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Background: The incidence of post-ERCP pancreatitis (PEP) has been reported to be significantly higher in patients without main pancreatic duct (MPD) obstruction who undergo transpapillary biliary ...

Endoscopic pancreatic stenting is used to prevent main pancreatic duct obstruction and relieve painful symptoms of chronic pancreatitis. However, the stent typically needs to be exchanged and the rate of adverse events is high. Few studies have evaluated the effect of stent shape on those outcomes. We evaluated the adverse events, stent patency, and total medical cost within 90 days of patients who received an 8.5 French (Fr) physiologically shaped pancreatic stent by comparing these features with those associated with a conventional straight-type stent for ≥ 90 days. The total stent-related adverse event rate was significantly lower for the physiologically shaped pancreatic stent (physiologically shaped, 6.7% [2/30]; straight-type, 50.6% [44/87]; P P P = 0.002) for the physiologically shaped stent. The stent-related adverse event rate was significantly higher for the 10 Fr straight type stent than for the 8.5 Fr physiologically shaped stent (10 Fr, straight-type vs. 8.5 Fr, physiologically shaped: 36.1% [13/36] vs. 6.7% [2/30]; P = 0.007). In conclusion, a physiologically shaped pancreatic stent was superior to a straight-type stent in terms of the patency rate and medical costs.

Background and Objective: EUS-guided pancreatic drainage (EUS-PD) is an efficacious, acceptable risk option for patients with pancreatic duct obstruction who fail conventional ERCP. The aim of this study was to define the learning curve (LC) for EUS-PD. Methods: Consecutive patients undergoing EUS-PD by a single operator were included from a dedicated registry. Demographics, procedural info, adverse events, and follow-up data were collected. Nonlinear regression and cumulative sum (CUSUM) analyses were conducted for the LC. Results: Fifty-six patients were included (54% of male, with a mean age of 58 years). Technical success was achieved in 47 patients (84%). Stent placement was antegrade in 36 patients (77%) and retrograde in 11 (23%). Clinical success was achieved in 46/47 (98%) patients who achieved technical success. Adverse events were seen in 13 patients (6 of whom did not achieve technical success) and included bleeding requiring embolization (n = 5), bleeding treated with clips peri-procedurally (n = 1), pancreatitis (n = 5), and a pancreatic fluid collection drained via EUS-drainage (n = 2). The median procedural time was 80 min (range 49–159 min). The CUSUM chart showed that 80-min procedural time was achieved at the 27th procedure. Durations further reduced 40th procedure onward, reaching a plateau indicating proficiency (nonlinear regression P < 0.0001). Conclusion: Endoscopists experienced in EUS-PD are expected to achieve a reduction in procedural time over successive cases, with efficiency reached at 80 min and a learning rate of 27 cases. Continued improvement is demonstrated with additional experience, with plateau indicating mastery suggested at the 40th case. EUS-PD is probably one of the hardest therapeutic endosonographic procedures to learn.

Objectives It is unclear whether the improved glucose metabolism in pancreas head cancer (PHC) patients after pancreaticoduodenectomy is due to the anatomical change or the relief of pancreatic duct obstruction. Methods We divided 170 patients into the PHC group (n = 54, 31.8%) and other pathology (non-PHC) group (n = 116, 68.2%). Glucose metabolic function was evaluated using the glucose tolerance index (GTI), and the pancreatic duct obstruction and dilatation was measured using the pancreatic atrophic index (PAI). Results The preoperative GTI was significantly higher in the PHC group (mean [standard deviation {SD}], 0.84 [1.16]) than in the non-PHC group (0.41 [SD, 0.59], P = 0.000). The postoperative GTI decreased significantly in the PHC group but remained unchanged in the non-PHC group. Similarly, the preoperative PAI was higher in the PHC group (0.32 [SD, 0.19]) than in the non-PHC group (0.13 [SD, 0.09], P = 0.000). The postoperative PAI decreased significantly in the PHC group, but not in the non-PHC group. Conclusions The impaired glucose metabolism in PHC can be caused by pancreatic duct obstruction. After pancreaticoduodenectomy, glucose metabolism is improved by the relief of pancreatic duct obstruction, and not by the anatomical change. The patients should be counseled accordingly.

