Pancreatic head resection preserving the main pancreatic duct for congenital hyperinsulinism of infancy

AbstractIntroduction: Pancreatic cancer is malignancy with poor prognosis for quality of life and overall survival. The incidence is variant, 7.7/100,000 in Europe, 7.6/100,000 in the USA, 2.2/100.000 in Africa. The only real benefit for cure is surgery, duodenopancreatectomy. The key points for this procedure are radicality, low morbidity and low mortality, the follow up and the expected overall survival. The benchmark of the procedure is the pancreaticojejunoanastomosis, with its main pitfall, postoperative pancreatic fistula B or C. Subsequently, the manner of creation of pancreaticojejunoanastomosis defines the safety, thus the postoperative morbidity and mortality. Finally, this issue remarkably depends on the surgeon and the surgical technique creating the anastomosis. We used 2 techniques with interrupted sutures, dunking anastomosis and duct-to-mucosa double layer technique. The objective of the study was to compare these 2 suturing techniques we applied, and the aim was to reveal the risk benefit rationale for dunking either duct to mucosa anastomosis.Material and method: In our last series of 25 patients suffering pancreatic head carcinoma we performed a standard dodenopancreatectomy. After the preoperative diagnosis and staging with US, CICT, tumor markers, they underwent surgery. Invagination-dunking anastomosis was performed in 15, whereas, duct-to-mucosa, double layer anastomosis was performed in 10. In the first group with dunking anastomosis, we had 6 patients with soft pancreas and 8 with narrow main pancreatic duct, less than 3 mm. In the duct-to-mucosa group there were 5 patients with soft pancreas and 4 with narrow main pancreatic duct. All other stages of surgery were unified, so the only difference in the procedure remained on the pancreatojejunoanastomosis. The onset of the postoperative pancreatic fistula was estimated with revelation of 3 fold serum level of alfa amylases from the third postoperative day in the drain liquid.Results: In the duct to mucosa group there wasn’t a clinically relevant postoperative pancreatic fistula, while in the dunking anastomosis group we had 4 postoperative pancreatic fistula B, 26 %. One of these 4 patients experienced intraabdominal collection – abscess, conservatively managed with lavation through the drain. Comparing the groups, there was no significant difference between the groups concerning the appearance of postoperative pancreatic fistula: p>0.05, p=0.125. From all 25 patients, in 21 patients biliary stent was installed preoperatively to resolve the preoperative jaundice. All 21 suffered preoperative and postoperative reflux cholangitis, extending the intra-hospital stay.Conclusion: So far, there have been many trials referring to opposite results while comparing these 2 techniques in creation of the pancreticojejunoanastomosis. In our study, the duct to mucosa anastomosis prevailed as a technique, proving its risk benefit rationale. However, further large randomized clinical studies have to be conducted to clarify which of these procedures would be the prime objective in the choice of the surgeon while creating pancreatojejunoanastomosis.

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Intraductal papillary mucinous neoplasm complicated with intraductal bleeding in a young woman mimicked a cystic solid pseudo-papillary tumor: a case report

BMC Gastroenterology ◽

10.1186/s12876-020-01436-3 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Jianman Wu ◽

Yin Lin ◽

Jingwen Wu

Keyword(s):

Pancreatic Duct ◽

Young Woman ◽

Intraductal Papillary Mucinous Neoplasm ◽

Main Pancreatic Duct ◽

Pancreatic Head ◽

Preoperative Imaging ◽

Moderate Degree ◽

Cystic Wall ◽

Mucinous Neoplasm ◽

Ct And Mri

Abstract Background There are only 6 cases of intraductal papillary mucinous neoplasm (IPMN) complicated with intraductal hemorrhage have been reported in English literatures. All these 6 cases of IPMN occurred in the old people. The present rare case of IPMN complicated with intraductal hemorrhage occurred in a young woman, and mimicked a cystic solid pseudo-papillary neoplasm (SPN) on preoperative imaging findings. Case presentation A 29-year-old young woman complained of a sustained mild right upper quadrant abdominal pain. CT and MRI showed a lobulated, partly ill-defined cystic lesion located in the pancreatic head. Spotted calcification within cystic wall was seen on CT. The lesion was demonstrated as predominantly homogeneous hyperattenuation on CT and homogeneous high signal without decreased signal on fat suppression sequence on T1WI. After contrast administration, the cystic wall and septa of lesion was showed gradually mild to moderate degree of enhancement over time both on CT and MRI. No communication between lesion and the main duct was found on MRCP and the main pancreatic duct and common bile duct were not dilated. Considering patient’s age, gender and manifestations of lesion on CT and MRI (calcification, bleeding and gradually enhanced pattern), the present case mimicked as a cystic SPN. The lesion was pathologically confirmed a branch type IPMN after surgical resection. Conclusion We propose that IPMN may need to be taken into account in the differential diagnosis when pancreatic cystic lesions occur in young women with bleeding, calcification, progressive enhancement of cystic wall and no communication with the main pancreatic duct.

