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Dorsal Pancreatic Duct Dominance in Pancreaticobiliary Maljunction
Abstracts
T1204 Morphological Changes After Steroid Therapy in Autoimmune Pancreatitis Terumi Kamisawa, Hitoshi Nakajima, Atsutake Okamoto Background and Aims: Although many patients with autoimmune pancreatitis undergo steroid therapy, detailed evaluation of morphological changes in the pancreas and bile duct following therapy has not been performed in this disease. We comparatively examined serological and morphological changes occurring during steroid treatment of autoimmune pancreatitis. Methods: Ten patients with autoimmune pancreatitis were treated with corticosteroids. Morphological findings were: pancreatic enlargement (nZ9), irregular narrowing of the main pancreatic duct (nZ10), and biliary stenosis (nZ9). Serum IgG4 concentration was elevated in 6 patients. Major symptom was obstructive jaundice in 6 patients. Initial dose of prednisolone was 40-30 mg/day, and this was tapered by 5 mg every 1-2 weeks. All patients underwent US and serological testing 1-2 weeks after commencing medication, followed by weekly serological testing and by CT and endoscopic retrograde cholangiopancreatography after1 month. Results: All 10 patients were responsive to steroid therapy. Pancreatic size normalized within 1 month; however, irregularity of the pancreatic duct remained in 6 patients. Rigidity or lateral deformity of the bile duct remained in 3 patients and biliary stenosis persisted in 5. No further morphological improvement was observed after tapering predonisolone dose to 10 mg/day. Biliary drainage tube could be withdrawn in all 4 patients within 1 month after therapy. Four patients in whom elevated serum IgG4 failed to normalize also showed incomplete morphological improvement. Three patients with complete improvement of the pancreatic duct stopped medication, but recurrence of pancreatitis did not occur. The other 7 patients continued maintenance steroid therapy without disease recurrence. No patients had to undergo surgery for bile duct stenosis or other autoimmune pancreatitis related complications. Conclusions: Although steroid therapy was morphologically and serologically effective in patients with autoimmune pancreatitis, cholangiopancreatographic abnormalities remained in many patients. Morphological improvement on cholangiopancreatography and normalization of serum IgG4 after steroid therapy appeared to be good indicators for ceasing medication in patients with autoimmune pancreatitis.
T1206 Clinical and Radiological Findings in Dominance of Santorini’s Duct Terumi Kamisawa, Naoto Egawa, Hitoshi Nakajima, Michio Maruyama, Noriko Matsushita, Masami Ando Background and Aims: Few studies on Santorini’s duct dominance, in which the ventral pancreatic duct is narrower than and anastomoses with Santorini’s duct have been performed. We examined clinical and radiological findings in cases characterized by dominance of Santorini’s duct. Methods: We reviewed 3800 cases of endoscopic retrograde cholangiopancreatography. Clinical and pancreatographic findings including caliber, course, terminal shape, and patency of Santorini’s duct were examined in cases of Santorini’s duct dominance. Results: Twenty-nine cases were diagnosed as Santorini’s duct dominant. Chronic pancreatitis, acute relapsing pancreatitis, pancreatic-type pain, and hyperamylasemia not associated with obvious pancreatitis were observed in 3, 1, 5, and 6 cases, respectively. Cholangiopancreatographic findings indicated congenital choledochal cyst (nZ2), branch fusion between the ventral and dorsal pancreatic ducts (nZ23), and normal pancreatic duct system characterized by a straight course through the body and tail to join the ventral pancreatic duct in the neck portion of the pancreas (nZ4). Maximum diameter of the ventral pancreatic duct was less than 1 mm in 13 cases, of which 4 cases showed as slender as 0.5 mm. Maximum diameter of Santorini’s duct exceeded 3 mm in 17 cases, and exceeded 4 mm in 5 cases without chronic pancreatitis. Regarding terminal shapes of Santorini’s duct, cudgel type (nZ9) and spindle type (nZ8), which sicantly more frequently than in controls. Patency of Santorini’s duct was observed in 90% (17/19). Conclusions: Many Santorini’s ductdominant cases exhibited branch fusion between the ventral and dorsal pancreatic ducts. Although Santorini’s duct functions well in most cases in which it is dominant, pancreatitis or pancreatic-type pain occurs in half of such cases due to relative impairment of function of the minor duodenal papilla.
