The controlled release of basic fibroblast growth factor promotes a rapid healing of pancreaticojejunal anastomosis with potent angiogenesis and accelerates apoptosis in granulation tissue.

BACKGROUND: Our previous study demonstrated that bFGF-GH promoted healing of the pancreaticojejunostomy (PJ) in an animal model. We examined the healing process in detail to investigate the significance of treatment with basic fibroblast growth factor (bFGF) incorporated in gelatin hydrogel (GH) microspheres for anastomotic healing. MATERIALS AND METHODS: The optimal dose of bFGF was determined by administering bFGF concentrations of 1, 10, and 100 µg in six beagle dogs and assessing the results on d 7. Next, 28 dogs received a jejunal subserosal injection of 10 µg bFGF-GH or GH alone. The healing process was sequentially analyzed on d 4, 7, 21, and 28. The following types of assessment were performed: breaking strength test, pathologic examination, and calculations of collagen content, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) index, and microvessel density (MVD). RESULTS: The administration of a bFGF dose of more than 10 µg induced a significantly higher breaking strength and more abundant granulation tissues. Histologic observations of the bFGF-GH group on d 7 and the GH-alone group on d 21 revealed abundant granulation tissue with migrating fibroblasts, inflammatory cells, and capillaries. Marked neovascularization and dense collagen deposition were detected in both groups on d 28. The collagen content and breaking strength did not significantly differ between both groups on d 28. A significantly higher TUNEL index and a rapid decline in the number of vimentin-positive cells were detected in the bFGF-GH group from d 21 onward. The MVD in the bFGF-GH group was significantly higher from d 7 onward CONCLUSIONS: Basic FGF-GH administration can promote the rapid completion of PJ anastomosis and may help improve the quality of the healing of granulation tissue by conferring potent angiogenesis and accelerating apoptosis.

Treatment of Advanced Pancreatic Body and Tail Cancer by En Bloc Distal Pancreatectomy with Transverse Mesocolon Resection Using a Mesenteric Approach.

BACKGROUND: Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes. METHODS: There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin). RESULTS: From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient. CONCLUSIONS: We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion.

Laparoscopic distal pancreatectomy preserving spleen and splenic vessels for pancreatic insulinoma.

We describe a 43-year-old woman who underwent laparoscopic distal pancreatectomy preserving the spleen and splenic vessels for the treatment of insulinoma in the pancreatic body. The patient experienced cold sweats on fasting, received diagnosis of insulinoma, and was referred to our hospital for laparoscopic surgery. Blood biochemistry studies showed low fasting blood glucose of 42 mg/dL, serial immunoreactive insulin of 15.2 microU/mL, and a Fajans index (immunoreactive insulin/blood glucose) of 0.36 (normal <0.30). Contrast-enhanced early-phase computed tomography of the abdomen showed a circular, intensely stained, 1.6-cm-diameter tumor in the pancreatic body close to the main pancreatic duct. A solitary insulinoma of the pancreatic body was diagnosed on the basis of the result of hematologic studies, and diagnostic imaging results. Because of the location of the tumor, we elected to perform distal pancreatectomy preserving the spleen and splenic vessels, rather than enucleation. Insulin and blood glucose levels were monitored during surgery. Before removal of the tumor, insulin levels remained consistently high, never decreasing to less than 10 microU/mL. After surgery, insulin levels decreased rapidly, to less than 5 microU/mL within 30 minutes and subsequently remained at the new low level, leading us to conclude that the entire tumor had been removed. There were no postoperative complications, and the patient was discharged from the hospital on day 7. There was no major intraoperative bleeding other than at the resected surface. The patient was ambulatory soon after the procedure, and had a brief hospital stay therefore, the surgery was judged to have been highly useful in this case.

[Pancreaticoduodenal lymph node metastasis of neuroendocrine carcinoma of unknown primary associated with duodenal carcinoma].