Objective: To create a structured computed tomography (CT) report for the systematic evaluation of pancreatic ductal adenocarcinoma (PDAC), based on the opinions of clinicians and surgeons. Materials and Methods: This was a prospective study in which we applied a 21-item questionnaire to experts in pancreatic diseases in order to create a model of a structured abdominal CT report. The questionnaire addressed the location and size of PDACs, as well as their effects on adjacent structures and on the vasculature, together with metastases. We used a Likert scale to determine which of those parameters should be included in the model. Results: A total of 18 experts (12 surgeons and 6 clinicians) from 9 institutions completed the questionnaire. All of the experts agreed that the following (if present) should be described in the CT report on a PDAC: the degree of enhancement; the diameter and location of the lesion; pancreatic duct obstruction; biliary dilatation; pancreatic atrophy; liver metastases; peritoneal nodules; ascites; lymph node enlargement; and invasion of adjacent structures. More than 80% of the experts agreed that the report should also describe the relationship between the PDAC and the surrounding vasculature. Conclusion: We have developed a template for a CT report on patients with PDAC, based on the opinions of experts involved in the treatment of such patients. Resumo Objetivo: Criar um modelo de laudo estruturado de tomografia computadorizada (TC) para a avaliação sistemática do adenocarcinoma ductal de pâncreas (ADP) com base na opinião de clínicos e cirurgiões. Materiais e Métodos: Realizamos estudo prospectivo aplicando um questionário abrangendo 21 tópicos para um modelo de laudo estruturado de TC do abdome na avaliação do ADP, contemplando dados sobre localização e tamanho tumoral, efeito sobre estruturas adjacentes, comprometimento vascular e presença de metástases. Utilizamos a escala de Likert para definir a pertinência de se inserir uma determinada informação. Resultados: Obtivemos respostas de 18 especialistas de 9 instituições (12 cirurgiões e 6 clínicos). Todos concordaram que deveriam ser descritos o grau de realce, o diâmetro da lesão, a localização e a presença ou a ausência de: obstrução do ducto pancreático, dilatação biliar, atrofia pancreática, metástases hepáticas, nódulos peritoniais, ascite, linfonodomegalias e invasão de estruturas adjacentes. Mais de 80% concordaram que deveria ser mencionada a relação do tumor com os vasos circunjacentes. Conclusão: Elaboramos um modelo de laudo estruturado de TC para a avaliação do ADP de pâncreas, atendendo às expectativas dos especialistas envolvidos no atendimento destes pacientes.

Background and study aims Although endoscopic retrograde cholangiopancreatography (ERCP) was introduced in Europe, Asia and America over four decades ago, East Africa and Africa as a whole has been slow in taking up this very important minimally invasive procedure for the management of various hepatopancreaticobiliary conditions. This has led to reliance on open surgery for even simple benign biliary strictures, stones and malignant causes of biliary and pancreatic duct obstruction that can be treated endoscopically without a need for a morbid open surgical intervention. In Uganda, ERCP was introduced in January 2017 after obtaining training and equipment support from Senior Experten Service (SES), German. We therefore report the first six cases of ERCP performed at our endoscopy unit. Patients and methods This is a case series report of six patients referred with yellowing of eyes and body itching as the main complaints. They predominantly had raised gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), total bilirubin and direct bilirubin. They also had different imaging investigations demonstrating hepatic ducts dilatation. Results Four out of the six patients had complete post ERCP symptom resolution. One patient had partial symptom resolution and the other patient recovered after conversion to open surgery. Conclusion Collaborative skills transfer made ERCP feasible in our institute and this marked the start of this specialised service in Uganda.

