Santorinicele and recurrent acute pancreatitis in pancreas divisum: diagnosis with dynamic secretin-stimulated magnetic resonance pancreatography and endoscopic treatment.
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Acute Disease↗
Biomedical subjects
M Mutignani
Publications and source records attributed to M Mutignani.
Pancreas divisum and "santorinicele": diagnosis with dynamic MR cholangiopancreatography with secretin stimulation.
PURPOSE: To evaluate the usefulness of magnetic resonance (MR) cholangiopancreatography (MRCP) before and after secretin administration in diagnosing santorinicele in patients with pancreas divisum. MATERIALS AND METHODS: One hundred seven patients suspected of having pancreatic disease underwent MRCP before and after secretin administration (S-MRCP). S-MRCP images were evaluated for pancreas divisum and santorinicele and for size of the main pancreatic duct and santorinicele. The onset of duodenal filling was calculated on dynamic S-MRCP images. RESULTS: Pancreas divisum was detected in five (5%) of 107 patients at MRCP and in 10 (9%) of 107 patients at S-MRCP. Santorinicele was detected in three (21%) of 14 patients at MRCP and in an additional four (seven [50%] of 14) patients at S-MRCP in patients with pancreas divisum. Santorinicele was confirmed in six of seven patients at endoscopic retrograde cholangiopancreatography (ERCP); in one of seven patients, ERCP was unsuccessful. The duct of Santorini was significantly (P: <.05) larger in the pancreatic head in patients with pancreas divisum and santorinicele (3.6 mm) compared with those with only pancreas divisum (2.2 mm). A noteworthy reduction in size of the pancreatic duct (26%) and of the santorinicele (63%) was observed after sphincterotomy. The onset of duodenal filling was delayed significantly in patients with santorinicele (2.1 vs 1.3 minutes; P: <.05). CONCLUSION: S-MRCP helps in identifying pancreas divisum and santorinicele, which may be the cause of impeded pancreatic outflow.
Adolescent↗
Adult medullary cystic disease of the kidney and pancreatic cystic disease: a new association.
A rare case of a woman with the adult form of medullary cystic disease associated with pancreatic cysts in pancreas divisum is described, which suggests that specific attention should be paid to computed tomography findings in the presence of pancreatic and renal cysts.
Female↗
Extracorporeal shock wave lithotripsy of pancreatic stones in chronic pancreatitis: immediate and medium-term results.
BACKGROUND: Obstruction of the main pancreatic duct with upstream hypertension and dilation is a cause of pain in patients with chronic pancreatitis. Pancreatic ductal drainage can be achieved endoscopically by intraductal stone removal after endoscopic pancreatic sphincterotomy and/or by insertion of a pancreatic stent. Extracorporeal shock wave lithotripsy may be needed whenever stones cannot be removed by endoscopic procedures. We present our results in 35 patients treated with a combined endoscopic-extracorporeal shock wave lithotripsy approach with at least 6 months of follow-up. METHODS: Thirty-five patients with severe chronic pancreatitis were treated by extracorporeal shock wave lithotripsy for endoscopically unretrievable obstructive stones. Extracorporeal shock wave lithotripsy was performed with an electromagnetic lithotriptor in 29 patients and an electrohydraulic lithotriptor in 6. RESULTS: The procedures were well tolerated by the majority of patients. Fragmentation of stones was obtained in all cases while complete clearance and decompression of pancreatic duct were obtained in 26 of 35 (74.3%) and in 30 of 35 (85.7%) cases, respectively. There was no mortality related to the procedure. Morbidity was observed in 8 of 35 patients (22.8%). CONCLUSIONS: Extracorporeal shock wave lithotripsy is a safe and effective treatment for endoscopically unretrievable pancreatic stones in the main pancreatic duct. Extracorporeal shock wave lithotripsy should be considered complementary and not an alternative to endoscopic drainage. Combined with endoscopy, extracorporeal shock wave lithotripsy may increase the success rate of nonsurgical treatment of patients with chronic pancreatitis.
Adult↗
Novel methods of management of trapped dormia baskets in the pancreatic and biliary ducts.
