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At least 343 records · Page 19Linked to original sources
PubMed2006

Management of ampullary lesions.

Adenomatous lesions of the ampulla of Vater are relatively rare neoplasms that raise many questions regarding standard management. Adenocarcinoma often will be found in ampullary lesions and should be treated by pancreaticoduodenectomy (PD). Benign-appearing adenomas may be treated by PD, transduodenal ampullectomy (AMP), or endoscopic ampullectomy (EA). AMP and EA have decreased morbidity and mortality compared with PD but are limited by concerns for appropriate resection margins, high recurrence rates, and the need for surveillance endoscopy or additional procedures. Preoperative endoscopic biopsies should be obtained to identify carcinoma, but they have high false-negative rates and cannot be relied upon to rule out malignancy. Intraoperative frozen section evaluation should be requested routinely during AMP, with conversion to PD if carcinoma is demonstrated. The gold standard management of benign adenomas has not been clarified, but the goal for all treatment modalities is complete resection. Patients with familial adenomatous polyposis may be exceptions to this, and routine surveillance endoscopy and biopsy with selective resection have been advocated by some as an alternative to complete resection. Adjuvant chemoradiation has a very limited role in the treatment of ampullary carcinoma and ideally should be offered in the setting of a clinical trial. Metastatic and locally advanced, unresectable lesions may be palliated by surgical or endoscopic bypass, as well as by celiac plexus blockade.

Journal Article↗
PubMed1998

Effects of biliary tract pressure on dynamics of the Oddi's sphincter and its nerve mechanism.

In order to explore the effect of biliary tract pressure on Oddi's sphincter and the mechanism of development of high pressure of biliary tract during acute obstructive and suppurative cholangitis (AOSC), house rabbits were used to establish model of high biliary pressure in acute biliary duct caecus. It was observed that when the pressure of the acute biliary tract was increased to 8 kPa, the electric activity of Oddi's sphincter was obviously enhanced, the pressure of Oddioes sphincter increased remarkably (P < 0.05), and even constant spasm appeared with accompanying increase of discharge frequency of the right greater splanchnic nerves (P < 0.05) and progressive decrease of mean arterial pressure. However, when lidocaine of 0.6% was used to block the right celiac plexus, no above-mentioned reaction happened when the biliary tract pressure was increased again. The results indicated that the acute biliary tract obstruction might induce the contraction or spasm of Oddi's sphincter and bring about a vicious cycle. Its mechanism is related to splanchnic nerves reflection and it is one of important factors in the development of AOSC course.

Acute Disease↗
PubMed1992

Urinoma masquerading as pancreatic pseudocyst.

In this article, we report on a patient with recurrent pancreatitis who had received multiple celiac plexus injections for control of pain, and then developed a cystic mass adjacent to the body and tail of the pancreas suggestive of a pancreatic pseudocyst. The cystic mass proved to be a urinoma. The distinction between pancreatic pseudocyst and urinoma was made by CT scan with intravenous contrast utilizing delayed films, which demonstrated leakage of contrast into the cystic structure. This is the first report of a urinoma that resembled a pancreatic pseudocyst.

Cysts↗
PubMed2000

Laparoscopic four-way ultrasound probe with histologic biopsy facility using a flexible tru-cut needle.

Laparoscopic ultrasound (LUS) is widely used in the staging of upper gastrointestinal malignancies. However, accurate N-staging and pathological confirmation of metastases have proved difficult. A new four-way laparoscopic ultrasound probe has been developed. The probe has a biopsy attachment with a needle guide for a flexible tru-cut needle or an aspiration needle. It is now possible to take real-time laparoscopic ultrasound guided biopsies. Furthermore, there is a possibility for interventionel LUS with tumor destruction, celiac plexus neurolysis, and cyst aspiration. In this short technical note, the equipment and the technique are described.

Biopsy, Needle↗
PubMed1999

Cost-benefit analysis of percutaneous interventional radiological procedures in cancer patients.