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.

Pancreatic duct stones are sequela of chronic pancreatitis. They can cause pancreatic duct obstruction which is the most important cause of pain in chronic pancreatitis. Stone resolution has shown to improve pain. The goal of this review is to highlight recent endoscopic and surgical advancements in treatment of pancreatic duct stones. Stone fragmentation by extracorporeal shock wave lithotripsy has become first line and the mainstay of treatment for majority of patients with pancreatic duct stones. Introduction of digital video pancreatoscopy in the last few years with the capability of guided lithotripsy has provided a robust therapeutic option where extracorporeal shock wave lithotripsy is unsuccessful or unavailable. Historically, surgery has been considered a more reliable and durable option when feasible. However, it had not been compared with more effective endoscopic therapy. Lithotripsy (extracorporeal and pancreatoscopy guided) is evolving as a strong treatment modality for pancreatic stones.

A insuficiência pancreática exócrina (IPE), doença comum principalmente em cães, é causada, usualmente, pela atrofia acinar do pâncreas, seguida de pancreatite crônica e obstrução do ducto pancreático, com consequente secreção inadequada de enzimas pancreáticas. O caso clínico descrito foi observado em um cão, macho, de oito anos de idade, em que o diagnóstico de IPE foi levantado pelo resultado do teste da atividade proteolítica fecal (prova do filme de raio-x). Até o presente momento, o tratamento instituído com suplementação de enzimas pancreáticas e adequação da dieta propiciou a resolução do quadro clínico.

Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release.To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI.For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors?The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist.In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.

Background Pancreatic duct obstructions are common in patients with pancreaticoduodenectomy. However, it is often neglected in follow up. This study was to review the outcomes of pancreatic duct obstruction and explore the prevention of pancreatic duct obstruction. Methods A retrospective analysis of 78 patients undergoing pancreaticojejunostomy without reccurence of disease within 24 months between 2004 and 2014. Pancreatic duct obstruction and long-term pancreatic complications were analysed. Results Twenty-five patients developed pancreatic duct obstruction following pancreaticojejunostomy, 13 of whom were found to have long-term pancreatic complications. The presence of pancreatic duct obstruction and early pancreatic obstruction were associated with long-term pancreatic complications, respectively (p = 0.002, p = 0.002). There are 10 patients with pancreatic duct stent more than 24 months, the postoperative median pancreatic parenchymal thickness in these 10 patients (17.1 mm, range 8.0 to 24.7 mm) was not significantly change than the median in them preoperative (16.4 mm, range 7.2 to 24.7 mm; p = 0.747). All of them have no long-term pancreatic complications, though the difference was not significantly (p = 0.068). Conclusions Early pancreatic duct obstruction is associated with postoperative pancreatic long-term complications. Sustained internal pancreatic stent may improve pancreatic duct obstruction.

PURPOSE: The aim of this study is to provide a technical detail and feasibility of percutaneous image-guided pancreatic duct (PD) drainage and to discuss its subtleties in a series of patients with obstructed PD. MATERIALS AND METHODS: Thirty patients presenting with PD obstruction from pancreatic head tumour or pancreatitis were subjected to percutaneous image-guided PD drainage under a guidance of ultrasound or computed tomography. Following the successful puncture of PD, a locking loop drainage catheter was placed using conventional guidewire techniques under real-time fluoroscopy guidance. RESULTS: The percutaneous drainage of obstructed PD was completed in 29 (96.7%) patients as an independent therapeutic intent or as a bridge to further percutaneous procedures. Clinical improvement following drainage was documented by the gradual reduction in clinical symptoms, including pain, nausea and fever and improved blood test results, showing the significant decrease of amylase concentration. The amount of pancreatic fluid drained post procedure was between 300 and 900 mL/day. No major procedure-related complications were observed. Subsequently, 14 of 29 patients underwent further procedures, including endoluminal placement of metal stent with or without radiofrequency ablation, balloon assisted percutaneous descending litholapaxy (BAPDL), endoluminal biopsy and balloon dilatation using the same drainage tract. CONCLUSION: The percutaneous PD drainage appears to be a safe and effective procedure. It should be considered in patients with obstructed PD secondary to malignancy, pancreatitis etc., where endoscopic retrograde cannulation has been failed or impracticable. The procedure can also be contemplated either as an independent treatment option or as an initial step for the subsequent therapeutic endoluminal procedures.

