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Early detection of Pancreatic Ductal Adenocarcinoma (PDAC), one of the most aggressive malignancies of the pancreas, is crucial to avoid metastatic spread to other body regions. Detection of pancreatic cancer is typically carried out by assessing the distribution and arrangement of tumor and immune cells in histology images. This is further complicated due to morphological similarities with chronic pancreatitis (CP), and the co-occurrence of precursor lesions in the same tissue. Most of the current automated methods for grading pancreatic cancers rely on extensive feature engineering involving accurate identification of cell features or utilising single number spatially informed indices for grading purposes. Moreover, sophisticated methods involving black-box approaches, such as neural networks, do not offer insights into the model's ability to accurately identify the correct disease grade. In this paper, we develop a novel cell-graph based Cell-Graph Attention (CGAT) network for the precise classification of pancreatic cancer and its precursors from multiplexed immunofluorescence histology images into the six different types of pancreatic diseases. The issue of class imbalance is addressed through bootstrapping multiple CGAT-nets, while the self-attention mechanism facilitates visualization of cell-cell features that are likely responsible for the predictive capabilities of the model. It is also shown that the model significantly outperforms the decision tree classifiers built using spatially informed metric, such as the Morisita-Horn (MH) indices., Competing Interests: AR has a consulting agreement with Voxel analytics LLC and consults for Genophyll, LLC. MB is currently employed with the Division of Data and Decision Sciences, Tata Consultancy Services, India. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The funders were not involved in the study design, collection, analysis, and interpretation of data, the writing of this article or the decision to submit it for publication., (Copyright © 2021 Baranwal, Krishnan, Oneka, Frankel and Rao.)

Background: In 2015, the Committee on Diagnostic Criteria of the Japanese Study Group on Pancreaticobiliary Maljunction (PBM) proposed a classification of PBM into four types: (A) stenotic type, (B) non-stenotic type, (C) dilated channel type, and (D) complex type. To validate this classification and clarify the clinical features of the four types of PBM, a retrospective multicenter study was conducted., Methods: The study group of 317 children with PBM was divided into the four types of PBM. Clinical features, preoperative complications, operations, and postoperative pancreatic complications were evaluated., Results: All patients underwent excision of the extrahepatic bile duct. In type A, the age was younger and there was a higher incidence of cystic dilatation. Non-dilatation of the common bile duct was frequently seen in type B. Abdominal pain with hyperamylasemia was frequently seen in types B and C. In particular, the incidence of protein plugs and biliary perforation was high in type C (56.1% and 14.3%, respectively). The overall incidence of acute pancreatitis was 7.3%. Pancreatitis after excisional surgery was rare in the children in this study. Two patients with type D (0.6%) developed chronic pancreatitis postoperatively., Conclusions: This proposed classification is simple and correlates well with clinical features., (© 2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Todani classification is extensively used to guide the surgical strategy of choledochal cysts, but no systematic investigations on the distal management of intrapancreatic choledochal cysts have been conducted. This study reports the distal classification and management of choledochal cysts in adults based on the relation between the cyst and pancreatic duct. Patients with choledochal cyst who underwent operation, including distal management, in our department from January 2009 to December 2014 were retrospectively reviewed. Patients presenting symptoms, coexisting diseases, surgical treatment, perioperative complications, and long-term follow-up according to the distal classification of choledochal cyst were analyzed. A total of 54 patients with choledochal cyst were included in the present retrospective study. Based on the distal classification of choledochal cyst, 39 patients (72.22%) were type 1, 13 patients (24.07%) were type 2, and 2 patients (3.70%) were type 3. Thirty-nine type 1 patients and 10 type 2 patients underwent excision of intrapancreatic choledochal cyst or bile duct. Three type 2 patients received excision of distal cylindrical cyst and papilla, followed by pancreatic duct plasty with duodenum mucosa. One type 3 patient underwent endoscopic sphincteroplasty, and another type 3 patient underwent transduodenal sphincteroplasty. After the operation, 11 patients (20.37%, 11/54) had short-term perioperative complications. The long-term follow-up results showed that the satisfactory rate (excellent and good outcomes) was 95.83%. Current distal classification of choledochal cysts could provide a more targeted strategy for complete excision to eliminate potential dead space within the pancreas, protect the pancreatic duct, and prevent reoperation.