The goal of this work was to evaluate the costs and benefits of percutaneous interventional radiological procedures (PIRP) in terminal cancer patients, from the perspective of the Radiodiagnostics Department. The subjects were 225 patients who underwent different kinds of treatments, such as placement of endovenous or urinary stents, percutaneous gastrostomy, alcoholization of metastatic disease, celiac plexus block, tumor embolization, and inferior vena caval filter. We retrospectively analyzed the consequences in terms of survival, quality of life and cost ratios and found that this study fully justifies the use of interventional radiology in palliative oncology: 60% and 40% of the patients, respectively, were still alive at 1 month and 3 months; the additional cost of PIRP procedures is low (< 12%) compared with the total cost of hospitalization.

Cost-Benefit Analysis↗
PubMed2005

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB): past, present, and future.

Endoscopic ultrasound (EUS) is a combination of endoscopy and intraluminal ultrasonography. EUS also enables ultrasonographic images of high resolution to be obtained. However, whether a lesion is malignant or benign cannot be diagnosed solely from the findings of EUS. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was developed to enhance the diagnostic capabilities of EUS by providing additional pathological findings. Though more than 10 years have passed since EUS-FNAB was first used for pancreatic disease, EUS FNAB has not been widely accepted in Japan. This may be due to the technical difficulties, relatively low sensitivity for the detection of malignancies, and Japanese gastroenterologists' and surgeons' inherent conservative way of thinking. We describe here a short history of EUS-FNAB, with details of technical tips, current indications and contraindications, diagnostic accuracy, and complications. The clinical utility of EUS-FNAB has been gradually understood and EUS-FNAB procedures have been increasing in number in Japan. So in the near future, EUS followed by EUS-FNAB will be routinely performed in the same manner as gastrointestinal endoscopy, followed by biopsy under direct vision. Also, therapeutic EUS procedures, such as EUS-guided celiac plexus neurolysis, pancreatic tumor ablation, drainage of pancreatic pseudocysts, and the development of an anastomosis may become feasible as less invasive and safer techniques than those used at present.

Biopsy, Fine-Needle↗
PubMed2003

Medical therapy for chronic pancreatitis pain.

Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.

Abdominal Pain↗
PubMed2004

AIDS Cholangiopathy.

AIDS is an advanced disease with systemic and infectious complications that can be fatal. When a patient with AIDS presents with right upper quadrant or midepigastric pain, cholestasis, and symptoms of cholangitis, AIDS cholangiopathy should be suspected and appropriate diagnostic and therapeutic interventions should be initiated. Opportunistic infections such as Cryptosporidium and cytomegalovirus are the most common cause of AIDS cholangiopathy. Four distinct cholangiographic abnormalities have been demonstrated by endoscopic retrograde cholangiopancreatography, the most common being papillary stenosis with sclerosing cholangitis. Antimicrobial therapy is often ineffective. Highly active antiretroviral therapy may enhance immune function and offers the best medical therapy to clear the opportunistic infections. Ursodeoxycholic acid has a limited benefit in patients with sclerosing cholangitis and cholestasis. Endoscopic sphincterotomy has been shown to relieve pain and biliary obstruction in patients with papillary stenosis. Balloon dilation of strictures and stent placement decompress the biliary system and may be helpful. Cholecystectomy is recommended to treat acalculous cholecystitis, and celiac plexus block may be offered to patients with terminal disease and intractable abdominal pain.

Journal Article↗
PubMed1984

Palliative surgery for unresectable carcinoma of the head of the pancreas, ampulla, and distal end of the common bile duct in Japan. A statistical review.

To elucidate the approximate present status of palliative surgery for unresectable carcinoma of the head of the pancreas, ampulla, and distal end of the common bile duct in Japan, surgical methods in 151 institutions were collected and analyzed. Biliary drainage alone was performed in 144 institutions (95 percent) and in 80 of them, cholecystectomy and choledochojejunostomy with a Roux-Y procedure was adopted. Gastric bypass with biliary drainage was routinely performed in 13 institutions (8.7 percent), whereas in 62 institution (41.3 percent), combined biliary and gastric drainage operations were performed as the primary procedures in selected cases. In over half the institutions, neither gastrectomy nor vagotomy was provided. Some means to alleviate the pain caused by tumor invasion were performed in about a third of the institutions (49), and about 80 percent of them added some manipulations of the celiac plexus.