A 73-year-old man was admitted with bloody stool. Duodenoscopy showed a hemorrhagic ulceration in the duodenum on the side opposite to the papilla of Vater. Abdominal CT demonstrated a well-defined hypervascular mass, adjacent to the lesion of the duodenum. Although as duodenal GIST was diagnosed, histologic examination for frozen sections during the procedure revealed tubular adenocarcinoma of the duodenum and pancreaticoduodenal lymph node metastasis of neuroendocrine carcinoma. He underwent a subtotal stomach-preserving pancreaticoduodenectomy. Clinicopathologically, the neuroendocrine carcinoma of the pancreaticoduodenal lymph node was considered to be metastasis from an unknown primary lesion.

Clinical outcome of laparoscopic distal pancreatectomy.

BACKGROUND: Few studies have compared laparoscopic distal pancreatectomy (Lap-DP) and open distal pancreatectomy (open-DP). The aim of this study was to evaluate the clinical outcome of Lap-DP and compare it to that of open-DP. METHODS: A total of 37 patients who underwent distal pancreatectomy (Lap-DP, 21 patients; open-DP, 16 patients) between January 2000 and March 2007 were enrolled in this study. Prior to January 2004, open-DP was the standard procedure for patients with a lesion in the distal pancreas without invasive ductal cancer; thereafter, Lap-DP was also an approved procedure. All 16 open-DP procedures were performed prior to January 2004. RESULTS: The operating times for the Lap-DP and open-DP patients were 308.4 +/- 124.6 and 281.5 +/- 83.3 min, respectively, and these were not significantly different (P = 0.4635). Blood loss for the Lap-DP group (249.0 +/- 239.8 ml) was significantly smaller than that for the open-DP group (714.1 +/- 650.4 ml) (P = 0.0055), and none of the patients in the Lap-DP group received transfusions. The frequency of complications for the Lap-DP and open-DP groups was 0 and 18.8%, respectively, which is not significantly different (P = 0.0784). The average hospital stay for the Lap-DP group was significantly shorter than that for the open-DP group (10.0 +/- 2.6 vs. 25.8 +/- 8.8 days; P < 0.0001). CONCLUSION: In pancreatic diseases, other than invasive ductal cancer, arising in the distal pancreas, Lap-DP might be a more feasible and safer than open-DP.

Laparoscopic pancreatic resection: some benefits of evolving surgical techniques.

Laparoscopic pancreatic resection began to be reported in the first half of the 1990s, with subsequent reports focusing primarily on the safety and usefulness of laparoscopic distal pancreatectomy (Lap-DP) for benign and low-malignancy lesions of the pancreatic body and tail (such as chronic pancreatitis, neuroendocrine tumor, mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm). Recently we have also begun to see retrospective case-control studies comparing these techniques with open surgery, with Lap-DP showing advantages not only in terms of esthetics related to the surgical wound, but also with regard to reduced intraoperative bleeding, postoperative recovery time, and days of postoperative hospitalization. Prospective randomized controlled trials are still needed for confirmation, but it appears likely that this technique will become a standard surgical procedure for the treatment of diseases of the pancreatic body and tail. In contrast, laparoscopic pancreatoduodenectomy (Lap-PD) remains controversial in the minds of many pancreatic surgeons. This is primarily due to the difficulty of laparoscopic reconstruction following resection. However, there have recently been a number of single-center reports on the use of this procedure in at least 20 patients per center, showing that Lap-PD is associated with considerable reduction in intraoperative bleeding. Our own experience has been similar. In carefully selected patients, we find Lap-PD to be a useful surgical procedure.

Features and choice of treatment of acute and chronic pancreatic pseudocysts--with special reference to invasive intervention.

