Hemosuccus pancreaticus: rara asociación entre pancreatitis aguda, alcoholismo y sesiones vasculares en la circulación esplácnica / Hemosuccus Pancreaticus: an unusual association of acute pancreatitis, alcoholism and vascular abnormalities of the splanchnic circulation

La pancreatitis aguda o crónica puede resultar en lesiones del conducto pancreático, además, la corrosión por el jugo pancreático puede provocar la ruptura de la pared vascular periférica, lo que conduce a hemosuccus pancreático (HP) definido como el sangrado del conducto pancreático a través de la ampolla de Vater. El sangrado suele ser intermitente, repetitivo y, a menudo, no lo suficientemente grave, como para causar inestabilidad hemodinámica. La mayoría de los pacientes tiene antecedentes de enfermedades pancreáticas originales y cuando esto no se cumple, debe incluirse en el diagnóstico diferencial para alcohólicos crónicos con hemorragia digestiva alta intermitente. Presentamos una forma clínica atípica en un paciente masculino de 55 años de edad, con antecedentes de HTA, alcoholismo y aneurisma de la aorta abdominal, quien consultó por dolor tipo cólico en abdomen superior, náuseas y vómitos; luego se asoció disminución del estado de conciencia, alternando con episodios de agitación psicomotriz y primo convulsión generalizada. Una vez ingresado, sucedieron varios episodios de melena. La tomografía abdominal mostró aumento de tamaño y densidad (unidades hounsfield de 58-61) en cabeza y cuerpo del páncreas, por lo que se realizó una angiografía abdominal con protocolo de páncreas y se evidenció doble lesión aneurismática de la arteria esplénica y la arteria gástrica. Falleció en el postoperatorio(AU)

Acute or chronic pancreatitis can result in lesions of the pancreatic duct; in addition, corrosion by the pancreatic juice can cause the rupture of the peripheral vascular wall, which leads to pancreatic hemosuccus defined as bleeding from the pancreatic duct through the Vater ampulla. Bleeding is often intermittent, repetitive, and often not severe enough to cause hemodynamic instability. Most of the cases have a history of strictly pancreatic original diseases, when this is not the case, the PH should be included in the differential diagnosis for chronic alcoholics with intermittent upper gastrointestinal bleeding, We report here an atypical presentation in a 55-year-old male patient with a history of hypertension, alcoholism and an abdominal aortic aneurysm. He consulted for colicky abdominal pain in the upper abdomen, nausea and vomiting; subsequently he presented decreased consciousness, alternating with episodes of psychomotor agitation and generalized seizures. Once hospitalized he had several bouts of melena. The abdominal tomography showed an increase in the size and density (hounsfield units of 58-61) of the head and body of the pancreas. An abdominal angiography with a pancreas protocol was performed, which evidenced a double aneurismal lesion of the splenic and gastric arteries. The patient died after surgery(AU)

Recurrent Pancreatitis Caused by Afferent Loop Syndrome with Pathologic Features of Type II Autoimmune Pancreatitis / 대한내과학회지

Afferent loop syndrome (ALS) is a rare cause of recurrent pancreatitis. Recurrent pancreatitis in association with ALS can develop due to impaired outflow of pancreatic juice or reflux of enteric secretions caused by increased intraluminal duodenal pressure. Here, we report a case of ALS presenting as recurrent acute pancreatitis due to chronic intermittent partial obstruction of the third portion of the duodenum caused by postoperative adhesion. Interestingly, pancreatic histology showed a granulocytic epithelial lesion, which is a diagnostic feature of type 2 autoimmune pancreatitis (AIP, idiopathic duct centric chronic pancreatitis [IDCP]). From this case we learned that the diagnosis of type 2 AIP should be made in the appropriate clinical setting.

