Diagnosis and treatment of biliary pancreatic duct dilatation / 中华消化外科杂志

Objective@#To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.@*Methods@#The retrospective and descriptive study was conducted. The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected. There were 6 males and 16 females, aged from 33 to 82 years, with an average age of 66 years. Surgical exploration was decided according to clinical symptoms, results of laboratory test and imaging examinations. For patients with space occupying lesions, surgical procedure was selected based on results of pathological examination. Patients without surgical exploration or space occupying lesions were allocated into follow-up. Observation indicators: (1) surgical exploration; (2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions; (3) surgical treatment; (4) follow-up. Follow-up using outpatient examination was performed on patients up to October 2018. Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations, no jaundice, normal laboratory indicators or mild abnormality, liver function, tumor markers and B-ultrasound were re-examined each month, and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months. Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase. Follow-up was performed on patients with negative results of imaging examination, jaundice, and mildly elevated CA19-9. TBil and CA19-9 were re-examined monthly, and if they were progressively elevated, patients were transferred to surgical exploration. For patients with negative results of imaging examination, no symptoms, and negative laboratory test, liver function, tumor markers, and B-ultrasound were re-examined once every 3 months, and enhanced CT and MRI were re-examined once every 6 months within one year. Follow-up was performed once every 6 months during the second year, and once a year after two years. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Count data were descibed as absolute numbers, and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.@*Results@#(1) Surgical exploration: of 22 patients, 11 underwent surgical exploration, and 11 underwent follow-up. Of the 11 patients with surgical exploration, 4 were positive for space occupying lesions including 1 of false negative, and 7 were negative for space occupying lesions. (2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions. ① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions: juandice was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (χ2=0, 0, P<0.05), with a sensitivity of 75.0% and specificity of 100.0%. ② Relationship between imaging examination and surgical exploration positive for space occupying lesions: results of CT, MRI, endoscopic retrograde cholangio-pancreatography, endoscopic ultrasonography, PET-CT, and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (χ2=0, 0.77, 0, 0, 1.00, 0, 0, 0, 0, P>0.05). PET-CT had no significant association with surgical exploration positive for space occupying lesions (P>0.05). ③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions: positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P<0.05), with a sensitivity of 50.0% and specificity of 100.0%. ④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions: of 22 patients, the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration, (13.0±2.8)mm and (3.5±0.5)mm for patients with negative surgical exploration, (11.6±2.4)mm and (3.2±0.4)mm for patients with follow-up, respectively, showing no significant difference between them (t=0.22, 0.36, P>0.05). (3) Surgical treatment: 9 of 11 patients with surgical exploration followed the standard procedure. Of the 9 patients, 4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection), 5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography, and was confirmed pancreatic head cancer by reoperation 3 months after the first operation). Two patients didn′t follow the exploratory procedure, and underwent the child operation only based on the preoperative imaging findings, without intraoperative pathological examination. Postoperative pathological examination showed chronic ampulla and chronic pancreatitis, respectively. (4) Follow-up: 22 patients were followed up for 12-60 months, with a median follow-up time of 36 months. Two of 11 patients with surgical exploration had postoperative gastroplegia, 1 had bile leakage, 1 had incisional infection, and they were improved after symptomatic treatment. Four patients undergoing surgeries for positive exploration had no recurrence during follow-up. Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage, 1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy, 4 were removed T-tube after by T-tube cholangiography at 2 months after surgery. During the follow-up, no positive signs showed in laboratory test or imaging examination. No recurrence occurred in the two patients undergoing pancreaticoduodenectomy. Of 11 patients with follow-up, 10 had abdominal pain before surgery, including 3 with pain during follow-up and 7 with symptoms disappeared. There was no abnormalities in the laboratory test.@*Conclusions@#The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation. Those patients who do not meet this criteria should be distributed into the follow-up. If no positive pathological results were obtained during the operation, the surgery should be terminated and the patients should be transferred into follow-up. The reckless biliary anastomosis or biliary stents placement is opposed.