AIMS: It was the aim of this study to characterize the features of acute and chronic pancreatic pseudocysts (PPs) and to identify the factors predictive of the need for invasive treatment. METHODS: Thirty-six patients with PPs treated at Nippon Medical School between January 1995 and December 2004 were studied retrospectively. The cases were divided into 4 groups based on 4 features: association with acute pancreatitis, association with chronic pancreatitis, spontaneous resolution, and persistent symptoms requiring therapeutic intervention. Group 1 included 9 patients with acute PPs which resolved spontaneously. Group 2 included 9 patients with acute PPs with persistent symptoms or associated complications requiring interventional treatment. Group 3 included 9 patients with chronic PPs which resolved spontaneously, and group 4 included 9 patients with chronic PPs with persistent symptoms or associated complications requiring interventional treatment. RESULTS: Among the 36 patients, 13 were women and 23 were men. The etiologies were pancreatitis due to alcoholism in 18 cases (50.0%), biliary tract disease in 8 cases (22.2%) and other conditions in 10 cases (27.8%). The average duration of follow-up was 24.2 +/- 18.5 months. The patients in group 1 were significantly older than those in group 2 (67.6 +/- 16.1 vs. 40.6 +/- 14.1 years; p = 0.011). The mean size of the PPs was significantly larger in groups 1 and 4 than in group 3 (p < 0.05) and significantly larger in group 2 than in group 4 (p < 0.05). There were no significant differences between groups 1 and 2 in the size of the PPs or in the Ranson score of previous pancreatitis. The increase in size of the PPs during follow-up in each of the spontaneously resolved groups (groups 1 and 3) differed significantly from that in each of the interventional treatment groups (groups 2 and 4; p < 0.05). The main cause of the acute pancreatitis in group 1 was biliary tract disease, while that in group 2 was alcoholism (significantly different, p < 0.05). The number of patients with symptoms related to pseudocysts at the time of diagnosis was significantly higher in group 1 than in group 3. CONCLUSIONS: Growth of the PPs during follow-up is the strongest predictor of the need for invasive treatment in both acute and chronic cases. Among acute PPs, the size of the pseudocyst is not in itself a predictor of invasive treatment. Invasive treatment may pose higher risks for pseudocysts with an etiology of alcoholic acute pancreatitis. However, the size of the pseudocyst may be a more important prognostic factor than an etiology of pancreatitis. and IAP.

Efficacy of a Blake drainR on pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND/AIMS: The aim of this study was to evaluate the efficacy of the Blake drain for the management of pancreatic fistula (PF) in comparison with the Duple drain. METHODOLOGY: Our study consisted of two parts: a retrospective review of 33 patients with PF after pancreaticoduodenectomy, and a basic experiment to investigate the effects of the Blake drain on the management of PF in an animal model. RESULTS: In the clinical study, 19 patients received Blake drains (B-group) and 14 received Duple drains (D-group). Grade C fistulas with abdominal bleeding developed in only 2 patients in the B-group. All the patients in the B-group healed with conservative treatment (P<0.01). and none of them required percutaneous drainage or reoperation (P<0.05). In the basic experiment, no collections of fluid were detected around the Blake drains. When leakage occurred, it did not lead to abdominal abscess, and a "drain canal" formation linking the anastomosis with the extracorporeal orifice was demonstrated all along the drainage route. CONCLUSIONS: Blake drains may be efficient therapeutic tools in patients with grade B fistulas. The basic experiment affirms that Blake drains provide excellent drainage and contribute to the formation of "drain canals" effective in localizing and controlling PF.

Early surgical management for periampullary retroperitoneal perforation caused by endoscopic sphincterotomy: report of a case.

A 67-year-old woman was admitted to our hospital for surgical management of cancer of the ascending colon. On admission, she had cholangitis due to choledocholithiasis. Abdominal computed tomography, ultrasonography, and magnetic resonance showed cholelithiasis, choledocholithiasis, and multiple liver tumors. Colonoscope showed advanced cancer of the ascending colon. Because of acute obstructive suppurative cholangitis, endoscopic sphincterotomy was performed. During the procedure, periampullary retroperitoneal perforation was identified on radiologic examination. Because computed tomography had shown extravasation of contrast medium and widespread pneumoretroperitoneum, an emergency operation was performed 2 hours after perforation. After cholecystectomy and choledocholithotomy had been performed and all bile duct stones had been removed, periampullary perforation was readily identified close to the duodenal diverticula and easily repaired. The postoperative course was uneventful. This patient could resume oral feeding soon after the operation, and colonic surgery could be performed immediately thereafter. Therefore, early surgical management is a possible first choice of treatment in patients with remaining biliary disease after periampullary perforation.