Predictive Value of Localized Stenosis of the Main Pancreatic Duct for Early Detection of Pancreatic Cancer

BACKGROUND/AIMS: In this study, we aimed to evaluate the predictive value of localized stenosis of the main pancreatic duct (MPD) for early detection of pancreatic cancer.METHODS: Among 689 patients who underwent endoscopic retrograde pancreatography from January 2008 to September 2018, 19 patients with MPD findings were enrolled. These patients showed findings for indicating suspicious pancreatic cancer at an early stage (FiCE); FiCE was defined as a single, localized stenosis in the MPD without a detectable mass (using any other imaging methods) and without other pancreatic diseases, such as definite chronic pancreatitis, intraductal papillary mucinous neoplasm, and autoimmune pancreatitis. Final diagnoses were established by examining resected specimens or through follow-up examinations after an interval of >5 years.RESULTS: Among 19 patients with FiCE, 11 underwent surgical resection and 8 were evaluated after a >5-year observation period. The final diagnosis of the MPD stenosis was judged to be pancreatic cancer in 9 patients (47%), including 3 with intraepithelial cancer, and to be a non-neoplastic change in 10. The sensitivity, specificity, and accuracy of preoperative pancreatic juice cytology were 75%, 100%, and 88%, respectively.CONCLUSIONS: The predictive value of FiCE for pancreatic cancer prevalence was 47%. Histological confirmation with pancreatic juice cytology is necessary before surgical resection.

Seguridad y eficacia del drenaje guiado por endosonografía de colecciones pancreáticas usando prótesis plásticas y metálicas tipo LAMS / Safety and efficacy of EUS-guided drainage of pancreatic fluid collections using plastic and lumen apposing metal stents (LAMS)

Background: Pancreatic fluid collections (PFC) are associated with severe acute pancreatitis. After maturation (after 4 weeks) they are classified as pancreatic pseudocyst (PP) and walled-off necrosis (WON). Endoscopic management is associated with lower morbidity and mortality compared with surgery. Aim: To describe the experience of EUS-guided drainage PFC drainage using plastic stent (PS) or metal stent (lumen apposing metal stents, or "LAMS"). Methods: Retrospective, observational study, between 2016-2019. Results: 17 patients in total. 8 cases were symptomatic PP and 9 were WON. Age 12-72 years. 12 cases in men. Indications: abdominal pain 5 cases and infection 11. The 8 cases of PFC were drained successfully using PS, without adverse effects. Regarding WON drainage, 3 cases were managed with PS and 6 with LAMS. In 5 cases, complementary endoscopic necrosectomy was required. A patient with LAMS required complementary surgical cleaning ("step-up") to treat collections far from the LAMS. Complications: one case of PS presented pigment occlusion with superinfection and another case presented migration to the stomach. Regarding LAMS, one case presented self-limited bleeding, another case presented obstruction of the stent with infection, which was managed endoscopically and with antibiotics. Conclusion: The endoscopic management of PFC is effective and safe, with plastic and metal stent (LAMS). The choice of type of stent depends on the characteristics of PFC (liquid vs solid), center experience and costs.

Introducción: Las colecciones pancreáticas (CP) se asocian a pancreatitis agudas graves. Luego de su maduración (después de las 4 semanas) se clasifican en pseudoquistes (PQ) y necrosis encapsulada (NE). El manejo endoscópico se asocia a menor morbimortalidad comparado con el quirúrgico. Objetivo: Describir la experiencia del drenaje de CP mediante el uso de prótesis plásticas (PP) o metálicas (lumen apposing metal stents, o "LAMS") mediante endosonografía. Método: Estudio retrospectivo, observacional, entre 2016-2018. Resultados: 17 pacientes en total. Ocho casos fueron PQ sintomáticos y 9 NE. Edad 12-72 años (12 casos en hombres). Indicaciones: dolor abdominal 5 casos e infección 11. Los 8 casos de PQ fueron drenados exitosamente con PP, sin efectos adversos. En relación con el drenaje de NE, 3 casos fueron manejados con PP y 6 con LAMS. En 5 casos se requirió necrosectomía endoscópica complementaria. Un paciente con LAMS requirió aseo quirúrgico complementario por colecciones alejadas al LAMS. En relación con las complicaciones, un caso de PP presentó oclusión del pigtail con sobreinfección y otro presentó migración al estómago. Respecto a LAMS, un caso presentó sangrado autolimitado y otro caso obstrucción de la prótesis con sobreinfección, que fue manejada endoscópicamente y con antibióticos. Conclusión: El manejo endoscópico de las CP es efectiva y segura, tanto con prótesis plásticas como metálicas (LAMS). La elección de la prótesis depende de las características de la lesión (líquido vs sólido), experiencia del centro y costos.