Common Bile Duct Neoplasms↗
PubMed1984

Intrathecal morphine for pelvic and sacral pain caused by cancer.

Ten patients underwent placement of a lumbar subarachnoid catheter attached to a subcutaneous reservoir allowing daily injection of intrathecal morphine sulfate by family members. Sacral and pelvic pain were fairly well controlled. Neck and leg pain and pain mediated by the celiac plexus were not as well controlled by the intrathecal injection of morphine. The only significant complication was collection of cerebrospinal fluid around three reservoirs. Using this technique, narcotic concentration and frequency of administration can be easily altered to provide a safe but effective dose. Lumbar administration appears to block pain from lumbar and sacral dermatomes without the sedating and mood-altering effects of systemic narcotics.

Adult↗
PubMed1991

Viscerotopic representation of preganglionic efferent vagus nerve in the brainstem of the rat: a Fluoro-Gold study.

To investigate the viscerotopic distribution of the cells of origin of preganglionic vagus nerve in rats, Fluoro-Gold was injected into various visceral tissues. After injections into the gastroesophageal junction and the gastric corpus, labelled cells were localized in the medial half of the dorsal motor nucleus of the vagus (dmnX). Cells in the nucleus ambiguous (nA) were also labelled after injections into the gastroesophageal junction. After injections into the pancreatic head and the celiac plexus, labelled cells were located bilaterally in the lateral part of the caudal dmnX. In the rostral dmnX, however, the pancreatic head was represented in the medial segment. After injections into the lung, duodenum, liver and ascending colon, no labelling was observed in the brainstem.

Adhesives↗
PubMed1993

CT-guided neurolytic splanchnic nerve block with alcohol.

Over a 3-year period, neurolytic abdominal visceral sympathectomy was performed bilaterally with 15 ml of alcohol solution (14 ml of alcohol and 1 ml of contrast material) through each needle under CT guidance to relieve upper abdominal or back pain in 27 cancer patients. Using the CT monitor, our intention was to achieve splanchnic nerve neurolysis rather than celiac plexus neurolysis. After determining the trajectory for needle placement on the CT image at the L1 level, the needles were inserted bilaterally with a simple guide apparatus. The needle tips were successfully positioned in the retrocrural space in 48 (83%) of 54 insertions. Pain was substantially relieved in 20 of 21 patients receiving bilateral splanchnic nerve neurolysis. Tissue pressure was significantly higher after alcohol injection when the needle tips were located in the retrocrural space than when they were placed in the anterocrural space. CT images after alcohol injection revealed antero- and posterocrural spread in 11 of 21 patients who received bilateral splanchnic nerve neurolysis. It was speculated that the alcohol spread through the aortic hiatus or gaps of the diaphragmatic crura. No neurologic complications were encountered. It is concluded that CT guided alcohol splanchnic nerve neurolysis is an effective treatment for upper abdominal cancer pain, and that 15 ml of alcohol solution through each needle is enough for splanchnic nerve neurolysis.

Aged↗
PubMed2006

Management of pain in small duct chronic pancreatitis.

Small duct chronic pancreatitis (CP) is defined by a nondilated main pancreatic duct, and the morphological and clinical features of chronic pancreatitis with pain are the most prominent symptoms. Current treatment strategies are based on pain history and the location and extent of disease. Traditionally, radical pancreatic resectional procedures have been carried out for small duct CP, especially with an associated head mass of uncertain aetiology. Based on the information from five randomized trials, the duodenum-preserving pancreatic head resection and its modifications have proven to provide excellent long-term pain relief and to be superior to more radical operations. Therefore, these procedures can be considered the standard for small duct CP with head dominant disease. The longitudinal V-shaped excision of the ventral pancreas combines extensive drainage and a limited resection and offers good pain relief in diffuse small duct CP. However, long-term results and larger series are awaited for definite conclusions. Thoracoscopic splanchnicectomy and endosonography-guided celiac plexus blocks require controlled trials before their routine use. This article provides an overview about the current and evidence-based pain management in small duct CP.

