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Autoimmune pancreatitis (AIP) is a disease concept that originated in Japan. It is characterized by diffuse pancreatic enlargement and irregular narrowing of the main pancreatic duct. Although the usefulness of the histological diagnosis of AIP using endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) and EUS-guided fine-needle biopsy (FNB) has been reported, enhanced diagnostic performance is expected with improvements in tissue collection methods and fine-needle techniques. Guidance for establishing the tissue diagnosis of AIP has been developed and is useful for histological evaluation. Histopathological diagnosis by EUS-FNA/FNB is expected to play a central role in AIP diagnosis in the future.

Patients with symptomatic gastrointestinal stromal tumor (GIST) typically present with gastrointestinal bleeding and abdominal pain. This report presents an unusual case of fundic GIST complicated by gastroduodenal intussusception, manifesting as acute pancreatitis. The patient presented with epigastric pain and pancreatic enzyme elevation; thus, he was diagnosed with acute pancreatitis. Computed tomography showed evidence of pancreatitis and a 4×4.7 cm well-defined hyperdense lesion in the 2nd part of the duodenum, compressing the pancreatic head and pancreatic duct. Esophagogastroduodenoscopy revealed invagination of the gastric folds into the duodenum, causing pyloric canal blockage consistent with gastroduodenal intussusception. Spontaneous reduction of the lesion during endoscopy revealed a 4 cm pedunculated subepithelial mass with central ulceration originating from the gastric fundus. Endoscopic ultrasound demonstrated a heterogeneous hypoechoic lesion originating from the 4th layer of the gastric wall. Laparoscopic-endoscopic intragastric wedge resection of the fundic lesion was subsequently performed, and surgical histology confirmed GIST.

Background/Aims Endoscopic ultrasonography (EUS) provides high-resolution images and is superior to computed tomography (CT) scan in diagnosing small pancreatic ductal adenocarcinoma (PDAC). As a result, the use of EUS for early detection of PDAC has attracted attention. This study aimed to identify the clinical and radiological characteristics of patients with PDAC diagnosed by EUS but not found on CT scan. Methods The medical records of patients diagnosed with PDAC at 12 tertiary referral centers in Korea from January 2003 to April 2019 were reviewed. This study included patients with pancreatic masses not clearly observed on CT scan but identified on EUS. The clinical characteristics and radiological features of the patients were analyzed, and survival analysis was performed. Results A total of 83 patients were enrolled. The most common abnormal CT findings other than a definite mass was pancreatic duct dilatation, which was identified in 61 patients (73.5%). All but four patients underwent surgery. The final pathologic stages were as follows: IA (n=31, 39.2%), IB (n=8, 10.1%), IIA (n=20, 25.3%), IIB (n=17, 21.5%), III (n=2, 2.5%), and IV (n=1, 1.4%). The 5-year survival rate of these patients was 50.6% (95% confidence interval, 38.8% to 66.7%). Elevated liver function testing and R1 resection emerged as significant predictors of mortality in the multivariable Cox regression analysis. Conclusions This multicenter study demonstrated favorable long-term prognosis in patients with PDAC diagnosed by EUS but indeterminate on CT scan. EUS should be considered for patients with suspected PDAC but indeterminate on CT scan.

Background A single center experience with sporadic pancreatic insulinoma was analyzed to develop an algorithm for modern surgical management. Methods Thirty-four patients undergoing surgery from 2001 to 2019 were reviewed. Results The majority underwent enucleation (10 laparoscopic, 15 open). Laparoscopy was performed in 22 patients with conversion to open in 11, mostly related to the proximity of the tumor to the pancreatic duct (n = 4). Tumors on the anterior and posterior surface of the pancreas in all anatomic locations were completed with laparoscopic enucleation. Overall, the clinically-relevant postoperative pancreatic fistula (CR-POPF) rate was 21%, with no difference between laparoscopic versus open enucleation (10% vs 20%, p = 0.50) or enucleation versus resection (16% vs 33%, p = 0.27). Laparoscopic enucleation had shorter median hospital length of stay (LOS) compared with open (4 vs 7 days, p = 0.02). Conclusions Laparoscopic enucleation does not increase the CR-POPF risk and provides an advantage with a shorter hospital LOS in select patients. Tumor location and relationship to the pancreatic duct guide surgical decision-making. These findings highlight tumor-specific criteria that would benefit from a minimally invasive approach.

We present 3D virtual pancreatography (VP), a novel visualization procedure and application for non-invasive diagnosis and classification of pancreatic lesions, the precursors of pancreatic cancer. Currently, non-invasive screening of patients is performed through visual inspection of 2D axis-aligned CT images, though the relevant features are often not clearly visible nor automatically detected. VP is an end-to-end visual diagnosis system that includes: a machine learning based automatic segmentation of the pancreatic gland and the lesions, a semi-automatic approach to extract the primary pancreatic duct, a machine learning based automatic classification of lesions into four prominent types, and specialized 3D and 2D exploratory visualizations of the pancreas, lesions and surrounding anatomy. We combine volume rendering with pancreas- and lesion-centric visualizations and measurements for effective diagnosis. We designed VP through close collaboration and feedback from expert radiologists, and evaluated it on multiple real-world CT datasets with various pancreatic lesions and case studies examined by the expert radiologists.

Background: Former studies showed that magnetic resonance cholangiopancreatography (MRCP) is useful in diagnosing the presence of santorinicele; however, few studies have evaluated MRCP in diagnosing wirsungocele and the association between pancreatitis and santorinicele or wirsungocele. The purpose of the study was to explore the performance of MRCP in diagnosing santorinicele and wirsungocele and investigate the potential association among pancreatitis, pancreas divisum, and santorinicele or wirsungocele. Method: Sixty-five patients (mean age, 55.68 years; range, 11-82 years) with santorinicele or wirsungocele were included and sorted into two groups: the santorinicele group (n = 48) and the wirsungocele group (n = 17). All patients underwent MRCP. The images were evaluated for the appearance and size of santorinicele or wirsungocele. The diagnostic sensitivity of MRCP was assessed. Additionally, whether two groups are correlated with pancreas divisum or pancreatitis were investigated. Result: The sensitivity of MRCP in detecting santorinicele and wirsungocele showed no difference (68.8% and 76.5%, respectively). The proportion of patients who developed pancreatitis in santorinicele and wirsungocele groups were 60.4% and 11.8%, respectively (p < 0.05). Pancreas divisum accounted for 77.1% and 11.8% of the patients in the santorinicele and wirsungocele groups, respectively (p < 0.05). Patients with santorinicele and pancreas divisum tended to be older when they acquired pancreatitis. Conclusion: MRCP could be an alternative imaging method to detect cystic dilation of the pancreatic duct. Pancreatitis is more common in patients with santorinicele than in those with wirsungocele. Moreover, santorinicele is more closely associated with pancreatitis than with pancreas divisum.

Background: There are many studies on the morphology of the liver and its blood vessels in experimental animals, but such studies are lacking in the mole rat (Spalax leucodon). The aim of this paper was a detailed basic study on the topography, morphology, vascular and biliary branching systems of the liver in the mole rat. Materials and methods: Coloured gelatine and mixture of coloured lead oxide and linseed oil were injection contrast masses used to obtain vascular and biliary branching pattern in the liver. It was revealed that the liver of the mole rat had five lobes (left, quadrate, right medial, right lateral and caudate lobes). Results: The left, undivided lobe was the largest lobe of the liver. The quadrate lobe was divided into two components by a deep notch. The gallbladder, of cylindrical shape, was present and attached to the quadrate lobe. The common bile duct was formed by the union of the left and right hepatic ducts. The pancreatic duct joined the common bile duct before it entered the duodenum. In the present study, only the right medial lobe and quadrate lobe always showed a single lobar artery, portal and hepatic veins. The left lobe showed four lobar arteries, portal and hepatic veins. The caudate lobe with its two processes and the right lateral and medial lobes had different arterial and portal blood supply as well as hepatic and biliary drainage of these lobes. The intrahepatic branches of the proper hepatic artery ran parallel to the branches of the common portal vein in the same lobes of the liver. Conclusions: The results of this study are significant for comparative studies among different species of rodents and other experimental animals. Morphology, vasculature and biliary tract of the liver in the mole rat were similar to that of other experimental animals and identified differences may be related to the adaptation to the mode of life and diet of this rodent.