Pancreatic Compression during Lymph Node Dissection in Laparoscopic Gastrectomy: Possible Cause of Pancreatic Leakage

PURPOSE: Postoperative pancreatic fistula is a serious and fatal complication of gastrectomy for gastric cancer. Blunt trauma to the parenchyma of the pancreas can result from an assistant's forceps compressing and retracting the pancreas, which in turn may result in pancreatic juice leakage. However, no published studies have focused on blunt trauma to the pancreas during laparoscopic surgery. Our aim was to investigate the relationship between compression of the pancreas and pancreatic juice leakage in a swine model. MATERIALS AND METHODS: Three female pigs were used in this study. The pancreas was gently compressed dorsally for 15 minutes laparoscopically with gauze grasped with forceps. Pancreatic juice leakage was visualized by fluorescence imaging after topical administration of chymotrypsin-activatable fluorophore in real time. Amylase concentrations in ascites collected at specified times was measured. In addition, pancreatic tissue was fixed with formalin, and the histology of the compressed sites was evaluated. RESULTS: Fluorescence imaging enabled visualization of pancreatic juice leaking into ascites around the pancreas. Median concentrations of pancreatic amylase in ascites increased from 46 U/L preoperatively to 12,509 U/L 4 hours after compression. Histological examination of tissues obtained 4 hours after compression revealed necrotic pancreatic acinar cells extending from the surface to deep within the pancreas and infiltration of inflammatory cells. CONCLUSIONS: Pancreatic compression by the assistant's forceps can contribute to pancreatic juice leakage. These findings will help to improve the procedure for lymph node dissection around the pancreas during laparoscopic gastrectomy.

Anatomy and Surgical Management of Ampullary Neoplasm / 대한췌담도학회지

Ampulla is a common channel where biliary and pancreatic duct join. The reason why it is called ampulla is that this area is enlarged where it penetrates the duodenal wall. As it protrudes into the duodenal lumen, it is also called papilla. Ampulla is surrounded by sphincter muscles which control the secretion of bile and pancreatic juice. Ampullary tumor includes broad spectrum of benign and malignant tumors which need different treatment options - Endoscopic papillectomy (EP), surgical ampullectomy (SA), and pylorus-preserving pancreatoduodenectomy (PPPD). There is a consensus that benign tumors need EP and malignant tumors need PPPD. However, there are controversies regarding how to treat high-grade dysplasia (HGD), carcinoma in-situ, or T1 cancer. Surgical treatment includes SA and PPPD. The indication of SA is usually benign tumors which extend to bile duct or pancreatic duct or too big tumors to snare completely by endoscopy. Compared to EP, SA is less likely to leave remnant tumor which results in re-resection. In some limited cases of early carcinoma, SA can be attempted. Oncologically, however, SA is not recommended because there might be incomplete resection, lymph node metastasis, lymphovascular invasion, or perineural invasion. As PPPD still has high morbidity, prolonged length of stay, and relatively high post-op mortality, SA can be recommended in old patients with co-morbidity that can be exacerbated after surgery. Technically important points of SA are as follows; first, resecting the whole layer of duodenum, second, re-implanting the bile duct and pancreatic duct with duodenal mucosa to keep the mucosal continuity. PPPD is a standard operation of malignant tumor because it can completely remove the tumor as well as regional lymph nodes.

Long-term follow-up may be needed for pancreaticobiliary reflux in healthy adults / 대한외과학회지

PURPOSE: The reflux of pancreatic enzymes into the biliary tract is associated with chronic inflammation and increases cellular proliferation of the biliary epithelium, leading to biliary carcinoma. The aim of this study is to detect the incidence of occult pancreaticobiliary reflux (OPBR) in patients who underwent elective cholecystectomy. METHODS: Forty-seven patients with symptomatic gallstones who underwent cholecystectomy were recruited for this study. The gallbladder bile samples were obtained from the specimen of gallbladder and the amylase level was measured. The immunohistochemistry of p53, SMAD4 and Ki-67 were performed for the detection of metaplasia and dysplasia. RESULTS: Biliary amylase was higher than the serum amylase in 10 patients (group A, 15,402.66 +/- 33,592.43 IU/L; group B, 13.06 +/- 18.12 IU/L). The mean age was 67.2 years in group A and 51.2 in group B (P < 0.01). The ratio of male to female was 1:2.3 and 1:1.8 in group A and B, respectively (P = 0.297). Eight patients in group A and thirteen patients in group B had inflammation (P = 0.014). The positive results of the Ki-67 test were exhibited in five cases in each group (P = 0.024). CONCLUSION: Results from the study indicate that the age was older, degree of inflammation and positive rate of Ki-67 were higher when OPBR was suspected. In conclusion, the patients with OPBR would need long-term follow-up, because the OPBR can cause dysplasia and the reflux of pancreatic juice may be considered as a risk factor for extrahepatic bile duct carcinoma.