On the basis of the similarities in the histopathologic findings and the clinical-biologic behaviors of select biliary and pancreatic conditions, a new disease concept, "biliary diseases with pancreatic counterparts," has been proposed. Both nonneoplastic and neoplastic pathologic conditions of the biliary tract have their counterparts in the pancreas. Immunoglobulin G4 (IgG4)-related sclerosing cholangitis is the biliary manifestation of IgG4-related sclerosing disease, and type 1 autoimmune pancreatitis is its pancreatic counterpart. People with chronic alcoholism can develop peribiliary cysts and fibrosis as well as pancreatic fibrosis and chronic pancreatitis simultaneously. Pancreatic ductal adenocarcinoma, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm are considered pancreatic counterparts for the biliary neoplasms of extrahepatic cholangiocarcinoma, intraductal papillary neoplasm of the biliary tract, and hepatic mucinous cystic neoplasm, respectively. The anatomic proximity of the biliary tract and the pancreas, the nearly simultaneous development of both organs from the endoderm of the foregut, and the presence of pancreatic exocrine acini within the peribiliary glands surrounding the extrahepatic bile ducts are suggested as causative factors for these similarities. Interestingly, these diseases show "nearly" identical findings at cross-sectional imaging, an observation that further supports this new disease concept. New information obtained with regard to biliary diseases can be used for evaluation of pancreatic abnormalities, and vice versa. In addition, combined genetic and molecular studies may be performed to develop novel therapeutic targets. For both biliary and pancreatic diseases, imaging plays a pivotal role in initial diagnosis, evaluation of treatment response, efficacy testing of novel drugs, and long-term surveillance., ((©)RSNA, 2016.)

Objective: To explore the improvement of typing and reasonable surgical treatment for pancreatic ductal stone (PDS)., Methods: Totally 89 patients with pancreatic ductul stone treated underwent surgeries from January 2000 to December 2012 were involved into this study. There were 57 male and 32 female patients, the average age was (52 ± 23) years. According to the magnetic resonance cholangiopancreatography imaging and finding during surgery, pancreatolithiasis was classified into three types: type I, the stones were located in the main pancreatic duct; type II, the stones were located both in main and branch pancreatic duct; type III, the stones were diffusely scattered in the branch pancreatic duct; the position of PDS within pancreatic parenchyma were subtitled. In this group, 43 type I PDS were extracted with endoscopic papillotomy or endoscopic pancreatic sphincterotomy, or pancreatolithotomy plus pancreato-jejunal lateral anastomosis with wide anastomotic stoma; 39 type II cases were treated by pancreatolithotomy plus pancreato-jejunal lateral anastomosis or/and resection of pancreatic section; 7 type III PDS were managed with resection of pancreatic section., Results: All surgeries were performed successfully. Among complications, 6 cases (6.7%) were pancreatic leakage which recovered after systematic non-surgical treatment, 2 cases (2.2%) were anastomotic bleeding which led to 1 death, 6 cases (6.7%) were residual pancreatolithiasis in branch pancreatic duct type. Seventy-eight patients were followed up for 6 to 131 months, 57 cases were still alive so far. Five cases were intermittent abdominal pain, 7 cases were diabetes resulted from 2 subtotal pancreatectomy and 5 distal pancreatectomy, 5 cases occurred pancreatolithiasis recurrence and 3 underwent secondary surgeries., Conclusions: The basis of this modified typing of pancreatolithiasis is the position of stone in pancreatic duct rather than pancreas parenchyma. It is more important and valuable for surgical principle of taking stones out completely and maintaining pancreatic function.