Chronic Disease↗
PubMed2004

An international survey of the clinical practice of EUS.

BACKGROUND: No comparative information exists regarding clinical variations in EUS practice patterns among American and international endosonographers. METHODS: Eligible attendees of the XIIIth International Symposium on EUS, October 4-6 2002, New York, New York, were asked to complete a 2-page survey questionnaire on clinical practice of EUS. RESULTS: A total of 191 of 391 eligible attendees (48.9%) participated in the survey (110 from the United States, 81 from 30 different countries). The mean age of participants was 40.5 (10.6) years, and 171 (89.5%) were men. A total of 102 endosonographers (53.4%) were in academic practice. The majority (150, 78.5%) also performed ERCP. Seventy-eight (40.8%) had performed EUS for more than 5 years and 21 (11%) for less than 1 year. Only 36 (18.8%) had more than 6 months of dedicated hands-on EUS training, and more than a third of the respondents learned to perform EUS by observing others or they were self-taught. Compared with respondents from the United States, relatively fewer international respondents were performing open-access EUS, pancreatobiliary EUS procedures, and interventions such as EUS-guided FNA and celiac plexus neuralysis. CONCLUSIONS: This survey provides insight into the status of EUS as practiced in the United States and internationally. Although it appears that over the last decade EUS has become disseminated fairly uniformly on a global basis, a lack of consistent training standards and also inadequate opportunities for EUS training remain important areas of concern.

Adult↗
PubMed1994

Treatment of cancer-related pain: when orally administered medications fail.

OBJECTIVE: To summarize the available pain-relieving interventions other than oral medications for cancer-related pain. DESIGN: The pertinent literature is reviewed, and the various options for treating pain in patients with cancer are discussed. MATERIAL AND METHODS: The appropriate situations for use of parenteral administration of opioids, spinal analgesia, neural blockade, and neurosurgical treatment are outlined, and the potential problems and complications associated with these techniques are described. RESULTS: The basic approach to the management of pain in patients with cancer is to begin treatment with less potent analgesic agents early and to progress toward use of more potent pharmaceutical agents, adjuvant drugs, and invasive procedures as needed for alleviation of pain. With parenteral administration of opioids, the dosage can be adjusted rapidly, and therapy can be continued even though a patient may have gastrointestinal dysfunction. A portable ambulatory infusion pump can be used in selected patients. The major advantage of spinal opioid analgesia is the intense analgesia provided with minimal side effects. The potential complications and the availability of treatment alternatives have limited the use of neurolytic blocks, which usually provide only temporary relief of pain. In carefully selected patients with pancreatic or other upper gastrointestinal neoplasms, however, neurolytic celiac plexus and splanchnic nerve blocks are effective. Patients who fail to respond to conservative interventions may be candidates for neurosurgical procedures, such as spinal cord, cortical, or brain-stem stimulation or neuroablative operations (most commonly, cordotomy). CONCLUSION: Cancer-related pain continues to be a major problem, and clinicians should be aware of the availability of effective treatment strategies and techniques. When orally administered medications fail to control pain or cause excessive side effects, patients should be referred to an appropriate specialist or medical center for consideration of other pain-relieving techniques.

Analgesia↗
PubMed2001

Endoscopic ultrasonography in benign pancreatic disease.

