Postoperative recurrence of an IPMN of the pancreas with a fistula to the stomach

We report on a case of a 74 year old man who was diagnosed with a recurrence of non-invasive carcinoma of intraductal papillary mucinous neoplasm (non-invasive IPMN) by postoperative gastroscopy (GS). A pylorus preserving pancreatico duodenectomy for IPMN in the pancreatic head was performed. A histopathological study revealed non-invasive adenocarcinoma. At first,the local recurrence of the tumor around the superior mesenteric artery circumference was diagnosed and disappeared with gemcitabine. Later,the GS showed the elevated lesion with mucin hypersecretion in the remnant stomach. The lesion had a central dip and a fistula common to the pancreas was confirmed on fisterography. We diagnosed a recurrence of IPMN and administered chemotherapy again. However,he died of his original illness. There are no reports of postoperative recurrence of IPMN checked by GS. It should be remembered that the elevated lesion of the remnant stomach is considered as one of the recurrent patterns of IPMN.

Monitoring salivary amylase activity is useful for providing timely analgesia under sedation

AIM:To detect the criteria and cause of elevated salivary amylase activity(sAMY)in patients undergoing endoscopic submucosal dissection(ESD)under sedation.METHODS:A total of 41 patients with early gastric cancer removed via ESD under deep sedation(DS)were enrolled.The perioperative sAMY,which was shown as sympathetic excitements(SE),was measured.The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level(IR,%)≥100%(twice the actual value)was assumed as the moment when the patient received SE.Among the 41 patients,we focused on 14 patients who exhibited an IR≥100% at any time that was associated with sAMY elevation during ESD(H-group)and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level.If a patient demonstrated an elevated sAMY level above twice the baseline level,the endoscopic procedure was immediately stopped.In the impossible case of discontinuance,analgesic medicines were administered.This study was performed prospectively.RESULTS:A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group.The baseline level of sAMY significantly increased in association with an IR of>100% at 5 min,with a significant difference(IR immediately before elevation/IR at elevation of sAMY=8.72±173/958±1391%,P<0.001).However,effective intervention decreased the elevated sAMY level immediately within only 5 min,with a significant difference(IR at sAMY elevation/immediately after intervention=958±1391/476±1031,P<0.001).The bispectral indices,systolic blood pressure and pulse rates,which were measured at the same time,remained stable throughout the ESD.Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes.Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level,independent of body movement.CONCLUSION:By detecting twice the actual sAMY based on the preoperative level,the release of the gastric wall tension or the administration of analgesic agents should be considered.