The mechanism of alcoholic pancreatitis is still unknown. It is of special interest why only about 5% of all alcoholics develop an episode of pancreatitis. We evaluated the role of long-term alcohol intake in the pathogenesis of alcoholic pancreatitis in rats.To evaluate the effect of long-term alcohol intake, rats were fed either a Lieber-DeCarli control diet (CD) or a Lieber-DeCarli alcohol diet (AD) for 6 weeks. Then, rats were infused over 2 h with either Ringer's solution (CO) or ethanol (E). In additional animals, alcoholic pancreatitis was induced by ethanol combined with hyperlipidemia and temporary pancreatic duct obstruction (EFO). Controls received Ringer's solution combined with hyperlipidemia and temporary pancreatic duct obstruction (RFO). Intravital microscopy (pancreatic perfusion and leukocyte adhesion), alcohol concentrations, amylase, lipase, cholesterine and triglyceride levels in plasma, myeloperoxidase activity and histology were evaluated at different time intervals.In those animals which received the Lieber-DeCarli control diet, capillary perfusion was reduced in the E group and further reduced in the EFO group as compared to the controls (CO, RFO; p0.01). Leukocyte adhesion was significantly increased in rats receiving E (p0.01), and was further increased in the combination group EFO (p0.01). EFO induced histologically evident acute pancreatitis. The additional administration of a long-term alcohol diet further increased microcirculatory disturbances and pancreatic injury significantly (EFO-ADEFO-CD).This study shows that alcoholic pancreatitis is induced by the combination of ethanol and individual cofactors. Chronic alcohol abuse intensifies these changes. Therefore, long-term alcohol intake seems to be a major factor in the pathogenesis of alcoholic pancreatitis.

Pseudoaneurysms of the splenic artery is a well-known complication of pancreatitis. However, to the best of our knowledge, a subcentimetric intrapancreatic pseudoaneurysm (without an associated pseudocyst) causing massive gastrointestinal bleeding and distal main pancreatic duct obstruction is a rare clinical phenomenon. Herein, we present such a unique complication with computed tomography images and subsequent successful endovascular treatment.

Pancreatic duct obstruction induces edematous but not hemorrhagic pancreatitis even when combined with maximal secretory stimulation. The aim of the present study was to test the hypothesis that pancreatic and bile duct obstruction exacerbates edematous pancreatitis induced by supramaximal secretory stimulation by caerulein.In in vivo studies using rats, biliopancreatic duct ligation was combined with supramaximal stimulation of caerulein, and pancreatic histology, serum amylase level, pancreatic edema, and intrapancreatic trypsin activation were evaluated. In in vitro studies, the pancreatic acini were isolated from the rats with biliopancreatic duct ligation, and amylase secretion, intracellular trypsin activation, and acinar cell fragility were evaluated.Biliopancreatic duct ligation exacerbated caerulein-induced pancreatitis from edematous to hemorrhagic only when the obstruction preceded caerulein administration. The amylase secretion from the acini was inhibited, and intracellular trypsin activation and the acinar cell fragility on the supramaximal stimulation with cholecystokinin in vitro were enhanced by the preceding in vivo biliopancreatic duct obstruction.Preceding biliopancreatic duct obstruction exacerbates caerulein-induced pancreatitis. Enhancement of intracellular trypsin activation is possibly involved in this mechanism.

