Diagnosis of mucin-producing tumor of the pancreas by balloon-catheter endoscopic retrograde pancreatography--compression study.

The procedure of choice for the treatment of mucin-producing pancreatic tumor (MPPT) remains controversial, since it includes not only malignant but also benign lesions. The purpose of the present study was to characterize 53 consecutive cases of MPPT and to elucidate the characteristics of benign or malignant MPPT according to the findings of an improved method of endoscopic retrograde pancreatography (ERP), namely balloon-catheter ERP-compression study (balloon ERP-CS), as well as endoscopic ultrasonography (EUS), in comparison with a histological examination. There were 37 male and 16 female cases with a median age of 63+/-11 (mean+/-SD). The balloon ERP-CS was performed in all cases, and the obtained pancreatograms were classified into two types: Main Duct type and Branch Duct type. The latter was further divided into subtypes A and B. The Branch Duct A type showed only cystic dilatation of the branch duct. If the main pancreatic duct downstream to a cyst showed more than a 5 mm dilatation, this was classified as a Branch Duct B type. Seventeen out of 19 Main duct types (89%) were histologically diagnosed as neoplasms including 13 lesions of cancer and 4 of adenoma. All the Branch Duct A type cases were diagnosed as hyperplasias. 23 Branch Duct B type cases contained 7 cancers, 8 adenomas, and 8 hyperplasias. In the Main Duct type, benign or malignant, the diagnostic ability of balloon ERP-CS was calculated as sensitivity 100%, specificity 40%, and accuracy 84%; in the Branch Duct type, sensitivity 73%, specificity 86%, and accuracy 82%. On EUS, it was found that the size of the tumor in the cyst, with respect to the maximum diameter as well as height, correlated well with the grade of malignancy. All tumors (n=35) greater than 20 mm in diameter were found to be cancerous. These findings indicate that the MPPT is highly suggestive of neoplasms when the dilatation of the main pancreatic duct is detected by balloon ERP-CS and when, in a case without dilatation of the main pancreatic duct, a nodular lesion greater than 10 mm in diameter is identified in the cyst by balloon ERP-CS as well as EUS. Our current patient management strategy for operations is as follows: Main Duct type patients and Branch Duct type patients with a nodular defect detected by balloon ERP-CS and with an elevation of more than 10 mm in EUS should have an operation. Other Branch Duct type patients without main pancreatic duct dilatation are followed up by balloon ERP-CS.

Colonic cancer in a patient with primary sclerosing cholangitis and long-standing ulcerative colitis.

A 27-year-old woman with a 9-year history of ulcerative colitis involving the entire colon was admitted to our hospital in August 1992 because of bloody stools and left lower abdominal pain. She had been treated with sulfasalazine since 1983 and the colitis had been clinically quiescent or mild for 7 years. She had also been diagnosed as having primary sclerosing cholangitis (PSC) 4 years prior to this admission, based on the clinical, laboratory, and cholangiographic findings. A barium enema and colonoscopy showed an irregular mass obstructing the bowel lumen in the distal portion of the descending colon. Biopsy specimens taken from the mass revealed moderately differentiated adenocarcinoma, and a subtotal colectomy was performed. Histologic examination of the mass lesion showed moderately differentiated adenocarcinoma invading the pericolic adipose tissue. She is currently alive 3 years after surgery. PSC has recently been reported as a risk factor for colonic neoplasia in patients with long-standing ulcerative colitis. In Japan, however, colorectal cancer associated with PSC and ulcerative colitis has rarely been reported. The present case suggests that the risk of colonic cancer is higher in patients with ulcerative colitis and PSC than in patients with ulcerative colitis alone.

Management of giant common bile duct stones in high-risk patients using a combined transhepatic and endoscopic approach.

BACKGROUND: Endoscopic sphincterotomy (EST) for removing common bile duct stones is regarded as the safest and most successful method, particularly in patients with a high surgical risk. However, giant immobile stones still continue to present a therapeutic problem. METHODS: In our 12 patients, when endoscopic sphincterotomy and lithotomy proved to be unsuccessful a transhepatic choledochoscopic lithotomy was attempted. RESULTS: The stones were fragmented using choledochoscopic electrohydraulic lithotripsy and then were completely removed through both the transhepatic route and an EST opening in all 12 patients. The number of sessions required for these choledochoscopic procedures combined with EST was fewer than that required for only a transhepatic approach (2.5 +/- 1.3 versus 3.2 +/- 1.2), which thus resulted in a shorter hospital stay. Minor complications occurred in three patients with bleeding (two from the bile duct, one from the EST opening) and in two with postprocedure chills and fever. CONCLUSIONS: A combined lithotomy through duodenoscopic and choledochoscopic approaches is considered to be an efficient method for removing giant biliary calculi in patients who are not successfully treated by an ordinary duodenoscopic lithotomy.

[Current diagnosis and treatment of early pancreatic cancer].

In the present study our current experience of early pancreatic cancer is described. The early pancreatic cancer was defined when the tumor was located within the pancreas and/or less than 2 cm in diameter. Between 1983 and 1995, 9 out of 183 cases with pancreatic cancer were fulfilled with the criteria of early pancreatic cancer. Among the diagnostic modalities including US, CT, ERP, balloon ERP-CS and EUS, the balloon ERP-CS as well as EUS appears the most valuable procedure for making diagnosis of small pancreatic cancer. Currently, 8 out of 9 patients are alive at 1-10 years after surgery.

Segmental pancreatectomy for the diagnosis and treatment of small lesions in the neck or body of the pancreas.

BACKGROUND/AIMS: To avoid any profound deficit in the pancreatic functions as well as to successfully make a histological diagnosis of such lesions, we performed resections of a small segment of the pancreatic neck or body. This article discusses the practicality of this procedure as well as the complications and evaluation of the pancreatic functions after surgery. PATIENTS AND METHODS: A segmental pancreatectomy was performed in patients with small lesions of the pancreatic neck or body. There were a total of 24 patients including 11 with hyperplasia, 7 with chronic pancreatitis, 4 with mucinous or serous cystadenoma, and each one with islet cell carcinoma (low-grade malignancy) and carcinoma in situ. RESULTS: No major complications occurred following surgery. The pancreatic endocrine and exocrine functions were well maintained in all patients except for two with chronic pancreatitis. CONCLUSIONS: Based on our findings, a segmental pancreatectomy for small lesions in the pancreatic neck or body seems to be a safe and effective procedure for minimizing the postoperative deficit in the pancreatic functions, while it also allows for an accurate diagnosis of lesions that are often difficult to differentially diagnose for malignancy.

Branch duct origin of solid type pancreatic ductal carcinoma.

A case of branch duct origin of solid type pancreatic ductal carcinoma is presented. Stepwise tissue sections of an entire specimen, including the carcinoma area, and mapping, with special reference to the relationship between the main duct and the carcinoma area, were performed. Carcinoma cells of the branch duct showed intraductal spread with minimal stromal invasion. No carcinoma tissue was observed in the main duct. Therefore this case was considered to be of branch duct origin. The finding of histologically identified branch duct origin of solid type pancreatic ductal carcinoma indicates a distinct advantage to be gained by giving special attention to both the main and branch ducts when using image diagnosis for early detection of carcinomas, and may represent the first reported surgically resected case.