It seems that EUS will most likely become the gold standard technique to diagnose chronic pancreatitis not diagnosed on plain radiography, standard transcutaneous sonography, or CT scanning. Because of its low risk and increased sensitivity, it will replace ERCP as a diagnostic test for this condition. Confirmation with cytology may be beneficial for indeterminate cases. EUS will also have an important role in determining the management of cystic lesions in the pancreas. EUS seems to be very effective in determining which cystic lesions have malignant potential. If a cyst appears malignant or produces symptoms, it requires resection and therefore does not require FNA. Prediction of the clinical course for cysts of indeterminate nature requires EUS-guided FNA and analysis of fluid. EUS, although quite accurate in diagnosing CBD stones, has a more limited role in diagnosis and management of stone disease because of current limitations of therapeutic maneuvers, which can be performed at the same time. In general, patients with probable CBD stones or sludge require therapeutic ERCP. Therefore, ERCP is the preferred initial test to diagnose and simultaneously treat these disorders. Patients with a low suspicion for CBD stones, or patients with relative contraindications to ERCP (i.e., pregnancy or bleeding disorders), can be evaluated first with EUS to determine whether further invasive treatment is required. EUS seems to be complementary to therapeutic ERCP for the aspiration and drainage of cysts and pseudocysts. Although celiac plexus nerve blocks using EUS-guided injection of neurolytic agents seems to be more effective than other nerve block techniques, surgical bypass or resection is likely to continue as the primary method of treatment of patients with pain from chronic pancreatitis or those who do not respond to endoscopic stenting when there is a dominant stricture that can be bypassed.

Chronic Disease↗
PubMed2002

Interventional endoscopy, neoadjuvant therapy and the gastroenterologist.

With current treatment, survival of greater than 1 year should be anticipated for many patients with pancreatic cancer. Cure rates (5-year survival) of greater than 10% have been achieved even for unresectable disease. Obstructive jaundice is managed successfully with endoscopic placement of a plastic stent early in the evaluation of a patient with suspected regional pancreatic cancer, and a metal wall stent is reserved for patients with known 1997 AJCC stage IVB carcinoma or nonoperative patients. Relief of biliary obstruction allows improvement in liver function and more time to evaluate tumor stage accurately to determine initial treatment (see Fig. 1). A cost-effective algorithm to determine accurate stage and treatment can start with the size of the mass on initial imaging studies. EUS-guided FNA represents a significant improvement over CT scan-guided FNA to make a tissue diagnosis. Small pancreatic masses that would be resected regardless of whether an FNA is positive or negative require only an EUS evaluation to establish an early resectable stage. Tumors reliably staged as unresectable by nonoperative imaging methods including EUS are treated with chemotherapy with or without concurrent radiotherapy because median survival of these patients is 2 years in some series. Tumors can be resected after neoadjuvant chemoradiotherapy. For chronic pain or gastric outlet obstruction not responding or treatable by chemoradiotherapy, endoscopically guided celiac plexus nerve block and stenting improve the quality of life for patients with pancreatic cancer. A team approach is required to achieve the objectives of improved quality of life, prolonged survival, and possible cure for pancreatic cancer. The optimal combination and sequencing of staging methods, including EUS, specialized CT scan, MR imaging, intraoperative findings, and pathologic evaluations, would improve selection of patients for potential curative resection. Interpretations of disease stage based on each of these methods may overlap but are not identical and are operator dependent. Rather than reliance on any single standard, clinical judgment and communication among the team are paramount to providing optimal care for patients with a pancreatic neoplasm.

Adenocarcinoma↗
PubMed1997

[Locally advanced adenocarcinoma of the pancreas: current therapeutic modalities].

Pancreatic cancer still have bad prognosis. At the time of diagnosis, less than 10% of patients can undergo surgery with an overall 5-year survival rate of less than 2%. For patients with localized pancreatic adenocarcinoma, the combination of radiation therapy and chemotherapy has been shown to control symptoms and to enhance patient survival. This treatment should be proposed to all the patients with good performance status and without icterus. Pain management should be optimized and often need morphinic and co-antalgic (anticonvulsivants, steroids) consumption. The celiac plexus block with alcohol gives an excellent pain relief and should be more frequently used.

Adenocarcinoma↗