Technical knacks and outcomes of extended extrahepatic bile duct resection in patients with mid bile duct cancer

BACKGROUNDS/AIMS: Mid bile duct cancers often involve the proximal intrapancreatic bile duct, and resection of the extrahepatic bile duct (EHBD) can result in a tumor-positive distal resection margin (RM). We attempted a customized surgical procedure to obtain a tumor-free distal RM during EHBD resection, so that R0 resection can be achieved without performing pancreaticoduodenectomy through extended EHBD resection. METHODS: We previously reported the surgical procedures of extended EHBD resection, in which the intrapancreatic duct excavation resembles a > or =2 cm-long funnel. This unique procedure was performed in 11 cases of mid bile duct cancer occurring in elderly patients between the ages of 70 and 83 years. RESULTS: The tumor involved the intrapancreatic duct in all cases. Deep pancreatic excavation per se required about 30-60 minutes. Cancer-free hepatic duct RM was obtained in 10 patients. Prolonged leakage of pancreatic juice occurred in 2 patients, but all were controlled with supportive care. Adjuvant therapies were primarily applied to RM-positive or lymph node-positive patients. Their 1-year and 3-year survival rates were 90.9% and 60.6%, respectively. CONCLUSIONS: We suggest that extended EHBD resection can be performed as a beneficial option to achieve R0 resection in cases in which pancreaticoduodenectomy should be avoided due to various causes including old age and expectation of a poor outcome.

Effectiveness of external drainage of the bile duct in pancreaticoduodenectomy: a single surgeon's experience

BACKGROUNDS/AIMS: The rates of surgery-related complications during and after pancreaticoduodenectomy (PD) remain very high, reaching up to 41%. They were primarily caused by leakage of pancreatic juice. We evaluated the effectiveness of external drainage of the bile duct using a pigtail drain to prevent pancreatic leakage in patients undergoing PD. METHODS: We evaluated 79 patients who underwent PD using a single-layer continuous suture between the pancreatic parenchyma and jejunum after duct-to-mucosa anastomosis by a single surgeon from April 2005 to December 2008. Of the 79, 44 underwent external drainage (ED) of the bile duct using a pigtail drain, performed in the intraoperative field via a retrograde transhepatic approach, whereas 35 did not undergo ED. RESULTS: Age, sex distribution, number of total complications, pancreatic duct size, pancreatic texture and duration of hospital stay did not differ between patients who did and did not undergo ED. In groups with or without ED, 0 and 4 patients, respectively, showed leakage of pancreatic juice and the difference was statistically significant (p=0.02). CONCLUSIONS: The fact that none of the patients who underwent external drainage experienced pancreatic leakage, suggests that external drainage of the bile duct with a pigtail drain to decompress the jejunum and to drain pancreatic and bile juice is useful in preventing the complications of pancreatic leakage.

Etecp cytology and EUS-FNA cytology in the diagnosis of malignant distal biliary and pancreatic duct strictures

Endoscopic retrograde cholangio-pancreatography [ERCP] with ductal brushings and pancreatic juice cytology is widely used in suspected pancreatic cancer, despite its low sensitivity. In contrast the accuracy rates of endoscopic ultrasound [EUS]-fine needle aspiration [FNA] for diagnosis of pancreatic malignancy is high. Aim of the study: To compare diagnostic performance of ERCP cytology [ERCP-C] with EUS-FNA in suspected patients with malignant pancreatic duct stricture. Patients and A prospective study included 56 patients with pancreatic duct stricture was performed. ERCP-C and EUS-FNA were carried out for cytopathological diagnosis. The final diagnosis was pancreatic malignancy in 60.7% patients and benign pancreatic disease in 39.3% patients. The sensitivity, specificity, positive [PPV] and negative [NPV] predictive values and accuracy of EUS-FNA for malignant pancreatic ductal stricture were 87.9%, 100%, 100%, 84.6% and 92.7, respectively. The sensitivity, specificity, PPV, NP V, and accuracy of ERCP brush cytology alone [41.4%, 100%, 100%, 55.3%, 66%, respectively], and combined with pancreatic juice cytology [48.3%, 100%, 100%, 58.3%, and 70%, respectively] were inferior to EUS-FNA. Significant dfferences between post ERCP-C and post-EUS-FNA pancreatitis were detected [P<0.001]. EUS-FNA is more sensitive and safer for cytopathological diagnosis of pancreatic duct stricture than ERCP-C

