Homeoprotein hhex-induced conversion of intestinal to ventral pancreatic precursors results in the formation of giant pancreata in Xenopus embryos

Liver and ventral pancreas develop from neighboring territories within the endoderm of gastrulae. ventral pancreatic precursor 1 (vpp1) is a marker gene that is differentially expressed in a cell population within the dorsal endoderm in a pattern partially overlapping with that of hematopoietically expressed homeobox (hhex) during gastrulation. In tail bud embryos, vpp1 expression specifically demarcates two ventral pancreatic buds, whereas hhex expression is mainly restricted to the liver diverticulum. Ectopic expression of a critical dose of hhex led to a greatly enlarged vpp1-positive domain and, subsequently, to the formation of giant ventral pancreata, putatively by conversion of intestinal to ventral pancreatic precursor cells. Conversely, antisense morpholino oligonucleotide-mediated knockdown of hhex resulted in a down-regulation of vpp1 expression and a specific loss of the ventral pancreas. Furthermore, titration of hhex with a dexamethasone-inducible hhex-VP16GR fusion construct suggested that endogenous hhex activity during gastrulation is essential for the formation of ventral pancreatic progenitor cells. These observations suggest that, beyond its role in liver development, hhex controls specification of a vpp1-positive endodermal cell population during gastrulation that is required for the formation of the ventral pancreas.     

Vertebral osteomyelitis due to infection with nontuberculous Mycobacterium species after blunt trauma to the back: 3 examples of the principle of locus minoris resistentiae.

Osteomyelitis due to infection with nontuberculous mycobacterial organisms is unusual, especially in the absence of nonpenetrating trauma. We describe 3 patients with vertebral osteomyelitis due to infection with nontuberculous mycobacterial organisms that was precipitated by blunt trauma; these 3 unusual cases illustrate the principle of locus minoris resistentiae.     

Psychosomatic and psychopathological aspects in dental-orofacial medicine with special reference to old age

The mouth is frequently affected by psychosomatic manifestations and communicative intimacy. Together with the age-related changes to central nervous system and organic changes in the chewing mechanism and oropharynx, these changes represent a failure of psychodynamic coping. With advanced age a "tempora minoris resistentiae" associates with a "locus minoris resistentiae". This etiopathogenetic constellation triggers psychosomatic conversion phenomena and "circumscribed" hypochondrias, as well as dysmorphobobic delusional developments, and hypochondric cyclothymic depressions. When there is an organic, nerval accentuation of these changes the symptoms often became chronic. It must be pointed out that a mimic disease often resembles a monosymptomatic masked depression, frequently resulting in false diagnosis. Contextual to anthropologic-psychologic dimensions of pain sensation, this work finally deals with the psychophysiologic complementary model of orofacial pain-dysfunction syndrome.     

Ventral pancreatectomy associated with segmental duodenectomy including the major papilla

During embryonic development, the head of the pancreas comprises ventral and dorsal primordia. The embryological fusion plane between the ventral and dorsal primordia reportedly separates the adult pancreas into the ventral and dorsal pancreas. The duct of Wirsung drains the ventral pancreas and terminates in the major papilla, while the duct of Santorini drains the dorsal pancreas and terminates in the minor papilla. However, complete resection of the ventral pancreas is difficult and impractical because the lower bile duct is buried in ventral pancreatic parenchyma and resection may lead to postoperative ischemic necrosis of the duodenum, particularly around the major papilla. We have therefore performed ventral pancreatectomy associated with segmental duodenectomy including the major papilla in 3 cases with intraductal papillary mucinous neoplasm that involved only the duct of Wirsung.     

A Histopathological Study on Ventral and Dorsal Pancreas Tissues in Patients with Pancreas Divisum

Abstract: Five cases of pancreas divisum, clinically diagnosed by endoscopic retrograde choledochopancreatography (ERCP), were studied histopathologically. They consisted of four biopsied cases and one patient who underwent pancreatoduodenectomy under the diagnosis of a suspected pancreatic carcinoma. Fibrosis was found in three out of the five cases, two cases with fibrosis in the dorsal pancreas and one in the ventral pancreas. In the two dorsal fibrosis pancreas cases, fibrosis was distributed in the intra- and interlobular areas and was accompanied by atrophy or disappearance of the acinar cells. These findings were compatible with chronic obstructive pancreatitis, distal to a stricture of the pancreatic duct. In the one ventral fibrosis pancreas case, i. e., the pancreatoduodenectomized case, fibrosis was distributed mainly in the interlobular area associated with hemosiderin deposition. Hemosiderin deposition was also observed in inflammatory foci at the posterior aspect of the ventral pancreas. Hence, such interlobular fibrosis developed in relation to the inflammatory foci, and was not caused by pancreas divisum. Therefore, in pancreas divisum, abnormal findings were observed in the dorsal pancreas tissue, and they were compatible with chronic obstructive pancreatitis. (Dig Endosc 1994; 6 : 74–79)     