OBJECTIVE Endoscopic papillary balloon dilatation (EPBD) has been reported to increase the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (4%-11%). Based on the hypothesis that performing endoscopic nasobiliary drainage (ENBD) could prevent this complication, we performed EPBD combined with ENBD (EPBD/ENBD) and analyzed the risk of pancreatitis. METHODS Thirty-four patients underwent EPBD followed by ENBD for common bile duct stone(s). Serum amylase levels the following morning and incidence of pancreatitis were compared with those previously reported and with complications of simple diagnostic ERCP performed in our institution. RESULTS After EPBD/ENBD, amylase levels the following morning were 214.5 +/- 152.9 U/L, and no cases developed pancreatitis or hyperamylasemia (>3 times normal). These outcomes were favorable compared with previous EPBD reports. Furthermore, despite the stress of EPBD/ENBD after ERCP, these outcomes were better, even compared with simple ERCP performed at our institution [amylase levels: 318.7 +/- 475.2 U/L; hyperamylasemia: 16.5% (P = 0.006); pancreatitis: 7.1%]. CONCLUSION Although EPBD has been regarded as a risk factor for post-ERCP pancreatitis, our results suggest the possibility that application of ENBD after EPBD decreases the incidence of pancreatitis and should be studied further. We speculate that ENBD itself prevents pancreatic duct obstruction by residual stones or papillary edema.

Objectives There are many experimental models for chronic pancreatitis. However, it remains unclear which animal models of pancreatic fibrosis can be categorized as chronic pancreatitis models. We compared the histologic features of some animal models of pancreatic fibrosis/chronic pancreatitis and chronic pancreatitis in humans. Methods and results Human chronic pancreatitis due to chronic alcohol abuse and unknown etiology showed interlobular fibrosis and a cirrhosis-like appearance. Histopathologically, spontaneous pancreatitis models, WBN/Kob rats and OLETF rats, showed localized/nodular fibrotic lesions, which consisted of swollen, aggregated, atrophic islets of Langerhans; loss of the exocrine parenchyma and hemosiderin deposition that was seldom distributed in the interlobular area. On the other hand, fibrosis in the canine model, which was produced by combining alcohol administration with incomplete pancreatic duct obstruction, was characterized by interlobular fibrosis admixed with a cirrhosis-like appearance very similar to that in human chronic pancreatitis. Conclusion Most experimental models for chronic pancreatitis, except alcohol administration combined with other procedures such as incomplete pancreatic duct obstruction, are different from human chronic pancreatitis.

We report herein a modification of the standard wirsungojejunostomy in patients with chronic pancreatitis, which includes concomitant duodenum-preserving resection of the head of the pancreas as described by Frey. This technique is safe and seems to provide more effective long-term pain relief than standard wirsungo-jejunal anastomosis.

Endoscopic pancreatic therapy is emerging as an exciting nonoperative alternative in the management of chronic pancreatitis, in particular in cases where pancreatic duct obstruction due to stones, protein plugs, or strictures is present. Although the preliminary results available are promising, prospective randomized trials comparing endoscopic and surgical techniques are much needed. Furthermore, the published data come from large endoscopic centers with very high levels of technical skill and experience, and, therefore, its widespread clinical use is limited. Time and well-designed prospective randomized clinical trials comparing surgical versus endoscopic techniques will help define the role of these procedures in the treatment of chronic pancreatitis.

Magnetic resonance cholangiopancreatography (MRCP) uses magnetic resonance (MR) pulse sequences in which static fluid appears bright against a low signal or dark background. When these MR images are subjected to postprocessing techniques, they produce images that resemble the pancreatograms obtained using endoscopic retrograde cholangiopancreatography (ERCP). The MRCP examination is easily performed, is noninvasive, requires no contrast injection, and has no known complications. The place of MRCP in the evaluation of disorders of the pancreas is not yet fully established, but several well-defined roles have already emerged. These include the evaluation of the pancreatic duct after failed or incomplete ERCP, and the evaluation of complete pancreatic duct obstruction. The technical aspects required for MRCP of the pancreatic duct, and the established and emerging roles for MRCP in the pancreatic duct, are described here.