T1205 Dorsal Pancreatic Duct Dominance in Pancreaticobiliary Maljunction Terumi Kamisawa, Michio Maruyama, Kumi Hasegawa, Masahide Ohbu, Ayaki Koide, Noriko Matsushita, Masami Ando
T1207 Predictors of Prolonged Treatment Duration: Laser and/or Extracorporeal Shock Wave Lithotripsy of the Pancreatic Stones Hiroki Kawashima, Yoshiki Hirooka, Akihiro Itoh, Senju Hashimoto, Kazuo Hara, Akira Kanamori, Hiroki Uchida, Jun Goto, Shigeto Ishikawa, Naoki Ohniya, Yasumasa Niwa, Hidemi Goto
Background and Aims: In patients with pancreaticobiliary maljunction (PBM), reflux of pancreatic juice to the bile duct may contribute to carcinogenesis of the biliary tract. This study aimed to investigate the pancreatographic findings in patients with PBM, and the relationship to their clinical findings in view of pancreatic juice flow. Materials and Methods: Seventy-eight cholangiopancreatograms of PBM were reviewed. When the maximum diameter of the Santorini’s duct was almost equal to or greater than that of the ventral pancreatic duct, the relationship between the two ducts was defined as dorsal pancreatic duct (DPD) dominance. Radiological and clinical findings including the incidence of associated biliary carcinoma were examined. Results: Pancreatographic findings were divided into two groups; a normal duct group (69 patients) and a DPD dominant group (9 patients). There was no significant difference in age and sex between the two groups. Although 40 patients (58%) with biliary carcinoma (gallbladder carcinoma, nZ35; bile duct carcinoma, nZ5) were identified in the normal duct group of PBM, only one gallbladder carcinoma (11%) occurred in DPD-dominant patients (P!0.01). In DPD-dominant patients, 8 patients underwent prophylactic surgical treatment except for one patient with advanced gallbladder carcinoma. There was no patient in which metachronous biliary carcinoma occurred during follow-up period. Patients with a dominant DPD included 7 patients with PBM with biliary dilatation and 2 with PBM without biliary dilatation. Although there was no difference in the diameter of the ventral pancreatic duct, the maximum diameter of the Santorini’s duct in DPD dominance was significantly larger than that of normal pancreatic duct system (mean 2.7 mm vs. 0.9 mm, p!0.01). A large-caliber Santorini’s duct was noted to flow straight from the upstream DPD in all patients with DPD dominance. Concentration of amylase in the bile of DPD dominance was significantly lower than that of normal pancreatic duct system (mean 85750 IU/L vs. 420600 IU/L, p!0.01). Conclusions: PBM sometimes exhibits DPD dominance. In PMB with DPD dominance, most pancreatic juice in the upper DPD is drained into the duodenum via the minor duodenal papilla, and reflux of pancreatic juice to the biliary tract might be reduced, resulting in reduced frequency of associated biliary carcinogenesis.
We reported single-session endoscopic treatment of the pancreatic stones using pancreatoscopic laser lithotripsy (PSLL) in a selected patient group (Hirai T. Endoscopy 2004; 36: 212-6). But the other many patients undergo extracorporeal shock wave lithotripsy (ESWL) in subsequent sessions, and need a long treatment period. This study investigated the predictors of prolonged treatment duration using PSLL and/or ESWL of the pancreatic stones. Methods: Sixty-two consecutive patients with symptoms who received PSLL and/or ESWL of pancreatic stones in our institute were included in this study. We excluded the patients who underwent only simple basket lithotomy. PSLL was selected for the first-choice treatment only for patients without sever stricture of the main pancreatic duct. Consequently, fifteen patients underwent only PSLL, 25 patients underwent PSLL and ESWL, and 22 patients underwent only ESWL. The clinical end point was defined as sufficient patency of the main pancreatic duct and without large stones in the main pancreatic duct. At 2 months from beginning of therapy, the patients did not get to the clinical end point were defined as prolonged treatment group. Various predictors, including size, location, number of stones, stone developing into branch ducts or not, therapeutic methods, cause of chronic pancreatitis, and sex were analyzed in relation to the prolonged treatment duration. Multivariate logistic regression analysis was performed to determine the significance of various predictive variables. The continuous variables were compared by the Student t-test. Results: The symptoms of all patients were disappeared or decreased after treatment. The prolonged group included 27 (43.5%) patients. Stone developing into branch ducts was only significant factor that predicted prolonged (more than 2 months) treatment duration (pZ0.0001). Mean treatment periods of the patients with stones developing into branch ducts or not were 77.9 G 14.6: 28.4 G 42.1 days (p!0.0001), respectively. Finally 56 patients (90.3%) got clinical end point, mean treatment duration of all patients was 48.7 G 37.9 days, and mean size of the stones was 14.6 G 6.7 mm. Conclusions: Our laser and/or extracorporeal shock wave lithotripsy of the pancreatic stones achieves high cure rate and disappearance or decrease of symptoms. The only significant factor that prolongs treatment duration is stone developing into branch ducts.
