Cases reported "Pancreatic Fistula"

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1/88. Communicating bronchopulmonary pancreatic foregut malformation.

    Bronchopulmonary foregut malformations include intralobar and extralobar pulmonary sequestrations, bronchogenic cysts, and communicating bronchopulmonary foregut malformations (CBPFM). These malformations, formes frustes, originate as developmental abnormalities of ventral foregut budding of the tracheobronchial tree or the gastrointestinal tract. The communication's patency with the parent viscus determines if a contained malformation occurs, or if an abnormal communication persists as a CBPFM. This case demonstrates a unique example of a CBPFM in which the main pancreatic duct communicated with pulmonary parenchyma through a retroperitoneal fistula.
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2/88. Biliopancreatic fistula associated with intraductal papillary-mucinous pancreatic cancer: institutional experience and review of the literature.

    Intraductal papillary-mucinous tumour is clinicopathologically characterized by papillary growth and mucin production within the pancreatic duct system. The category includes a wide range of dysplasia, ranging from adenoma to carcinoma, the latter designated as intraductal papillary-mucinous cancer. In general, the tumor renders a favorable prognosis after complete resection. However, intraductal papillary-mucinous tumor with overt invasion outside the gland has been reported to have a poor prognosis, as is the case with the usual type of duct cell cancer of the pancreas. We experienced two cases of intraductal papillary-mucinous cancer with obstructive jaundice due to impaction of thick mucus protruding from the pancreas via a "spontaneous" biliopancreatic fistula. Preoperative examinations of both patients showed a large intraductal papillary-mucinous tumor in the head of the pancreas with fistula formation between the intrapancreatic portion of the common bile duct and the main pancreatic duct. Histopathological investigation of the two resected specimens suggested that the fistula may not have developed from invasion by papillary or tubular adenocarcinoma, but from compression and destruction of the intercalating tissues by abundant mucinous secretion. The first patient died of peritoneal carcinomatosis with clinicopathologic features of pseudomyxoma peritonei 6 years after surgery. The second patient is alive and has been well for 2 years postoperatively. review of the world literature showed that half of the patients with intraductal papillary-mucinous cancer plus biliopancreatic fistula had no stromal invasion around the fistula, indicating that the fistula might have been caused by mechanical pressure. However, the other half of the cases did have stromal invasion around the fistula. Two-thirds of these cases, including our own patients, had foci of mucinous carcinoma in the stroma around the fistulization, implying that mucinous lakes in the stroma may have served as part of the "waterway" from the pancreatic duct to the bile duct, assisted by increased pressure by mucus production. Since intraductal papillary-mucinous cancer with biliopancreatic fistula has a comparatively favorable prognosis, surgical resection should be considered.
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3/88. Marked effect of octreotide acetate in a case of pancreatic pleural effusion.

    A pancreaticopleural effusion is a rare complication of chronic pancreatitis. fasting, a protease inhibitor, and/or a surgical intervention are generally selected for the treatment of the pancreatic effusion. We reported here the case, in which octreotide acetate was effective for resolving pancreatic effusion. A 67-year-old man was admitted with a massive pleural effusion. This effusion contained a high level of amylase. Endoscopic retrograde pancreatography followed by computed tomography revealed a pancreaticopleural fistula. The pleural effusion was not improved by the treatment of the protease inhibitor with total parenteral nutrition and fasting. A pancreatic stent could not be emplaced because the major pancreatic duct was coiled. Administration of octreotide acetate, a long-acting somatostatin analogue, markedly diminished the effusion and closed the pancreaticopleural fistula. Transient eosinophilia of peripheral blood was seen on admission, but the number of eosinophils decreased after the octreotide therapy and normalised when pleural effusion disappeared. octreotide is one of the effective options for the treatment of pancreatic pleural effusion.
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4/88. Biliopancreatic fistulas complicating pancreatic pseudocysts: a report of three cases demonstrated by endoscopic retrograde cholangiopancreatography.

    Three patients were found to have fistulation of the pancreatic and common bile ducts, complicating chronic pancreatitis in one patient and acute pancreatitis in two patients. Closure of the fistula was achieved with biliary and pancreatic stenting in one patient; the other two patients were treated surgically because endoscopic treatment had failed. The clinical and radiological features of this exceptional complication are presented, with a brief review of the topic.
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5/88. Percutaneous embolization of the distal pancreatic duct to treat intractable pancreatic juice fistula.

    Pseudocysts and post-necrotic collections of the pancreas are sometimes treated by percutaneous drainage. In cases of post-necrotic collection, intractable pancreatic juice fistula is often formed by disruption of the main pancreatic duct in the necrotized region. We radically treated intractable pancreatic juice fistulae by selective cannulation into the distal pancreatic duct via the route for percutaneous drainage of post-necrotic collections to extinguish the exocrine function of the caudal pancreas. We performed this procedure in two patients in whom the major pancreatic duct was damaged at the body of the pancreas, which was extensively necrotic. Although mild symptoms of acute pancreatitis appeared in both patients after the first procedure, they recovered without severe side effects. Neither recurrence of pancreatic juice fistulae nor reduction of the glucose tolerance was caused by removing the exocrine function of the caudal pancreas in either patient 32 and 24 months after treatment, respectively. This method is an effective treatment modality with which to treat intractable pancreatic juice fistulae with damage of the main pancreatic duct.
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6/88. The first histological demonstration of pancreatic oxidative stress in human acute pancreatitis.