A Case Report of Anomalous Pancreaticobiliary Duct Connection with Choledocholithiasis and Acute Pancreatitis

Abstract: A 25-year-old man was admitted to hospital with epigastric pain. He had had a history of episodic abdominal pain since early childhood. An anomalous pancreaticobiliary duct connection was seen by endoscopic retrograde cholangiopancreatography. In many cases, this type of abnormality is caused by an anomaly in the ventral pancreas. In this case, however, the common bile duct, with calculi, was joined to the pancreatic duct which did not arise from the ventral pancreas but from the dorsal pancreas. The pancreatic duct arising from the ventral pancreas was absent in this case. The patient underwent a prophylactic cholecystectomy, a transduodenal sphincteroplasty, a choledocholithotomy, a partial resection of the common bile duct, and a hepaticojejunostomy, performed by a Roux-en-Y anastomosis. His postoperative recovery was satisfactory. An anomalous pancreatobiliary duct connection allows pancreatic juices and bile to mix. This is considered to be an etiological factor in pancreatitis and choledocholithiasis.     

Intraductal papillary-mucinous adenoma developed in the ventral pancreas in a patient with pancreas divisum

A 34-year-old man was admitted to our hospital with the chief complaints of back pain and epigastralgia. The physical examinations on admission disclosed no abdominal tumor. The serum concentration of total bilirubin was 1.4?mg/dl. The serum elastase-1 level was elevated to 526?ng/dl. Computed tomography showed a cystic lesion, 1?cm in diameter, in the head of the pancreas, without dilatation of the main pancreatic duct. Endoscopic retrograde cholangiopancreatography via the papilla of Vater and the accessory papilla revealed an enlarged ventral pancreatic duct and pancreas divisum. The preoperative diagnosis was mucin-producing pancreatic tumor in the ventral pancreas of a patient with pancreas divisum. A pylorus-preserving pancreatoduodenectomy was performed. The gross findings of the cut surface of the resected specimen disclosed mural nodules in the dilated duct of the ventral pancreas. A histological examination of the mural nodules in the ventral pancreas revealed mucin and intraductal papillary adenoma. Benign tumors associated with pancreas divisum are rare; to the best of our knowledge, only three cases have been reported. Although in these three patients the tumor developed in the dorsal pancreas, the tumor developed in the ventral pancreas in our patient.     

Pott's disease occurring after percutaneous vertebroplasty: an unusual illustration of the principle of locus minoris resistentiae

We report an unusual case of a multifocal tuberculous spondylitis that has been diagnosed after several percutaneous vertebroplasty. This event supports the theory that surgical or radiological intervention such as a percutaneous vertebroplasty should be considered as an intentional traumatism that can lead to the initiation of a locus minoris resistentiae, probably by reactivating an inactive tuberculous lesion.     

Minor papilla cannulation and dorsal ductography in pancreas divisum

Until recently, pancreas divisum represented a major technical barrier to a complete evaluation of pancreatic ductal anatomy. Technical refinements have now made it possible to achieve minor papilla cannulation and dorsal ductography in more than 90% of attempts. In 120 consecutive dorsal ductograms, structural pathology was demonstrated in 36 subjects (30%): chronic pancreatitis in 23, pancreatic stones in 10, pseudocyst(s) in 4, ductal "cut-off" in 7, pancreatic cancer in 3, and partial agenesis in 1 (some patients had more than one finding). For patients in whom alcohol abuse was excluded, ductal pathology was present in 25%. Abnormal ventral ductograms were present in only 8% of cases, demonstrating that dorsal ductography has an appreciable additional diagnostic yield. When the clinical situation indicates the need for pancreatography, minor papilla cannulation should be performed if major papilla cannulation fails or reveals only the ventral pancreatogram of pancreas divisum.     