A lot of contradictory data regarding the serious side effects of incretin-based therapies are currently available, with more being prepared or published every month. Considering the widespread use of these drugs it should be considered a priority to establish both short- and long-term risks connected with incretin treatment. We performed an extensive literature search of the PubMed database looking for articles dealing with connections between incretin-based therapies and pancreatitis, pancreatic cancer, thyroid cancer and other neoplasms. Data obtained indicate that GLP-1 agonists and DPPIV inhibitors could increase the risk of pancreatitis and pancreatic cancer, possibly due to their capacity to increase ductal cell turnover, which has previously been found to be up-regulated in patients with obesity and T2DM. GLP-1 analogues exenatide and liraglutide seem to be connected with medullary thyroid carcinoma in rat models and, surprisingly, GLP-1 receptors have been found in papillary thyroid carcinoma, currently the most common neoplasm of the thyroid gland in humans. Changes in expression of DPPIV have been described in ovarian carcinoma, melanoma, endometrial adenocarcinoma, prostate cancer, non-small cell lung cancer and in certain haematological malignancies. In most cases loss of DPPIV activity is connected with a higher grading scale, more aggressive tumour behaviour and higher metastatic potential. In conclusion animal and human studies indicate that there could be a connection between incretin-based therapies and pancreatitis, pancreatic cancer, thyroid cancer and other neoplasms. Therefore whenever such therapy is started it would be wise to proceed with caution, especially if personal history of neoplasms is present., (Copyright © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

A novel method is proposed to establish the classifier which can classify the pancreatic images into normal or abnormal. Firstly, the brightness feature is used to construct high-order tensors, then using multilinear principal component analysis (MPCA) extracts the eigentensors, and finally, the classifier is constructed based on support vector machine (SVM) and the classifier parameters are optimized with quantum simulated annealing algorithm (QSA). In order to verify the effectiveness of the proposed algorithm, the normal SVM method has been chosen as comparing algorithm. The experimental results show that the proposed method can effectively extract the eigenfeatures and improve the classification accuracy of pancreatic images.

Liquid-based cytology preparations are being increasingly used in nongynecologic specimens. The aim of this study is to objectively evaluate pancreatic disease by ThinPrep (TP) liquid-based cytology using morphometric image analysis. In all, 30 patients undergoing preoperative evaluation of pancreatic disease by TP were investigated from January to April 2009. We analyzed cytological features, such as cluster area, cluster circularity, and nucleus area, using morphometric image analysis software and further investigated the cytological findings of TP to determine which are useful for detecting malignancy. Pancreatic cytological findings of TP showed small clusters and loss of cluster irregularity in malignant cells. The patients were diagnostically categorized as inadequate, normal or benign, indeterminate, suspected malignancy, and malignant in 6.6% (2), 46.7% (14), 13.3% (4), 13.3% (4), and 20.0% (6) of the cases, respectively. Morphometric image analysis of 28 patients by TP,excluding two inadequate patients, showed no statistical difference in cluster area or cluster circularity among these cytological categories. In contrast, nucleus area in the normal or benign, indeterminate, suspected malignancy, and malignant categories was 17.6, 57.2, 67.4, and 68.0 μm(2) , respectively, and was associated with diagnostic category (P < 0.05). Pancreatic cytological findings of TP preparations generally show small, round cluster shapes in pancreatic disease; however, nucleus size is a more important criteria for detecting malignancy by TP in pancreatic disease., (Copyright © 2011 Wiley Periodicals, Inc.)

