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Compared with acute pancreatitis caused by other factors， hyperlipidemic acute pancreatitis often has a higher rate of severe conditions， greater difficulties in predicting prognosis， and a more complex and unclear pathogenesis. At present， the pathogenesis of hyperlipidemic acute pancreatitis may be associated with the elevation of serum free fatty acids， but the lipid-lowering treatment regimens do not reduce the incidence rate of this disease. Recent studies have further confirmed that pancreatic duct hypertension is an important pathogenesis of acute pancreatitis. The latest research advances have shown that hyperlipidemia can lead to pancreatic duct obstruction by causing pancreatic duct hyperplasia， forming protein embolism at the biliary-pancreatic junction， and damaging the secretory function of the pancreatic duct， while pancreatic duct obstruction can in turn cause pancreatic duct obstruction. This article reviews the latest research advances in hyperlipidemia in causing pancreatic duct obstruction and emphasizes that pancreatic duct hypertension is one of the important pathogeneses of hyperlipidemic acute pancreatitis， which will provide new ideas for exploring the pathogenesis of hyperlipidemic acute pancreatitis.
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El síndrome del ducto pancreático desconectado (SDPD) consiste en la disrupción del ducto pancreático principal con pérdida de continuidad entre el remanente pancreático distal viable y el tracto gastrointestinal, generalmente causado por necrosis ductal secundaria a pancreatitis aguda grave. Esto resulta en fuga de fluido pancreático, provocando un curso de enfermedad prolongado y complicaciones. La literatura sobre este tema es limitada, con algoritmos de tratamiento poco claros. Hemos realizado una revisión de la literatura sobre el tema. Revisión en Pubmed y Scielo (2011-2021) de artículos en inglés y español utilizando términos «síndrome del conducto pancreático desconectado», «DPDS» y «páncreas desconectado» encontrando 16 artículos relevantes. Dadas las pocas citas, se revisaron las referencias de estos artículos. Finalmente, revisamos un total de 21 artículos. Entre las referencias encontradas existe 1 metaanálisis, 4 estudios prospectivos y no existen ensayos aleatorizados.
Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the viable upstream pancreatic parenchyma and the gastrointestinal tract, generally caused by ductal necrosis after severe acute necrotizing pancreatitis. This compromised ductal integrity leads to extraductal leakage of pancreatic secretions, causing a prolonged disease course and complications. The existing literature is limited, with unclear therapeutic algorithms. We have performed a review of the literature on DPDS. Review in Pubmed and Scielo (2011-2021) of articles in English and Spanish using the terms "disconnected pancreatic duct syndrome", "DPDS" and "disconnected pancreas" finding 16 relevant articles. Given the few citations, the references of these articles was reviewed. Finally, we found 21 articles. Among them, there is one meta-analysis, 4 prospective studies and no randomized trials.
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Objective:To explore the preventive effects of pancreatic duct stent combined with rectal administration of indomethacin suppository for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after difficult bile duct intubation during endoscopic retrograde cholangiopancreatography (ERCP).Methods:From January 2019 to December 2021, patients with biliary and pancreatic diseases undergoing ERCP in Hangzhou Hospital Affiliated to Nanjing Medical University were given 100 mg indomethacin suppository to anal canal 30 minutes before the operation. And those with difficult bile duct intubation during the operation ( n=204) were included in this study. According to the random number table, they were divided into the combination group (implanted with pancreatic duct stent during the operation, n=104) and the indomethacin group (not implanted with stent, n=100). The incidences of hyperamylasemia and PEP were compared between the two groups. Results:The incidences of postoperative hyperamylasemia [21.2% (22/104) VS 34.0% (34/100), χ2=4.22, P=0.040] and PEP [14.4% (15/104) VS 32.0% (32/100), χ2=8.88, P=0.003] in the combination group were significantly lower than those in the indomethacin group. There was no significant difference in the incidence of severe PEP between the two groups [1.0% (1/104) VS 1.0% (1/100), χ2=0.001, P=0.978]. Conclusion:Compared with rectal administration of indomethacin suppository alone, the incidences of hyperamylasemia and PEP after difficult bile duct intubation during ERCP can be further reduced when it is combined with pancreatic duct stent placement.