Morphological Study of Pancreas Divisum in Niigata Using ERCP

Abstract: The morphological characteristics and incidence of pancreas divisum (PD) in Niigata were investigated by studying 16,646 cases diagnosed by ERCP. These cases had been patients in 16 hospitals located in Niigata prefecture. PD was found in 114 (63 cases confirmed, 51 cases unconfirmed) of these 16,646 cases (0.68%). An unconfirmed case was defined as being a patient in whom only the short ventral pancreatic duct was visible through the main papilla, and the confirmed cases were classified into the 3 types according to the ductal systems of the dorsal and ventral pancreas. The classification of these 3 types was as follows. Type 1: Nonfusion between the ventral (VPD) and dorsal pancreatic ducts (DPD), which was visualized through the main papilla (MP) and the accessory papilla (AP), separately. Type 2: Only DPD was visualized through the AP. In spite of the cannulation of the MP, the VPD was not demonstrated. Type 3: Miscellaneous cases. The frequency of Type 1, Type 2, and Type 3 was 58.7% (37 cases), 28.6% (18 cases), and 12.7% (8 cases), respectively. Type 3 consisted of two subtypes. One (7 cases) was regarded as being when the patient had a very fine communicating branch between VPD and DPD, whether an obvious communicating branch could be detected or not by ERCP. The other subtype (only one case) showed very strange findings in which through the AP a short pancreatic duct distributed to the head of the pancreas and to the uncinate process was visualized and in which through the MP a long pancreatic duct to the tail was demonstrated, separately.     

Perforation of jejunal diverticulum with ectopic pancreas

Perforation of jejunal diverticulum is a rare complication. Here, we report a case of jejunal diverticulum penetration with surrounding ectopic pancreas. An 83-year-old female patient was admitted to our department with acute onset of severe abdominal pain lasting for half a day. Abdominal computed tomography showed outpouching of the small intestine that contained air/fluid, with multiple surrounding air bubbles in the mesentery of the small intestine. She was diagnosed with penetration of the small intestine, and an emergency laparotomy was indicated. The penetrated jejunal diverticulum was identified ~20-cm distal to the ligament of Treitz. Partial resection of the jejunum was performed, and her postoperative course was uneventful. The pathological findings confirmed diverticulum penetration into the mesentery and severe inflammation at the site, with surrounding ectopic pancreas. Furthermore, the pancreatic ducts were opened through the penetrated diverticulum. This rare case shows that the ectopic pancreas might have caused penetration of jejunal diverticulum owing to the pancreatic duct opening through the diverticulum.     

Annular pancreas with high confluence of pancreaticobiliary ducts in an adult

A man in his 80's was admitted complaining of epigastralgia, and acute pancreatitis was diagnosed. Abdominal CT and MRI showed enlargement of the pancreatic head encircling the descending part of the duodenum and a duodenal diverticulum. Endoscopic retrograde cholangio-pancreatography (ERCP) revealed annular pancreas and high confluence of pancreaticobiliary ducts. Annular pancreas had been reported to have associated with a broad spectrum of pancreatic anomalies, few cases of annular pancreas coexisting with high confluence of pancreaticobiliary ducts, or pancreaticobiliary maljunction have been reported. Combination of both anomalies was interesting from the view point of embryology. We report a rare case of annular pancreas with high confluence of pancreaticobiliary ducts.     

Giant colonic diverticulum,clinical presentation,diagnosis and treatment: Systematic review of 166 cases

AIM: To investigate the clinical presentation,diagnosis,and treatment of giant colonic diverticulum(GCD,by means of a complete and updated literature review).GCD is a rare manifestation of diverticular disease of the colon.Less than 200 studies on GCD were published in the literature,predominantly case reports or small patient series.METHODS: A systematic review of the literature was performed using the Embase and PubM ed databases toidentify all the GCD studies.The following MESH search headings were used: "giant colonic diverticulum"; "giant sigmoid diverticulum".The "related articles" function was used to broaden the search,and all of the abstracts,studies,and citations were reviewed by two authors.The following outcomes were of interest: the disease and patient characteristics,study design,indications for surgery,type of operation,and postoperative outcomes.Additionally,a subgroup analysis of cases treated in the last 5 years was performed to show the current trends in the treatment of GCD.A GCD case in an elderly patient treated in our department by a sigmoidectomy with primary anastomosis and a diverting ileostomy is presented as a typical example of the disease.RESULTS: In total,166 GCD cases in 138 studies were identified in the literature.The most common clinical presentation was abdominal pain,which occurred in 69% of the cases.Among the physical signs,an abdominal mass was detected in 48% of the cases,whereas 20% of the patients presented with fever and 14% with abdominal tenderness.Diagnosis is based predominantly on abdominal computed tomography.The most frequent treatment was colic resection with en-bloc resection of the diverticulum,performed in 57.2% of cases,whereas Hartmann's procedure was followed in 11.4% of the cases and a diverticulectomy in 10.2%.An analysis of sixteen cases reported in the last 5 years showed that the majority of patients were treated with sigmoidectomy and en-bloc resection of the diverticulum; the postoperative mortality was null,morbidity was very low(1 patient was hospitalized in the intensive care unit for postoperative hypotension),and the patients were discharged 4-14 d after surgery.CONCLUSION: Giant colonic diverticulum is a rare manifestation of diverticular diseases.Surgical treatment,consisting predominantly of colonic resection with en bloc resection of the diverticulum,is thepreferred option for GCD and guarantees excellent results.     

