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.     

Diagnosis and therapy of pancreas divisum

Pancreas divisum patients make up a small but problematic portion of ERCP cases. Minor papilla cannulation techniques have been improved. Recurrent pancreatitis patients generally benefit from minor papilla therapy. Methods to select patients who are likely to respond to invasive therapy need refinement. Clinicians and endoscopists are strongly encouraged to be cautious and conservative with this patient group until stronger data indicate optimal management schemes.     

Combined percutaneous-endoscopic therapy for recurrent pancreatitis and pancreas divisum

BACKGROUND: Oesophageal motility is often impaired in patients with megaduodenum and other forms of intestinal pseudo-obstruction in which a visceral myopathy or neuropathy may be present. Idiopathic longstanding megacolon with onset in adult life is still a poorly defined entity, which may also be part of a more widespread motility disorder but in which oesophageal motility has not been yet systematically studied. AIMS: To assess oesophageal motility in patients with longstanding idiopathic megacolon with onset in adult life. PATIENTS: 14 consecutive subjects with idiopathic megacolon whose symptoms began after the age of 10 and a clinical history of 2-22 years. METHODS: Standard barium enema, water perfused oesophageal manometry, and also anorectal manometry. RESULTS: Oesophageal motility was impaired in five patients (36%; 95% confidence intervals 16 to 61%). Normal peristalsis was substituted by low amplitude multiple peaked simultaneous contractions in four subjects and by undetectable contractions in one. In three of them the lower oesophageal sphincter did not relax after swallows; in the same patients anal relaxation after rectal distension was also undetectable. All five patients with impaired oesophageal motility had a colonic dilatation sparing the rectum. Three of them reported constipation and a history of pesudo-obstruction and the other two only abdominal distension. CONCLUSIONS: Oesophageal manometry should be performed in patients with longstanding idiopathic megacolon with onset in adult life, in particular if the rectum is not dilated and even in absence of pseudo-obstruction. This simple test may disclose a more widespread visceral neuropathy or myopathy. Such a diagnosis helps to better understand the cause of the colonic dilatation and may be clinically relevant for treatment of the patients.     

Pathogenesis of duct hyperplasia in the pancreas

Causative factors in duct hyperplasia were histologically examined by using 1,388 autopsied pancreases. Duct hyperplasia was frequent in pancreases having primary carcinoma and in those having necrotizing pancreatitis, but it was not frequent in those with interstitial pancreatitis, ductal pancreatitis, and other disorders. Duct hyperplasia was almost always found in ducts which connected with small ducts having a feature of adenomatous hyperplasia or ductular aggregation in foci of intralobular fibrosis. A histologic examination revealed that these fibrous foci are likely the vestiges of fat necrosis, mostly of a subclinical one.     

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.     

Definitive surgery for duct cell carcinomas of the pancreas

BACKGROUND AND DESIGN: As changes in the health care system aim to reduce the cost of medical care, physicians need to understand and be able to justify their reasons for referring patients. To learn the basis for making referrals, we asked 116 referring physicians why they made referrals to one university-based physician. We also assessed the referring physicians' satisfaction. RESULTS: A total of 112 of the 116 physicians responded in reference to 114 patients. The responses fit into five categories. Fifty of 114 patient were referred for therapy; 16 patients, for a diagnosis; and 16, for a combination of diagnosis and therapy. Other reasons in descending order of frequency were (1) a nondermatologist referring the patient to a dermatologist, (2) self-referral, ie, the patient was not referred by the physician, and (3) the patient's personality was difficult. The referring physicians were satisfied in 94 instances. CONCLUSIONS: The most frequent reason for referral was for therapy. This observation may be generally true for many physicians, since it is consistent with results of two other studies, in different fields, that we were able to find. Eighty-two percent of referrals were satisfactory to the referring physicians. Most of the physicians who were unsatisfied with the referral process stated they had not received a follow-up letter from the consulted physician.     

Intraluminal brachytherapy in the treatment of pancreas and bile duct carcinoma

PURPOSE: A new method of palliation of malignant obstructive jaundice is presented. METHODS AND MATERIALS: Twelve patients with carcinoma of the extrahepatic bile ducts (EHBD-five patients) or pancreatic head (PH-seven patients) received radiation therapy between 1988 and 1991. Percutaneous transhepatic biliary drainage was performed in four EHBD patients and an endoprosthesis was placed during endoscopic retrograde cholangiopancreatography (ERCP) in the other eight patients. All 12 received intraluminal brachytherapy (ILBT): 20-50 Gy calculated at 1 cm from the Iridium-192 (192Ir) wire. In four PH patients the source was placed in the duct of Wirsung; in the other eight patients ILBT was performed via the common bile duct. Five of the seven PH patients and one of the five EHBD patients received External Beam Radiation Therapy (EBRT): 26-50 Gy, alone or with concomitant 5-Fluorouracil (5-FU). RESULTS: Cholangitis occurred in six patients. Three PH patients treated with EBRT+ILBT developed gastrointestinal toxicities. With a minimum follow-up of 18 months, median survival times were 14 months (EHBD) and 11.5 months (PH); one of the seven PH patients is alive (29 months) and two of the EHBD patients are alive (18 and 43 months). All patients had satisfactory control of jaundice. CONCLUSIONS: The results in the EHBD patients suggest that the addition of ILBT after biliary drainage prolongs survival. Further experience is necessary to determine whether ILBT in the common bile duct and/or in the duct of Wirsung may be, in PH patients, an alternative boost technique to Interstitial Brachy-therapy (IBT) or Intraoperative Electron Beam Radiation Therapy (IOEBRT).     