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Adult↗
Endoscopic mechanical lithotripsy of difficult common bile duct stones.
BACKGROUND: Mechanical lithotripsy for the management of difficult common bile duct stones has sometimes yielded conflicting results. METHODS: A series of 162 consecutive patients who underwent mechanical lithotripsy was evaluated retrospectively and a large number of variables tested for their association with successful outcome. RESULTS: The procedure was safe (morbidity rate 1.8 per cent) and effective (84.0 per cent stone clearance rate). Univariate and multivariate analysis showed that stone size was the only outcome predictor (mean(s.d.) diameter of grasped versus non-grasped stones 21.7 (6.7) versus 28.3(10.4) mm; F = 10.72, 98 d.f., P = 0.002). The cumulative probability of bile duct clearance ranged from over 90 per cent for stones with a diameter less than 10 mm to 68 per cent for those greater than 28 mm in diameter (P < 0.02). CONCLUSION: Patients at high risk of lithotripsy failure (stone diameter of 28 mm or more) might more wisely undergo surgery or other non-surgical procedures, such as extracorporeal shock-wave lithotripsy or long-term biliary stenting.
Adult↗
Endoscopic treatment of chronic idiopathic pancreatitis in children.
The purpose of this study was to analyze the preliminary results obtained with endoscopic treatment of children with chronic idiopathic pancreatitis. The disease appears to be caused by a deficit of pancreatic stabilizing proteins that leads to precipitation of solutes contained in the pancreatic secretions; these precipitates are the cause of inflammation. The possible role of a congenital malformation in the pathogenesis of this disease is being regarded with increasing scepticism. Between October 1991 and April 1994, five cases of chronic pancreatitis were referred to the Division of Pediatric Surgery of the Policlinico "A. Gemelli" of Rome. The age range of the patients (3 boys, 2 girls) was 3 to 14 years (mean, 10.8 years); all had a history of acute attacks and had blood chemistry findings compatible with pancreatitis. None of the patients' families had a history of pancreatic disease. All diagnoses were confirmed by endoscopic retrograde cholangiopancreatography, and the disease was staged according to the criteria of Cremer et al. Endoscopic pancreatic sphincterotomy, with or without removal of calculi, was performed in four cases (2 in the authors' hospital, 2 in another institution). Three of the children have had no further symptoms (mean follow-up period, 20 months), and their growth and weight gain have been normal. The fourth child, a 3-year-old girl, has had two episodes of pain since treatment. These attacks, both of which subsided spontaneously, probably were caused by the passage of protein plugs through the sphincterotomy. The fifth patient received no treatment because she had remained asymptomatic since the first examination (28 months ago). The short-term effects observed in these children indicate that endoscopic treatment of chronic idiopathic pancreatitis is associated with a high rate of success with respect to pain control. Because of the short follow-up, the effects on endocrine and exocrine function have not been assessed. No deaths or complications occurred. Conservative treatment of this type can be repeated if pain recurs, an important factor given the chronic nature and early onset of this disease, and it does not preclude the possibility of subsequent surgery. The authors' experience indicates that this approach should be considered the initial treatment of choice for children with chronic pancreatitis.
Child↗
Intraluminal brachytherapy in the treatment of pancreas and bile duct carcinoma.
PURPOSE: A new method of palliation of malignant obstructive jaundice is presented. METHODS AND MATERIALS: Twelve patients with carcinoma of the extrahepatic bile ducts (EHBD-five patients) or pancreatic head (PH-seven patients) received radiation therapy between 1988 and 1991. Percutaneous transhepatic biliary drainage was performed in four EHBD patients and an endoprosthesis was placed during endoscopic retrograde cholangiopancreatography (ERCP) in the other eight patients. All 12 received intraluminal brachytherapy (ILBT): 20-50 Gy calculated at 1 cm from the Iridium-192 (192Ir) wire. In four PH patients the source was placed in the duct of Wirsung; in the other eight patients ILBT was performed via the common bile duct. Five of the seven PH patients and one of the five EHBD patients received External Beam Radiation Therapy (EBRT): 26-50 Gy, alone or with concomitant 5-Fluorouracil (5-FU). RESULTS: Cholangitis occurred in six patients. Three PH patients treated with EBRT+ILBT developed gastrointestinal toxicities. With a minimum follow-up of 18 months, median survival times were 14 months (EHBD) and 11.5 months (PH); one of the seven PH patients is alive (29 months) and two of the EHBD patients are alive (18 and 43 months). All patients had satisfactory control of jaundice. CONCLUSIONS: The results in the EHBD patients suggest that the addition of ILBT after biliary drainage prolongs survival. Further experience is necessary to determine whether ILBT in the common bile duct and/or in the duct of Wirsung may be, in PH patients, an alternative boost technique to Interstitial Brachy-therapy (IBT) or Intraoperative Electron Beam Radiation Therapy (IOEBRT).