    Necrotizing acute pancreatitis is associated with an inflammatory explosion involving numerous pro-inflammatory mediator cascades and oxidative stress. Acinar oxygen free radical production aggravates pancreatic tissue damage, and promotes cellular adhesion molecule upregulation resulting in leukocyte adherence and activation. The cerium capture oxygen free radical histochemistry combined with reflectance confocal laser scanning microscopy allows the "in situ" histological demonstration of oxygen free radical formation in live tissues. Here we present a case report, where oxidative stress is demonstrated on a histological level for the first time in human acute pancreatitis. A 44-year-old male patient suffering from acute exacerbation of his chronic pancreatitis developed a pancreato-pleural fistula with amylase-rich left pleural exudate causing respiratory compromise. Subsequent to an urgent thoracic decompression a distal pancreatectomy and splenectomy was performed with the closure of abdomino-thoracic fistula. The postoperative course was uneventful, except for a transient pancreatico-cutaneous fistula, which healed after conservative treatment. To carry out cerium capture oxygen free radical histochemistry the resected pancreas specimen was readily perfused with cerium-chloride solution through the arteries on the resection surface. frozen sections were cut, E-, p-selectin, ICAM and VCAM were labeled by immunofluorescence. The tumor-free margin of an identically treated pancreas carcinoma specimen served as a control. Intrapancreatic oxidative stress and cellular adhesion molecule expression were detected by confocal laser scanning microscopy. Numerous pancreatic acini and neighboring capillaries showed oxygen free radical-derived cerium-perhy-droxide depositions corresponding to strong local oxidative stress. Acinar cytoplasmic reflectance signals suggested xanthine-oxidase as a source of oxygen free radicals. These areas presented considerably increased endothelial p-selectin expression with adherent, oxygen free radical-producing polymorphonuclear leukocytes displaying pericellular cerium-reflectance. Modest ICAM upregulation was noted, e-selectin and VCAM expression was negligible. The control pancreas specimen showed minimal oxidative stress with weak, focal p-selectin expression. The development of deleterious pancreatic oxidative stress was based on indirect evidence in human acute pancreatitis. To the best of our knowledge this is the first report demonstrating persistent intrapancreatic oxidative stress histologically in human acute pancreatitis. We have noted p-selectin overexpression with a preponderance in the areas of acinar oxidative stress.
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7/88. Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter embolization.

    We report the case of a 56-year-old woman with a presyncopal episode followed by melena. A sentinel clot sign in the pancreatic duct on precontrast computed tomography and the presence of a splenic artery aneurysm on postcontrast computed tomography strongly suggested a fistula between the aneurysm and the duct, as visualized by magnetic resonance imaging. The patient was treated successfully by complete embolization of the splenic artery aneurysm.
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8/88. Preoperative endoscopic pancreatic stenting for safe local pancreatic resection.

    Local pancreatic resection and enucleation have the advantage of preserving pancreatic parenchyma but pancreatic fistula often occurs postoperatively. We describe a case in which preoperative endoscopic pancreatic stenting prevented pancreatic fistula formation following local pancreatic resection. A pancreatic stent seems to prevent leakage from small pancreatic branch ducts not identified or ligated intraoperatively, via the pancreatic decompression effect. The present case demonstrates a novel indication for endoscopic pancreatic stenting.
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9/88. Percutaneous embolization of the pancreatic duct with cyanoacrylate tissue adhesive in disconnected duct syndrome.

    Traditionally, patients with chronic end-pancreatic fistulas caused by pancreatic necrosis have been treated with long-term percutaneous catheter drainage and/or surgical procedures such as resection or open drainage. With surgical treatment, the endocrine and exocrine functions of the removed pancreatic segment are sacrificed. Surgery in this patient population presents additional risks because of the inflammatory changes of pancreatitis and associated venous thromboses. The authors devised a method of percutaneous embolization of the pancreatic duct in a patient with catheter-dependent pancreatic fistula who wished to avoid surgery. The procedure was performed under fluoroscopic guidance with use of a microcatheter and wire system to access the duct, which was embolized with opacified n-butyl cyanoacrylate tissue adhesive. After 1 year of surveillance, the patient remains symptom-free. There has been no need for replacement of the drainage catheter and no further intervention has been performed.
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ranking = 10
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10/88. Placement of self-expanding metallic stents in the pancreatic duct for treatment of obstructive complications of pancreatic cancer.

    BACKGROUND: stents have been placed through malignant pancreatic strictures, mainly to alleviate pain of presumed obstructive origin. Self-expanding metallic stents have major advantages over plastic stents when used for treatment of malignant biliary strictures. However, there are few reports of their use in patients with malignant pancreatic duct strictures, especially those with complications related to ductal obstruction. methods: Self-expanding metallic stents were placed in the pancreatic ducts of 3 patients with obstructive complications of pancreatic cancer: smoldering pancreatitis, a disrupted pancreatic duct with pseudocyst caused by open surgical biopsy, and a disrupted pancreatic duct with fistula and resultant liver abscess. All 3 patients had metallic stents placed concomitantly in the biliary tract; one had enteral stents placed as well. Clinical and pathology records and imaging studies were reviewed retrospectively. OBSERVATIONS: In all cases, there was resolution of the specific clinical problem and reasonable survival (1.5 years in one patient). CONCLUSIONS: The use of self-expanding metallic stents for treatment of certain obstructive complications of pancreatic tumors is feasible and effective.
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ranking = 9
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