Surgical treatment for isolated multiple pancreatic metastases from renal cell carcinoma: report of a case.

A 70-year-old man was admitted to our hospital for evaluation of multiple pancreatic tumors. Twelve years earlier he had undergone left radical nephrectomy for renal cell carcinoma (RCC). Computed tomography revealed two well-defined mass lesions in the head and tail of the pancreas, with strong contrast enhancement in the arterial phase. Fluorine-18 fluorodeoxyglucose positron emission tomography detected an elevated uptake within the lesions but no extrapancreatic uptake. The preoperative diagnosis was isolated multifocal metastatic pancreatic tumors from RCC. The patient underwent total pancreatectomy with splenectomy. Both of the tumors were well-demarcated, gray-white, and firm on gross observation. Microscopic examination, meanwhile, revealed solid tumors consisting of clear oval cells with severe nuclear atypia. These pathologic findings were consistent with the preoperative diagnosis of pancreatic metastasis from RCC. Radical resection improves the long-term survival of patients, and total pancreatectomy may be an appropriate procedure.

Experimental pancreatic cancer model using PGHAM-1 cells: characteristics and experimental therapeutic trials.

We developed short-term pancreatic cancer models in hamsters using PGHAM-1 cells and examined the utility of the models for research on metastasis and for therapeutic trials. With 3 PGHAM-1 models, including 1) primary pancreatic cancer and simultaneous liver metastasis by intrapancreatic transplantation, 2) liver metastasis alone by intrasplenic transplantation, 3) peritoneal dissemination by intraperitoneal transplantation, within 21 days after inoculation, we studied the specific characteristics of metastases and the effects of several antiangiogenic substances on primary and metastatic pancreatic tumors. Several experiments showed that vascular endotherial growth factor and anatomical characteristics were important factors for metastasis. In therapeutic experiments, the incidence, size, diameter, microvessel density, and apoptotic index of the tumors were preferably influenced by the antiangiogenic substances. In addition, PGHAM-1-Luc, which is luciferase-positive PGHAM-1 cell line, was newly developed and is expected to be a useful new animal model. These models would be suitable for the study of pathogenesis of pancreatic cancer and its metastasis and for preclinical trials of chemotherapeutic agents, such as antiangiogenic substances.

Controlled release of basic fibroblast growth factor promotes healing of the pancreaticojejunal anastomosis: a novel approach toward zero pancreatic fistula.

BACKGROUND: Several reconstructive surgical techniques have been proposed for restoring pancreatico-jejunal continuity. Little has been done, however, to evaluate the efficacy of tissue engineering on anastomotic healing. We examined the effects of basic fibroblast growth factor (bFGF) incorporated in gelatin hydrogel (GH) microspheres on the anastomotic healing of pancreaticojejunostomy. METHODS: As a preliminary experiment, 20 female Wistar rats received a jejunal subserosal injection of 1 microg of bFGF-GH (n = 10), 1 microg of Free-bFGF (n = 5), or gelatin alone (n = 5) to study the effects of bFGF on the histology of normal jejunum on day 7 after the injection. Next, 12 beagle dogs received a jejunal subserosal injection of 100-microg bFGF-GH (n = 7) or gelatin alone (n = 5) at the anastomotic site of pancreaticojejunostomy. Four types of assessment were performed to compare the 2 groups: pancreatography, breaking strength test, pathologic examination, and calculation of the microvessel density (MVD). RESULTS: The bFGF-GH injection led to markedly increased levels of collagen and fibroblastic cellularity in the subserosal layer of the Wistar rats. In contrast, the rats treated by gelatin alone exhibited no such effects. No anastomotic failures were observed in the dogs treated by bFGF-GH. Histologic observations of this group revealed abundant granulation tissues. Treatment with bFGF-GH significantly increased the breaking strength and MVD over the levels measured in the control group (P < .01). CONCLUSIONS: bFGF-GH accelerates healing of pancreaticojejunal anastomosis during the early postoperative period. Basic FGF-GH may show promise as a new technique for preventing anastomotic failure of pancreaticojejunostomy.