Diagnosis and treatment of biliary pancreatic duct dilatation / 中华消化外科杂志

Objective To summarize the diagnosis and treatment of biliary pancreatic duct dilatation.Methods The retrospective and descriptive study was conducted.The clinical data of 22 patients with biliary pancreatic duct dilatation who were admitted to Renji Hospital of Shanghai Jiaotong University School of Medicine between October 2013 to September 2017 were collected.There were 6 males and 16 females,aged from 33 to 82years,with an average age of 66 years.Surgical exploration was decided according to clinical symptoms,results of laboratory test and imaging examinations.For patients with space occupying lesions,surgical procedure was selected based on results of pathological examination.Patients without surgical exploration or space occupying lesions were allocated into follow-up.Observation indicators:(1) surgical exploration;(2) relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions;(3) surgical treatment;(4) follow-up.Follow-up using outpatient examination was performed on patients up to October 2018.Follow-up was performed on patients with positive surgical exploration to detect postoperative complications.For patients with positive results of imaging examinations,no jaundice,normal laboratory indicators or mild abnormality,liver function,tumor markers and B-ultrasound were re-examined each month,and computed tomography (CT) and magnetic resonance imaging (MRI) was performed once every 3 months.Surgical exploration was performed when total bilirubin (TBil) or tumor markers showed a progressive increase.Follow-up was performed on patients with negative results of imaging examination,jaundice,and mildly elevated CA19-9.TBil and CA19-9 were re-examined monthly,and if they were progressively elevated,patients were transferred to surgical exploration.For patients with negative results of imaging examination,no symptoms,and negative laboratory test,liver function,tumor markers,and B-ultrasound were re-examined once every 3 months,and enhanced CT and MRI were re-examined once every 6 months within one year.Follow-up was performed once every 6 months during the second year,and once a year after two years.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were descibed as absolute numbers,and they were analyzed using the chi-square test under R×C chart or Fisher exact probability.Results (1) Surgical exploration:of 22 patients,11 underwent surgical exploration,and 11 underwent followup.Of the 11 patients with surgical exploration,4 were positive for space occupying lesions including 1 of false negative,and 7 were negative for space occupying lesions.(2) Relationship of clinical symptoms and preoperative examinations with surgical exploration positive for space occupying lesions.① Relationship of clinical symptoms and laboratory test with surgical exploration positive for space occupying lesions:juandice was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),and elevated TBil and DBil were significantly associated with surgical exploration positive for space occupying lesions (x2 =0,0,P＜0.05),with a sensitivity of 75.0％ and specificity of 100.0％.(② Relationship between imaging examination and surgical exploration positive for space occupying lesions:results of CT,MRI,endoscopic retrograde cholangiopancreatography,endoscopic ultrasonography,PET-CT,and combined imaging examinations had no significant association with surgical exploration positive for space occupying lesions (x2 =0,0.77,0,0,1.00,0,0,0,0,P＞0.05).PET-CT had no significant association with surgical exploration positive for space occupying lesions (P＞0.05).③ Relationship of imaging examination and laboratory test with surgical exploration positive for space occupying lesions:positive imaging examination combined with elevated TBil and CA19-9 was significantly associated with surgical exploration positive for space occupying lesions (P＜0.05),with a sensitivity of 50.0％ and specificity of 100.0％.④ Relationship of preoperative diameters of biliary ducts and pancreatic ducts with surgical exploration positive for space occupying lesions:of 22 patients,the diameters of biliary ducts and pancreatic ducts were (13.8±4.3)mm and (4.6±1.5)mm for patients with positive surgical exploration,(13.0±2.8)mm and (3.5±0.5) mm for patients with negative surgical exploration,(11.6±2.4) mm and (3.2±0.4) mm for patients with follow-up,respectively,showing no significant difference between them (t =0.22,0.36,P＞0.05).(3) Surgical treatment:9 of 11 patients with surgical exploration followed the standard procedure.Of the 9 patients,4 were found space-occupying lesions at the choledocho-pancreatico-duodenal junction (3 undergoing pancreaticoduodenectomy and 1 undergoing duodenal papilla partial resection),5 with negative exploration underwent common bile duct incision and T-tube drainage (one patient was unable to pinch the T-tube one month after operation and detected obstruction at the lower end of the bile duct by radiography,and was confirmed pancreatic head cancer by reoperation 3 months after the first operation).Two patients didn't follow the exploratory procedure,and underwent the child operation only based on the preoperative imaging findings,without intraoperative pathological examination.Postoperative pathological examination showed chronic ampulla and chronic pancreatitis,respectively.(4) Follow-up:22 patients were followed up for 12-60 months,with a median followup time of 36 months.Two of 11 patients with surgical exploration had postoperative gastroplegia,1 had bile leakage,1 had incisional infection,and they were improved after symptomatic treatment.Four patients undergoing surgeries for positive exploration had no recurrence during follow-up.Of 5 patients with negative exploration undergoing common bile duct incision and T-tube drainage,1 was confirmed pancreatic head cancer and underwent pancreaticoduodenectomy,4 were removed T-tube after by T-tube cholangiography at 2 months after surgery.During the follow-up,no positive signs showed in laboratory test or imaging examination.No recurrence occurred in the two patients undergoing pancreaticoduodenectomy.Of 11 patients with follow-up,10 had abdominal pain before surgery,including 3 with pain during follow-up and 7 with symptoms disappeared.There was no abnormalities in the laboratory test.Conclusions The positive imaging examinations combined with jaundice and elevated CA19-9 is an absolute indication for surgical exploration in patients with biliary duct dilatation.Those patients who do not meet this criteria should be distributed into the follow-up.If no positive pathological results were obtained during the operation,the surgery should be terminated and the patients should be transferred into follow-up.The reckless biliary anastomosis or biliary stents placement is opposed.