Clinical Characteristics of Biliary Tract Cancer Associated with Choledochal Cyst

PURPOSE: Choledochal cysts are rare congenital or acquired cystic dilatations of the intra- or extra-hepatic bile ducts. The mechanism of carcinogenesis in choledochal cyst has not been clearly elucidated, although stasis of bile and reflux of pancreatic juice appear to be important factors. The aim of this study was to identify the clinical risk factors predicting development of biliary tract cancers in patients with choledochal cyst. METHODS: The study subjects included 170 consecutive patients who underwent surgery for choledochal cysts at Seoul National University Hospital between December 1980 and May 2008. We analyzed the demographic characteristics, clinical symptoms, laboratory findings, type of choledochal cysts, pathologic characteristics, and long-term outcomes of the patients with associated biliary tract cancers. RESULTS: Out Of 170 patients with choledochal cysts, combined biliary tract cancers ware identified in 29 patients, which included extrahepatic bile duct (n=15; 51.7%), gallbladder (n=12; 41.4%), and ampulla of Vater cancers (n=2; 6.9%). There were no significant differences in gender, clinical symptoms (abdominal pain, jaundice, and abdominal masses), laboratory findings (leukocytosis, hyperbilirubinemia, and increased alkaline phosphatase), and Todani classification of choledochal cysts between the two groups with or without combined biliary tract cancer. Multivariate analysis revealed that age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. CONCLUSION: Age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. Therefore, the possibility of associated biliary tract cancers should be considered when planning surgical management for patients with these risk factors.

Clinical Characteristics of Biliary Tract Cancer Associated with Choledochal Cyst

PURPOSE: Choledochal cysts are rare congenital or acquired cystic dilatations of the intra- or extra-hepatic bile ducts. The mechanism of carcinogenesis in choledochal cyst has not been clearly elucidated, although stasis of bile and reflux of pancreatic juice appear to be important factors. The aim of this study was to identify the clinical risk factors predicting development of biliary tract cancers in patients with choledochal cyst. METHODS: The study subjects included 170 consecutive patients who underwent surgery for choledochal cysts at Seoul National University Hospital between December 1980 and May 2008. We analyzed the demographic characteristics, clinical symptoms, laboratory findings, type of choledochal cysts, pathologic characteristics, and long-term outcomes of the patients with associated biliary tract cancers. RESULTS: Out Of 170 patients with choledochal cysts, combined biliary tract cancers ware identified in 29 patients, which included extrahepatic bile duct (n=15; 51.7%), gallbladder (n=12; 41.4%), and ampulla of Vater cancers (n=2; 6.9%). There were no significant differences in gender, clinical symptoms (abdominal pain, jaundice, and abdominal masses), laboratory findings (leukocytosis, hyperbilirubinemia, and increased alkaline phosphatase), and Todani classification of choledochal cysts between the two groups with or without combined biliary tract cancer. Multivariate analysis revealed that age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. CONCLUSION: Age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. Therefore, the possibility of associated biliary tract cancers should be considered when planning surgical management for patients with these risk factors.

Complications Following and Supplementary Procedures for a Pancreas-preserving Total Gastrectomy

PURPOSE: A pancreas-preserving total gastrectomy (PPTG) was introduced to decrease the postoperative complications due to pancreatic resection. However, some complications, such as leakage of pancreatic juice, are still reported. Thus, the purpose of this study was to propose a supplementary procedure based on the results of treatment for gastric cancer at our hospital. MATERIALS AND METHODS: From Jan. 1997 to Dec. 2004, the cases of 141 patients who underwent a PPTG for gastric cancer were reviewed retrospectively. The patients were divided into Group A (38 cases), patients who were treated using a conventional PPTG, and Group B (103 cases), patients who were treated using a new and improved PPTG. Their postoperative complications were compared. RESULTS: No statistically significant differences in clinicopathologic data were noted between the two groups. The comparison of complications showed for groups A and B, respectively, 4 and 0 cases of pancreatic fistula, 1 and 0 cases of intraabdominal abscess, 2 and 0 cases of intraoperative pancreatic necrosis, and 2 and 2 cases of minor leakage. The difference in the prevalence of complications between the two groups was statistically significant (P=0.0001). CONCLUSION: In order to reduce the risk of PPTG-related complications, we used vascular clamps to observe the necrosis of the pancreatic tail before dividing the splenic artery, and this method resulted in a significant decrease in postoperative complications. Thus, we conclude that our use of vascular clamps in a PPTG is a simple and useful method for preventing postoperative complications.