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Objective:To investigate the value of the extrahepatic bile duct and main pancreatic duct segment patterns on magnetic resonance cholangiopancreatography (MRCP) for differentiating the periampullary carcinoma (PAC).Methods:The clinicopathologic data of 125 patients with PAC who were admitted to Wuxi No.2 People’s Hospital from June 2013 to December 2021 were retrospectively analyzed, including 72 males and 53 females, aged (64.9±8.6) years. According to its anatomy, the extrahepatic bile duct (B) was divided into suprapancreatic and intrapancreatic (including ampullary) segments, and the main pancreatic duct (P) was divided into tail-body and head segments. MRCP patterns: i. the extrahepatic bile duct or main pancreatic duct visible without dilatation, ii. cutoff of the distal extrahepatic bile duct or main pancreatic duct with upstream dilatation, iii. cutoff of the intrapancreatic or head segment with upstream dilatation and remnant intrapancreatic or head segments invisible, iv. cutoff of the intrapancreatic or head segment with upstream dilatation and nondilated remnant intrapancreatic or head segments, were represented as 0, 1, 2, and 3, respectively. Segment patterns of B1/P0+ B1/P1, B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3, B3/P0, and B0/P0+ B2/P0 on MRCP were compared in PAC patients.Results:Of the 125 patients, there were 57 (45.6%) with pancreatic head carcinoma, 36 (28.8%) with ampullary carcinoma, 20 (16.0%) with distal cholangiocarcinoma, and 12 (9.6%) with periampullary duodenal carcinoma. Segment patterns of B0/P2+ B0/P3+ B2/P2+ B2/P3+ B3/P3 were found in 52 patients with pancreatic head carcinoma (91.2%, 52/57), with a significant difference between PAC (χ 2=110.66, P<0.001). Segment patterns of B1/P0+ B1/P1were found in 36 patients with ampullary carcinoma (100.0%, 36/36), fallowed by 11 (91.7%, 11/12) with periampullary duodenal carcinoma, with a significant difference between PAC (χ 2=129.95, P<0.001). Segment pattern of B3/P0 presented in 16 patients with distal cholangiocarcinoma (80.0%, 16/20), with a significant difference between PAC (χ 2=62.45, P<0.001). The segment patterns of B0/P0+ B2/P0 were only seen in 3 of 57(5.3%) patients with pancreatic head carcinoma. Conclusion:On MRCP, cutoff of the head segment with upstream dilatation and remnant head segment invisible or nondilated indicates the pancreatic head carcinoma. Cutoff of the intrapancreatic segment with upstream dilatation, remnant intrapancreatic segment visible, and main pancreatic duct nondilated, indicates the distal cholangiocarcinoma. And cutoff of the distal extrahepatic segment with upstream dilatation and main pancreatic duct dilatation or not, indicates the ampullary or periampullary duodenal carcinoma.
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Objective:To analyze the medical imaging in misdiagnosing serous cystic neoplasm(SCN) of the pancreas with pancreatic duct dilatation as other pancreatic lesions.Methods:Data of 21 patients with SCN and pancreatic duct dilatation who underwent surgical resection from January 2011 to November 2021 at the First Affiliated Hospital of Naval Medical University were retrospectively analyzed. There were 9 males and 12 females with ages ranging from 25 to 74, mean ± s. d. (57.4±13.4) years. The clinical features, surgical treatments, CT and MRI imaging features, and misdiagnosis were analyzed.Results:Of 11 patients who presented with abdominal pain, 1 patient had backache, 1 patient was jaundice, 1 patient had weight loss, 1 patinet had fatigue and 6 patients were asymptomatic. Ten patients were operated using pancreaticoduodenectomy, 8 distal pancreatectomy, 2 segmental pancreatectomy and 1 total pancreatectomy. For 11 patients, the lesion was located in the head of pancreas, and for 10 patients in the body and tail of pancreas. The tumor size was 23.0-92.0 (45.8±17.8) mm. All 21 patients had upstream pancreatic duct dilatation but no downstream pancreatic duct dilatation. The inner diameter of the pancreatic duct was 4.0-11.0(7.1±2.0) mm. Of 13 patients showed a low signal intensity on T 1-weighted imaging, 18 patients showed a markedly high signal intensity on T 2-weighted imaging, 13 patients showed no limitation on diffusion weighted imaging. Among the 11 patients who underwent CT examination, 5 patients were diagnosed to have intraductal papillary mucinous neoplesm (IPMN), 3 SCN, 1 pancreatic neuroendocrine tumor, 1 pancreatic cancer and 1 cyst. The misdiagnotic rate of CT was 72.7% (8/11). Among the 18 patients who underwent MRI examination, 9 patients were diagnosed to have IPMN, 3 mucinous cystic neoplasm, 3 SCN, 2 pancreatic cancer and 1 solid pseudopapillary tumor. The misdiagnosis rate of MRI was 83.3% (15/18). Conclusion:SCN with pancreatic duct dilatation was easily misdiagnosed as IPMN or other pancreatic solid tumors. The difference between SCN with pancreatic duct dilatation and IPMN was that the downstream pancreatic duct of SCN was normal. SCN showed a markedly high signal intensity on T 2-weighted imaging and no limitation on diffusion weighted imaging, which can help to distinguish SCN from other pancreatic solid tumors.