Aged↗
Pancreatic juice 90K and serum CA 19-9 combined determination can discriminate between pancreatic cancer and chronic pancreatitis.
OBJECTIVES: Differential diagnosis of pancreatic cancer versus chronic pancreatitis may be difficult. The aim of this study is to determine whether a group of tumor-associated antigens could differentiate between the two pathologies. METHODS: CA 19-9, TAG-72, CAR-3, and a newly discovered antigen termed "90K" were determined in the serum and in the pancreatic juice of 19 patients with pancreatic cancer, 20 patients with chronic pancreatitis, and seven controls with lithiasis of extrapancreatic bile ducts. RESULTS: The serum antigen levels of all three markers except 90K were significantly higher in pancreatic cancer than in chronic pancreatitis. High correlations were found between serum CA 19-9 and both TAG-72 and CAR-3. 90K did not correlate with other markers. In pancreatic juice, only 90K values were significantly higher in chronic pancreatitis than in pancreatic cancer, and only 90K and CA 19-9 were significantly correlated. At the stepwise discriminant analysis, serum CA 19-9 and pancreatic juice 90K had independent diagnostic roles. Used in combination, they correctly identified 84.2% of pancreatic cancer and 90% of chronic pancreatitis. CONCLUSIONS: These data suggest that pancreatic juice 90K and serum CA 19-9 can discriminate between chronic pancreatitis and pancreatic cancer. The data further support the complementary use of tumor-associated antigens along with other diagnostic tools.
Antigens, Neoplasm↗
[Pancreatic duct system: radiologic anatomy, anatomical variations, and general principles of pancreatographic semiology].
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Humans↗
[Results of endoscopic biliary drainage in primary tumors of the common bile duct (cholangiocarcinoma)].
Endoscopic drainage is an effective therapy for palliation of patients with bile duct carcinoma. From November 1987 to November 1994 112 patients with cholangiocarcinoma were observed. The success rate of the procedure was 94.5%. The biliary drainage was successful in 99% of patients (in 4% of patients the complete biliary drainage was obtained with the aid of a transhepatically inserted guide-wire with the "rendez-vous" procedure). In 15 patients an intraluminal radiation therapy with Iridium-192 was associated. The morbility was 13% and the 30-days mortality 11%. A surgical operation was performed in 26% of patients with radical intent. The mean survival time in patients treated only endoscopically was 208 days for patients with lesions of the distal and middle third of the bile duct and 281 days for patients with hilar cholangiocarcinoma. In patients with intraluminal radiation therapy the mean survival time was 357 days, with a significative difference with the only endoscopically treated group (357 vs 238 days, p < 0.05). We conclude that endoscopic drainage is a safe and effective management for patients with cholangiocarcinoma and it does not preclude definitive surgical treatment in appropriate candidate.
Adult↗
[The percutaneous retrieval of the fragment of a balloon catheter that ruptured in the biliary tract during endoscopic dilatation].
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Biliary Tract↗
Treatment of "obstructive" pain by endoscopic drainage in patients with pancreatic head carcinoma.