Background: Existing postoperative pancreatic fistula risk scores rely on intraoperative parameters, which limits their value in the preoperative setting. A preoperative predictive model to stratify the risk of developing postoperative pancreatic fistula before pancreatoduodenectomy was built and externally validated. Methods: A regression risk-tree model for preoperative postoperative pancreatic fistula risk stratification was developed in the Verona University Hospital training cohort using preoperative variables and then tested prospectively in a validation cohort of patients who underwent pancreatoduodenectomy at San Raffaele Hospital of Milan. Results: In the study period 566 (training cohort) and 456 (validation cohort) patients underwent pancreatoduodenectomy. In the multivariable analysis body mass index, radiographic main pancreatic duct diameter and American Society of Anesthesiologists score ≥3 were independently associated with postoperative pancreatic fistula. The regression tree analysis allocated patients into 3 preoperative risk groups with an 8%, 21%, and 32% risk of postoperative pancreatic fistula (all P < .01) based on main pancreatic duct diameter (≥ or

Background/objectives The diagnostic ability of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been fully studied; however, the efficacy of other endoscopic samplings (OESs) is less clear. The aim of this study was to examine the diagnostic efficacies of OESs for pancreatic head cancer (PHC). Methods The diagnostic efficacies of endoscopic samplings were retrospectively analyzed in 448 PHC cases and 63 cases of mass-forming pancreatitis (MFP) during initial transpapillary biliary drainage. The OESs included duodenal biopsy (118 PHCs and 50 MFPs), biliary biopsy (218 and 51) with cytology (368 and 53), and pancreatic duct biopsy (23 and 13) with cytology (56 and 43). EUS-FNA was conducted in a different session (149 and 62). Factors associated with OES sensitivity were analyzed. The sensitivity of biliary biopsy was compared between 1.95 mm and 1.8 mm forceps. Results Cancer cells were confirmed in 87.9% of the EUS-FNA samplings and in 64.1% (268/418) obtained by combined OESs (average 1.7 OES types per case): 68.6% by duodenal biopsy, 59.6% by biliary biopsy, 32.6% by biliary cytology, 73.9% by pancreatic duct biopsy, and 33.9% by pancreatic duct cytology. No MFP cases revealed cancer by any sampling. OESs did not increase adverse events. Duodenal stenosis, serum bilirubin, tumor size, and pancreatic juice amounts were associated with OES sensitivity. Biliary biopsy had the same sensitivity with different forceps. Conclusion EUS-FNA was the most diagnostic protocol; however, OESs can be safely applied during the initial biliary drainage to reduce the demand for EUS-FNA while providing good diagnostic yields.

Zusammenfassung. Die interventionelle Endoskopie hat im hepato-pankreatiko-biliären Bereich in den letzten Jahren eine aufregende Entwicklung durchlaufen und eine Vielzahl therapeutischer Fähigkeiten dazu gewonnen. Durch neuartige Endoskope konnte aber auch die Diagnostik verbessert werden, durch direkte Visualisierung des Gallen- und Pankreasgangsystems inklusive visuell geführter Biopsien von luminalen Läsionen. Die Therapie komplexer Gallensteine mit einer cholangioskopisch-geführten Lithotripsie ist so ebenfalls möglich. Die biliäre Dekompression bei maligner Obstruktion kann heute endosonographisch gesteuert mit sogenannten «Lumen-apposing metall stents» (LAMS) erfolgen, welche extraanatomische Verbindungen zu den Gallenwegen erlauben, ausserhalb den traditionellen, transpapillären oder perkutanen Zugängen. Mit einer endosonographisch-gesteuerten, transgastrischen Drainage kann auch bei veränderter Anatomie nach Operation ein biliärer Zugang erreicht werden. In gleicher Weise ist auch die Drainage des Pankresganges möglich. Die ERCP-basierte Radiofrequenzablation und Photodynamische Therapie ermöglicht zudem eine gezielte Lokaltherapie von Gallengangsneoplasien. Auch in der Endotherapie der chronischen Pankreatitis werden die neuen Methoden zur endoluminalen Diagnostik, Lithotripsie und transgastrischer Drainage eingesetzt. Der vorliegende Artikel gibt einen detaillierten Überblick über die modernen Behandlungsoptionen an Gallenwegen und Pankreas in der interventionellen Gastroenterologie.

The perioperative management and technical details of laparoscopic clamp-crushing enucleation for low-malignant-potential pancreatic neuroendocrine neoplasms (PNENs) located close to the main pancreatic duct (MPD) in the body/tail of the pancreas using a perioperative MPD stent are reported. The procedure was performed in two patients with PNEN (13 and 10 mm in diameter) in the body/tail of the pancreas. A naso-pancreatic stent (NPS) was placed preoperatively in both patients. Resection was performed using Maryland-type bipolar forceps. The surgical duration was 139 and 55 min, and the estimated blood loss was 5 and 0 mL, respectively. One patient was discharged uneventfully on postoperative day (POD) 12. The other patient developed a grade B pancreatic fistula, but was discharged on POD 22. Laparoscopic clamp-crushing enucleation with an NPS might be a viable treatment option for tumors located close to the MPD.

Propionic acidaemia (PPA) is a disorder of amino acid and odd-chain fatty acid metabolism. Hypoglycaemia is a more commonly described finding rather than hyperglycaemia during metabolic decompensation of PPA. There is a high mortality rate in patients with organic acidaemias having severe insulin-resistant hyperglycaemia. We report a nine-month-old boy with PPA who was admitted to tertiary care hospital in Muscat, Oman, in 2018 with metabolic decompensation, persistent hyperglycaemia and transient insulin resistance. Hyperglycaemia did not respond to high insulin infusion. Plasma glucose only improved when glucose infusion rate (GIR) reached 7 mg/kg/min. The patient has full recovery and was discharged, with follow up plan. It is important to balance the GIR to achieve the targeted insulin level, beyond which the risks of hyperglycaemia start to outweigh the potential anabolic benefits of additional insulin secretion. Timely clinical attention should be given to achieve adequate caloric delivery through alternative sources other than high GIR to permit better glycaemic control, especially when insulin-resistant hyperglycaemia is present. Keywords: Propionic Acidaemia; Insulin Resistance; Infant; Case Report; Oman.

Pancreatic ductal adenocarcinoma (PDAC) is one of the most fatal malignant tumors of the digestive system. Many patients are diagnosed at an advanced stage and lose eligibility for surgery. Moreover, there are few effective methods for treating pancreatic ductal cell carcinoma. Increasing attention has been given to microRNAs (miRNAs) and their regulatory roles in tumor progression. In this study, we investigated the effects of exosomes extracted from human umbilical cord mesenchymal stem cells (HUCMSCs) carrying hsa-miRNA-128-3p on pancreatic cancer cells. Based on existing experimental and database information, we selected Galectin-3, which is associated with pancreatic cancer, and the corresponding upstream hsa-miRNA-128-3p. We extracted HUCMSCs from a fresh umbilical cord, hsa-miRNA-128-3p was transfected into HUCMSCs, and exosomes containing hsa-miRNA-128-3p were extracted and collected. The effect of exosomes rich in hsa-miRNA-128-3p on pancreatic cancer cells was analyzed. The expression of Galectin-3 in normal pancreatic duct epithelial cells was significantly lower than that in PDAC cell lines. We successfully extracted HUCMSCs from the umbilical cord and transfected hsa-miRNA-128-3p into HUCMSCs. Then we demonstrated that HUCMSC-derived exosomes with hsa-miRNA-128-3p could suppress the proliferation, invasion, and migration of PANC-1 cells in vitro by targeting Galectin-3. Hsa-miRNA-128-3p could be considered as a potential therapy for pancreatic cancer. We provided a new idea for targeted therapy of PDAC.