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There are many methods of pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy. It is suggested that the formation of "sinus healing" by pancreaticojejunostomy benefits pancreatic juice extravasation and intestinal fluid reflux. The healing of fibrous layer is based on mechanical connection, and there are various forms of connection. Our team summarized the experience since laparoscopic pancreaticoduodenectomy, using the improved "double needle pancreaticoenterostomy" and combined with "variable diameter measurable drainage catheter" to support the pancreatic duct to form "sinus healing" at the pancreaticointestinal anastomosis.The main techniques and experiences are summarized as follows.
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Objective:To investigate the effect of different drainage methods on pancreatic fistula after pancreaticoduodenectomy (PD).Methods:The data of all patients with PD in Xijing Hospital, the First Affiliated Hospital of the Fourth Military Medical University from January 2007 to December 2018 were retrospectively analyzed. A total of 670 patients were enrolled, including 415 males and 255 females, aged (58.4±7.3) years, ranging from 24 to 82 years. According to the different method of pancreatic duct drainage, the propensity score was matched, and the patients were divided into internal drainage group ( n=529) and external drainage group ( n=141). The pancreatic fistula rate was compared between the two groups. Factors influencing pancreatic fistula after PD were analyzed by univariate and multivariate logistic regression. Results:The incidence of pancreatic fistula in the internal drainage group was 12.5% (66/529), which was significantly higher than that in the external drainage group 6.4% (9/141) (χ 2= 4.16, P=0.041). Multivariate logistic regression analysis showed that age ≥65 years ( OR=2.004, 95% CI: 1.185-3.390), complicated with digestive diseases ( OR=3.087, 95% CI: 1.599-5.959), history of upper abdominal surgery ( OR=2.031, 95% CI: 1.104-3.734) increased the risk of pancreatic fistula after PD (all P<0.05), decreased the risk of pancreatic fistula after PD in patients with external drainage ( OR=0.470, 95% CI: 0.223-0.989, P=0.047), and decreased the risk of pancreatic fistula after PD with the tumor size ( OR=0.725, 95% CI: 0.556-0.944, P=0.017), tumor located in the common bile duct after PD increased the risk of pancreatic fistula ( OR=1.497, 95% CI: 1.192-1.880, P=0.001). Conclusions:Compared with pancreatic duct drainage, external pancreatic duct drainage is better because of preventing postoperative pancreatic fistula.
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Resumen Se presentan 6 pacientes con disrupción ductal del páncreas (DDP) tratados mediante drenaje percutáneo guiado por imágenes con apoyo de la endoscopia. Inicialmente, los pacientes presentaron necrosis pancreática infectada tratada con drenaje percutáneo transgástrico y luego de resolver la infección desarrollaron DDP. En el estudio por imágenes se diagnosticaron 4 pacientes con disrupción ductal parcial y 2 con disrupción total, a quienes se les indicó la colocación de una prótesis transgástrica percutánea para lograr el drenaje del líquido pancreático hacia el estómago. La duración promedio de la prótesis fue de 183 días; no hubo casos de mortalidad. Se pudo evidenciar que esta opción terapéutica mínimamente invasiva tiene baja morbimortalidad, por lo que se plantea el abordaje percutáneo transgástrico apoyado por la endoscopia como posible tratamiento de la DDP.
Abstract A total of six patients with pancreatic ductal disruption (PDD), treated with image-guided endoscopy percutaneous drainage were enrolled. Initially, patients had infected pancreatic necrosis, treated with transgastric percutaneous drainage, and after the infection was controlled, they developed PDD. In the imaging study process, four patients were diagnosed with partial duct disruption and two patients with complete duct disruption. In both cases the placement of a percutaneous transgastric prosthesis to drain the pancreatic fluids to the stomach was indicated. The prosthesis remained 183 days on average and there were no mortality cases. This therapeutic minimally invasive alternative has low rates of morbimortality and thus, the endoscopy percutaneous transgastric approach is considered as a viable treatment in PPD.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Pancreas , Drainage , Pancreatitis, Acute Necrotizing , Patients , Stomach , Endoscopy , InfectionsABSTRACT
Resumen Objetivo: Presentar el caso de un paciente masculino adulto joven, con ascitis pancreática secundaria a lesión del conducto pancreático por trauma abdominal cerrado, tratado con éxito con terapia conservadora. Materiales y Método: Datos e imágenes recopilados de la historia clínica del Hospital Universitario de Santander, previo consentimiento informado. Resultados: Sexo masculino de 21 años con antecedente de trauma abdominal cerrado, quien consulta por distensión, dolor abdominal progresivo y pérdida de peso no cuantificada. Ante sospecha de lesión de conducto pancreático se solicitó pancreatografía por resonancia magnética que evidencia una alteración del segmento proximal del conducto pancreático principal asociado a lesión quística en el borde anterior de la unión de la cabeza con el cuerpo pancreático. Se decidió manejo conservador por 4 semanas con colocación de dren abdominal, reposo intestinal, asociado a nutrición parenteral total y análogos de somatostatina. Discusión: Un 5% del trauma abdominal cerrado puede provocar pancreatitis y fugas en el conducto pancreático. Conclusión: La lesión del conducto pancreático principal debe sospecharse en todos los pacientes con trauma abdominal cerrado. El manejo debe realizarse con una planificación cuidadosa y exhaustiva.