Obstruction of the main pancreatic duct with secondary upstream ductal hypertension is one cause of pain in patients with pancreatic cancer. Pancreatic endoscopic stenting and decompression of the pancreatic duct have been effective in the treatment of pain secondary to chronic calcifying pancreatitis and in one case of pancreatic cancer. We describe eight patients with unresectable cancer of the pancreatic head associated with upstream dilatation of the pancreatic duct and severe pancreatic "obstructive"-type pain (correlation with meals and pain radiation to the back) in which a pancreatic stent was inserted across the neoplastic stricture. No mortality was associated with the procedure. All patients but one were free of pain within 48 hours after endoscopic pancreatic stenting, and all discontinued narcotics. Mean survival time was 165.5 days (range, 26 to 575 days). Six patients were still without symptoms, whereas two had a painful relapse a few days before death. No clinical evidence of pancreatic clogged stent was observed during follow-up. Endoscopic pancreatic drainage is a safe and effective way of controlling cancer pain in selected cases and should be considered as a further therapeutic option in these patients.
Aged↗
Endoscopic pancreatic stenting in pancreatic cancer.
Most pancreatic carcinomas are unresectable at the time of diagnosis; therefore, palliative treatment is very often the main concern of clinicians in this setting. The main symptoms resulting in the need for palliation in pancreatic cancer are obstructive jaundice, duodenal obstruction and pain. Therapeutic endoscopy plays a major role in the palliation of obstructive jaundice by stent placement into the biliary ducts. Initial experience has also been gained recently with endoscopic placement of expandable metallic stents to treat gastric outlet obstruction. Much less is known about the possible role of endoscopic pancreatic stenting in patients with unresectable pancreatic carcinoma. The main indication for pancreatic ductal stenting is 'obstructive' pain related to meals in patients with dilated main pancreatic duct beyond the stricture and intraluminal brachyradiotherapy. The technique of endoscopic pancreatic stenting does not substantially differ from that applied on the biliary tree. When technically possible, placement of 10 French plastic stents is preferred. According to the authors' indications, only about 15% of patients with advanced pancreatic cancer (55 of 355 in the present study) may potentially benefit from this technique. Pancreatic stenting may be obtained in more than 80% of these selected patients, with low morbidity (less than 10%) and no procedure-related mortality. According to the authors of the present and other studies reported in the literature, about 60% of patients treated because of 'obstructive' pain become symptom-free, and another 20% to 25% significantly reduce the amount of analgesic drugs required. Intraluminal brachyradiotherapy with 192iridium in the main pancreatic duct is a feasible and safe method to deliver high radiation doses to the tumour while sparing adjacent organs. Brachyradiotherapy may be performed alone or in conjunction with external beam radiotherapy. Because of the small number of patients suitable for this treatment, only a multicentre study will be able to detect whether intraluminal brachyradiotherapy in pancreatic cancer may have any positive impact on survival.
Abdominal Pain↗
Concomitant radiochemotherapy in unresectable carcinoma of the exocrine pancreas: cost-effectiveness analysis.
One of the principal therapeutic options in unresectable carcinoma of exocrine pancreas is concomitant radiochemotherapy. However, in current scientific literature cost analyses of this therapeutic modality are lacking. A payer-oriented cost-effectiveness analysis of concomitant radiochemotherapy was carried out. Outcomes and differences in costs relatively to two different therapeutic strategies were compared retrospectively: biliary drainage + observation (group 1); biliary drainage + concomitant radiochemotherapy (group 2). Cost-effectiveness was assessed based on the analysis of incremental cost of benefit in terms of survival in group 2. As incremental cost of group 2 was considered that of radiochemotherapy, costs of diagnosis and staging being similar in the two groups. The unit of measurement used was $/Lys (LYS = years of life saved). For estimates of cost-effectiveness in different clinical situations, a sensitivity analysis was carried out. The incremental cost of standard concomitant radiochemotherapy was shown to be $4,755. Incremental costs relatively to the situations of minimum and maximum treatment were shown to be $4,410 and $8,375, respectively. Median survival was 4.5 and 10 months in group 1 and 2 respectively (logrank: p = 0.0046). The benefit in terms of survival achieved by concomitant radiochemotherapy was shown to be 5.5 months equal to 0.46 years. Therefore, in the standard situation, the treatment cost-effectiveness can be estimated in: $4,755/0.46 years = $10,337/LYS, that is, the cost of a year of life saved was shown to be $10,337. Results of sensitivity analysis showed that cost-effectiveness can be estimated in the range $7,603 and $25,379/LYS. In conclusion, concomitant radiochemotherapy in patients with unresectable pancreatic carcinoma is able to improve the quality of life through the relief of related symptoms as well as median survival (10 vs 4.5 months). Costs of these benefits, even if considering better survival only, based on this analysis, were shown to be acceptable.