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Postoperative Complications of Beger Procedure

Case Reports in Surgery ◽

10.1155/2015/970785 ◽

2015 ◽

Vol 2015 ◽

pp. 1-3

Author(s):

Nayana Samejima Peternelli ◽

Tali Wajsfeld ◽

Felipe Henrique Yazawa Santos ◽

Otavio Schmidt de Azevedo ◽

Rodrigo Altenfelder Silva ◽

...

Keyword(s):

Postoperative Complications ◽

Conservative Treatment ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Pancreatic Head ◽

Unusual Complication ◽

Refractory Pain ◽

Beger Procedure ◽

Pancreaticojejunal Anastomosis

Introduction. Chronic pancreatitis (CP) is considered an inflammatory disease that may cause varying degrees of pancreatic dysfunction. Conservative and surgical treatment options are available depending on dysfunction severity.Presentation of Case. A 36-year-old male with history of heavy alcohol consumption and diagnosed CP underwent a duodenal-preserving pancreatic head resection (DPPHR or Beger procedure) after conservative treatment failure. Refractory pain was reported on follow-up three months after surgery and postoperative imaging uncovered stones within the main pancreatic duct and intestinal dilation. The patient was subsequently subjected to another surgical procedure and intraoperative findings included protein plugs within the main pancreatic duct and pancreaticojejunal anastomosis stricture. A V-shaped enlargement and main pancreatic duct dilation in addition to the reconstruction of the previous pancreaticojejunal anastomosis were performed. The patient recovered with no further postoperative complications in the follow-up at an outpatient clinic.Discussion. Main duct and pancreaticojejunal strictures are an unusual complication of the Beger procedure but were identified intraoperatively as the cause of patient’s refractory pain and explained intraductal protein plugs accumulation.Conclusion. Patients that undergo Beger procedures should receive close outpatient clinical follow-up in order to guarantee postoperative conservative treatment success and therefore guarantee an early detection of postoperative complications.

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A case of intraductal tubulopapillary neoplasm of the pancreas in a branch duct: a rare case report and literature review

BMC Gastroenterology ◽

10.1186/s12876-021-01744-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Atsushi Yamaguchi ◽

Takuro Hamada ◽

Kaoru Wada ◽

Riho Moriuchi ◽

Kanae Tao ◽

...

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Case Reports ◽

Pancreatic Head ◽

Side Branch ◽

World Health ◽

Colonic Surgery ◽

Branch Duct ◽

Intraductal Tubulopapillary Neoplasm ◽

Post Surgery

Abstract Background Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a new disease concept defined by the World Health Organization in 2010. ITPN progresses with tubulopapillary growth in the pancreatic duct and is known to have a fair prognosis. Localization in the main pancreatic duct (MPD) is one characteristic. There are few case reports of ITPN in a branch of the pancreatic duct (BD). Case presentation We encountered a case of ITPN localized in BD. An 85-year-old man was followed after colonic surgery for rectal carcinoma. An abdominal computed tomography scan revealed a cystic mass in the pancreatic head and further examination was done. A T2 weighted intension picture in magnetic resonance imaging showed a 20 mm cystic lesion with an internal mass of 15 mm. Duodenal papilla were slightly open and endoscopic retrograde pancreatography revealed mild and diffuse dilatation of the main pancreatic duct and mucin in the MPD. In consideration with the image examinations, we diagnosed the tumor as an intraductal papillary mucinous neoplasm with carcinoma because of its large mural nodule (> 10 mm in size) in a cyst. Consequently, a pancreaticoduodenectomy was performed. Macroscopically, a white solid tumor sized 2.5 × 1.8 × 1.0 was identified in the head of the pancreas. The cut surface of the resected pancreas showed a side-branch type intraductal tumor with tubulopapillary architecture without mucin secretion. Immunohistochemical staining was positive for MUC1, and negative for MUC2 and MUC5AC. The final diagnosis was determined to be pancreatic ITPN from BD. At the time of this report (48 months post-surgery), the patient remains disease-free without evidence of recurrence. Conclusion ITPNs localized in BD are rare and diagnosis prior to surgery is difficult. In our case, the shape was round, not papillary, and with little fluid. These characteristics are different from a branch duct type IPMN and can be a clue to suspect ITPN in BD.