Aim: To present the case of a young adult male patient, with pancreatic ascites secondary to pancreatic duct injury due to blunt abdominal trauma, treated successfully with conservative therapy. Materials and Method: Data and images were obtained from the clinical chart of the "Hospital Universitario de Santander" with prior informed consent. Results: 21-year-old male patient with a blunt abdominal trauma background, who consulted for distension, progressive abdominal pain, and subjective weight loss. Due to suspicion of a pancreatic duct injury, a magnetic resonance cholangiopancreatography was requested, which showed an alteration of the proximal segment of the main pancreatic duct associated with a cystic lesion at the anterior border of the junction between the pancreatic head and body. Treatment consisted of a 4-week conservative therapy with the placement of an abdominal drain, bowel rest, associated with total parenteral nutrition and somatostatin analogs. Discussion: A 5% of blunt abdominal trauma can cause pancreatitis and pancreatic duct leaks. Conclusión: Pancreatic duct injury should be suspected in every patient with blunt abdominal trauma. Management must be done with careful and thorough planning.
Subject(s)
Humans , Male , Young Adult , Pancreatic Diseases/diagnosis , Pancreatic Diseases/etiology , Ascites/etiology , Ascites/diagnostic imaging , Cysts/diagnosis , Cysts/etiology , Abdominal Injuries/complicationsABSTRACT
Objective:To investigate the clinical efficacy of early pancreatic duct stenting in the treatment of acute pancreatitis.Methods:The retrospective and descriptive study was conducted. The clinical data of 201 patients with acute pancreatitis who were admitted to General Hospital of Ningxia Medical University from October 2011 to December 2017 were collected. There were 106 males and 95 females, aged from 18 to 90 years, with a median age of 62 years. Of 201 patients, there were 178 cases with moderate severe acute pancreatitis and 23 cases with serious severe acute pancreatitis. Patients were treated with pancreatic duct stenting within 48 hours after admission. Observation indicators: (1) treatment; (2) follow-up. Follow-up was conducted using outpatient examination and telephone interview to detect recurrence of acute pancreatitis after surgery up to June 2019. Measurement data with normal distribution were represented by Mean± SD, and the independent sample t test was used for comparison between groups, and the matched samples t test was used for comparison between before and after. Measurement data with skewed distribution were represented by M( P25 ,P75) or M(range), and the Mann-Whitney U test was used for comparison between groups, and the Wilcoxon signed rank sum test was used for comparison between before and after. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test . Results:(1) Treatment: 201 patients received pancreatic duct stenting successfully, 63 of which were detected pancreatic obstruction with white-floc. The interval time from admission to surgery , operation time, time for initial oral intake, duration of hospital stay and hospital expenses of 201 patients were 10 hours(4 hours,22 hours), (35±15)minutes, 3 days(2 days,5 days), 6 days(5 days,10 days) and 3.8×10 4 yuan (3.0×10 4 yuan,4.9×10 4 yuan). Of 201 patients, 22 patients were transferred to intensive care unit, including 1 case with serious severe underwent inhospital death and 1 case with moderate severe and 7 cases with serious severe underwent auto-discharge from hospital. There were 25 cases with local complications, including 17 cases with pancreatic infectious necrosis, 7 cases with pancreatic walled-off necrosis and 1 case with spleen infarction. All 25 patients were cured after surgical inter-vention or conservative treatment. Further analysis showed that cases being transferred to intensive care unit, cases undergoing surgical treatment, the time for initial oral intake, duration of hospital stay and cases undergoing auto-discharge from hospital were 6, 11, 3 days(2 days,5 days), 6 days(5 days,10 days) and 1 for the 178 moderate severe cases, versus 16, 5, 7 days(4 days,9 days), 9 days (7 days,17 days) and 7 for the 23 serious severe cases, showing significant differences ( χ2=91.561, 6.730, Z=6.485, 5.463, χ2=47.561, P<0.05). The white blood cell count, serum amylase indexes and chronic health evaluation Ⅱ score of 201 patients were (14±6)×10 9/L, 928 U/L(411 U/L,1 588 U/L), 9±5 before admission, versus (10±4)×10 9/L, 132 U/L(72 U/L,275 U/L), 6±4 at 48 hours after admission, respectively, showing significant differences ( t=12.219, Z=11.639, t=16.016, P<0.05). (2) Follow-up: of 201 patients, 153 cases were followed up for 40 months (27 months,55 months). During the follow-up, 32 of the 153 cases had recurrence of acute pancreatitis. Conclusion:Early pancreatic duct stenting is safe and feasible in the treatment of acute pancreatitis.
