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BACKGROUND: Malignant ampullary tumors (AT) require pancreatico-duodenectomy (PD) for curative treatment whereas benign AT can be appropriately treated by local resection. This study evaluated the accuracy of endoscopic exploration combining side-viewing duodenoscopy (SVD) with forceps biopsies, endoscopic sphincterotomy (ES), and endoscopic ultrasonography (EUS) to distinguish benign AT from malignant one. PATIENTS AND METHODS: Twenty-six patients with AT had preoperative SVD with forceps biopsies, including 9 with ES, and EUS. Nodal status was evaluated by EUS in all patients, but could not evaluate parietal spread in 6 in whom ES was previously done. Results of endoscopic examination were compared with pathologic examination after resection (2 local excisions for 2 benign AT, and 24 PD for 20 malignant and 4 benign AT). RESULTS: Accuracy of histologic examination of the 26 biopsies of the papilla was 69%. After ES, accuracy of intra-ampullary biopsies was 77%. The EUS had a 75% accuracy for the parietal spread (tumor limited to ampulla or not) and a 69% accuracy for the nodal status. In 11 patients, all explorations were consistent with a benign lesion, but 6 of these patients had a histologically proven malignancy, including one with nodal metastases and two with duodenal involvement. CONCLUSIONS: Side-viewing duodenoscopy with biopsies, even after ES, combined with EUS is not accurate enough to preoperatively ensure that an AT is benign. Indication for a local resection based on these explorations alone is not safe.

Calcitonin release has rarely been reported in patients (pts) with neuroendocrine pancreatic tumors (NPT). The aim of this study was to describe the characteristics of calcitonin-secreting tumors (CST) of the pancreas. Serum calcitonin determination was part of the prospective evaluation of 66 pts with NPT referred to our institution over a 3-year period. Six pts (9) had elevated calcitonin levels [at least twice the limit f the normal value (N)]. Abdominal ultrasonography, computed tomography scan, and endoscopic ultrasound were performed to identify the primary tumor(s) and metastases. Immunostaining using anticalcitonin and other antibodies was performed on the surgical resection specimen (four pts) or biopsy of liver metastases (two pts). Three of the six pts (four males, two females; median age, 51.5 years) had diarrhea. Serum calcitonin levels (median, range) were 17.5 N (6N-40N). Slight elevations in serum somatostatin (1.2N-2.3N) were associated in three pts. Pancreatic tumors were single in five of six pts and evenly distributed in the head and in the tail. Five pts had metastases, mainly in the liver. Multiple endocrine neoplasia type I was present in one pt. Immunostaining using calcitonin and somatostatin antibodies was positive in four pts each, respectively, and areas that were positive for one peptide were negative for the other. Diarrhea disappeared in the two pts who responded to treatment of the tumors (s). Three of the four pts with liver metastases died from tumor progression after 2, 10, and 24 months, respectively. CST of the pancreas are often malignant and can be considered as functional in half of the cases, irrespective of the serum calcitonin levels. Somatostatin secretion is often associated. Although rare, calcitonin secretion should be investigated in NPT pts presenting with diarrhea that cannot be explained by an increase in other hormone levels or in patients with nonfunctioning NPT.

This study compared diet, type of alcoholism, and smoking in three groups of alcoholic men, with chronic pancreatitis (n56), with histological cirrhosis (n50), and without pancreatitis or cirrhosis (controls; n50) by a multidimensional analysis. Only patients in whom the first symptom of pancreatitis or cirrhosis was present for <1 year before the interview were included. Patients with pancreatitis consumed more nonalcohol calories than cirrhotics (p< 0.05). The percentage of calories taken as proteins (p< 0.0003) and lipids (p< 0.0001) was higher and the percentage of calories taken as alcohol (p< 0.0003) was lower in patients with pancreatitis than in cirrhotics and control patients. There was no difference among the three groups for total calories/basal energy expenditure ratio, total nonalcohol calories/basal energy expenditure ratio, mineral and vitamin intake, or tobacco consumption. The duration of excessive alcohol consumption and the total alcohol consumption in patients with pancreatitis was similar to that of controls but lower than that of cirrhotics (p< 0.002 and p< 0.05, respectively). Three parameters were found to be independently different in the three groups by discriminant analysis: percentage of calories taken as lipids (p< 0.0001), duration of excessive alcohol consumption (p< 0.002), and percentage of calories taken as proteins (p< 0.08). These three parameters explained 24 of the variance. We conclude that the reasons alcoholic men develop chronic pancreatitis may be explained partly by dietary habits. The main predisposing or associated factor is a high caloric proportion of fat and protein intake. Type and quantity of alcohol, tobacco, and vitamins do not seem to play an important role.

The purpose of the study was to determine (a) the frequency and cause of mortality in patients with chronic pancreatitis; (b) the cumulative survival rates corrected by comparison of patients with a matched French population; and (c) the factors associated with mortality by a unidimensional and multidimensional analysis. The study population consisted of 240 patients (men = 208, women = 32; alcoholic = 210, nonalcoholic = 30) followed for a mean time of 8.7 yr. The status of the patients (dead or alive) was recorded in February 1987. Mean age at onset of chronic pancreatitis was 41.5 yr. Fifty-seven patients died. Mean age at time of death was 52.3 yr. “Overmortality” after 20 yr of course was 35.8% in comparison with a matched French population (p < 0.0001). Chronic pancreatitis was the direct cause of death for only 19.3% of patients. The main causes of death have been alcoholic hepatopathy (n = 10), cancer (n = 9), postoperative mortality (n = 8). Unidimensional analysis of mortality rates showed that male sex (p < 0.03), surgery (p < 0.007), hepatopathy (p < 0.01), diabetes mellitus (p < 0.02), and absence of attack of acute pancreatitis (p < 0.02) were associated with mortality. Multidimensional analysis showed that the following variables were linked with mortality: in a first model including the totality of the study population: surgery (p < 0.006), hepatopathy (p < 0.008), no attack of acute pancreatitis (p < 0.03), male sex (p < 0.03); in a second model excluding cirrhosis: surgery (p < 0.001), male sex (p < 0.06), diabetes mellitus (p < 0.09). Nevertheless, surgery did not seem to interfere with long-term mortality. The lower mortality of patients with attacks of acute pancreatitis suggests a favorable influence for alcohol abstinence.