An anomalous union of the pancreaticobiliary duct that was treated by drainage of the accessory ampulla / 대한내과학회지

An anomalous union of the pancreaticobiliary duct is defined as a condition in which the junction between the common bile duct and the pancreatic duct is located outside the duodenal wall. Therefore, the sphincter of Oddi does not influence the junction; there is always communication between these ducts, and so pancreatic juice flows into the biliary tract through the communication, which may cause pancreaticobiliary diseases. Pancreas divisum is a congenital variant of the pancreatic ductal anatomy, and the mechanism is that the dorsal and ventral pancreatic buds fail to fuse during the gestation. We report here on a 21 year old woman who previously had suffered with recurrent pancreatitis, and an anomalous union of the pancreaticobiliary duct associated with the incomplete type of pancreas divisum was revealed by ERCP. She was treated with minor papilla sphincterotomy and stent insertion.

Pancreaticogastrostomy as a Beneficial Alternative to a Pancreaticojejunostomy

Pancreaticogastrostomy (PG) has been used as an alternative procedure for pancreaticojejunostomy (PJ) for reconstruction after a pancreaticoduodenectomy (PD). Leakage at the pancreatoenteric anastomosis is still a major cause of morbidity and mortality after a PD. Therefore the major goal of technical modifications should be elimination or at least a reduction of pancreatic leakage. A number of published studies have shown that PG is associated with a low rate of anastomotic leakage. PG is easier to perform due to the thick posterior wall of the stomach and its excellent blood supply being proximal to the remaining pancreas. Furthermore, the pancreatic juice appears to be neutralized by the gastric juice, resulting in a reduction in the morbidity and mortality associated with anastomotic leakage. PG also results in a straight alignment of the digestive tract without an A-loop. PG and PJ showed an impaired exocrine and endocrine pancreatic function with a similar extent. The activity of the pancreatic enzymes is inhibited in the stomach after a PG. The enzymes become activated when gastric pH exceeds 3.1, which normally occurs after the ingestion of a meal. In conclusion, we recommend duct-to-mucosa PG as a beneficial alternative to a PJ, even in the hands of an inexperienced surgeon.

Multivariate analysis of perioperative risk factors of pancreatic remnant leakage after pancreaticoduodenectomy

This study was carried on 24 patients suffering from periampullary carcinoma. All the patients were admitted to Department of Surgery, Main Alexandria University Hospital, and underwent the original Whipple's operation. After Whipple's operation, anastomosis of the pancreatic stump was done by means of pancreaticojejunostomy dunking method, pancreatieo-jejunostomy mueosa to mucosa, pancreatico-gastrostomy implantation method and pancreatico-gastrostomy rnucosa to mucosa method. Each method was done in 6 patients. Leakage occurred in 5 patients [20.8%], 3 [12.5%] of them had leaked after pancreaticojejunostomy dunking method, and the other 2 [8.3%] leaked after panereatieogastrostomy implantation method. After pancreaticojejunostomy dunking method 2 leaking patients died within 30 days of surgery, and the other patient resolved with conservative management. The leaked patients after pancreaticogastrostomy implantation method resolved with conservative management. The incidence of leakage increased with older age, lengthened operative time, increased blood replacement, soft pancreatic texture at the site of cutting and preoperative biliary drainage

Pancreaticopleural Fistula : Complication of Chronic Pancreatitis

A 64 year-old male, with a history of alcoholism, presented at our hospital with dyspnea. He had a history of admission to hospital for treatment of chronic pancreatitis 4 month ago. Chest radiography showed a marked amount of right pleural effusion. Thoracentesis revealed an exudate of amylase-rich fluid. After conservative management he was discharged, but 1 month later increased right pleural effusion was detected. A pancreaticopleural fistula was detected on ERCP and abdomen CT. After 2 months of conservative management, there had been no improvement of the fistula; therefore, the authors decided to operate. The pancreas was hard and atrophic, with severe adhesion to adjacent tissues. Several pancreatic duct stones were found intraoperatively, with a pseudocyst was also found at the body portion. A suspicious fistula tract was observed at the posterior aspect of the body, which was subsequently ligated. A distal pancreatectomy, with a lateral pancreaticojejunostomy, and an additional side-to-side choledochojejunostomy were performed. A small amount of right pleural effusion was detected, with thoracentesis performed on the 8th postoperative day. The pleural effusion did not show a pancreatic juice nature, with amylase and protein levels of 9 U/L and 2,127 mg/L, respectively. No further increase in the amount of pleural effusion was observed, and the patient was discharged on the 16th postoperative day, without any complications. There was no evidence of recurrence at the 6 month follow up.