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Introduction: Pancreatic duct system shows wide range of variations/anomalies due to complexity in itsdevelopment from two different sources namely Dorsal and Ventral pancreatic buds. Knowledge on these variationsholds great importance during various surgical procedures such as drainage procedure in pancreatitis,pancreatico-jejunostomy, reconstruction after pancreatectomy and management of pancreatitis. The presentstudy aims to explore different variations of pancreatic ducts.Materials and Methods: This cross sectional observational study was conducted in 39 pancreases. Posteriorapproach was chosen to expose the duct system. Two parallel incisions were made on the posterior surface of thepancreas. Tissue between these two incisions was removed by piece meal dissection and exposed the ductsystem.Observation and Results: out of 39 duct systems, 13 (33.3%) were normal and 26 (66.7%) were variations. Thesevariations include 8 (20.5%) cases of Obliterated Duct of Santorini and 12 (30.76%) cases of absent Duct ofSantorini, 4 (10.25%) complete pancreas divisum, 1 (2.56%) incomplete Pancreas divisum and 1 (2.56%) case ofmultiple ducts connecting main pancreatic duct and terminal CBD which is reported for the first time.Conclusion: Present study is in accordance with findings of most of the studies. Absent duct of Santorini wasfound to be higher (30.76%) among all types of variations and incomplete Pancreas Divisum with lowest occurrence(2.56%). The knowledge on the prevalence and various types of variations is highly recommended for the surgeons,Physicians and Radiologists for accurate diagnosis and efficient management of various diseases related topancreas and pancreatico biliary apparatus.
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Objective@#To study the use of different techniques of pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy (LPD) for patients with slim pancreatic ducts.@*Methods@#The clinical data of 45 patients with slim pancreatic ducts (<3 mm) who underwent LPD in People's Hospital of Zhengzhou University from May 2017 to March 2019 were studied. These patients were divided into 2 groups: Chen's suturing technique (group A, n=31), and the imbedding pancreaticojejunostomy (group B, n=14). The postoperative pancreatic fistula (PF) rates, complication rate, pancreaticojejunostomy time, and length of postoperative hospital stay were compared between the 2 groups.@*Results@#There was no significant difference in the general data between the two groups (P>0.05). The incidence of postoperative pancreatic fistula in group A (4 cases) was significantly lower than that in group B (6 cases) (12.9% vs. 42.9%, P<0.05). The operation time of pancreaticojejunostomy in group A was significantly shorter than that in group B [(26.5±0.8) min vs. (28.0±2.4) min, P<0.05]. There was no significant difference in the length of postoperative hospital stay between the 2 groups (P>0.05).@*Conclusion@#Chen's suturing technique was a safe and effective pancreaticojejunostomy technique in LPD carried out in patients with slim pancreatic duct patients.
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Objective@#To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.@*Methods@#The retrospective and descriptive study was conducted. The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected. There were 6 males and 16 females, aged from 33 to 82 years, with an average age of 66 years. Surgical exploration was decided according to clinical symptoms, results of laboratory test and imaging examinations. For patients with space occupying lesions, surgical procedure was selected based on results of pathological examination. Patients without surgical exploration or space occupying lesions were allocated into follow-up. Observation indicators: (1) surgical exploration; (2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions; (3) surgical treatment; (4) follow-up. Follow-up using outpatient examination was performed on patients up to October 2018. Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations, no jaundice, normal laboratory indicators or mild abnormality, liver function, tumor markers and B-ultrasound were re-examined each month, and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months. Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase. Follow-up was performed on patients with negative results of imaging examination, jaundice, and mildly elevated CA19-9. TBil and CA19-9 were re-examined monthly, and if they were progressively elevated, patients were transferred to surgical exploration. For patients with negative results of imaging examination, no symptoms, and negative laboratory test, liver function, tumor markers, and B-ultrasound were re-examined once every 3 months, and enhanced CT and MRI were re-examined once every 6 months within one year. Follow-up was performed once every 6 months during the second year, and once a year after two years. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were descibed as absolute numbers, and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.@*Results@#(1) Surgical exploration: of 22 patients, 11 underwent surgical exploration, and 11 underwent follow-up. Of the 11 patients with surgical exploration, 4 were positive for space occupying lesions including 1 of false negative, and 7 were negative for space occupying lesions. (2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions. ① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions: juandice was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (χ2=0, 0, P<0.05), with a sensitivity of 75.0% and specificity of 100.0%. ② Relationship between imaging examination and surgical exploration positive for space occupying lesions: results of CT, MRI, endoscopic retrograde cholangio-pancreatography, endoscopic ultrasonography, PET-CT, and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (χ2=0, 0.77, 0, 0, 1.00, 0, 0, 0, 0, P>0.05). PET-CT had no significant association with surgical exploration positive for space occupying lesions (P>0.05). ③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions: positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), with