PURPOSE The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). METHODS From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. RESULTS The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P

Several scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics.Patients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk.A total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was "soft" in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P.001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 "90-1000" model, a 2-value score relying on these cutoffs, significantly (P.001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 "90-1000" score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies.A combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy.

Background and aims Indirect peroral cholangiopancreatoscopy (IPOC) is a relatively new diagnostic and therapeutic tool for biliopancreatic diseases. This international survey aimed to evaluate clinical practice patterns in IPOC among endoscopists in Europe. Methods An online survey was developed comprising 66 questions on the use of IPOC. Questions were grouped into four domains. The survey was sent to 369 endoscopists who perform IPOC. Results 86 respondents (23.3 %) from 21 different countries across Europe completed the survey. The main indications for cholangioscopy were determination of biliary strictures (85 [98.8 %]) and removal of common bile duct or intrahepatic duct stones (79 [91.9 %]), accounting for an estimated use of 40 % (interquartile range [IQR] 25–50) and 40 % (IQR 30–60), respectively, of all cases undergoing cholangioscopy. Pancreatoscopy was mainly used for removal of pancreatic duct stones (68/76 [89.5 %]), accounting for an estimated use of 76.5 % (IQR 50–95) of all cases undergoing pancreatoscopy. Only 13/85 respondents (15.3 %) had an institutional standardized protocol for targeted cholangioscopy-guided biopsy sampling. IPOC with lithotripsy was used as first-line treatment in selected patients with bile duct stones or pancreatic stones by 24/79 (30.4 %) and 53/68 (77.9 %) respondents, respectively. Conclusions This first European survey on the clinical practice of IPOC demonstrated wide variation in experience, indications, and techniques. These results emphasize the need for prospective studies and development of an international consensus guideline to standardize the practice and quality of IPOC.

To prospectively evaluate the clinical feasibility of the magnetic resonance cholangiopancreatography (MRCP) protocol using both contact-free physiological monitoring (CFPM) and compressed sensing (CS) (CS-CFPM-MRCP) and to compare its performance with that of the standard navigator-triggered (NT) CS-NT-MRCP and NT-MRCP.A total of 63 patients (36 males, 27 females, age range: 18-83 years, mean age: 52.30 ± 15.70 years) suspected with duct-related pathologies were prospectively enrolled and performed the three MRCP protocols randomly. The acquisition time was compared. The pancreaticobiliary system was divided into 12 segments and evaluated based on a five-point Likert scale and compared by the Friedman test with a post hoc test. The diagnostic performance of the 3 MRCP was evaluated by the AUC value and compared by Delong's test. The interobserver agreement was evaluated by Kendall's W test.Compared to NT-MRCP, the acquisition time of CS-NT-MRCP and CS-CFPM-MRCP was significantly decreased (both p0.001). There is no significant difference in the overall imaging quality (p0.05) between the NT-MRCP and CS-CFPM-MRCP protocols. CS-CFPM-MRCP depicted pancreatic duct and intrahepatic ducts better than CS-NT-MRCP (all p0.05) and was comparable with that of the NT-MRCP (all p0.05). For identification of abnormalities and diseases associated with MPD anatomy, the mean AUC value for NT-MRCP and CS-CFPM-MRCP were 0.896 (95%CI: 0.834, 0.958) and 0.905 (95%CI: 0.846, 0.964), which were significantly higher when compared to that for CS-NT-MRCP (0.713 [95%CI:0.622, 0.805]) (p = 0.001 and0.001). All evaluations showed good to excellent agreement (0.619-0.897).The combination of CS and CFPM is considered feasible for shortening the scan time of 3D free breath MRCP without impairing the imaging quality and CS-CFPM-MRCP is considered feasible for patients suspected with pancreaticobiliary diseases.

Pancreatic duct adenocarcinoma is an aggressive tumor which constitutes the fourth leading cause of cancer-related mortality in the USA. Despite the fact that surgery is an integral part of treatment, 5-year survival rates remain unfavorable, partly because of the complex genetic background, delayed diagnosis and also the absence of effective therapeutic approaches. To optimize surgery’s results in recent years, the use of patients’ genetic profile has been implemented through classification into subtypes; subtypes based on mutations which could efficiently lead oncologists to the path of targeted novel neoadjuvant regimens. This approach aims to achieve the most effective selection of patients undergoing surgery, to increase the number of potentially resectable tumors and also control micro-metastases, aiming to extend overall survival.

Background and study aims Approximately 11 % of biliary cannulations are considered difficult. The double guidewire (DGW-T) and transpancreatic sphincterotomy (TPS) are two useful techniques when difficult cannulation exists and the main pancreatic duct is unintentionally accessed. We carried out a systematic review and meta-analysis to evaluate the effectiveness and security of both DGW-T and TPS techniques in difficult biliary cannulation. Methods We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. Were included all RCT which showed a comparison between TPS and DGW in difficult biliary cannulation. Endpoints computed were successful cannulation rate, median cannulation time, and adverse events rate. Results Four studies were selected (4 RCTs). These studies included 260 patients. The mean age was 64.79 ± 12.99 years. Of the patients, 53.6 % were men and 46.4 % were women. The rate of successful cannulation was 93.3 % in the TPS group and 79.4 % in the DGW-T group (P = 0.420). The rate of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) was lower in patients who had undergone TPS than DGW-T (TPS: 8.9 % vs DGW-T: 22.2 %, P = 0.02). The mean cannulation time was 14.7 ± 9.4 min in the TPS group and 15.1 ± 7.4 min with DGW-T (P = 0.349). Conclusions TPS and DGW are two useful techniques in patients with difficult cannulation. They both have a high rate of successful cannulation; however, the PEP was higher with DGW-T than with TPS.

Esophageal cancer survival has improved owing to improvements in surgical techniques and preoperative chemoradiation. Excessive alcohol consumption is a shared risk factor for esophageal cancer and chronic alcoholic pancreatitis. Puestow’s procedure is a treatment choice for pain relief and pancreatic duct decompression. It is logical to perform Puestow’s procedure on patients undergoing esophagectomy with underlying chronic pancreatitis to preserve pancreatic function and restore quality of life in the setting of improved esophageal cancer overall survival. Herein, we report our preliminary experience with two patients who underwent both of these procedures during the same operation and achieved acceptable outcomes.

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

A 71-year-old man was receiving follow-up examination because of a retention cyst in the pancreatic body that extended to the dorsal extrahepatic area, but presented to the Emergency Department at our hospital with dyspnea and cough. Chest X-ray showed a large amount of left-sided pleural effusion and abdominal computed tomography (CT) showed reduction in size of the cystic lesion. Biochemical testing of the pleural effusion revealed high levels of pancreatic enzymes. We, therefore, diagnosed rupture of the pancreatic cystic lesion into the chest cavity. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated stenosis of the pancreatic duct and leakage of contrast medium at the cystic lesion. CT after ERCP revealed leakage of contrast medium from the cystic lesion through the dorsal extrahepatic area into the chest cavity. Endoscopic naso-pancreatic drainage was performed, but the cystic lesion and pleural effusion remained unimproved. Distal pancreatectomy was, therefore, performed. Microscopic examination revealed eosinophilic infiltration of the pancreatic parenchyma, leading to a diagnosis of eosinophilic pancreatitis (EP). Pancreatic retention cyst secondary to chronic pancreatitis associated with eosinophilic infiltration was considered to have ruptured into the chest cavity. EP is a rare etiology of pancreatitis and few cases have been reported. This case was thus considered valuable.

