Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined)

Article Abstract:

Pancreas divisum, an abnormality of the pancreatic ducts in which the dorsal and ventral ducts do not fuse, has been noted in patients with pancreatitis and pancreatic pain. The probable pathophysiology responsible for this association is the impeded flow of the pancreatic secretions. It has been found that dominant dorsal duct abnormalities occur in about 10 percent of the population; they therefore are fairly commonplace and should not be considered a morbid condition. For disease to occur, an additional factor must be present, such as accessory papilla stenosis, or narrowing. A study was undertaken of 100 patients with either episodic acute pancreatitis (49 percent) or pancreatic pain (51 percent). The average age of the patients was 35 and there were 77 women and 23 men. Patients who underwent surgery were followed for an average of 53 months. Classic pancreas divisum, type I, was present in 71 patients. Twenty-three patients had type II, dorsal duct with an absent Wirsung's or pancreatic duct, and six had type III, a connection between the dorsal and ventral ducts. Surgery was performed on 88 patients who underwent repair of the accessory papilla sphincter. The overall improvement rate following surgery was 70 percent. The best predictor of surgical success was found to be ultrasonography with secretin stimulation. Restenosis has occurred in seven patients, with six patients undergoing reoperation. It is concluded that for pancreas divisum to create sickness, another condition must be present, such as accessory papilla stenosis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Abnormalities, Pancreatic diseases, Pancreatitis, Pancreatic duct

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Differential diagnosis of sclerosing cholangiocarcinomas of the common hepatic duct (Klatskin tumors)

Article Abstract:

Painless jaundice suggests that the patient may have a tumor obstructing the bile duct. An ultrasound or computed tomographic scan is normally performed to locate the blockage; this is followed by a cholangiogram (a radiographic study that outlines the major bile ducts). The identification of a focal stenotic lesion usually leads to the diagnosis of cholangiocarcinoma (bile duct cancer); stenosis of the common hepatic (liver) duct often indicates Klatskin tumor (sclerosing tumor of the bile duct). Since biopsies are usually inconclusive, treatment of the patient is begun based on the results of the scans and cholangiogram alone. The accuracy and the implications of these assumptions have not been evaluated. To investigate this area, a comparison was made between the preoperative and the final diagnosis in 98 patients who were thought to have a Klatskin tumor prior to surgery. In 68 patients (69 percent) the final diagnosis was sclerosing cholangiocarcinoma of the bile duct, confirming the preoperative diagnosis. However, 30 patients (31 percent) had other diseases, including 5 cases of papillary duct cancer; 12 gallbladder cancers with invasion into the bile duct; and 5 metastatic cancers that had spread to the bile duct. Seven benign lesions that were initially misdiagnosed included two Mirizzi syndromes, three granulomas, and three cases of benign focal stenosis of unknown origin. These findings suggest that assuming a focal stenosis of the hepatic duct is a Klatskin tumor is not always correct. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Diagnosis, Cancer, Cholestasis, Cancer diagnosis, Diagnosis, Differential, Differential diagnosis, Jaundice, Obstructive

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Histologic findings and prognostic factors in carcinoma of the upper bile duct

Article Abstract:

Thirty-four cancerous tumors surgically removed from the lining of the upper bile duct, which carries bile from the gallbladder to the intestines, were examined microscopically. Three-quarters of the patients with papillary adenocarcinoma survived three years while none of the patients with poorly differentiated adenocarcinoma had survived two years after surgery. Survival rates were poor for patients whose cancer had infiltrated the lining of the bile duct, spread to the lymph nodes, or invaded blood vessels. In patients with papillary adenocarcinoma, none of the tumors had invaded the liver or spread to the lymph nodes, and only a few had infiltrated the lining of the bile duct. In contrast, patients with poorly differentiated adenocarcinoma often had cancer spread to the liver, lymph nodes, and lining of the bile duct. Seventy-five percent of patients with papillary adenocarcinoma, but only 22 percent of patients with poorly differentiated adenocarcinoma, were cured by surgery. The type of cancer, as revealed by microscopic examination, strongly influences the prognosis of patients with cancer of the lining of the upper bile duct and can be used to determine the extent of this tumor.

Adenocarcinoma

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