Background and Study Aims: The accurate diagnosis of indeterminate pancreaticobiliary strictures presents a clinical dilemma. Probe-based confocal laser endomicroscopy (pCLE) offers real-time in vivo microscopic tissue examination that may increase sensitivity for the detection of malignancy. the objective of this study was to develop and validate a standard descriptive classification of pcle in the pancreaticobiliary system., Patients and Methods: A total of 102 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with pCLE to assess indeterminate pancreaticobiliary strictures were enrolled in a multicenter registry; 89 of these patients were evaluable. Information and data on the following were collected prospectively: clinical, ERCP, tissue sampling, pCLE, and follow-up. A uniform classification of pCLE findings ("Miami Classification") was developed, consisting of a set of image interpretation criteria. Thereafter, these criteria were tested through blinded consensus review of 112 randomized pCLE videos from 47 patients, and inter-observer variability was assessed in 42 patients ., Results: A consensus definition of the specific criteria of biliary and pancreatic pCLE findings for indeterminate strictures was developed. Single-image interpretation criteria did not have a high enough sensitivity for predicting malignancy. However, combining two or more criteria significantly increased the sensitivity and predictive values. The characteristics most suggestive of malignancy included the following: thick white bands (>20 µm), or thick dark bands (>40 µm), or dark clumps or epithelial structures. These provided sensitivity, specificity, positive predictive value, and negative predictive value of 97%, 33%, 80%, and 80% compared with 48%, 100%, 100%, and 41% for standard tissue sampling methods. Inter-observer variability was moderate for most criteria., Conclusion: The Miami Classification enables a structured, uniform, and reproducible description of pancreaticobiliary pCLE. Combining individual characteristics improves the sensitivity for the detection of malignancy., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The objective of our present study was to assess the efficacy of carcinoembryonic antigen (CEA) for differentiating and diagnosis of pancreatic and liver diseases in Pokhara valley., Materials and Methods: A hospital based retrospective study was carried out using data retrieved from the register maintained in the Department of Biochemistry of the Manipal Teaching Hospital, Pokhara, Nepal between 1st January, 2011 and 31st October, 2011. Estimation of CEA was performed by ELISA reader for all cases. Approval for the study was obtained from the institutional research ethical committee., Results: Of the 771 subjects, 208 (27%), 60(7.8%), 240(31.1%), 54(7.0%) , 75(9.7%), 59(7.7%), 75(9.7%) cases were of active chronic hepatitis , cryptogenic cirrhosis, alcoholic cirrhosis, primary biliary cirrhosis, hepatoma, acute or chronic pancreatitis, carcinoma of pancreas respectively. The majority of cases (104) of active chronic hepatitis had CEA levels <5 ng/ml(50%). CEA levels were found to be increased in cases of alcoholic cirrhosis with maximum number of cases (106) in range of 10 to 20 ng/ml (44%). There were no cases having more than 20 ng/ml of CEA in primary biliary cirrhosis and acute or chronic pancreatitis. In cases of pancreatic cancer, maximum number of cases (35) were having CEA >20 ng/ml(47%)., Conclusion: High levels of CEA are associated with advanced stage of disease. CEA can thus provide an important improvement in the diagnosis by differentiating pancreatic cancer especially from chronic pancreatitis when there is a high suspicion of malignancy. Increased CEA levels may also signify progression from benign to malignant transformation in the liver.

Context: Portal annular pancreas is a rare congenital anomaly resulting from fusion of the pancreatic parenchyma around the portal vein/superior mesenteric vein. It is asymptomatic, but could have serious consequences during pancreatic surgery, if unrecognized. We describe a variant of this anomaly encountered during pancreaticoduodenectomy and propose a new classification., Case Report: We report a 51-year-old male who underwent a pancreaticoduodenectomy for periampullary carcinoma. After division of the pancreatic neck, a sheath of tissue was found posterior and extending to the left of the portal vein. When we divided this tissue, a large duct was encountered; this duct communicated with the main pancreatic duct. On review of the CT images, the main pancreatic duct was seen to be passing posterior to the portal vein and a smaller accessory pancreatic duct was present anterior to the portal vein. We describe the surgical implications., Conclusion: This variant of portal annular pancreas has not yet been reported during pancreaticoduodenectomy and we propose a new classification for this fusion anomaly.

Context: Anomalous junction of pancreaticobiliary ducts is a condition in which the pancreatic duct and the bile duct join outside the duodenal wall with a long common channel. The most accepted classification of various types of anomalous pancreaticobiliary junction is the new Komi classification. The majority of cases of type III anomalous pancreaticobiliary junction are reported from Japan and very seldom from outside Japan. This study evaluates the prevalence of type III anomalous pancreaticobiliary junction in the Indian population., Objective: To retrospectively evaluate the prevalence of type III anomalous pancreaticobiliary junction revealed by endoscopic retrograde cholangiopancreatography (ERCP) examinations carried out between 1985 and 2005., Design: ERCP records of 3,827 patients satisfying inclusion criteria between 1985 and 2005 were retrospectively analyzed., Main Outcome Measure: Patients demonstrating anomalous pancreaticobiliary junction were identified and classified according to the new Komi classification., Results: A total of 101 patients had anomalous pancreaticobiliary junction (2.6% of all ERCP). Only 2 patients (2.0% of all anomalous pancreaticobiliary junction cases and 0.05% of all ERCP examinations) had type III anomalous pancreaticobiliary junction. Both cases were associated with choledochal cysts and chronic pancreatitis., Conclusion: Type III anomalous pancreaticobiliary junction is a rare occurrence in Indian patients as compared to Japanese patients in whom the majority of cases are reported. This demographic variation is still unexplained.