The present study investigated the histological features of the spleen and pancreas of the Egyptian Nile monitor lizard (Varanus niloticus). After gross observations the representative samples were collected from three adult male monitor lizards and were processed for histological examination. Grossly, the spleen was brownish in color and embedded in the mesentery near the stomach and pancreas. The pancreas was yellowish in color and consisted of a ventrally placed principal lobe which was pyramidal and extended in the mesentery, whereas the dorsally located splenic lobe was small and was attached to the spleen. a single duct was emerged from the pancreas. Histologically, the spleen was nodular and was encapsulated by the connective tissue capsule covered by mesothelium. it was composed of white and red pulps. Many ellipsoids, melano-macrophage centers, periarterial and periellipsoidal lymphatic sheaths (PALS and PELS; respectively) were observed. The pancreas demonstrated a thicker capsule covered by mesothelium and the exocrine portion was formed of tubule-acinar cells. Main pancreatic duct passed across the length of the pancreas and was lined by stratified cuboidal epithelium. The Islets were found in the ventral lobe where it was in various sizes. This is the first report about the histological structure of the spleen and pancreas of the Egyptian Nile monitor lizard, where the spleen showed a unique structure while the pancreas was similar to what was described in other varanus species. The information in this study will be a baseline knowledge for future studies regarding endocrine or immune organs in this species.

The incidence of pancreatic incidentalomas (PIs) detected in otherwise asymptomatic patients is growing with the increasing quality and use of advanced imaging techniques. PI can present as isolated main pancreatic duct dilation or as a solid or cystic lesion. Although historically thought to be relatively rare, PIs are rather common, particularly cystic lesions of the pancreas, which can be detected in up to 49% of the general population. With the poor prognosis of pancreatic cancer, PIs are an opportunity for prevention and early diagnosis, but when managed poorly, they can also lead to overtreatment and unnecessary morbidity. The management of PI should begin with a dedicated pancreas protocol computed tomography (CT) scan or magnetic resonance imaging (MRI) to accurately characterize duct size, lesion characteristics and establish an accurate baseline for subsequent follow up. Diagnosis and subsequent management depends on the extent of main duct dilation and solid versus cystic appearance. Solid lesions are highly concerning for malignancy. Cystic lesions can be further categorized as intraductal papillary mucinous neoplasms of the pancreas (IPMNs) or mucinous cystic neoplasms (MCNs), both of which harbour malignant potential, or as serous cystic neoplasms (SCNs) that are benign. In this paper, we summarize the major challenges related to PI and present pragmatic suggestions for management.

BACKGROUND Disconnected pancreatic duct syndrome (DPDS) frequently occurs in patients with acute necrotizing pancreatitis and resultant pancreatic fluid collection (PFC). We performed a systematic review and meta-analysis to evaluate outcomes of endoscopic ultrasound-guided treatment of PFCs according to the presence of DPDS. METHODS Using PubMed, Embase, and the Cochrane database, we identified clinical studies published until January 2021 with data comparing outcomes of endoscopic ultrasound-guided drainage of PFCs between DPDS and non-DPDS patients. We pooled data on technical and clinical success rates, PFC recurrence, and adverse events using the random-effects model. RESULTS We identified five eligible articles including 941 PFC patients treated with endoscopic ultrasound-guided interventions. Clinical success, defined as resolution of the PFC and symptoms, was achieved in a majority of the cases irrespective of DPDS (pooled odds ratio [OR] comparing DPDS to non-DPDS patients, 0.77; 95% confidence interval [CI] 0.33-1.81). Compared to patients without DPDS, patients with DPDS were more likely to undergo PFC recurrence (pooled OR 6.72; 95% CI 2.72-16.6) after clinical resolution of PFC. Prolonged plastic stent placement following the clinical resolution was more frequently performed in DPDS patients than in non-DPDS patients (pooled OR 15.9; 95% CI 2.76-91.9). No statistically significant difference was observed between the groups in terms of the rate of technical success, adverse events, or mortality. CONCLUSION Disconnected pancreatic duct syndrome was associated with higher rate of PFC recurrence after successful endoscopic treatment of PFCs. Future studies should evaluate effectiveness and optimal duration of long-term placement of transmural plastic stents for PFCs with DPDS.

Objectives To investigate useful MRI features in pancreatic neuroendocrine tumor (PNET) patients for predicting recurrence and its timing after surgery. Methods A total of 99 patients with PNET who underwent MRI and surgery from 2000 to 2018 were enrolled. Two radiologists independently assessed MRI findings, including size, location, margin, T1 and T2 signal intensity, enhancement patterns, common bile duct (CBD) or main pancreatic duct (MPD) dilatation, vascular invasion, lymph node enlargement, DWI, and ADC value. Imaging findings associated with recurrence and disease-free survival (DFS) were assessed using logistic regression analysis and Cox proportional hazard regression analysis. Results The median follow-up period was 40.4 months, and recurrence after surgery occurred in 12.1% (12/99). Among them, 6 patients experienced recurrence within 1 year, and 9 patients experienced recurrence within 2 years after surgery. In multivariate analysis, major venous invasion (OR 10.76 [1.14-101.85], p = 0.04) was associated with recurrence within 1 year, and portal phase iso- to hypoenhancement (OR 51.89 [1.73-1557.89], p = 0.02), CBD or MPD dilatation (OR 10.49 [1.35-81.64], p = 0.03) and larger size (OR 1.05 [1.00-1.10], p = 0.046) were associated with recurrence within 2 years. The mean DFS was 116.4 ± 18.5 months, and the 5-year DFS rate was 85.7%. In multivariate analysis, portal phase iso- to hypoenhancement (HR 21.36 [2.01-197.77], p = 0.01), ductal dilatation (HR 5.22 [1.46-18.68], p = 0.01), major arterial invasion (HR 42.90 [3.66-502.48], p = 0.003), and larger size (HR 1.04 [1.01-1.06], p = 0.01) showed a significant effect on poor DFS. Conclusion MRI features, including size, enhancement pattern, vascular invasion, and ductal dilatation, are useful in predicting recurrence and poor DFS after surgery in PNET. Key Points • MRI features are useful for predicting prognosis in patients with PNET after surgery. • PV or SMV invasion (OR 10.49 [1.35-81.64], p = 0.04) was significantly associated with 1-year recurrence. • Portal phase iso- to hypoenhancement (HR 21.36), CBD or MPD dilatation (HR 5.22), arterial invasion (HR 42.90), and larger size (HR 1.04) had significant effects on poor DFS (p

Background Resectable pancreatic ductal adenocarcinoma (R-PDAC) often recurs early after radical resection, which is associated with poor prognosis. Predicting early recurrence preoperatively is useful for determining the optimal treatment. Patients and methods One hundred and seventy-eight patients diagnosed with R-PDAC on computed tomography (CT) imaging and undergoing radical resection at Hirosaki University Hospital from 2005 to 2019 were retrospectively analyzed. Patients with recurrence within 6 months after resection formed the early recurrence (ER) group, while other patients constituted the non-early recurrence (non-ER) group. Early recurrence prediction score (ERP score) was developed using preoperative parameters. Results ER was observed in 45 patients (25.3%). The ER group had significantly higher preoperative CA19-9 (p = 0.03), serum SPan-1 (p = 0.006), and CT tumor diameter (p = 0.01) compared with the non-ER group. The receiver operating characteristic (ROC) curve analysis identified cutoff values for CA19-9 (133 U/mL), SPan-1 (78.2 U/mL), and preoperative tumor diameter (23 mm). When the parameter exceeded the cutoff level, 1 point was given, and the total score of the three factors was defined as the ERP score. The group with an ERP score of 3 had postoperative recurrence-free survival (RFS) of 5.5 months (95% CI 3.02–7.98). Multivariate analysis for ER-related perioperative and surgical factors identified ERP score of 3 [odds ratio (OR) 4.63 (95% CI 1.82–11.78), p = 0.0013] and R1 resection [OR 3.20 (95% CI 1.01–10.17), p = 0.049] as independent predictors of ER. Conclusions For R-PDAC, ER could be predicted by the scoring system using preoperative serum CA19-9 and SPan-1 levels and CT tumor diameter, which may have great significance in identifying patients with poor prognoses and avoiding unnecessary surgery.