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Criteria for the Selection of Diagnostic Signs of Chronic Pancreatitis with Obstruction of the Main Pancreatic Duct

Vestnik of Experimental and Clinical Surgery ◽

10.18499/2070-478x-2020-13-2-76-85 ◽

2020 ◽

Vol 13 (2) ◽

pp. 76-85

Author(s):

Alexander R Propp ◽

Evgeny Nikolaevich Degovtsov

Keyword(s):

Chronic Pancreatitis ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Structural Changes ◽

Early Stage ◽

Pancreatic Head ◽

Diagnostic Methods ◽

Entire Length ◽

Diagnostic Signs ◽

Selection Of

Introduction. Clinical outcomes of surgery for patients with chronic pancreatitis (CP), considering low rates of 10-year survival, are often unsatisfying for surgeons. Due to the absence of common diagnostic criteria, especially at an early stage of the disease, patients of young and working age undergo surgery at different periods and with different methods. The development of optimal criteria for the selection of diagnostic signs of chronic pancreatitis will improve treatment outcomes.The aim of the study is 1) to perform a comparative assessment of the informative value of methods that specify diagnostics of CP with obstruction of the main pancreatic duct; 2) to develop criteria for the selection of diagnostic signs to highlight the main types of structural changes in the pancreas in chronic pancreatitis with obstruction of the main pancreatic duct.Materials and methods. The study included radiological findings of 231 patients with CP with obstruction of the main pancreatic duct operated from 1996 to 2018 in Omsk regional surgical hospital. X-ray investigations were performed in 120 patients, ultrasound investigations were performed in 231 patients, multislice spiral computed tomography (MSCT) was performed in 226 patients, MRI was performed in 18 patients, endoscopic retrograde cholangiopancreatography (ERCP) was performed in 22 patients and angiography was performed in 5 patients. All patients were divided into two groups: control (n = 88, until 2008) and case (n = 143, after 2008), where new methods of surgery were used and the structure of the applied diagnostic methods has been changed.Results. Ultrasound sensitivity was 74.5%, fistulography/virsungography sensitivity was 80%, MSCT sensitivity was 97.8%, MRI sensitivity was 88.9% and ERPC sensitivity was 95.5%. The use of invasive diagnostic methods in the main group of patients was minimized with the priority of MSCT. The main criteria for the selection of diagnostic signs of CP were determined as follows: obstruction of the main pancreatic duct (with localization at the level of the pancreatic head exclusively or along its entire length), dilatation of the main pancreatic duct (more than 3 mm), local damage to the pancreatic head with an increase in its size over 32 mm, cystic formations (more than 5 mm) in the projection of any part of the pancreas. The main types of structural changes in the pancreas were identified as follows: 1. CP with obstruction of the main pancreatic duct at the level of the pancreatic head exclusively; 2. CP with obstruction of the main pancreatic duct along its entire length with an increase in the size of the pancreatic head; 3. CP with obstruction of the main pancreatic duct along its entire length without an increase in the size of the pancreatic head.Conclusion. 1) MSCT has the highest sensitivity in CP diagnostics (98.6%). MRI (Magnetic Resonance Cholangiopancreatography (MRCP)) complements MSCT and replaces it in case of patients intolerance to contrast media. Indications for ERCP should be minimized. 2) The designed criteria for the selection of diagnostic signs of CP will optimize diagnostics of chronic pancreatitis with obstruction of the main pancreatic duct and highlight the main types of structural changes in the pancreas, the fact being important for validation of surgical treatment methods and techniques.

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Immediate and Long-Term Results of Original Methods of Longitudinal Pancreatojejunostomy With The Expansion of the Area of Pancreatojejunal Anastomosis

Russian Sklifosovsky Journal Emergency Medical Care ◽

10.23934/2223-9022-2020-9-1-35-45 ◽

2020 ◽

Vol 9 (1) ◽

pp. 35-45

Author(s):

A. R. Propp ◽

E. N. Degovtsov ◽

S. A. Nikulina

Keyword(s):