Adenoma of the minor papilla associated with pancreas divisum.

Tumors of the minor papilla of the duodenum are quite rare. We report the first documented case of an adenoma of the minor papilla complicating pancreas divisum. A 52-year-old woman was admitted to our hospital for treatment of an asymptomatic duodenal tumor detected by computed tomography scan. Endoscopy showed an 18-mm, whitish-colored, sessile mass located in the descending duodenum proximal to a normal appearing major papilla. Endoscopic retrograde pancreatography revealed divisum of the pancreas with dilatation of pancreatic duct ranged in the dorsal pancreas. Transduodenal minor papillectomy was performed because there is malignant potential of the tumor and the possibility of acute pancreatitis. The Santorini orifice was then re-approximated to the duodenal wall for protection against acute pancreatitis caused by scarring and stenosis of the duct orifice as a possible late complication. The patient's postoperative course was uneventful and she has been asymptomatic without evidence of tumor recurrence or stenosis of the Santorini orifice on endoscopic examination for the last 4 years.

Preventing liver metastasis by resecting the primary pancreatic carcinoma at an early stage of intrapancreatic transplantation in hamsters.

PURPOSE: To determine whether early primary pancreatic tumor resection can prevent liver metastases of intrapancreatic transplantation in a hamster model. METHODS: Cells from the PGHAM-1 cell line were transplanted into the pancreases of 30 Syrian golden hamsters. A suspension of 5 x 10(6) cells was injected into the splenic lobe of each pancreas. The primary pancreatic tumor was resected in 15 of the hamsters 10 days after transplantation (resection group). Fifteen other animals with transplantation but without resection served as controls (control group). All hamsters were killed 21 days after transplantation. The primary pancreatic tumors were measured for size and volume and examined histologically and immunohistologically for angiogenesis and tumor proliferation. RESULTS: In the resection group, small pancreatic tumors 4.7 +/- 0.94 mm in diameter were found and resected 10 days after transplantation. Neither pancreatic tumors nor liver metastases were found in the resection group at the end of the experiment. All animals in the control group had pancreatic tumors 12.3 +/- 3.29 mm in size, and 11 of 15 (73.3%) had liver metastases. The primary pancreatic tumors in the group with liver metastasis were significantly larger in diameter and volume than those in this group without liver metastasis (p<0.01). In the control group, proliferation of the primary pancreatic tumor, evaluated according to argyrophilic nucleolar organizer region, showed no differences within the pancreatic tumor group. On the other hand, the microvessel density of pancreatic tumors with liver metastases was significantly higher than that of tumors without liver metastases. CONCLUSIONS: Our results suggest that 10 days after transplantation, the pancreatic tumors were small in size and volume and ready to proliferate but not yet ready to begin metastasizing through angiogenesis. This is one reason why early resection of the primary tumor prevents liver metastasis.

Usefulness of Color Coding Resected Samples from a Pancreaticoduodenectomy with Tissue Marking Dyes for a Detailed Examination of Surgical Margin Surrounding the Uncinate Process of the Pancreas.