Background: Post-operative pancreatic fistula (POPF) can be life-threatening, and gadoxetic acid-enhanced MRI is routinely performed in patients undergoing pancreatic surgery. However, previous reports have not investigated if gadoxetic acid-enhanced MRI can be used to predict POPF risk. Objective: This study aims to explore if gadoxetic acid-enhanced MRI can predict pancreatic fibrosis and the need for POPF treatment before surgery. Methods: We retrospectively analyzed gadoxetic acid-enhanced MR images from 142 patients who underwent pancreatic surgery between January 1, 2011, and April 30, 2018. Pre-dynamic signal intensity (SI) and values for the portal, transitional, and hepatobiliary phase standardized based on pre-dynamic study values were analyzed. The diameter of the main pancreatic duct (DMPD) was measured, and the degree of pancreatic fibrosis was classified as F0 – F3. We defined POPF higher than grade B as significant. Results: Odds ratios for combinations that led to any degree of fibrosis higher than grade B were defined as significant risk factors. The highest odds ratio was obtained for F0 vs. F1 – F3 (p = 0.038). DMPD (p < 0.001), pre-SI (p = 0.008), portal-SI/pre-SI (p < 0.001), transitional-SI/pre-SI (p < 0.001), and hepatobiliary-SI/pre-SI (p = 0.012) were significantly correlated with the presence of fibrosis. Moreover, the presence of fibrosis was best detected by DMPD (AUC = 0.777). Individual specificity values of transitional-SI/pre-SI and DMPD were 95.5% and 86.6%, respectively, and their combined specificity was 97.7%. Conclusion: The absence of pancreatic fibrosis is a risk factor for developing POPF higher than grade B. DMPD was the most useful diagnostic indicator for the presence of fibrosis among our analysis, and its specificity increased when combined with transitional-SI/pre-SI.

BACKGROUND: The indications for endoscopic retrograde cholangiopancreatography (ERCP) in infant patients (age

Background Primary pancreatic lymphoma (PPL) is a rare neoplasm. Being able to distinguish it from other pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC) is important for appropriate management. Unlike PDAC, PPL is highly sensitive to chemotherapy and usually does not require surgery. Therefore, being able to identify PPL preoperatively will not only direct physicians towards the correct avenue of treatment, it will also avoid unnecessary surgical intervention. Aim To evaluate the typical and atypical multi-phasic computed tomography (CT) imaging features of PPL. Methods A retrospective review was conducted of the clinical, radiological, and pathological records of all subjects with pathologically proven PPL who presented to our institutions between January 2000 and December 2020. Institutional review board approval was obtained for this investigation. The collected data were analyzed for subject demographics, clinical presentation, laboratory values, CT imaging features, and the treatment received. Presence of all CT imaging findings including size, site, morphology and imaging characteristics of PPL such as the presence or absence of nodal, vascular and ductal involvement in these subjects were recorded. Only those subjects who had a pre-treatment multiphasic CT of the abdomen were included in the study. Results Twenty-nine cases of PPL were diagnosed between January 2000 and December 2020 (mean age 66 years; 13 males/16 females). All twenty-nine subjects were symptomatic but only 4 of the 29 subjects (14%) had B symptoms. Obstructive jaundice occurred in 24% of subjects. Elevated lactate dehydrogenase was seen in 81% of cases, whereas elevated cancer antigen 19-9 levels were present in only 10% of cases for which levels were recorded. The vast majority (90%) of tumors involved the pancreatic head and uncinate process. Mean tumor size was 7.8 cm (range, 4.0-13.8 cm). PPL presented homogenous hypoenhancement on CT in 72% of cases. Small volume peripancreatic lymphadenopathy was seen in 28% of subjects. Tumors demonstrated encasement of superior mesenteric vessels in 69% of cases but vascular stenosis or occlusion only manifested in 5 out of the twenty-nine individuals (17%). Mild pancreatic duct dilatation was also infrequent and seen in only 17% of cases, whereas common bile duct (CBD) dilation was seen in 41% of subjects. Necrosis occurred in 10% of cases. Size did not impact the prevalence of pancreatic and CBD dilation, necrosis, or mesenteric root infiltration (P = 0.525, P = 0.294, P = 0.543, and P = 0.097, respectively). Pancreatic atrophy was not present in any of the subjects. Conclusion PPL is an uncommon diagnosis best made preoperatively to avoid unnecessary surgery and ensure adequate treatment. In addition to the typical CT findings of PPL, such as homogeneous hypoenhancement, absence of vascular stenosis and occlusion despite encasement, and peripancreatic lymphadenopathy, this study highlighted many less typical findings, including small volume necrosis and pancreatic and bile duct dilation.

The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to determine imaging features and their diagnostic accuracy for predicting high-grade dysplasia (HGD)/malignancy in BD-IPMN, including mixed type. The PubMed, Embase, and Cochrane databases were searched, and data were extracted from relevant studies. As the main diagnostic accuracy index, diagnostic odds ratios (DORs) of imaging features for diagnosing HGD/malignancy in BD-IPMNs were pooled using the random-effects model. A bivariate random-effects approach was used to construct summary receiver operating characteristic curves for sensitivity and specificity estimation. The pooled DOR was the highest for the enhanced solid component/mural nodule (MN) (DOR, 12.21; 95 % confidence interval [CI], 6.14–24.27), followed by a main pancreatic duct (MPD) diameter of 10 mm or greater (DOR, 7.93; 95 % CI, 3.02–20.83), solid component (DOR, 4.85; 95 % CI, 2.49–9.42), lymphadenopathy (DOR, 4.84; 95 % CI, 1.11–21.06), MN (DOR, 4.48; 95 % CI, 3.15–6.39), an MPD diameter of 5 mm or greater (DOR, 3.69; 95 % CI, 2.62–5.19), abrupt change in MPD caliber with distal pancreatic atrophy (DOR, 2.65; 95 % CI, 1.66–4.24), thickened/enhancing walls (DOR, 2.38; 95 % CI, 1.57–3.60), and cyst size of 3 cm or larger (DOR, 1.98; 95 % CI, 1.48–2.64). The largest area under the curve (0.89 and 0.95, respectively) and high specificity (0.95 and 0.98, respectively) also were found for enhanced solid component/MN and an MPD diameter of 10 mm or greater, albeit with low sensitivity (0.38 and 0.14, respectively). The aforementioned imaging features could aid in predicting HGD/malignancy of BD-IPMN. Furthermore, enhanced solid component/MN and an MPD diameter of 10 mm or greater were the most important predictors of HGD/malignancy in BD-IPMN and should be considered as indications for surgery.