AB192 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
www.mosby.com/gie
T1204 Morphological Changes After Steroid Therapy in Autoimmune Pancreatitis Terumi Kamisawa, Hitoshi Nakajima, Atsutake Okamoto Background and Aims: Although many patients with autoimmune pancreatitis undergo steroid therapy, detailed evaluation of morphological changes in the pancreas and bile duct following therapy has not been performed in this disease. We comparatively examined serological and morphological changes occurring during steroid treatment of autoimmune pancreatitis. Methods: Ten patients with autoimmune pancreatitis were treated with corticosteroids. Morphological findings were: pancreatic enlargement (nZ9), irregular narrowing of the main pancreatic duct (nZ10), and biliary stenosis (nZ9). Serum IgG4 concentration was elevated in 6 patients. Major symptom was obstructive jaundice in 6 patients. Initial dose of prednisolone was 40-30 mg/day, and this was tapered by 5 mg every 1-2 weeks. All patients underwent US and serological testing 1-2 weeks after commencing medication, followed by weekly serological testing and by CT and endoscopic retrograde cholangiopancreatography after1 month. Results: All 10 patients were responsive to steroid therapy. Pancreatic size normalized within 1 month; however, irregularity of the pancreatic duct remained in 6 patients. Rigidity or lateral deformity of the bile duct remained in 3 patients and biliary stenosis persisted in 5. No further morphological improvement was observed after tapering predonisolone dose to 10 mg/day. Biliary drainage tube could be withdrawn in all 4 patients within 1 month after therapy. Four patients in whom elevated serum IgG4 failed to normalize also showed incomplete morphological improvement. Three patients with complete improvement of the pancreatic duct stopped medication, but recurrence of pancreatitis did not occur. The other 7 patients continued maintenance steroid therapy without disease recurrence. No patients had to undergo surgery for bile duct stenosis or other autoimmune pancreatitis related complications. Conclusions: Although steroid therapy was morphologically and serologically effective in patients with autoimmune pancreatitis, cholangiopancreatographic abnormalities remained in many patients. Morphological improvement on cholangiopancreatography and normalization of serum IgG4 after steroid therapy appeared to be good indicators for ceasing medication in patients with autoimmune pancreatitis.
T1206 Clinical and Radiological Findings in Dominance of Santorini’s Duct Terumi Kamisawa, Naoto Egawa, Hitoshi Nakajima, Michio Maruyama, Noriko Matsushita, Masami Ando Background and Aims: Few studies on Santorini’s duct dominance, in which the ventral pancreatic duct is narrower than and anastomoses with Santorini’s duct have been performed. We examined clinical and radiological findings in cases characterized by dominance of Santorini’s duct. Methods: We reviewed 3800 cases of endoscopic retrograde cholangiopancreatography. Clinical and pancreatographic findings including caliber, course, terminal shape, and patency of Santorini’s duct were examined in cases of Santorini’s duct dominance. Results: Twenty-nine cases were diagnosed as Santorini’s duct dominant. Chronic pancreatitis, acute relapsing pancreatitis, pancreatic-type pain, and hyperamylasemia not associated with obvious pancreatitis were observed in 3, 1, 5, and 6 cases, respectively. Cholangiopancreatographic findings indicated congenital choledochal cyst (nZ2), branch fusion between the ventral and dorsal pancreatic ducts (nZ23), and normal pancreatic duct system characterized by a straight course through the body and tail to join the ventral pancreatic duct in the neck portion of the pancreas (nZ4). Maximum diameter of the ventral pancreatic duct was less than 1 mm in 13 cases, of which 4 cases showed as slender as 0.5 mm. Maximum diameter of Santorini’s duct exceeded 3 mm in 17 cases, and exceeded 4 mm in 5 cases without chronic pancreatitis. Regarding terminal shapes of Santorini’s duct, cudgel type (nZ9) and spindle type (nZ8), which sicantly more frequently than in controls. Patency of Santorini’s duct was observed in 90% (17/19). Conclusions: Many Santorini’s ductdominant cases exhibited branch fusion between the ventral and dorsal pancreatic ducts. Although Santorini’s duct functions well in most cases in which it is dominant, pancreatitis or pancreatic-type pain occurs in half of such cases due to relative impairment of function of the minor duodenal papilla.