BACKGROUND: Characteristics of a cancer-positive margin around a resected uncinate process of the pancreas (MUP) due to a pancreticoduodenectomy are difficult to understand by standardized evaluation because of its complex anatomy. The purposes of this study were to subclassify the MUP with tissue marking dyes of different colors and to identify the characteristics of sites that showed positivity for cancer cells in patients with pancreatic head carcinoma who underwent circumferential superior mesenteric arterial nerve plexus-preserving pancreaticoduodenectomy. Results of this evaluation were used to review operation procedures and perioperative methods. METHOD: We divided the MUP into 4 sections and stained each section with a different color. These sections were the pancreatic head nerve plexus margin (Area A), portal vein groove margin (Area B), superior mesenteric artery margin (Area C), and left of the superior mesenteric artery margin (Area D). The subjects evaluated were 45 patients who had carcinoma of the pancreatic head and were treated with circumferential superior mesenteric arterial nerve plexus-preserving pancreaticoduodenectomy. RESULTS: Of the 45 patients, nine cases (90%) of incomplete resection showed cancer-positivity in the MUP. Among the 4 sections of the MUP, the most cases of positive results [MUP (+) ] were found in Area B, with Area A (+), 0 case; Area B (+), 6 cases; Area C (+), 2 cases; and Area D (+), 3 cases (total, 11 sites in 9 patients). Relapse occurred in 7 of the 9 patients with MUP (+). Local recurrence was observed as initial relapse in all 3 patients with Area D (+). In contrast, the most common site of recurrence other than that in patients with Area D (+) was the liver. CONCLUSION: By subclassifying the MUP with tissue marking dyes of different colors, we could confirm regional characteristics of MUP (+). As a result, circumferential superior mesenteric arterial nerve plexus-preserving pancreticoduodenectomy was able to be performed in R0 operations in selected patients while a better postoperative quality of life was maintained. Furthermore, Area D (+) represents an extension beyond the limit of the local disease and may indicate the need for early aggressive adjuvant chemotherapy.

One-step palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent.

AIM: To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent (EMS) used in the treatment of obstructive jaundice caused by unresectable malignancies. METHODS: Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure. RESULTS: One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered. CONCLUSIONS: One-step percutaneous transhepatic insertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient's quality of life.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases.

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis: a case report.

A 69-year-old man presented with obstructive jaundice and dark urine. Contrast-enhanced computed tomography revealed an enlarged pancreas with homogenous enhancement. Endoscopic retrograde pancreatography demonstrated short-segmental, irregular narrowing of the main pancreatic duct. The patient underwent exploratory laparotomy and needle biopsies of the pancreas, which showed marked fibrotic change with lymphocyte infiltration. These clinicopathologic findings suggested autoimmune pancreatitis. Four years later, computed tomography demonstrated marked periaortic soft tissue surrounding a calcified infrarenal abdominal aorta compatible with retroperitoneal fibrosis. We diagnosed retroperitoneal fibrosis with noncontiguous pancreatic fibrosis. This patient responded well to corticosteroid treatment. Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis seems to be extremely rare, and to our knowledge, only a few cases have been reported.

Pancreatic arteriovenous malformation involving adjacent duodenum with gastrointestinal bleeding: report of a case.

A 54-year-old man was admitted to our hospital with the symptoms of palpitation, dyspnea, and tarry stool. Upper gastroduodenal endoscopy revealed submucosal lesions with vascular ectasia in the second part of the duodenum. Dynamic computed tomography (CT) detected a hypervascular lesion in the pancreatic head and the duodenum. Selective angiography showed proliferation of a vascular network and early filling of the portal vein at the early arterial phase. With a diagnosis of pancreatic arteriovenous malformation (AVM), we performed pylorus-preserving pancreaticoduodenectomy. At laparotomy, localized and meandering vessels were seen on the surface of the head of the pancreas. Histological examination showed dilated tortuous vessels accompanied by severed elastic fibers in the vessel media and blood clot formation. The incidence of pancreatic AVM remains extremely low, and recurrent gastrointestinal bleeding is a frequent complication. To prevent recurrent bleeding and progressive portal hypertension, surgery may be the definitive management of symptomatic AVM.