A 79-year-old man underwent pancreatoduodenectomy with Imanaga reconstruction for an ampullary adenocarcinoma in 2003. After that, he experienced recurrent pancreatitis with a suspicious stenotic pancreatojejunal anastomosis. Although endoscopic drainage through the pancreatojejunal anastomosis was attempted, the stenotic anastomosis could not be located endoscopically. Therefore, endosonography-guided rendezvous drainage through the anastomosis was performed, and endoscopic pancreatic stent placement was successfully completed. Thereafter, the patient did not experience any further attacks of pancreatitis. Endosonography-guided rendezvous drainage is a feasible treatment option for recurrent pancreatitis due to stenosis of pancreatojejunal anastomosis.

7. Sidd JJ, Kemp HG, Coffin R. Acute myocardial infarction in a 19-year-old student in the absence of coronary obstructive disease. N EnglJMed 1970; 282 : 1306. 8. Flohr KH, Reavill RB, Gobel FL et al. Myocardial infarction in young adults due to spasm of an arteriographically normal coronary artery. Schweiz Med Wochenschr 1980; 110 : 1631. 9. Penny W], Colvin BT, Brooks N. Myocar1994; VoL 61. No. 1

Endoscopic palliation of malignant biliary obstruction due to pancreatic cancer has become an accepted alternative to surgical bilioenteric bypass over the last decade. Clinical experience and randomi

We present the case of a 65-year-old man with a pancreatic nonfunctioning neuroendocrine tumor causing main pancreatic duct obstruction that presented as excessive hyperglycemia. We considered the tumor elicited worsening of diabetes in this case, and we performed review of the relevant literature.

Pancreatic fluid collections (PFCs) are non-epithelial-lined, cystic, fluid-filled cavities that develop as a result of inflammatory conditions of the pancreas in acute or chronic pancreatitis, pancreatic trauma, or pancreatic duct obstruction (Bollen et al. 2007). Approximately 16–50% of episodes of acute pancreatitis and 20–40% of chronic pancreatitis complicate with fluid collections (Bollen et al. 2007; Singhal et al. 2006; Giovannini 2005). The majority of PFCs are asymptomatic and resolve spontaneously (Giovannini 2005). For symptomatic PFCs, the clinical presentation is related to the location and size of the collection, and the presence of infection.

膵管結紮家兎にて膵腺房細胞の変化と新しい蛋白分解酵素阻害剤E3123の保護効果を検討した.3時間の短期間膵管閉塞とsecretin (0.2CU/kg・hr) 投与にて, 門脈血中amylase (46±4U/ml) (p

Background/Aims: Obstruction of the main pancreatic duct (MPD) has been considered one of the major causes for pain in chronic pancreatitis (CP). In this study, we evaluated the efficacy of MPD stenting in painful CP, and tried to determine a guideline for stent removal. Methods: Sixteen patients with painful CP who underwent MPD stenting were included. Follow up ERCP was performed 3 months after stenting in all patients. Stents were removed in patients who achieved pain relief, complete stone clearance, and decreased MPD diameter after 3 months. Results: Before stenting, ERCP showed MPD stricture in 11 cases, MPD dilatation by stone in 1 case, concomitant stricture and stone in 4 cases. After stenting, complete pain relief was achieved in 13 patients (81.3%) and partial pain relief was achieved in 3 patient (18.7%). There was no patient whose pain was not relieved. Stents were removed in 7 patients who achieved pain relief, complete stone clearance, and decreased MPD diameter after 3 months. Decrease of MPD diameter was significantly greater in patient who could remove stent than those who could not (72.9% vs. 127.9% of initial MPD diameter, p=0.008). Conclusions: If partial or full pain relief is achieved after MPD stenting and follow up ERCP after 3 months shows decreased MPD diameter compared to the initial one, stent removal might be considered. (Gut and Liver 2007;1:63-67)