T1205 Dorsal Pancreatic Duct Dominance in Pancreaticobiliary Maljunction Terumi Kamisawa, Michio Maruyama, Kumi Hasegawa, Masahide Ohbu, Ayaki Koide, Noriko Matsushita, Masami Ando
T1207 Predictors of Prolonged Treatment Duration: Laser and/or Extracorporeal Shock Wave Lithotripsy of the Pancreatic Stones Hiroki Kawashima, Yoshiki Hirooka, Akihiro Itoh, Senju Hashimoto, Kazuo Hara, Akira Kanamori, Hiroki Uchida, Jun Goto, Shigeto Ishikawa, Naoki Ohniya, Yasumasa Niwa, Hidemi Goto
Background and Aims: In patients with pancreaticobiliary maljunction (PBM), reflux of pancreatic juice to the bile duct may contribute to carcinogenesis of the biliary tract. This study aimed to investigate the pancreatographic findings in patients with PBM, and the relationship to their clinical findings in view of pancreatic juice flow. Materials and Methods: Seventy-eight cholangiopancreatograms of PBM were reviewed. When the maximum diameter of the Santorini’s duct was almost equal to or greater than that of the ventral pancreatic duct, the relationship between the two ducts was defined as dorsal pancreatic duct (DPD) dominance. Radiological and clinical findings including the incidence of associated biliary carcinoma were examined. Results: Pancreatographic findings were divided into two groups; a normal duct group (69 patients) and a DPD dominant group (9 patients). There was no significant difference in age and sex between the two groups. Although 40 patients (58%) with biliary carcinoma (gallbladder carcinoma, nZ35; bile duct carcinoma, nZ5) were identified in the normal duct group of PBM, only one gallbladder carcinoma (11%) occurred in DPD-dominant patients (P!0.01). In DPD-dominant patients, 8 patients underwent prophylactic surgical treatment except for one patient with advanced gallbladder carcinoma. There was no patient in which metachronous biliary carcinoma occurred during follow-up period. Patients with a dominant DPD included 7 patients with PBM with biliary dilatation and 2 with PBM without biliary dilatation. Although there was no difference in the diameter of the ventral pancreatic duct, the maximum diameter of the Santorini’s duct in DPD dominance was significantly larger than that of normal pancreatic duct system (mean 2.7 mm vs. 0.9 mm, p!0.01). A large-caliber Santorini’s duct was noted to flow straight from the upstream DPD in all patients with DPD dominance. Concentration of amylase in the bile of DPD dominance was significantly lower than that of normal pancreatic duct system (mean 85750 IU/L vs. 420600 IU/L, p!0.01). Conclusions: PBM sometimes exhibits DPD dominance. In PMB with DPD dominance, most pancreatic juice in the upper DPD is drained into the duodenum via the minor duodenal papilla, and reflux of pancreatic juice to the biliary tract might be reduced, resulting in reduced frequency of associated biliary carcinogenesis.
We reported single-session endoscopic treatment of the pancreatic stones using pancreatoscopic laser lithotripsy (PSLL) in a selected patient group (Hirai T. Endoscopy 2004; 36: 212-6). But the other many patients undergo extracorporeal shock wave lithotripsy (ESWL) in subsequent sessions, and need a long treatment period. This study investigated the predictors of prolonged treatment duration using PSLL and/or ESWL of the pancreatic stones. Methods: Sixty-two consecutive patients with symptoms who received PSLL and/or ESWL of pancreatic stones in our institute were included in this study. We excluded the patients who underwent only simple basket lithotomy. PSLL was selected for the first-choice treatment only for patients without sever stricture of the main pancreatic duct. Consequently, fifteen patients underwent only PSLL, 25 patients underwent PSLL and ESWL, and 22 patients underwent only ESWL. The clinical end point was defined as sufficient patency of the main pancreatic duct and without large stones in the main pancreatic duct. At 2 months from beginning of therapy, the patients did not get to the clinical end point were defined as prolonged treatment group. Various predictors, including size, location, number of stones, stone developing into branch ducts or not, therapeutic methods, cause of chronic pancreatitis, and sex were analyzed in relation to the prolonged treatment duration. Multivariate logistic regression analysis was performed to determine the significance of various predictive variables. The continuous variables were compared by the Student t-test. Results: The symptoms of all patients were disappeared or decreased after treatment. The prolonged group included 27 (43.5%) patients. Stone developing into branch ducts was only significant factor that predicted prolonged (more than 2 months) treatment duration (pZ0.0001). Mean treatment periods of the patients with stones developing into branch ducts or not were 77.9 G 14.6: 28.4 G 42.1 days (p!0.0001), respectively. Finally 56 patients (90.3%) got clinical end point, mean treatment duration of all patients was 48.7 G 37.9 days, and mean size of the stones was 14.6 G 6.7 mm. Conclusions: Our laser and/or extracorporeal shock wave lithotripsy of the pancreatic stones achieves high cure rate and disappearance or decrease of symptoms. The only significant factor that prolongs treatment duration is stone developing into branch ducts.
AB192 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
www.mosby.com/gie