A Choledochal Cyst Combined with a Hilar Cholangiocarcinoma

A choledochal cyst, also referred to as cystic dilatation of bile duct, is a relatively rare lesion. Moreover, carcinoma arising from such a choledochal cyst has rarely been reported on. The incidence of carcinoma in choledochal cyst is much higher than that seen for the normal population. The mechanism of carcinogenesis in choledochal cyst is not clear, although reflux of pancreatic juice and stasis of the bile appears to be important factors. To our knowledge, there is no literature reporting on a case of choledochal cyst combined with a hilar cholangiocarcinoma. We report here on a case of choledochal cyst combined with a hilar cholangiocarcinoma in 46-year-old male patient.

Endoscopic Diagnosis in Pancreatic Cancer / 한국간담췌외과학회지

Pancreatic ductal adenocarcinoma is the most common malignancy occurring in the pancreas. This entity almost always shows fatal outcome and the complete cure is extremely difficult. The fatal outcome seems to be caused by the fact that this entity is usually diagnosed at its' advanced stage and the biological behavior is different from other curable types of malignancy. Endoscopic approach to the diagnosis of pancreas cancer comprises mainly of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS). Upon ERCP, pancreatic cancer usually shows stricture or complete obstruction of main pancreatic duct and distal bile duct obstruction in case of pancreas head cancer. Endoscopic brush cytology, forcep biopsy or pancreatic juice analysis can offer histologic diagnosis but the sensitivity is very low. Upon EUS, pancreatic cancer is usually observed as a hypoechoic or mixed echogenic mass and outer margin of the mass becomes more indistinct as the size of the mass increases. EUS can offer more accurate local tumor staging than helical computed tomography, in terms of nodal involvement and vascular invasion. EUS-guided fine needle aspiration can give additional histological information of the mass and therapeutic strategy can be modified according to the histology and EUS staging. EUS has limitations in the diagnosis of distant nodal involvement and hepatic metastasis. Endoscopic approach can detect pancreatic mass with high sensitivity and especially EUS can give detailed information about local tumor extent. However, physician should also understand the benefits and limitations of other imaging modalities such as computed tomography or magnetic resonance cholangiopancreatography, and try to make more accurate diagnosis of the lesion and extent.

Molecular Diagnosis and Tumor Markers in Pancreatic Cancer / 한국간담췌외과학회지

Pancreatic cancer is a devastating disease with a fatal prognosis due to late diagnosis. Current imaging studies are inadequate for early detection and CA 19-9, the best tumor marker thus far, has low sensitivity in small pancreatic cancer, so the use of new markers is our most promising approach. Activation of the proto-oncogene K-ras and inactivation of the tumor suppressor genes p53, p16 and SMAD4 are characteristics for pancreatic cancer. K-ras mutation can be detected from pancreatic juice in 55~79% of patients with pancreatic cancer but can occur in the setting of chronic pancreatitis up to 32%. Telomerase activity in pancreatic juice can be used to distinguish between cancer and pancreatitis. The progression model of pancreatic cancer proposes that pancreatic intraepithelial neoplasia is the pre-cancerous lesion and this model is important for developing screening tools to detect early curable cancer. Pancreatic cancer harbors aberrant methylation of many cancer-related genes and detection of DNA hypermethylation by methylation specific PCR is attractive new candidate suitable for early detection. Recent large- scale gene expression studies can be done using cDNA and oligonucleotide microarrays and serial analysis of gene expression. Hundreds of overexpressed genes were already identified in pancreatic cancer. Large-scale analysis of proteins in biologic samples is possible by proteomics which has been applied to discovery proteins that could be used as potential markers. It is hoped that the understanding of genetic alterations and development of high throughput technologies will lead to the rapid discovery of biomarkers that will save lives by enabling aggressive therapy at the early stage.