a sensitivity of 50.0% and specificity of 100.0%. ④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions: of 22 patients, the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration, (13.0±2.8)mm and (3.5±0.5)mm for patients with negative surgical exploration, (11.6±2.4)mm and (3.2±0.4)mm for patients with follow-up, respectively, showing no significant difference between them (t=0.22, 0.36, P>0.05). (3) Surgical treatment: 9 of 11 patients with surgical exploration followed the standard procedure. Of the 9 patients, 4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection), 5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography, and was confirmed pancreatic head cancer by reoperation 3 months after the first operation). Two patients didn′t follow the exploratory procedure, and underwent the child operation only based on the preoperative imaging findings, without intraoperative pathological examination. Postoperative pathological examination showed chronic ampulla and chronic pancreatitis, respectively. (4) Follow-up: 22 patients were followed up for 12-60 months, with a median follow-up time of 36 months. Two of 11 patients with surgical exploration had postoperative gastroplegia, 1 had bile leakage, 1 had incisional infection, and they were improved after symptomatic treatment. Four patients undergoing surgeries for positive exploration had no recurrence during follow-up. Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage, 1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy, 4 were removed T-tube after by T-tube cholangiography at 2 months after surgery. During the follow-up, no positive signs showed in laboratory test or imaging examination. No recurrence occurred in the two patients undergoing pancreaticoduodenectomy. Of 11 patients with follow-up, 10 had abdominal pain before surgery, including 3 with pain during follow-up and 7 with symptoms disappeared. There was no abnormalities in the laboratory test.@*Conclusions@#The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation. Those patients who do not meet this criteria should be distributed into the follow-up. If no positive pathological results were obtained during the operation, the surgery should be terminated and the patients should be transferred into follow-up. The reckless biliary anastomosis or biliary stents placement is opposed.
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Objective To analyze the results of longitudinal pancreaticojejunostomy in treatment of paediatric chronic pancreatitis with dilated pancreatic ducts.Methods A retrospective study was carried out on 13 patients with paediatric chronic pancreatitis complicated with dilated pancreatic ducts treated with longitudinal pancreaticojejunostomy in Children's Hospital of Chongqing Medical University from December 2011 to January 2017.The perioperative morbidity and mortality rates,long-term treatment results and postoperative growth of these children were analyzed.Results The 13 patients all underwent successful surgery.In 11 patients,the serum and urine amylase levels returned to normal after 8 days of operation,and the abdominal pain disappeared completely.In 1 patient,the abdominal pain gradually disappeared in 1 year,and the serum and urine amylase levels gradually returned to normal.This patient gained weight well.In the remaining patient who had severe pancreatic atrophy,the patient took high-fat diets before and after surgery,and drank alcohol occasionally.The patient developed repeated attacks of abdominal pain with occasional increase in serum and urine amylase levels and had poor weight gain.There were no complications such as postoperative bleeding,pancreatic leakage and intestinal obstruction in this study.The body weight and growth rates of the whole group of patients before and 1 year after surgery were different.Conclusion Longitudinal pancreaticojejunostomy for paediatric chronic pancreatitis complicated with dilated pancreatic ducts was safe and effective in alleviating symptoms,improving quality of life,and resulted in normal growth of these children.
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Objective To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.Methods The retrospective and descriptive study was conducted.The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected.There were 6 males and 16 females,aged from 33 to 82years,with an average age of 66 years.Surgical exploration was decided according to clinical symptoms,results of laboratory test and imaging examinations.For patients with space occupying lesions,surgical procedure was selected based on results of pathological examination.Patients without surgical exploration or space occupying lesions were allocated into follow-up.Observation indicators:(1) surgical exploration;(2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions;(3) surgical treatment;(4) follow-up.Follow-up using outpatient examination was performed on patients up to October 2018.Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations,no jaundice,normal laboratory indicators or mild abnormality,liver function,tumor markers and B-ultrasound were re-examined each month,and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months.Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase.Follow-up was performed on patients with negative results of imaging examination,jaundice,and mildly elevated CA19-9.TBil and CA19-9 were re-examined monthly,and if they were progressively elevated,patients were transferred to surgical exploration.For patients with negative results of imaging examination,no symptoms,and negative laboratory test,liver function,tumor markers,and B-ultrasound were re-examined once every 3 months,and enhanced CT and MRI were re-examined once every 6 months within one year.Follow-up was performed once every 6 months during the second year,and once a year after two years.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were descibed as absolute numbers,and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.Results (1) Surgical exploration:of 22 patients,11 underwent surgical exploration,and 11 underwent followup.Of the 11 patients with surgical exploration,4 were positive for space occupying lesions including 1 of false negative,and 7 were negative for space occupying lesions.