Objective Bile duct dilation (BDD) of unclear etiology is a common indication for further imaging via endoscopic ultrasound (EUS). We aimed to assess the yield of EUS in determining BDD etiology in patients with prior non-diagnostic imaging studies. Methods A retrospective chart review was performed at a single, tertiary-care university hospital for patients referred for EUS for BDD with or without pancreatic duct dilation (PDD). EUS-guided fine needle aspiration (FNA) was performed if a focal lesion was identified. Cases with an etiology of BDD diagnosed or strongly suggested by prior imaging were excluded. EUS findings believed to represent a structural cause for BDD included a wide range of pancreaticobiliary and luminal pathology as well as patients' clinical factors. Results In total, 307 patients were identified. Findings to explain BDD were found by EUS in 213 patients for a diagnostic yield of 69.4%. Patients with jaundice were significantly more likely to receive a diagnosis by EUS than those without (78.8% vs 55.3%, P Conclusions EUS continues to play a substantial role in evaluating BDD of unclear etiology, most notably in patients with jaundice. In addition, given that 8.1% of asymptomatic patients without jaundice or abnormal LFT had malignancy diagnosed on EUS, the use of EUS for BDD of unclear etiology remains warranted. Take home messages The diagnostic yield of EUS in patients referred for bile duct dilation of unclear etiology was substantial at 69.4%. Nearly 1/5 (19.5%) of patients referred for evaluation of a dilated bile duct failed to have confirmation of bile duct dilation on EUS. Even among patients with normal LFT, a malignancy was found by EUS in 8.1% of patients. Because important pathology, including malignancy, was frequently discovered by EUS in patients with seemingly incidental bile duct dilation, the routine use of EUS and EUS-FNA/FNB for this indication seems warranted.

We encountered 4 patients with acute pancreatitis (AP) of various etiologies and coexisting acute cholangitis who underwent endoscopic biliary stenting (EBS) and nasopancreatic drainage (NPD) via endoscopic retrograde cholangiopancreatography (ERCP) during the early phase of AP. ERCP is performed to treat acute cholangitis even in the context of AP. However, in difficult cases, accidental contrast media injection or guidewire insertion into the pancreatic duct can happen during ERCP for the purpose of EBS. It is concerned that cannulation injury and increased pancreatic duct pressure can exacerbate existing AP. Because pancreatic guidewire-associated techniques were required for all of them due to difficult biliary cannulation, we performed a NPD catheter placement using the pancreatic guidewire to decompress the pancreatic duct to prevent further exacerbating AP. Surprisingly, all patients dramatically improved without systemic or local complications. NPD could be performed without any adverse events and did not worsen the course of AP. Early decompression of a pancreatic duct using NPD may rather improve AP that had already developed. Further prospective research is needed to confirm our observations.

Aim. To compare the aspects of the use of various stents in hepatopancreatobiliary zone diseases.Materials and methods. We analyzed the experience of using biliary plastic and metal self-expanding stents placed by the antegrade percutaneous (n = 45) or retrograde endoscopic method (n = 160). Pancreatic stenting with 5 Fr plastic stents was performed in 35 patients.Results. Our experience shows the high efficiency of stenting performed by antegrade and endoscopic retrograde access for bile and pancreatic ducts obstruction. Pancreatic stenting is justified in the prevention of acute pancreatitis (in the presence of a risk factor) and in treatment of post-ERCP pancreatitis, as well as in the treatment of acute biliary pancreatitis with impacted stone in papilla Vater.Conclusion. Minimally invasive technologies has a leading role in the treatment of patients with ductal failure of the hepatopancreatobiliary zone. Stenting should be used to prepare for radical surgery or as a final palliative treatment method. A differentiated approach is important in selecting a stent, depending on the specific clinical task. For biliary drainage in patients with obstructive jaundice of various etiologies, it is permissible to use both the retrograde and antegrade stenting. The choice of the decompression method depends on the level of the biliary obstruction, the cause of obstructive jaundice, the technical equipment of the department and the training of specialists in retrograde and (or) antegrade endobiliary technologies. Antegrade access is preferred for proximal obstruction of the bile ducts, retrograde endoscopic access is preferred for distal obstruction.

Background A validated classification of endoscopic ultrasound (EUS) morphological characteristics and consequent therapeutic intervention(s) in pancreatic and peripancreatic fluid collections (PFCs) is lacking. We performed an interobserver agreement study among expert endosonographers assessing EUS-related PFC features and the therapeutic approaches used. Methods 50 EUS videos of PFCs were independently reviewed by 12 experts and evaluated for PFC type, percentage solid component, presence of infection, recognition of and communication with the main pancreatic duct (MPD), stent choice for drainage, and direct endoscopic necrosectomy (DEN) performance and timing. The Gwet’s AC1 coefficient was used to assess interobserver agreement. Results A moderate agreement was found for lesion type (AC1, 0.59), presence of infection (AC1, 0.41), and need for DEN (AC1, 0.50), while fair or poor agreements were stated for percentage solid component (AC1, 0.15) and MPD recognition (AC1, 0.31). Substantial agreement was rated for ability to assess PFC–MPD communication (AC1, 0.69), decision between placing a plastic versus lumen-apposing metal stent (AC1, 0.62), and timing of DEN (AC1, 0.75). Conclusions Interobserver agreement between expert endosonographers regarding morphological features of PFCs appeared suboptimal, while decisions on therapeutic approaches seemed more homogeneous. Studies to achieve standardization of the diagnostic endosonographic criteria and therapeutic approaches to PFCs are warranted.

