Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Clinical Study of Intraductal Papillary Mucinous Tumor of the Pancreas

PURPOSE: Intraductal papillary mucinous tumor (IPMT) of the pancreas pathologically shows papillary proliferation and its tumor cells display a spectrum of changes ranging from adenoma to infiltrating carcinoma. Because of this variability, there have been many difficulties for making an accurate diagnosis and administering proper treatment. The aim of this study was to determine the treatment strategy and differential diagnosis of benign and malignant IPMT. METHODS: Between January 2000 and June 2007, 24 patients with IPMT of the pancreas underwent surgery. The relationships among the clinopathologic features and tumor locations and subtypes were retrospectively investigated. In addition, the type of surgical procedures and findings, the microscopic finding, the immunohistochemical staining and the clinopathological features were analyzed. RESULTS: There were 17 men and 7 women with a mean age of 65 (range: 45~81). Pathologically, 11 cases were benign, 9 were borderline and 4 were malignant. The tumor was located in the head of the pancreas in 17 patients. 16 cases received Whipple's procedure and pylorus preserving pancreaticoduodenectomy, and the others were received different kinds of operations. Regarding the subtypes of IPMT, 2 cases were the main duct type, 19 were the branched type and 3 were the combined type. There were no statistically significant differences in the clinical manifestations, radiologic findings and immnohistochemical staining between the patients with benign and malignant IPMT. Except two patients who were not followed up, all the patients had no recurrence and they survived. CONCLUSION: It is very difficult to exactly differentiate malignant IPMT from benign IPMT with using the current preoperative evaluations and immunohistochemical staining of the resected specimens. The patients who were operated on and followed in our hospital had no recurrence and they all survived. Therefore, if IPMT is suspected, we think the patients should be operated on and we should continue studying other specific antibodies for immunohistochemical staining.

Bile Peritonitis associated with Biliary Leakage after Removal of T-tube from Common Bile Duct / 한국간담췌외과학회지

BACKGROUND: It is common practice for surgeons to place a T-tube after common bile duct exploration. T-tubes are regarded as safe and they allow postoperative cholangiography. But the unexpected cases of bile peritonitis after T-tube removal raised questions of common factors in etiology. The aim of this study is to investigate risk factors of biliary leakage after removal of T-tube from common bile duct. Materials and METHODS: Seven cases of biliary leakage after removal of T-tube have been experienced in Department of Surgery of Chonnam National University Hospital from January 1988 to March 2000. Seven cases were investigated with respect to the following parameters : presenting disease, underlying disease, laboratory findings, nutritional status, findings associate with T-tube, clinical findings and the results of treatments. RESULTS: The mean age of the patients was 62.9years(range, 45-77years). The presenting diseases were CBD stone with GB stone in three cases, CBD stone in two cases, IHBD stone in two cases. Previous medical history was unremarkable with the exceptions of one hypertensive patient and one patients with early gastric cancer concurrently undergoing treatment for hypertrophic cardiomyopathy. The mean body mass index(BMI) of the patients was 20.5. Arterial blood gas analyses and pulmonary function tests were normal. Preoperative laboratory findings were unremarkable except one patient of hypoalbuminemia. Liver function tests were normal, except in one patient with toxic hepatitis. In all cases, silastic T-tube was inserted following cholecystectomy and choledocholithotomy. The mean CBD diameter was 16.4mm (range, 12-21mm). CBD repair was done with absorbable sutures. Postoperative T-tube cholangiography revealed a remnant stone in the patients with the left intrahepatic stone and were unremarkable in all other cases. The T-tube was removed after a mean duration of 24.6days(range, 15-53). The abdomial pain and tenderness in all patients, most frequently in the right upper qudrant, was the significant sign and symptom associated with bile leakage. The symptoms resolved in four of five patients by drainage using a nelaton tube. The remaining patients(n=3) underwent reinsetion of T-tube. CONCLUSIONS: It is very difficult to predict the occurrence of bile leakage after T-tube removal. And early diagnosis and immediate percutaneous drainage make a good result in patient with localized peritonitis.