(2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions.① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions:juandice was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (x2 =0,0,P＜0.05),with a sensitivity of 75.0％ and specificity of 100.0％.(② Relationship between imaging examination and surgical exploration positive for space occupying lesions:results of CT,MRI,endoscopic retrograde cholangiopancreatography,endoscopic ultrasonography,PET-CT,and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (x2 =0,0.77,0,0,1.00,0,0,0,0,P＞0.05).PET-CT had no significant association with surgical exploration positive for space occupying lesions (P＞0.05).③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions:positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),with a sensitivity of 50.0％ and specificity of 100.0％.④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions:of 22 patients,the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration,(13.0±2.8)mm and (3.5±0.5) mm for patients with negative surgical exploration,(11.6±2.4) mm and (3.2±0.4) mm for patients with follow-up,respectively,showing no significant difference between them (t =0.22,0.36,P＞0.05).(3) Surgical treatment:9 of 11 patients with surgical exploration followed the standard procedure.Of the 9 patients,4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection),5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography,and was confirmed pancreatic head cancer by reoperation 3 months after the first operation).Two patients didn't follow the exploratory procedure,and underwent the child operation only based on the preoperative imaging findings,without intraoperative pathological examination.Postoperative pathological examination showed chronic ampulla and chronic pancreatitis,respectively.(4) Follow-up:22 patients were followed up for 12-60 months,with a median followup time of 36 months.Two of 11 patients with surgical exploration had postoperative gastroplegia,1 had bile leakage,1 had incisional infection,and they were improved after symptomatic treatment.Four patients undergoing surgeries for positive exploration had no recurrence during follow-up.Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage,1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy,4 were removed T-tube after by T-tube cholangiography at 2 months after surgery.During the follow-up,no positive signs showed in laboratory test or imaging examination.No recurrence occurred in the two patients undergoing pancreaticoduodenectomy.Of 11 patients with follow-up,10 had abdominal pain before surgery,including 3 with pain during follow-up and 7 with symptoms disappeared.There was no abnormalities in the laboratory test.Conclusions The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation.Those patients who do not meet this criteria should be distributed into the follow-up.If no positive pathological results were obtained during the operation,the surgery should be terminated and the patients should be transferred into follow-up.The reckless biliary anastomosis or biliary stents placement is opposed.
ABSTRACT
Introduction: Without the knowledge of the normal pattern of the duct system and its variations, a radiologistcan’t interpret an Endoscopic Retrograde Cholangiopancreatography (ERCP) picture. So it becomes important tostudy the anatomy of pancreatic ducts, their relation to each other, to common bile duct and to duodenum in theavailable human cadavers. The present paper is about the study of distance between minor and major duodenalpapilla from pylorus which was carried out on 96 cadaveric specimens of human duodeno-pancreas. To visualiseand to see distance between minor and major duodenal papillae is necessary for the endoscopist who aims toperform the dilation, stenting, or papillotomy of the minor papilla.Materials and Methods: The study was conducted in 96 (64 male and 32 female) cadavers. Major and minorduodenal papillae were visualized through eosin dye installation in both common bile duct and the accessorypancreatic duct. The measurement of distance between the duodenal papillae and to pylorus was done in cm.Results: In the present work, the mean ± SD of the Distance between pylorus to MAP is 8.05 ± 1.71 cm, pylorus toMIP is 6.19 ± 1.49 cm, the major to minor duodenal papilla was on an average 2.02 ± 0.40 cm, these distanceswere more in males as compared to females. But the size of Orifice of MAP in specimens is 7.25 ± 1.25 mm morein females as compared to males.Conclusion: The length of the duct shows sexual dimorphism; the length being more in males than females.
ABSTRACT
The accessory pancreatic duct is the smaller and less constant pancreatic duct in comparison with the mainpancreatic duct. We investigated the patency of the accessory pancreatic duct and its role in pancreaticpathophysiology. The present study was carried out in the department of Anatomy and forensic medicine, ACSRGovt. medical college, Nellore, Andhra Pradesh, India and in the department of Anatomy, RIMS, Ongole, AndhraPradesh, India. With 96 human cadavers (64 males and 32 females) with 30 to 80 years age group have beenstudied after obtained of ethical committee permission. The dissection method was followed to obtain specimenof pancreas along with C-loop of duodenum, papillae were identified ad dye was injected into APD to see itspatency at MIP. 93.75% specimens present MIP. The prevalence of patency of APD at MIP in population understudy was 38.89%; this is more in males was 43.33%, when compared to the females was 30% but this differencewas not significant statistically. It observed that out of 35 patent APD cases, 33 cases had inter papillarydistance either 2cm or more than 2cm. I t indicates 94.29% of patent APD cases had inter-papillary distancee”2cm. So there is strong relationship between APD patency and inter papillary distance in population understudy. The means inter-papillary distance in patent APD cases was 2.29 ± 0.2cm and non-patent APD cases was1.85 ± 0.25 cm. This difference was statistically significant.