Background. Chronic pancreatitis (CP) is characterized by a number of specific changes in the structure and function of the pancreas, including atrophy of functional tissue, fibrosis and ductal degeneration, a decrease in the number of islets. Despite a large number of possible etiological factors, the main pathophysiological mechanisms of CP development have much in common. Thus, with the preservation of secretory activity under obstruction of the ducts and their compensatory expansion, pancreatic secret infiltrates the surrounding tissue with the formation of edema, followed by intrapancreatic activation of digestive enzymes, in particular trypsinogen, which initiates proteolytic necrobiosis of the pancreocytes. The duct cells make up to 30 % of the human pancreas, compared to 1–2 % of endocrine cells. One of the first signs of CP is the abnormal increase in the number of ductal branches. It has also been shown that in the ducts of CP patients, the number of cells containing insulin increases, as well as cells that contain other endocrine and exocrine markers. Modeling chronic, acute and complicated pancreatitis in rats also confirmed that epithelial cells are involved in the regulation of extracellular matrix of the pancreas. Materials and methods. Comprehensive histopathological and immunohistochemical (IHC) study was performed in the laboratory of histological and immunohistochemical diagnosis of the university hospital of Zaporizhia State Medical University on postoperative material of 40 patients with CP aged 28 to 74 years, who were opera­ted at the clinic of surgery and minimally invasive technologies of Zaporizhia State Medical University. Immunohistochemical exa­mination was carried out according to standard procedures using a mouse monoclonal antibody Alpha Smooth Muscle Actin (Clone 1A4) against the a-isoform of smooth muscle actin (a-SMA) and Desmin (Clone D33) against desmin (DAKO, USA), monoclonal rabbit antibody against collagen I (Clone RAH C11) anti-collagen type 1 (Imtek, RF) and rabbit polyclonal antibodies against fibronectin (DAKO, USA). Quantitative determination of the intensity and the relative area of the markers’ stromal expression was reproduced using the program for medical digital image processing ImageJ v.1.48, embedded plugin Colour Deconvolution analysis circuit and coloring H DAB (hematoxylin + DAB) for determi­ning the area occupied by immunopositive structure in immunohistochemical preparations and optical (densitometric) intensity of immunostaining by patented procedure. Results. Pathohistological study of biopsies with a specific staining of collagen (by Van Gieson and Masson’s trichrome) showed that fibrotic changes in all the patients with CP were characterized by a combination of pronounced perilobular fibrosis, which covered all lobules, widespread intralobular fibrosis, and significant periductal fibrosis near large, sharply defined narrowed and cystically dilated ducts. There was also a pronounced expansion of interlobular fibrosis, a noticeable thickening of intralobular connective tissue strands directed deep into the lobules and connective tissue strands that surrounded some acini, as well as a significant tortuosity and widening of the ducts with retention cysts. In most cases, the deformation of the ductal system was one of the most significant structural changes. Thus, 87.5 % of cases were characterized by the unevenly narrowed and cystic-altered interlobular ducts, pronounced concentric fibrosis, protein plugs and concrements observed in the ducts. In 7.5 % of the cases, in the main pancreatic duct, foci of the epithelium atrophy were present, which alternated with foci of papillary intraepithelial hyperplasia, identified as pancreatic intraepithelial neoplasia. The parenchyma of the pancreas was thus constituted small, atrophic acini, surrounded by dense fibrous strands, with an increased number of gaping ducts of different diameters. Also, in 17.5 % of cases, phenomena of acinar-ductal metaplasia were observed. In the centers of the acinar-ductal metaplasia zones, the transformation of some acinar cells into ductal cells was determined with the formation of small duct-like structures, the so-called tubular complexes, which, according to the literature, are the primary focus of acinar tissue regeneration. In particular, a large number of activated a-SMA + pancreatic stellate cells (PSC) is detected in the zones of fibrosis. The pattern of expression of this marker is characterized by pronounced a-SMA-immunopositive staining of both PSC and their processes, and, in part, of the fibrillar component. Primary statistical processing of morphometry data revealed a direct relationship between the expression of a-SMA and the area of collagen I type, but this relationship was not significant (r = +0.321, p > 0.05). In order to further objectify the statistical studies, we isolated a group of cases characterized by low a-SMA expression (n = 9). A further study using medical statistics methods showed that the average area of type I collagen and the intensity of its expression in this group was significantly lower than in the other biopsy specimens (p < 0.05). In contrast, desmin expression was identified both in connective tissue, which was characterized by a lower intensity of immunostaining, in acinar tissue and in the epithelium of the pancreatic ducts. The pattern of its expression in fibrosis zones in CP was similar to that of a-SMA, but in 27.5 % of cases, the intensity of staining was below the threshold for determination by morphometric methods. We isolated a group of cases characterized by high expression of fibronectin (n = 9). A further study using medical statistics showed that the average area of type I collagen and the intensity of its expression in this group was significantly higher than in the other biopsy specimens (p < 0.05). Thus, IHC study of the material obtained from patients with CP showed that a large number of activated PSC expressing a-SMA and desmin are concentrated in the pancreatic ductal zones. Also, in these zones, a significant accumulation of fibronectin was found, which is synthesized in excess by activated PSC. The pattern of IHC staining of type I collagen in the zones of severe pancreatic fibrosis is characterized by a weak and moderate intensity with a average level of its expression. Conclusions. A characteristic morphological picture of the CP development is a combination of fibrosis with deformation of the ductal system due to periductal fibrosis with the expansion of interlobular fibrosis, thickening of intralobular connective tissue strands, as well as considerable tortuosity and widening of the ducts with retention cysts. Significant structural reorganization of the pancreatic duct system in patients with CP was observed in 87.5 % of cases, in 17.5 % of cases, the picture was supplemented by phenomena of acinar-ductal metaplasia with the transformation of acinar cells into ductal cells and the formation of small duct-like structures, the so-called tubular complexes. In 7.5 % of cases, in the main pancreatic duct, foci of atrophy of the epithelium were identified, which alternated with foci of papillary intraepithelial epithelial hyperplasia (PanIN). The development of pancreatic fibrosis in CP is facilitated by the accumulation of a-SMA+ activated pancreatic stellate cells synthesizing an excess of components of the extra-cellular matrix, in particular type I collagen. The mean area of type I collagen and the intensity of its expression were significantly lower with reduced a-SMA expression (p < 0.05), and significantly higher in cases of pronounced fibronectin expression (p < 0.05).

Objective The concept of early chronic pancreatitis (ECP) and its diagnostic criteria were first proposed by Japan, using endoscopic ultrasonography (EUS) findings for diagnosis. However, these findings have not been supported by pathological findings. We aimed to examine the association between the EUS and pathological findings of the same area of the pancreas. Methods In 12 patients who underwent pancreaticoduodenectomy for distal bile duct cancer without accompanying pancreatitis, a comparative analysis between preoperative EUS and pathological findings was performed. The part of the pancreas adjoining the portal vein was evaluated. Results In 7 cases, abnormal EUS findings included in the diagnostic criteria for ECP were seen; the correlation of the accuracy of lobularity seen on EUS compared with the pathological findings of the pancreatic parenchyma (inflammatory cell infiltration, atrophy of acinar cells, and fibrosis) was high (83.3%-91.7%). Pancreatic duct findings revealed that the accuracy of the hyperechoic margin of the pancreatic duct on EUS compared with pathological findings (wall thickness of pancreatic duct) was high (83.3%). Conclusions Endoscopic ultrasonography findings for ECP, according to Japan's 2019 revised criteria, lobularity, and the hyperechoic margin of the pancreatic duct may highly correspond to the pathological findings of chronic inflammation.

Background/Objectives Enucleation is an effective surgical method to treat pancreatic insulinoma, however, the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) is high. We aim to investigate the risk factors for CR-POPF which have not been well characterized and develop effective methods to prevent CR-POPF after enucleation. Methods This retrospective cohort study included 161 patients diagnosed with insulinoma from June 2016 to July 2020 in Peking Union Medical College Hospital. The risk factors for CR-POPF were evaluated and the role of prophylactic pre-operative pancreatic stent to prevent the occurrence of CR-POPF after enucleation of pancreatic insulinoma were explored. Results A cohort of 161 insulinoma cases were reviewed. The CT or MRI imaging reports could be tracked in 108 cases. A total of 96 patients underwent surgery, while 81 experienced pancreatic enucleation. Univariate and multivariate analyses showed that the distance from insulinoma to the main pancreatic duct (MPD) ≤2 mm was an independent risk factor for CR-POPF (p = 0.003, OR = 6.011, 95% Cl 1.852–19.512). The pre-operative pancreatic stent substantially reduced the incidence of CR-POPF in patients with tumor located in proximity to (distance ≤2 mm) the MPD (CR-POPF of the stented group vs the non-stented group: 37.5% vs 71.4%, p = 0.028). Conclusions The distance from insulinoma to MPD ≤2 mm is a predictive factor for CR-POPF after enucleation. Pancreatic duct stenting may benefit patients with insulinoma in proximity to the MPD by enabling a lower CR-POPF rate, so it should be considered before the enucleation of the insulinoma in proximity to the MPD (distance ≤2 mm).

A secure pancreatic-enteric anastomosis is widely accepted as the 'Achilles heel' in reconstruction following a pancreaticoduodenectomy. Most morbidity following the procedure is related to the failure of this anastomosis, resulting in intra-abdominal collections, secondary haemorrhage, delayed gastric emptying, need for radiological interventions and re-operation for some patients. Of several techniques available, the 'duct-to-mucosa' technique is widely employed for pancreaticojejunal anastomosis. Among several refinements to facilitate this anastomosis, viz; mobilization of pancreatic stump, magnification with loupes and modifications made on the jejunal side to enable a tension free anastomosis, none seems to address the pancreatic duct in particular. The operative technique of anterior pancreatic duct split described by us enables a wider, well visualized pancreatic duct for a secure duct to mucosa pancreaticojejunal anastomosis.

The paper is devoted to the assessment of prevention methods of post-ERCP pancreatitis on the analysis of hyperamilasemia in patients with pathology of the pancreatobiliary system, who underwent endoscopic transpapillary interventions.The aim of the study: initial assessment of the impact of possible methods for the prevention of pancreatitis in endoscopic transpapillary interventions on the level of amylasemia.The study is based on a continuous retrospective analysis of 73 case histories of patients undergoing EPST. For analysis, patients were divided into three groups: in the 1st, stenting of the pancreatic duct was performed by plastic stents, in the 2nd group, parapapillary blockade of 0.5% novocaine solution in a volume of 10ml was performed, in the 3rd group the described methods were not used. In the study, in patients with stenting, the development of hyperamilasemia was detected in 22% of cases, with only parapapillary blockade with novocaine solution - in 38% of cases, without the use of the described methods of prevention - in 15%. Amylasemia relief periods were significantly longer with stenting. The study demonstrated the equally low effectiveness of the methods used and the need to continue data analysis of described methods for the prevention of post-ERCP pancreatitis.

