No abstract

A single institutional experience with endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients was reviewed, focusing on the method of anesthesia, choice of an endoscope, indications, and complications. The medical records of 50 ERCPs performed in 42 infants and children (14 male and 28 female) were reviewed retrospectively. The patients' ages ranged from 57 days to 15 years. Forty-four ERCPs were diagnostic and 6 were therapeutic, including incision of choledochocele, and sphincterotomy and extraction of pancreatic stones. All procedures were successful. The most common indication for ERCP was to evaluate congenital biliary dilatation, in 28 patients (67%). Mild cholangitis occurred as a complication in 1 patient, but was alleviated with medication. A conventional duodenoscope could be used in patients older than 10 years. A pediatric duodenoscope was always used in patients under 1 year of age. Either type was chosen individually for those aged 1 to 10 years depending on the purpose, diagnostic or therapeutic. It is noteworthy that ERCP and/or sphincterotomy in a 1-year-old infant and two 2-year-old children were safely performed with the conventional endoscope. General anesthesia was employed in those younger than 9 years and intravenous sedation and local anesthesia in those older than 11 years. For children aged 9 to 11 years, anesthesia was chosen individually. We concluded that ERCP is a relatively easy and safe technique even for infants and children when performed by skilled hands with an appropriate duodenoscope under suitable anesthesia. The minimum age for use of the conventional duodenoscope may be 1 year.

Adenosquamous carcinoma of the pancreas is a rare variant of pancreatic exocrine carcinoma. We herein report two patients with this entity. One patient was a 60-yr-old Japanese man complaining of a palpable mass, 5.5 cm in the greatest diameter, in the epigastrium. Serum CA 19-9 was increased (2010 U/ml). Ultrasonography and computed tomography showed a mass in the pancreatic tail with central necrosis and invading the posterior wall of the stomach. Angiography showed an encasement of the splenic artery and complete obstruction of the splenic vein. Distal pancreatectomy, splenectomy, and partial resection of the stomach were done. The patient died of uncontrolled bleeding from the duodenal ulcer four months after operation. The other patient was a 73-yr-old man who presented with jaundice. The CA 19-9 was also elevated (354.8 U/ml). Ultrasonography showed a pancreatic head mass of heterogeneous echogeneity and computed tomography demonstrated a cystic mass with an enhanced rim, indicating necrosis in the tumor center. Angiography showed a hypervascular mass in the head of the pancreas. Pylorus-preserving pancreatoduodenectomy was done, but the patient died of multiple liver metastases 10 months after the operation. From our experience with the two patients, the presence of central necrosis in an infiltrative huge pancreatic tumor seems to be suggestive of the diagnosis of adenosquamous carcinoma of the pancreas.

Technical improvements, such as mechanical lithotripsy, stenting or nasobiliary drainage, and wire-guided cannulation, have reduced the risk of complications in endoscopic sphincterotomy. To determine the extent of this reduction in risk, we assessed the medical records of 1352 patients with common bile duct stones in whom the procedure was conducted. Complications examined were: acute cholangitis and pancreatitis. Stone clearance was achieved in 1256 patients (92.8%), with an overall morbidity rate of 7.7% and a mortality rate of 0.15%. One hundred and forty-two patients had stones with a diameter greater than 20mm; 97 of these patients did not undergo lithotripsy. Cholangitis occurred in 10 of these 97 patients (10.3%), whereas, in the 45 patients who underwent lithotripsy, there were no cases of cholangitis (P = 0.02). Stone removal was not immediately accomplished or attempted in 396 patients. In 82 of these patients in whom a stent or a nasobiliary drain was placed in the common bile duct, the incidence of cholangitis was 1.2%, significantly less (P = 0.045) than the incidence of 6.4% in the other 314 patients given no stenting or nasobiliary drain. To overcome difficult cannulation, precut sphincterotomy was conducted in 134 patients and wireguided sphincterotomy, a recently introduced procedure, was conducted in 55 patients. When the precutting technique was used, the incidence of acute pancreatitis was significantly higher (8/134; 6.0%) than that in the patients in whom the standard procedure was conducted, i.e., neither the precut technique nor wire-guided ES was used (23/1218; 1.9%) (P = 0.008). There were no cases of pancreatitis in the 55 patients in whom wire-guided sphincterotomy was performed, although the difference was not statistically significant because of the small number of patients (P = 0.06). Based on these findings, we conclude that improved technologies have led to a significant reduction of complications in endoscopic sphincterotomy. Offprint requests to: M. Tanaka

Adenosquamous carcinoma of the pancreas is a rare variant of pancreatic exocrine carcinoma. We herein report two patients with this entity. One patient was a 60-yr-old Japanese man complaining of a palpable mass, 5.5 cm in the greatest diameter, in the epigastrium. Serum CA 19-9 was increased (2010 U/ml). Ultrasonography and computed tomography showed a mass in the pancreatic tail with central necrosis and invading the posterior wall of the stomach. Angiography showed an encasement of the splenic artery and complete obstruction of the splenic vein. Distal pancreatectomy, splenectomy, and partial resection of the stomach were done. The patient died of uncontrolled bleeding from the duodenal ulcer four months after operation. The other patient was a 73-yr-old man who presented with jaundice. The CA 19-9 was also elevated (354.8 U/ml). Ultrasonography showed a pancreatic head mass of heterogeneous echogeneity and computed tomography demonstrated a cystic mass with an enhanced rim, indicating necrosis in the tumor center. Angiography showed a hypervascular mass in the head of the pancreas. Pylorus-preserving pancreatoduodenectomy was done, but the patient died of multiple liver metastases 10 months after the operation. From our experience with the two patients, the presence of central necrosis in an infiltrative huge pancreatic tumor seems to be suggestive of the diagnosis of adenosquamous carcinoma of the pancreas.