Chronic Pancreatitis ◽

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Comparison Group ◽

Pancreatic Head ◽

Main Group ◽

Long Term Results ◽

Hospital Treatment ◽

Enzyme Preparations

RELEVANCE. The dependency results of draining operations on the efficcacy of drainig of ductal system of the pancreas and adequate outflow of the pancreatic juce through anastomosis are undoubtful, therefore the development of new techniques of longitudinal pancreatojejunostomy (LPJ) extending area of anastomosis is an actual challenge.AIM OF STUDY. To compare the immediate and long-term results of longitudinal pancreatojejunostomy with the expansion of the area of anastomosis in patients with chronic pancreatitis.MATERIAL AND METHODS. We analysed immediate and long-term results of LPJ in 58 patients with chronic pancreatitis with impaired patency of the major pancreatic duct (MPD) without the head enlargement.RESULTS. All patients were divided into two groups: comparison group ( n=26, operated up to 2008 ) and main group (n=32, operated stumps during the MPD diastasis and posterior pancreatic surface (n=3) into anastomosis, with resection of the anterior pancreatic surface in the form of triangular fragments (n=11), with circulation of the small intestine loop during the recovery phase (n=19). The original LPJ in the study group of patients did not lengthened the surgery (160 [135, 185]) and intraoperative blood loss (265 [175, 340]). In the main group of patients there was no postoperative complications and fatal outcomes, but the average duration postoperative hospital treatment (18 [16; 20.5]) exceeded some data of foreign and domestic authors. Pain within 5 years after surgery in patients of the main group exceeded 26.6% and the appearance of diarrheal syndrome with dependance from reception of enzyme preparations was twice lower than in patients og the comparison group. According to questionnaire EORTC QLQ-C30, 5 years after surgery statistically significant differences between groups in terms of scales CF, NV, DY (p=0.03, 0.02, 0.006 respectively), indicating the advantage of intervention performed in the mail group.CONCLUSIONS. 1. An indication for longitudinal pancreatojejunostomy in chronic pancreatitis is impaired patency of the main pancreatic duct in the absence of an increase and inflammatory mass in the pancreatic head.2. The width of the main pancreatic duct is less than 5 mm and the presence of diastasis between its proximal and distal stumps with the posterior surface of the pancreas preserved, is not a reason for refusing longitudinal pancreatic jujunostomy in favor of the resection method.3. The expansion of pancreatojejunal anastomosis when performing longitudinal pancreatojejunostomy can improve the immediate and longterm results of surgical treatment for chronic pancreatitis.

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A duodenum-preserving and bile duct–preserving total pancreatic head resection with associated pancreatic duct-to-duct anastomosis

Journal of Gastrointestinal Surgery ◽

10.1016/j.gassur.2003.11.007 ◽

2004 ◽

Vol 8 (2) ◽

pp. 220-224 ◽

Cited By ~ 22

Author(s):

T Takada

Keyword(s):

Bile Duct ◽

Pancreatic Duct ◽

Pancreatic Head ◽

Pancreatic Head Resection

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Diagnostics of pancreatic duct hypertension by the serotonin-stimulating magnetic resonance cholangiopancreatography (MRCP): A preliminary study.

Journal of Clinical Oncology ◽

10.1200/jco.2014.32.3_suppl.196 ◽

2014 ◽

Vol 32 (3_suppl) ◽

pp. 196-196

Author(s):

Alexey Kashintsev

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Drug Application ◽

Pancreatic Head ◽

Magnetic Resonance Cholangiopancreatography ◽

Papilla Vateri ◽

The Mean ◽

Concentrated Solution ◽

Pancreatic Duct Hypertension ◽

Positive Results

196 Background: Serotonin is a neurotransmitter which stimulates the pancreatic secretion. Pancreatic and periampullary tumors can cause the dilatation of the main pancreatic duct. Its partial stenosis can remain undiagnosed on conventional MRCP. Increasing secretion of pancreatic juice after stimulation by the serotonin can help to detect the location and length of a lesion. Methods: Eighteen patients with pancreatic cancer (n=14) and tumor of papilla Vateri (n=4) were included into the study. Median age was 64.9 years with range 45-84 years. Serotonin (0,01mg/kg) was administered perorally (n=2), intramuscularly (n=2), or intravenously with dilution (n=5) and without it (n=9). MRCP was performed before the drug application and 7 minutes later. Results: In cases where serotonin was administered perorally, intramuscularly or intravenously with dilution we did not receive any significant results. The positive results were obtained in 5 (55.6%) of 9 cases when MRCP was performed 7 minutes after intravenous administration of concentrated solution. The mean increase in width of the main pancreatic duct was 1.1 mm (range 0.9-1.9 mm). Conclusions: The method of serotonin stimulating MRCP can improve the diagnosis of pancreatic ductal hypertension. In these 5 cases, a presented technique allowed us to detect the size and localization of a lesion more precisely: tumor of a papilla (n=2), cancer of a pancreatic head (n=3) including one case with involvement of the pancreatic body. In cases of primary ductal dilatation more than 5 mm (n=3), we did not receive any positive results, so these patients were excluded from the study.

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