Objective: To set up a stand for surgical classification of pancreatic duct stone and evaluate the benefits of different management according to the classification., Methods: Retrospectively analysis the diagnosis and prognosis of different management of 33 cases pancreatic duct stones to establish a new standard of classification and strategy of management of pancreatic duct stone., Results: According to the results of imaging examination (B-US, CT, ERCP) and finding during surgery, pancreatic duct stone can be classified into four different types: Type I: The stones mainly located in the head of pancreas. Endoscopic pancreas drainage and remove of stones is the first line choice of treatment. If it fail the Whipple procedure should be applied. Type II, The stones mainly located in the body of pancreas. It can be treated by Pusetow procedure. Type III, The stones mainly located in the tail of pancreas. The resection of the tail of pancreas or combined with spleenectomy was recommended for the management of this type stones. Type IV, The stones can be found from the head to tail of the main duct of pancreas. The Pusetow-Gillesby procedure or dividing of the neck of pancreas removing stones from both ends of pancreatic duct and reconstructed by two ends pancreatic duct-ileostomy in Roux-en-Y fashion are the choice of management., Conclusion: The invadulaized strategy of the management based upon correct diagnosis and classification play the most important role in the treatment of pancreatic duct stone.

Aim: To evaluate the clinical value of various imageological methods in diagnosing the pancreato-biliary diseases and to seek the optimal procedure., Methods: Eighty-two cases of pancreato-biliary diseases confirmed by surgery and pathology were analyzed. There were 38 cases of cholelithiasis, 34 cases of pancreato-biliary tumors and 10 other cases. The imageological methods included B-US, CT, ERCP, PTC, cross-sectional MRI and MR cholangiopancreatography (MRCP)., Results: The accuracy rate of MRCP in detecting the location of pancreato-biliary obstruction was 100%. In differentiating malignant from benign obstruction, the sensitivity of the combination of MRCP and cross-sectional MRI was 82.3%, the specificity was 93.8%, and the accuracy rate was 89.0%. The accuracy rate for determining the nature of obstruction was 87.8%, which was superior to that of B-US (P=0.0000) and CT (P=0.0330), but there was no significant difference between direct cholangiopancreatography and the combination of MRCP and conventional MRI (P=0.6666)., Conclusion: In most cases, MRCP can substitute direct cholangiopancreatography for diagnosis. The combination of MRCP and cross-sectional MRI should be considered as an important means in diagnosing the pancreato-biliary diseases, pre-operative assessment and post-operative follow-ups.

The Viennese collection of pathological specimens (Collectio Rokitansky) comprises a large number of objects from all fields of pathological anatomy and is one of the largest historical collections in the entire world. We reviewed the original diagnoses in a series of pancreatic specimens using modern histopathological techniques. It was found that the histological structure of eleven pancreatic specimens was surprisingly well preserved. In three cases of extrapancreatic pseudocysts, we identified chronic pancreatitis as the underlying disease. Two specimens contained tumours that proved to be ductal adenocarcinomas. A third, rather large tumour was identified as a solid-pseudopapillary carcinoma and a fourth one as a neuroendocrine carcinoma. The remaining cases were classified as fibrotic atrophy, congenital cysts, microcystic serous cystadenoma, and necrotic sequestration of the pancreas. The application of immunohistochemical methods failed. In conclusion, the surprisingly well-preserved exhibits from the Collectio Rokitansky, which have been on display for more than 100 years, are accessible to modern histopathological investigation without the use of immunohistochemical techniques. Such examinations allow us to assess the occurrence of diseases and tumours in the sociocultural environment of the 19th century.