Adult↗
Extrahepatic bile duct carcinoma: a western experience with 118 consecutive patients.
BACKGROUND/AIMS: This study was designed to evaluate the effectiveness of a diagnostic and therapeutic approach adopted in 118 consecutive patients affected by primary malignancy of the extrahepatic bile duct. METHODOLOGY: After diagnostic procedures were performed (ultrasound examination, endoscopic retrograde cholangiopancreatography and computed tomography scan) 25 patients underwent surgical resection. For the remaining 93 patients considered unresectable for cure, stenting by endoscopic means was almost always the only palliative treatment performed. RESULTS: The morbidity and mortality rates were 28% and 8% for patients treated with surgical resection and the curative and overall 3-year survival rate was 30% and 22% respectively. The procedure related morbidity and mortality rates were 13% and 4% for patients endoscopically treated and the median survival rate was 7.3 months. The quality of life evaluated in 68 patients out of 93 was good in 57% of cases, fair in 19% and poor in the remaining 22%. CONCLUSIONS: The results of the present study demonstrate the safety and efficacy of endoscopic stenting in the palliative treatment of extrahepatic bile duct cancer while potential cure can only be achieved by radical surgical resection.
Adult↗
An apparent idiopathic case of relapsing acute pancreatitis.
We describe a case of relapsing acute pancreatitis apparently idiopathic in a 55-year-old man. The patient did not smoke and was a modest and irregular drinker of wine. Endoscopic retrograde cholangiopancreatography showed an initial dilatation of secondary ducts like a chronic pancreatitis of class I of Cremer. Ultrasound and computed tomography resulted negative for pancreatic lesions. In the follow-up however, magnetic resonance cholangiopancreatography detected the presence of an intraductal mucin-hypersecreting neoplasm, a duct-ectatic mucinous cystic tumor of the pancreas, in the uncinate process. This is a benign lesion clearly recognized nowadays by magnetic resonance cholangiopancreatography, because this radiological technique shows the grape-like clusters of cystic lesions in secondary ducts communicating with the main duct on the same plane. The radiological picture above excludes a malignant lesion and a biopsy specimen is not required. Furthermore, an intraductal mucin-hypersecreting neoplasm of the pancreas does not require an immediate surgical resection because of its slow evolution and can be followed-up. Conversely cystoadenocarcinoma spreads in peripheral ducts and does not communicate with the Wirsung duct. It requires both surgical resection and a biopsy specimen for histological diagnosis. In the last episode of acute pancreatitis, a sphincterotomy was performed at endoscopic retrograde cholangiopancreatography and our patient had no more pain for one year.
Acute Disease↗
Diagnosis of exocrine diseases of the pancreas: is there still a role for endoscopic retrograde cholangiopancreatography (ERCP)?
In the diagnosis of exocrine diseases of the pancreas, three major questions should be addressed: when only MR cholangiopancreatography should be applied; when endoscopic retrograde cholangiopancreatography should be applied directly; when a combined approach should be applied. In pancreatic disease MRI has many indications because ultrasonography, the procedure of choice, is rarely able to resolve the diagnostic problem, with a clearcut indication for therapeutic endoscopic retrograde cholangiopancreatography. One of the rare cases where MRI could be omitted is represented by pancreatic cancer with biliary obstruction in non operable patients in whom a pancreatic mass was already visualized on ultrasonography. In all other diseases of the pancreas, the combination of MRI/MRCP with secretin stimulation and ERCP usually favors the first procedure, preventing a number of diagnostic ERCP.
Cholangiopancreatography, Endoscopic Retrograde↗