Longitudinal pancreaticojejunostomy for paediatric chronic pancreatitis with dilated pancreatic ducts / 中华肝胆外科杂志

Objective To analyze the results of longitudinal pancreaticojejunostomy in treatment of paediatric chronic pancreatitis with dilated pancreatic ducts.Methods A retrospective study was carried out on 13 patients with paediatric chronic pancreatitis complicated with dilated pancreatic ducts treated with longitudinal pancreaticojejunostomy in Children's Hospital of Chongqing Medical University from December 2011 to January 2017.The perioperative morbidity and mortality rates,long-term treatment results and postoperative growth of these children were analyzed.Results The 13 patients all underwent successful surgery.In 11 patients,the serum and urine amylase levels returned to normal after 8 days of operation,and the abdominal pain disappeared completely.In 1 patient,the abdominal pain gradually disappeared in 1 year,and the serum and urine amylase levels gradually returned to normal.This patient gained weight well.In the remaining patient who had severe pancreatic atrophy,the patient took high-fat diets before and after surgery,and drank alcohol occasionally.The patient developed repeated attacks of abdominal pain with occasional increase in serum and urine amylase levels and had poor weight gain.There were no complications such as postoperative bleeding,pancreatic leakage and intestinal obstruction in this study.The body weight and growth rates of the whole group of patients before and 1 year after surgery were different.Conclusion Longitudinal pancreaticojejunostomy for paediatric chronic pancreatitis complicated with dilated pancreatic ducts was safe and effective in alleviating symptoms,improving quality of life,and resulted in normal growth of these children.

A Small Pancreatic Neuroendocrine Tumor with Marked Pancreatic Duct Dilatation and Parenchymal Atrophy / 대한내과학회지

Pancreatic ductal adenocarcinomas often cause marked pancreatic duct dilatation and associated parenchymal atrophy. We present the case of a small pancreatic neuroendocrine tumor with upstream pancreatic duct dilatation and severe parenchymal atrophy. A small enhancing tumor was observed at the head of the pancreas on computed tomography (CT). Endoscopic ultrasonography-guided fine-needle aspiration was negative for malignancy. We performed a pylorus-preserving pancreatoduodenectomy since we could not exclude the presence of pancreatic ductal adenocarcinoma. The pathological and immunohistochemical examination revealed a serotonin-positive neuroendocrine tumor, measured 1.0 x 0.5 cm. The pathological specimen was remarkable for the marked stromal fibrosis in the area of the tumor, which resulted in narrowing of the main pancreatic duct. Here, we report a rare small pancreatic neuroendocrine tumor, the CT image of which resembled that of pancreatic ductal adenocarcinoma, in which the expression of serotonin and associated fibrosis might be a possible mechanism for the marked main pancreatic duct dilatation.

A Case of Pancreatic Neuroendocrine Tumor Mimicked Intraductal Papillary Mucinous Neoplasm / 대한췌담도학회지

Neuroendocrine tumors of the pancreas are exremely rare tumors, but recent imaging examination advances, diagnostic frequency is also increasing. However, there is difficulty of diagnosis of pancreatic serotonin producing neuroendocrine tumors, because tumors grow slowly and clinical symptoms are not significant. A 60-year-old male patient with pancreatic duct dilatation progresses gradually during the seven years without obstructing lesion in imaging studies, we suspected the mass as intraductal papillary mucinous neoplasm. However, we diagnosed his case as neuroendocrine tumor after surgery and report here with literature review.

A Case of Ampullary Adenomyoma Associated with Dilatations of Pancreatic and Biliary Ducts / 대한소화기내시경학회지

Adenomyoma is a nonneoplastic lesion that can be found anywhere in the gastrointestinal tract, but it's rarely found in the ampulla of Vater. To the best of our knowledge, it is a benign lesion, but most cases are misdiagnosed as carcinoma or adenoma by a preoperative endoscopic or radiologic procedure, and this leads to unnecessarily extensive surgical resection. We report here on a case of ampulla of Vater adenomyoma that resulted in biliary and pancreatic duct dilatation. The tumor was diagnosed by endoscopic papillectomy.