The detection of a cystic tumour of the pancreas is a challenge which puts not only the surgeon's knowledge and expertise to the test, but also those of the team of radiologists and pathologists with whom he works. The diagnosis of a suspected pancreatic cystic tumour is morphological and is based on modern imaging techniques and, in the case of intraductal papillary mucinous tumours, on endoscopic findings. In the search for the correct preoperative diagnosis, however, it is of fundamental importance to bear in mind the limitations of the various instrumental investigations, and particularly those of fine-needle aspiration cytology. In this light the main morphological and clinicopathological features of serous cystadenomas, mucinous adenomas and adenocarcinomas, intraductal papillary mucinous tumours and papillary cystic and solid tumours are analysed as well as the surgical indications. In fact only the surgeon, on the basis of his knowledge of the patient's medical history and symptoms, will be in a position to determine to which nosological "cystic" entity the morphological findings described belong. A deeper knowledge of the natural history of each of these cystic tumours will help the surgeon formulate the most appropriate treatment indication. Providing the patient's condition fulfills the necessary operability criteria, resection will be mandatory whenever there exists a doubt that the tumour may be malignant or whenever its natural history suggests a malignant potential.

We characterised a consecutive cohort of 132 youth onset diabetic individuals (age at onset<30 years, mean duration of disease 5.5+/-6.0 years) from North India, by serological determination of the determination of the islet cell autoantibodies, GAD(65) and IA2, and clinically for coexisting autoimmune thyroid disease, malnutrition and pancreatic calcification. Five types of diabetes were delineated: Type 1 (37%), ketosis resistant (32%), Type 2 (13%), fibrocalculous pancreatopathy (11%) and autoimmune polyglandular syndrome (7%). C-peptide response to glucagon was assessed in a representative subset of 50 patients with Type 1, ketosis resistant, and autoimmune polyglandular syndrome. A total of 22.4% of Type 1 and 30% of autoimmune polyglandular syndrome subjects showed both GAD(65) plus IA-2 autoantibody positivity, significantly more than the 4.7% positivity shown by the ketosis resistant type. However, GAD(65) antibody positivity alone was seen in 38% of ketosis resistant subjects which was significantly more than the 14.2 and 10% positivity seen in Type 1 and autoimmune polyglandular groups, respectively. The fibrocalculous pancreatopathy group showed GAD(65) plus IA-2 autoantibody positivity in 14.2% and GAD(65) autoantibody alone positivity in 7.1%. 26 and 60%, respectively, of the Type 1 and autoimmune polyglandular syndrome groups had thyroid microsomal autoantibody positivity. Type 1 showed significantly less C-peptide response to glucagon when compared to the ketosis resistant and autoimmune polyglandular syndrome groups. The controls and Type 2 diabetic individuals tested negative for islet cell autoimmunity markers. These findings demonstrate a role of islet cell autoimmunity in the pathogenesis of four out of the five clinical types of youth onset diabetes seen in North India.

Surgeons frequently find pancreatic head mass when operating. The obvious difficulty is to make the correct preoperative differential diagnosis between chronic pancreatitis and pancreatic tumor. The first step is to reach a diagnosis, with some certainty, prior to the operation. The second step in the case of a tumor is the accurate staging and deciding whether or not it is resectable. On the one hand, time and cost must be considered; on the other hand, the therapy must be decided. Obtaining information about the characteristics of the pancreatic disease (nature, size, exact location) and establishing the tissue diagnosis preoperatively may simplify the decision to operate and the operation itself. In the case of chronic pancreatitis, the aim of the operation is to eliminate pain and other symptoms, while in the case of cancer, the purpose is to remove the malignant tissue. In most patients, it is possible to identify the disease on the basis of previous examinations together with preoperative diagnostic techniques such as exploration, palpation and fine-needle aspiration biopsy. Chronic pancreatic head mass should be operated upon with Beger s or Frey s procedure while pancreatic head tumors should be treated by means of head resection with the aim of preserving the pylorus or the Whipple procedure may be used. When the diagnosis is in doubt, a radical approach is thought to be best. Our conclusion is that there is no diagnostic method capable of making a definitive differential diagnosis as to the nature of the pancreatic head mass. Further study is required as to the extent to which differential diagnosis should be investigated.

