[A case of intraductal papillary mucinous neoplasm with internal pancreatic fistula causing left ureteral obstruction].

A 75-year-old man had been admitted to another hospital because of left abdominal pain, and was given a diagnosis of left hydronephrosis and acute pancreatitis. After a JJ stent insertion and medication, he was transferred to our hospital for further examinations. US and EUS revealed a chronic pancreatitis-like pattern and multicystic lesion in the pancreas head and body. At that time enhanced CT findings showed an extrapancreatic low density area to be inflammatory change, extending from the pancreas body to the left crus of the diaphragm and posteriorly the spreading from the left crus of the diaphragm via the left urinary duct into the left iliopsoas muscle, in which MRI revealed partial high intensity. ERCP and MRCP showed focal irregular narrowing of the pancreatic duct of unknown cause, and we decided that an internal pancreatic fistula due to pancreatitis had induced left ureteral obstruction, caused by a protein plug or alcohol. Follow-up 6 months later showed that extrapancreatic spreading of the low density area had markedly regressed without any change in the ureteral obstruction.

[A case of primary carcinoma of the cystic duct with limy bile].

A 78-year-old man had been admitted to a previous hospital because of epigastralgia and a diagnosis of cholecystolithiasis had been made. He had been transferred to our institution for further examination. CT scan and US revealed chronic cholecystitis and gallstone, however, ERC revealed severe obstruction of the cystic duct and EUS revealed dilation of that duct and a solitary mass there. Carcinoma of the cystic duct was diagnosed, and we performed cholecystectomy and resection of the extrahepatic duct with two-field lymphadenectomy. The pathological specimen showed a round flat elevated mass localized in the cystic duct. Histopathologically, the diagnosis was well differentiated tubular adenocarcinoma of the cystic duct with limy bile and tiny gallstone.

[Evaluation of the endoprosthesis by metallic stent and tube stent for malignant biliary stenosis].

We evaluated the effect of biliary endoprotheses for 20 malignant stenosis patients by an expandable metallic stent and hydrophilic heparinized tube (H-PSD) connected to an implantable port (IP), which reduces bacterial adherence. Group A consisted of 6 patients of cholangiocarcinoma who underwent hepatic arterial infusion chemotherapy associated with radiotherapy. Groups B and C consisted of 8 and 6 patients of stage IVa and IVb pancreatic carcinoma, respectively, who underwent hepatic and splenic arterial infusion chemotherapy following transcatheter peripancreatic arterial embolization. The 50% patent time was 12 months, 6 months and 7 months in groups A, B and C and the 50% overall survival time was 16 months, 23 months and 13 months, respectively. There were two complications, 1 case of infection around the IP in which the IP was withdrawn, and 3 cases of cholangitis in which we had easy access to the bile duct via IP. This technique appears to offer significant benefit in selecting patients with this type of biliary obstruction.