ABSTRACT
Pancreatic duct stone is a sequel of chronic pancreatitis and may be found in the main ducts,side branches or parenchyma.These stones obstruct the pancreatic ducts and produce ductal hypertension,which leads to pain,the cardinal feature of CP.Surgical operation has been the preferred treatment of pancreatic duct stones in many domestic and external pancreatic medical centers.Lithotomy by longitudinal pancreatic duct incision and Roux-en-Y anastomosis of pancreatic duct to jejunum is the main and effective surgical procedure,while micro-surgery was also rational for the treatment of pancreatic duct stones.However,further studies with a larger sample size and longer follow-up duration are needed to improve the surgical technique and verify our initial results.
ABSTRACT
Resumen Hemos visto con preocupación que, en el postquirúrgico de la colangiopancreatografía retrógrada endoscópica (CPRE), existe confusión en cuanto a la aparición de pancreatitis y a la elevación transitoria de las amilasas (hiperamilasemia sin repercusión clínica), por lo que nos dimos a la tarea de realizar esta investigación, cuyo objetivo principal era determinar la prevalencia del incremento de niveles séricos de amilasas y de pancreatitis en los pacientes sometidos a colangiopancreatografía retrógrada endoscópica, según variables demográficas, clínicas y procedimentales. Es un estudio descriptivo, prospectivo, analítico y observacional, la población de estudio estuvo integrada por 98 pacientes atendidos en Unión de Cirujanos SAS, quienes requirieron colangiopancreatografía retrógrada endoscópica. Resultados: la frecuencia de pancreatitis aguda después de la CPRE fue del 2%, en 2 de los 98 casos estudiados; el 30% presentó hiperamilasemia (30 pacientes); la canulación del conducto pancreático mostró asociación con pancreatitis post-CPRE, con un valor de p<0,05. De los 2 pacientes que presentaron pancreatitis post-CPRE, a uno de ellos se le realizó contraste del conducto pancreático. La dilatación con balón se asoció con la hiperamilasemia (p<0,041). Conclusiones: la pancreatitis post-CPRE se presentó en un 2% de los pacientes, y este porcentaje se encuentra incluido dentro de los pacientes que presentaron hiperamilasemia, uno de los criterios para el diagnóstico de pancreatitis. Nuestro grupo se encuentra en el rango inferior del promedio internacional (1,8% al 7,2%). La hiperamilasemia asintomática se presentó en un 30%. Recomendamos que, si después de la CPRE, el paciente no presenta dolor, no se midan las amilasas, porque estas van a estar elevadas en gran número de los casos y, entonces, solo causaría confusión.
Abstract We have seen with concern that there is confusion regarding the appearance of pancreatitis and the transient elevation of amylases (hyperamylasemia without clinical repercussions) in the postoperative period following ERCP (endoscopic retrograde cholangiopancreatography). For this reason, we embarked on the task of determining the prevalence of increased serum amylases and pancreatitis in patients who have undergone endoscopic retrograde cholangiopancreatography according to demographic, clinical and procedural variables. This is a descriptive, prospective, analytical and observational study. The study population consisted of 98 patients treated in the Union of SAS Surgeons who required endoscopic retrograde cholangiopancreatography. Results: Acute pancreatitis was found in 2% of the patients who had undergone ERCP (Two of the 98 cases studied). Thirty patients (30%) presented hyperamylasemia. Cannulation of the pancreatic was associated with post-ERCP pancreatitis (p <0.05). Pancreatic duct contrast had been used in one of the two patients who presented post-ERCP pancreatitis. Balloon dilation was associated with hyperamylasemia (p <0.041). Conclusions: Post-ERCP pancreatitis was found in two patients (2%), both of whom also presented hyperamylasemia which is one of the criteria for diagnosis of pancreatitis. The rate in our group is at the lower end of the international range of averages from 1.8% to 7.2%. Asymptomatic hyperamylasemia was present in 30% of our group. Following ERCP, we recommend that there is no need to measure amylases in patients who do not present pain. Amylase levels will be elevated in a large number of cases and will only cause confusion.
Subject(s)
Cholangiopancreatography, Endoscopic Retrograde , Choledocholithiasis , Hyperamylasemia , Pancreatic Ducts , PancreatitisABSTRACT
Objective To study the indication, efficacy, safety, anesthesia method, and complication of extracorpereal shockwave lithotripsy (ESWL) in combination with endoscopic retrograde eholangiopanereatography (ERCP) for pancreatic duct stones. Methods From November 2011 to February 2016, we observed the success rate and safety of ESWL in combination with ERCP in treatment of 33 patients with chronic pancreatitis and large pancreatic duct stones and evaluate the efficacy in 6 month and 4 years follow-up. Results All the 33 patients underwent 52 ESWL, the successful fragmentation rate was 100.00%; complete clearance was achieved in 27 patients (81.82%) under the treatment of ESWL in combination with ERCP. Their pain and steatorrhea relieved, the weight increased. Conclusions ESWL combined with ERCP is effective, safe for chronic pancreatitis with pancreatic duct stones.