review of literature on clinical pancreatology - The Pancreapedia

alcoholics due to increased gut permeability, may trigger overt necroinflammation <strong>of</strong> thepancreas in alcoholics and one that may also play a critical role in progression to chronicpancreatitis (acinar atrophy and fibrosis) via activation <strong>of</strong> pancreatic stellate cells (PSCs).Chronic pancreatitis is a major risk factor for the development <strong>of</strong> pancreatic cancer, which isthe fourth leading cause <strong>of</strong> cancer-related deaths in humans. Increasing attention has beenpaid in recent years to the role <strong>of</strong> the stroma in pancreatic cancer progression. It is now wellestablished that PSCs play a key role in the production <strong>of</strong> cancer stroma and that theyinteract closely with cancer cells to create a tumor facilitatory environment that stimulateslocal tumor growth and distant metastasis. One <strong>review</strong> summarized recent advances in theunderstanding <strong>of</strong> the pathogenesis <strong>of</strong> alcoholic pancreatitis and pancreatic cancer, withparticular reference to the central role played by PSCs in both diseases. An improvedknowledge <strong>of</strong> PSC biology has the potential to provide an insight into pathways that may betherapeutically targeted to inhibit PSC activation, thereby inhibiting the development <strong>of</strong>fibrosis in chronic pancreatitis and interrupting stellate cell-cancer cell interactions so as toretard cancer progression [293].Pancreatic duct stonesAlthough radiopaque pancreatic duct stones can be targeted by extracorporeal shock wavelithotripsy (ESWL) and extracted by ERCP, large and radiolucent stones remain atherapeutic challenge. Four symptomatic patients with large (> 1 cm) radiolucent stonesoccluding the main pancreatic duct that could not be retrieved by standard endoscopicmaneuvers. Pancreatic sphincterotomy followed by balloon dilation <strong>of</strong> the pancreatic orificeto aid retrieval <strong>of</strong> large radiolucent stones occluding the main pancreatic duct was performed.Technical success was defined as the ability to achieve pancreatic duct clearance in oneendoscopic encounter. The procedure was technically successful in all 4 patients. Pancreaticduct clearance was achieved in all 4 patients in 1 endoscopy session with complete symptomrelief at 12-month follow-up. Mild post-ERCP pancreatitis developed in 1 patient, and minorbleeding developed in another patient; both were managed conservatively. It was concludedthat endoscopic balloon dilation <strong>of</strong> the pancreatic orifice after sphincterotomy is a safetechnique that facilitates the removal <strong>of</strong> large radiolucent stones from the main pancreaticduct in [294].Duodenal dystrophyOne paper presented the morphological characteristics <strong>of</strong> intraoperative specimens takenfrom patients with duodenal dystrophy characterized by cystic changes in the elements <strong>of</strong>pancreatic heterotopic tissue in the duodenal wall. It is emphasized that the development <strong>of</strong>cysts may be associated with that <strong>of</strong> an inflammatory process in the pancreatic heterotopictissue in young persons or may be caused by chronic alcoholic pancreatitis [295].On the basis <strong>of</strong> a <strong>review</strong> <strong>of</strong> the <strong>literature</strong> and description <strong>of</strong> a clinical case, the aim <strong>of</strong> onepaper was to evaluate the role <strong>of</strong> pancreaticoduodenectomy as the primary therapeuticchoice in a rare, serious condition such as cystic dystrophy <strong>of</strong> the duodenal wall inheterotopic pancreas. The diagnosis is difficult because <strong>of</strong> the non-specific clinicalmanifestations, and radiological and endoscopic imaging are decisive. Computedtomography and magnetic resonance are very useful for demonstrating the presence <strong>of</strong> cystsin a thickened duodenal wall but endoscopic ultrasonography is the most useful imagingexamination. The choice <strong>of</strong> therapeutic option is still debated. Although some authors haveproposed a medical approach using octreotide or endoscopic treatment for selected patients,pancreaticoduodenectomy is usually proposed for symptomatic patients. When surgery isneeded, pancreaticoduodenectomy should be preferred, reserving by-pass procedures for