Recent advances in molecular genetics have established a molecular basis for persistent hyperinsulinemic hypoglycemia of infancy (PHHI) and resulted in the identification of a number of well-defined genetic defects. On the basis of the available information on the molecular changes so far described, an attempt has been made to classify PHHI patients according to their genotype and phenotype, with reference to molecular genetics, pancreatic pathology and clinical appearance. This classification has resulted in the differentiation of three groups of PHHI patients, two with diffuse beta cell hyperfunction and one with focal beta cell hyperfunction.

The pancreas and biliary tree (and their confluence at the papilla of Vater) are frequent sites for disease. In recent years there has been a proliferation of relevant technologies. Diagnostic methods include percutaneous ultrasound, standard CT scans, helical CT, magnetic resonance imaging, MRCP, endoscopic ultrasound, angiography, ERCP, laparoscopy, and laparoscopic ultrasound. Cytology and biopsy specimens can be taken in conjunction with many of these techniques. In addition to standard open surgical intervention, there are now many alternative therapeutic approaches wielded by endoscopists, interventional radiologists and laparoscopic surgeons. Novel chemotherapy and radiation oncology techniques and further dimensions. Many studies have attempted to evaluate the role of one particular modality, or to compare two diagnostic or therapeutic techniques. It is more important (and more difficult) to devise and test relevant management algorithms. These assessments are bedevilled by the problem of generalizability, since the results of many techniques are operator-dependent. This raises another issue-whether patients with these problems should be managed in regional specialty centers. Another complexity is that the management of a particular problem is influenced not only by the disease and its stage but also by the type of patient in whom it occurs (age, comorbidities, etc.). Multidisciplinary collaboration is a great challenge (12, 13).

Pancreatic specimens of six patients with nesidioblastosis were studied by light microscopy and immunohistochemistry in order to classify the changes of the endocrine pancreas and relate them to the clinical outcome. Neuron-specific enolase immunostaining was useful in demonstrating the distribution of whole pancreatic endocrine cells. The six cases with nesidioblastosis were classified into two types; four cases of focal type (head 1, body 1, tail 2), and two cases of diffuse type. The histological classification show a correlation to the clinical outcome. The patients with a focal body or tail type showed normal blood sugar levels immediately after operation. On the other hand the patients with both diffuse type and a focal head type needed medical treatment within a few months after operation. Therefore, these cases should be followed with great care postoperatively. A partial 80% to 90% pancreatectomy might be sufficient for each type except for the focal head type. When the intraoperative examination (both macroscopic and microscopic) is suggestive of focal head type, a pancreatectomy of 95% or more is called for.

The paper summarizes the cytologic features of tumor and non-tumor pathology of the pancreas observed in 108 cases. Cytologic examination proved highly (90%) reliable in differential diagnosis of pancreatic pathology. A cytologic classification of pancreatic lesions is suggested.

Except cystic fibrosis, disorders of the exocrine pancreas are uncommon in the child; however they are numerous and varied in terms of their pathogenesis and clinical manifestations. The author surveys the various diseases of this organ in pediatrics. More recent theories concerning pancreatic involvement in cystic fibrosis are discussed.

A classification of supradiaphragmatic extension of benign pancreatic disease is proposed based on 74 cases from the literature and three new cases. The three main categories include pleural accumulation of amylase-rich fluids, direct extension of the pseudocyst, and fistula formation.

The aim of the present work is to provide a new classification of the exocrine pancreatic diseases in childhood by means of a simple and practicable scheme which is in line with the recognized classification of Internal Medicine. The article presents a definite distinction between organic diseases of the pancreas -- such as deformities, congenital insufficiences, pancreatitis, cysts and tumors -- functional disturbances of the pancreas secretion and pseudo-pancreas insufficiency caused by extrapancreatic factors. New investigative methods help to distinguish between various disorders encountered.