Acinar cell cystadenoma, also known as an acinar cystic transformation of the pancreas, is an exceedingly rare but benign pancreatic lesion. A 51-year-old woman was transferred to Inje University Busan Paik Hospital because of an 8 cm-sized calcified, multiseptated, and multilocular cystic mass in the pancreatic tail observed during abdominal CT performed at another hospital. The patient did not complain of abdominal pain or other symptoms, and her laboratory findings were normal. MRI showed that the cyst was not connected to the main pancreatic duct. A pancreatic serous cystadenoma was suspected, and a laparoscopic distal pancreatectomy was performed. The resected mass was composed of variable sized multilocular cysts with incomplete septa and focally lined by epithelium with acinar differentiation. The patient was diagnosed with acinar cell cystadenoma and is currently being followed up regularly. No complications or recurrences have been observed.

Introdução: Pancreas Divisum é uma anomalia anatômica do ducto pancreático em que a maioria do suco pancreático passa pela papila menor e a minoria pela papila maior. Relato de caso: Paciente com 54 anos com Pâncreas Divisumque obteve diagnóstico de pâncreas divisum ocasionalmente durante investigação para elucidação de enzimas hepáticas alteradas e dispepsia. Discussão: Pâncreas Divisum é uma entidade pouco abordada devido à falta de sintomatologia na maioria dos casos, mas há indícios mais recentes que apontam que essa entidade poderia estar relacionada com a maior incidência de outras patologias como pancreatites e tumor pancreático. Conclusão: Por ser uma doença rara e assintomática e, pela possibilidade de evoluir com complicações, deve-se pensar preemptivamente no intuito de prever diagnósticos mais precoces para que se possa intervir em casos de necessidade e evitar desfechos desfavoráveis.

INTRODUCTION Acinar cystic transformation (ACT) of the pancreas is characterized by multiple cysts lined by dual ductal and acinar-type of epithelium. ACT is typically a disease of adulthood and has not been described in a neonate. Case report: Autopsy of this term 3-day old male demonstrated cystic transformation of the entire pancreas measuring 42 mm in its largest dimension. The main pancreatic duct was patent. The numerous variable-sized cysts were lined by both ductal (CK7-positive) and acinar (trypsin-positive) epithelium. Congenital hemochromatosis of the liver, complete proximal jejunal atresia, gangrene of the post-atretic jejunum, and subglottic stenosis were associated features. Discussion/Conclusion: ACT may occur in the neonate in association with other abnormalities.

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a primarily diagnostic to therapeutic procedure in hepatobiliary and pancreatic disease. Most commonly, ERCPs are performed for choledocholithiasis with or without cholangitis, but improvements in technology and technique have allowed for management of pancreatic duct stones, benign and malignant strictures, and bile and pancreatic leaks. As an example of necessity driving innovation, the new disposable duodenoscopes have been introduced into practice. With the advantage of eliminating transmissible infections, they represent a paradigm shift in quality improvement within ERCP. With procedures becoming more complicated, the necessity for anesthesia involvement and safety of propofol use and general anesthesia has become better defined. The improvements in endoscopic ultrasound (EUS) have allowed for direct bile duct access and EUS facilitated bile duct access for ERCP. In patients with surgically altered anatomy, selective cannulation can be performed with overtube-assisted enteroscopy, laparoscopic surgery assistance, or the EUS-directed transgastric ERCP. Cholangioscopy and pancreatoscopy use has become ubiquitous with defined indications for large bile duct stones, indeterminate strictures, and hepatobiliary and pancreatic neoplasia. This review summarizes the recent advances in infection prevention, quality improvement, pancreaticobiliary access, and management of hepatobiliary and pancreatic diseases. Where appropriate, future research directions are included in each section.

Purpose Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery. Methods A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested. Results Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p Conclusion Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.

Background and Aim Postoperative pancreatic fistula (POPF) is an important cause of major morbidity and mortality after pancreaticoduodenectomy. We intend to estimate the incidence and study the risk factors and outcomes of patients who developed this dreaded complication. Methods This is a retrospective observational study. We included all patients who underwent pancreaticoduodenectomy at a specialized surgical unit of a single tertiary care cancer center in Northeast India. The period of study was from 23 April 2012 to 27 December 2019. The 2016 update on the definition of POPF by the International Study Group for Pancreatic Fistula was used to define the complication. Chi‐square test and Fischer's exact test were applied to categorical variables. t‐test was used to quantify mean difference among continuous variables. P value, Postoperative pancreatic fistula remains a potentially life‐threatening complication of pancreaticoduodenectomies. Preoperative hyperbilirubinemia, pancreatic duct size less than or equal to 3 mm, hypoalbuminemia, preoperative biliary decompression, and prolonged duration of surgery were identified as risk factors for POPF. POPF also resulted in increased 90‐day mortality (20%).The knowledge and management of modifiable risk factors for this condition may help in mitigating this problem.

The study aims to determine the morphology and histology of the duct system in pancreases ofrabbits and guinea pigs as two important experimental models in diverse medical investigations. To perform this aim, eight adult animals of each species have been collected and used. Animals were euthanized and subsequent dissection was implemented to cut and collect the pancreases. Samples from these organs were fixed by using 10% neutral buffered formalin which then processed routinely to prepare sections stained by either hematoxylin-eosin or Masson’s trichrome stains. Gross findings of the rabbit pancreas revealed an absence of major pancreatic duct and the persistence of only minor pancreatic duct as well as an accessory small pancreatic duct, whereas, in guinea pigs, the only minor pancreatic duct was detected. Microscopically, similar branched ducts were found but with some differences between the two species. In both, it was started with centroacinar cells, then connected to intercalated ducts that were lined with cuboidal cells (in the guinea pig, ducts were surrounded with myoepithelial cells). The latter converged to form interlobular ducts lined with columnar cells (in guinea pig, ducts showed goblet cells and subepithelial mucous glands). The larger interlobular ducts were converged to form a minor pancreatic duct that was lined with tall columnar epithelium with goblet cells surrounded by connective tissue (in guinea pigs, also mucous glands were found invested in the surrounding fibrous tissue with the presence of circularly arranged smooth muscle fibers).

Contains fulltext : 238998.pdf (Publisher’s version ) (Open Access) BACKGROUND: Pancreatic duct disruption or disconnection is a potentially severe complication of necrotizing pancreatitis. With no existing treatment guidelines, it is unclear whether there is any consensus among experts in clinical practice. We evaluated current expert opinion regarding the diagnosis and treatment of pancreatic duct disruption and disconnection in an international case vignette study. METHODS: An online case vignette survey was sent to 110 international expert pancreatologists. Expert selection was based on publications in the last 5 years and/or participation in development of IAP/APA and ESGE guidelines on acute pancreatitis. Consensus was defined as agreement by at least 75% of the experts. RESULTS: The response rate was 51% (n = 56). Forty-four experts (79%) obtained a MRI/MRCP and 52 experts (93%) measured amylase levels in percutaneous drain fluid to evaluate pancreatic duct integrity. The majority of experts favored endoscopic transluminal drainage for infected (peri)pancreatic necrosis and pancreatic duct disruption (84%, n = 45) or disconnection (88%, n = 43). Consensus was lacking regarding the treatment of patients with persistent percutaneous drain production, and with persistent sterile necrosis. CONCLUSION: This international survey of experts demonstrates that there are many areas for which no consensus existed, providing clear focus for future investigation.