To examine the relation between hepatic reticuloendothelial system (RES) dysfunction and the development of acute biliary pancreatitis. In an opossum model, the authors tested the hypothesis that RES blockade can turn the mild pancreatitis seen after pancreatic duct obstruction (PDO) into the severe form.Biliary obstruction is considered the decisive event in gallstone pancreatitis. Suppression of the RES occurs during biliary obstruction.Eighteen opossums were placed into three groups of six animals each: group A, RES blockade with lambda-carrageenan; group B, PDO; and group C, PDO and RES blockade with carrageenan. The severity of pancreatitis was evaluated by enzyme serum levels and percentage of pancreatic tissue necrosis. RES capacity was measured by dynamic liver scintigraphy, and hepatic blood flow was documented using the hydrogen clearance technique.No changes in hepatic blood flow occurred in groups A to C. RES capacity was suppressed in groups A and C; in group B, RES function remained unchanged. In group A, amylase and lipase levels remained normal, 3 +/- 1.9% of pancreatic tissue were necrotic. The animals in group B developed mild edematous pancreatitis with an increase in amylase and lipase levels and 15 +/- 10% of pancreatic necrosis. In group C, amylase and lipase increased significantly and histology revealed severe necrotizing pancreatitis, with 72 +/- 11% of necrotic areas.Artificial RES blockade can promote the progression from mild pancreatitis as observed after PDO to the severe necrotizing form of the disease. Thus, RES dysfunction resulting from biliary obstruction might be an important cofactor in the pathogenesis of bile-induced pancreatitis.

Among patients with advanced chronic pancreatitis and morphologically demonstrable main pancreatic duct (MPD) abnormalities who are candidates for endotherapy, about two-thirds have a MPD stricture and require stenting to achieve appropriate ductal decompression. The standard stent used in this indication is the plastic stent, which provides a median patency rate of 6 to 12 months. The requirement for stent exchange represents a limitation for the treatment of this relatively young patient population. By analogy with the biliary tract, the authors hypothesize that self-expandable metal stents might offer a long-lasting drainage of the MPD. Several years ago the authors used such stents on an experimental basis to treat patients with MPD strictures. Although routine use of self-expandable metal stents should be discouraged, the authors propose some guidelines for further technical improvement.

Pancreatic duct obstruction may explain some cases of acute pancreatitis, of which ampullary dysfunction and pancreas divisum are the most controversial examples. There is no consensus regarding the value of secretin-ultrasound testing for functional pancreatic outlet obstruction, but refinements may improve its clinical utility.

Expanding metal stents were used to treat symptomatic pancreatic duct obstruction in two patients with chronic pancreatitis. Both patients initially underwent percutaneous external pancreatic duct drainage and then had metal stents inserted for internal drainage. Both patients remained asymptomatic, and the stents were patent during short-term follow-up periods of 6 and 9 months, respectively. Percutaneous insertion of metal stents, which can be performed to treat pancreatic duct obstruction after a trial of external drainage has been shown to relieve the patient's symptoms, should be considered as an alternative to endoscopic stent placement or surgical drainage.