Three-dimensional structure of the rat pancreatic duct in normal and inflammated pancreas

We observed the corrosion casts of the Wistar rats' pancreatic ducts with scanning electron microscopy (SEM), and their conventionally fixed pancreatic tissue with SEM and transmission electron microscopy (TEM). These findings revealed the following facts about the three-dimensional structure of pancreatic duct. (1) The interlobular and intralobular ducts branch like a tree, and the intercalated ducts wind and fork into two branches, although parts of the intercalated ducts anastomose with each other. The intercellular secretory canaliculi extend from the central lumina, which run straight through the center of the acini, finally approaching close to the basement membranes of acini. (2) The lumina of pancreatic ducts (i.e., the interlobular up to the intercalated ducts) are cylindric and have smooth surfaces. The luminal surface of each epithelial cell, however, is decorated by numerous microvilli and a single cilium. The length of the latter tends to be short in proportion to the diameter of pancreatic duct. Moreover the epithelial cell surfaces, which border each central lumen, have various densities of microvilli. (3) The intraductal cilium core is provided with nine microtubules, which is different from the number of microtubules encountered within the cilium core of uterine tube or bronchial epithelium. The number of microtubules in the cross-sectioned intraductal cilia decreases toward the distal portion of cilia. SEM and TEM observations on WBN/Kob rats' pancreatic ducts suggest that increased pancreatic ductal pressure causes the helical shape of the pancreatic ductal lumen. Such a helical form might also be caused by the protrusion of epithelial cell boundaries into their lumen and the hypertrophy and hyperplasia of epithelial cells, thus leading to the formation of numerous depressions equipped with elongated cilia.     

Hemangioendothelioma of the pancreas obstructing the common bile duct and duodenum

A 6-mo-old male with a hemangioendothelioma of the pancreas obstructing the common bile duct and duodenum required temporary bypass of these structures while awaiting involution of the tumor treated primarily by corticosteroids and radiation therapy.     

Pancreatic duct antibodies and subclinical insufficiency of the exocrine pancreas in Sj?gren''s syndrome]

AIM: To investigate prognostic factors and complications after radical hysterectomy followed by postoperative radiotherapy for carcinoma of the uterine cervix. PATIENTS AND METHODS: One hundred twenty-eight patients with T1b-2b carcinoma of the uterine cervix following radical hysterectomy with bilateral pelvic lymphadenectomy and postoperative radiation therapy were reviewed. Pathologic and treatment variables were assessed by multivariate analysis for local recurrence, distant metastases and cause specific survival. RESULTS: The number of positive nodes (PN) in the pelvis was the strongest predictor of pelvic recurrence and distant metastases. These 2 failure patterns independently affect the cause specific survival. The 5-year cumulative local and distant failure were PN(0): 2% and 12%, PN(1-2): 23% and 25%, PN(2 <): 32% and 57%, respectively (p = 0.0029 and p = 0.0051). The 5-year cause specific survival rates were PN(0): 90%, PN(1-2): 59% and PN(2 <): 42% (p = 0.0001). The most common complication was lymphedema of the foot experienced by one-half of the patients (5-year: 42%, 10-year: 49%). CONCLUSION: These results suggest that patients with pathologic T1b-T2b cervix cancer with pelvic lymph node metastases are at high risk of recurrence or metastases after radical hysterectomy with pelvic lymphadenectomy and postoperative irradiation.     

K-ras oncogene mutations in osteoclast-like giant cell tumors of the pancreas and liver: genetic evidence to support origin from the duct epithelium

Osteoclast-like giant cell tumors (OCGTs) of the pancreas and liver are enigmatic tumors. Despite their striking morphologic resemblance to certain mesenchymal tumors of bone and tendon sheath, it has been suggested that these tumors may, in fact, arise from epithelial precursors. It is also unclear whether the osteoclast-like giant cells in OCGTs are neoplastic or nonneoplastic. We identified OCGTs of the pancreas and liver that were associated with atypical intraductal epithelial proliferations or mucinous cystic neoplasms. To determine the relationship between the noninvasive epithelial proliferations and the infiltrating OCGTs, each individual component was analyzed for mutations at codon 12 of the K-ras oncogene. Four of the five-duct epithelial lesions harbored activating mutations of the K-ras oncogene. In each case, the same K-ras mutation was also present in the mononuclear cells from the paired OCGT. Moreover, these same mutations were detected when the osteoclast-like giant cells were individually microdissected and analyzed. A panel of immunohistochemical stains was performed, and the osteoclast-like giant cells demonstrated macrophage differentiation. These cells were consistently reactive for the monocyte/macrophage marker KP1, but showed absent staining for a panel of epithelial markers. The infiltrating mononuclear cells lacked strong staining for epithelial markers and monocyte/macrophage markers. These findings suggest that OCGTs of the pancreas and liver are undifferentiated carcinomas that arise directly from intraductal epithelial precursors. The finding of K-ras mutations in the osteoclast-like giant cells may reflect their propensity to phagocytize tumor cells.