is the method of choice when assessing the patency of pancreatic-digestive anastomosis.     

Characteristics and treatment of mucin-producing tumor of the pancreas

BACKGROUND/AIMS: There has been no thorough clinicopathological analysis of a large number of cases with mucin-producing tumor of the pancreas. The aim of this study was to investigate the clinicopathological features of and therapeutic strategy for this ailment. METHODOLOGY: Two hundred and fifty-nine cases of mucin-producing tumor of the pancreas were analyzed clinicopathologically. RESULTS: Mucin-producing tumor of the pancreas was found in 177 males and 82 females (M:F=2.2:1). The mean age was 65.5 years. Jaundice, diabetes mellitus and a past history of pancreatitis were found in 15-19% of the cases. The tumor was most frequently (62%) found in the head of the pancreas. Pathologically, hyperplasia or adenoma was found in 58 cases, and adenocarcinoma in 160 cases. Five-year survival rate by the Kaplan-Meier method was 82.6% in all of the cases, and the post-operative survival curve was much better in cases with this type of carcinoma than in cases with ordinary pancreatic duct cell carcinoma (5-year survival rate: 17.3%). Organ-function preserving procedures, such as duodenum preserving subtotal resection of the head of the pancreas or spleen preserving distal pancreatectomy, might be recommended for this disease without infiltration. CONCLUSIONS: Mucin-producing tumor has unique clinicopathological characteristics, such as the dilated main pancreatic duct or branches, dilatation of the orifice of the papilla of Vater, or a good prognosis. Organ-function preserving procedures should be recommended in some cases with this ailment.     

Duodenal obstruction by gallstones (Bouveret's syndrome). Presentation of a new case and literature review

Bouveret's syndrome is a rare entity consisting in a duodenal obstruction due to the passage of gallstones from the gallbladder to the duodenum through a cholecystoduodenal fistula. Approximately 225 cases are reported in the literature. It is most common in old women with a previous history of biliary tract disease. The clinical picture is nonspecific and pre-operative diagnosis is not easy. Oral endoscopy is the main diagnostic procedure and sometimes, a therapeutic option, too. Surgery is the elective treatment specially when endoscopy is unsuccessful. We report a new case of this syndrome successfully treated by surgery, and an extensive review of the literature concerning this issue, focusing mainly on the clinical findings, diagnosis, therapeutic procedures and results. We conclude that Bouveret's syndrome is rare but more frequent in older females with previous biliary disease, better diagnosed by pyloric obstruction syndrome, plain abdominal x-ray, ultrasonography, contrast gastric study and/or gastroscopy (confirming and best procedure). When conservative endoscopic procedure fails, surgical treatment must be carried out, thus obtaining good results.     

Clinical evaluation of 99mTc-pyridoxylideneglutamate for hepatobiliary scanning

Clinical evaluation of hepatobiliary scanning using 99mTc-PG was done in twenty normal volunteers and eighty-three patients with liver and biliary tract disease. Satisfactory images of the biliary tract were obtained using small dosages of this agent. In normal humans, the agent reached the liver in 5 minutes, and the common bile duct, gallbladder, and duodenum in 10 to 20 minutes. The gallbladder was not visualized when the cystic duct was obstructed in patients with acute and chronic cholecystitis. In patients with partial common bile duct obstruction, a distended duct was visualized and there was delay in transit of radioactivity into the duodenum. With complete common bile duct obstruction, no radioactivity was seen in the biliary or gastrointestinal tracts up to 24 hours after injection. Hepatocellular disease was characterized by delayed liver clearance and delayed visualization of the biliary and gastrointestinal tracts. There were no toxic or other untoward effects in any patients.     

Clinical evaluation of pulsed ND:YAG dental laser applied on oral soft tissues

This investigation was conducted to evaluate the pulsed Nd: YAG dental laser, as a surgical tool for many of the oral surgical procedures. Gingivoplasty, minor gingivectomy, operculectomy excision of pedunculated tumors, frenectomy, incision and drainage of oral abscesses, control of oral bleeding and many other procedures were included in the study. The results presented here suggest that the pulsed Nd: YAG laser can be used to cut efficiently through vascular tissues, necrotic tissues and thin pedunculated masses. So it could be considered selective but not conclusive in surgery of the oral soft tissues.     

Ventral pancreatic resection for adenoma and low-grade malignancies of the head of the pancreas

The head of the pancreas can be anatomically divided into two sections, one drained by the duct of the Santorini system, and the other drained by the ventral pancreatic duct. This study was undertaken to determine whether independent resection of the ventral pancreas drained by the ventral pancreatic duct could be performed safely and effectively, by employing the following method in four patients. First, the duodenum and pancreas were sufficiently separated preserving the mesoduodenum and the posterior pancreaticoduodenal artery. Next, the main pancreatic duct was divided at the papillary portion, and sectioned at its junction with the duct of Santorini, ensuring preservation of the intrapancreatic bile duct. After the ventral pancreas had been detached from the glistening intrapancreatic bile duct, the ventral pancreas was connected with the dorsal pancreas by only the pancreatic parenchyma. The ventral pancreatic resection was completed following the incision of this border. A pancreatic fistula developed in one patient postoperatively, but this healed within 30 days. The hospital stay after surgery ranged from 35 to 58 days, and a good quality of life was maintained in all four patients. Thus, we conclude that ventral pancreatic resection can be safely performed and is especially valuable for treating the increasingly frequent adenomas and borderline malignancies in the main pancreatic duct system of the head of the pancreas.     

The role of nuclear scintigraphy of suspected bile duct injury following laparoscopic cholecystectomy

Nuclear scintigraphy is a rapid and non-invasive tool for the diagnosis of suspected bile duct injury following laparoscopic cholecystectomy. We describe our experience with this technique in 19 out of more than 1,000 cases of laparoscopic cholecystectomy in our department. Of the five patients in whom nuclear scintigraphy revealed abnormalities, three showed bile leak to the peritoneum and underwent immediate laparotomy. Only one of these required choledochojejunostomy; in the others the leak would have closed spontaneously without surgery. In the remaining two patients there was apparently no passage to the duodenum on nuclear scintigraphy. Endoscopic retrograde cholangiopancreatography (ERCP) performed in one showed a normal bile duct. In the other patient, repeated scintigraphy done 12 h later, prior to ERCP, showed normal passage to the duodenum. Our experience indicates that laparotomy could have been avoided had ERCP been performed first. Therefore, we suggest that if nuclear scintigraphy fails to demonstrate passage to the bowel or shows a bile leak, ERCP is indicated.