In the treatment of pancreatic pseudocysts, percutaneous and endoscopic drainage have, in certain cases, become alternatives to surgery. However, each treatment modality carries risks of complications and recurrences that may be minimized by the appropriate allocation of therapy. This article proposes the use of an endoscopic retrograde cholangiopancreatography (ERCP)-based algorithm as a means to allocate pseudocyst therapy based on the findings of pancreatic duct obstruction or pseudocyst communication. To evaluate this algorithm, the records of a series of patients with pancreatic pseudocysts seen at Duke University Medical Center from 1984 to 1990 were reviewed. Of 102 patients, 73 had symptomatic pseudocysts that required treatment. Forty of the 69 elective interventions were preceded by ERCPs and retrospectively applied to the algorithm. The number of adverse outcomes (treatment failures + complications) of the group that followed the algorithm was 3 of 26 (12%), while the number of adverse outcomes of the group that did not follow the algorithm was 6 of 14 (43%) (p less than 0.04 by Fisher's exact test). These two subgroups were similar in all other characteristics examined. Therefore, this ERCP-based algorithm may be used to allocate pseudocyst treatment; however, a prospective trial is necessary to prove its efficacy.

Eleven cases of pancreatic islet cell tumors were reviewed to compare diagnostic ability of endoscopic retrograde pancreatography (ERP) with other imaging modalities. ERP localized three out of five tumors studied and showed a suspicious finding in an additional patient. All these tumors were located in the pancreatic head. Thus, the diagnostic ability of ERP was superior in the head portion, where recognition of a tumor is often difficult at the operation, and a more complicated procedure is required for removal. Nonfunctioning islet cell tumors were localized by hypervascularity on angiogram, but retroperitoneal leiomyosarcoma remained to be excluded in one patient. ERP with an indwelling balloon catheter revealed the pancreatic origin of the tumors and precisely determined the line of pancreatic resection by vividly visualizing pancreatic duct obstruction and intact distal branches. We conclude that ERP is helpful to localize functioning islet cell tumors of the pancreas especially in the head portion and plays an important role for planning resection of nonfunctioning islet cell tumors.

Background: DACP, as an adjunct to ERCP allows for direct visualization of the biliary duct and pancreatic duct.We aim to assess the technical feasibility of DACP for a variety of clinical indications and to determine its impact on disease management. Methods: 94 consecutive DACP examinations were performed in 57 patients with 3 groups of disorders, choledocholithiasis (CDL), biliary strictures(BS) and pancreatic disease(PD), age range (24 to 91 years; mean 69). All DACPs were performed using the Pentax FCP-8P or 9P. Data pertaining to indication, technical success, and clinical impact of DACP on disease management were collected and analyzed using cMore endoscopic database. Results: CDL (n=53, 27 pts ) Indications included stone fragmentation using EHL (n=34), evaluation of biliary tree post-stone removal (n=14), distinction between stone and stricture, evaluation of biliary tree for stones despite normal cholangiogram (n=5). Technical success was achieved in 29/53 DACPs. The 24/53 failures represent partial fragmentation of stones with EHL in 8 patients with extensive disease. Use of DACP resulted in complete removal of biliary tree stones in 10/34 examinations (10 patients) and demonstrated the presence of stones in 4 patients with normal post-interventional cholangiograms. Furthermore DACP helped to confirm the absence of stones after removal by basket or balloon in 11/12 patients. BS (n=33, 23 pts) Indications included evaluation of stricture(n=21) or Wallstent occlusion (n=4), and monitoring of cholangiocarcinoma progression in a single patient (n=7). Technical success was achieved in 29/33 cases. DACP assisted in confirming or clarifying the nature of a stricture in 16/29 cases, and in stent management in 20/29 cases. PD (n=7) Indications included evaluation of pancreatic duct obstruction in chronic pancreatitis (n=4) and malignancy (n=1), and evaluation of PD for IPMT (n=2). An additional use of DACP was in the evaluation of hemobilia (n=1) where no source was seen. There were no complications reported with the use of DACP. Conclusion: DACP is technically feasible in the management of pancreatico-biliary diseases. Lack of complete technical success in the use of EHL to fragment stones is due to extensive stone disease in a limited number of patients. Otherwise DACP impacts on the management of complicated biliary tract disease by clarifying cholangiograms, assisting in EHL stone fragmentation, and guiding stenting and surgical management.