Intestinal obstruction caused by omphalomesenteric duct remnant: usefulness of laparoscopy.

The anomalies related to omphalomesenteric duct remnant constitute an uncommon cause of intestinal obstruction, of which Meckel"s diverticulum and its variants represent the most important clinical presentation. In most cases they are asymptomatic and usually affect young patients. When symptomatic, they usually present episodes of gastrointestinal bleeding or acute abdomen syndromes caused by strangulation of intestinal loops as a result of fibrous intraabdominal remnants or inflammation produced by the diverticulum. In most cases, the unexpected presence of these alterations makes intraoperative diagnosis necessary. Treatment is surgical and consists in exeresis of the diverticulum or the fibrous band causing the clinical picture. We report two cases of persistence of the vitelline duct resolved by laparoscopic approach.     

症状性十二指肠憩室的临床特点分析

目的探讨症状性十二指肠憩室病例的临床、内镜及影像学表现、治疗方法,并分析其临床意义。方法回顾性分析武汉大学人民医院2008年1月-2011年1月症状性十二指肠憩室病例,分析其临床表现、内镜及影像学表现、治疗方法等临床资料。结果共35例患者诊断为症状性十二指肠憩室,其中腹痛者15例、呕吐者2例、呕血或黑便者12例、黄疸患者6例,腹痛患者4例有反复发作史、黑便患者2例。所有病例中并发十二指肠憩室炎5例、急性胰腺炎1例、胆总管结石6例、肠梗阻1例、上消化道出血12例。35例症状性十二指肠憩室分别位于十二指肠球部9例、降部22例、水平部4例,其中单发25例、多发10例。经由消化道钡餐检查发现十二指肠憩室13例、胃镜9例、经内镜逆行胰胆管造影(endoscopic retrograde cholangio-pancreatography,ERCP)7例,双气囊小肠镜2例、腹部CT检查4例。结论十二指肠憩室症状不典型,对于不明原因上腹痛、消化道出血及胰腺炎患者,需考虑此病因,可行相关检查明确,治疗上除内科保守外还可以进行内镜下或者手术治疗。     

A new embryologic hypothesis of annular pancreas

Annular pancreas is a developmental anomaly of the pancreas. There are two major hypotheses concerning development of the annular pancreas from the ventral pancreatic anlage; adhesion of the right ventral anlage to the duodenal wall (Lecco's theory), and persistence of the left ventral anlage (Baldwin's theory) reported in 1910, but each theory has some problems and can account for only a few types of annular pancreas. We report a new embryologic hypothesis of annular pancreas which can account for the developmental mechanism of three types of arrangement of annular ducts. The tip of the left ventral anlage adheres to the duodenum and stretches to form a ring. Whether the tip is proximal or distal to the bile duct creates several arrangements of the annular duct.     

Prevalence and clinical evolution of isolated ventral pancreatitis in alcoholic chronic pancreatitis

BACKGROUND: The role of pancreas divisum in chronic pancreatitis is controversial. Ductal changes limited to the pancreatic ventral duct (isolated ventral pancreatitis) have only been described as isolated case reports. METHODS: In a cohort of 542 patients with chronic pancreatitis we determined the frequency of ventral chronic pancreatitis among patients with pancreas divisum and analyzed the clinical presentation of 10 patients with isolated ventral alcohol-induced pancreatitis compared with 10 patients with isolated dorsal alcohol-induced pancreatitis and 30 patients with chronic pancreatitis and without pancreas divisum. Magnetic resonance pancreatography under secretin stimulation was used to evaluate the status of the dorsal pancreatic duct in some patients during follow-up. RESULTS: We identified 62 (11.4%) patients with pancreas divisum and 16 (2.9%) patients with incomplete pancreas divisum. The ventral duct was affected by chronic pancreatitis in 74% of these patients. Isolated ventral or dorsal duct alterations were identified in 14% and 26%, respectively, of patients with pancreas divisum. Patients with isolated ventral pancreatitis had pain symptoms similar to those of the two other groups but had no endocrine or exocrine insufficiency on initial presentation. After a mean follow-up of 44 months, 83% of patients studied with isolated ventral pancreatitis developed alterations of the dorsal ductal part of the gland. CONCLUSION: We conclude that isolated ventral alcohol-induced pancreatitis is one of the first manifestations of generalized pancreatic disease where the anatomic factor of pancreas divisum plays only a marginal role.     

An improved technique for accessory papilla cannulation in pancreas divisum

Cannulation of the accessory papilla with dorsal pancreas ductography was accomplished in 13 of 15 consecutive cases of pancreas divisum. When routine cannulation of the main pancreatic papilla fails to produce a pancreatogram or yields only a ventral pancreas, the use of intravenous secretin and a 23-gauge needle catheter is recommended to facilitate accessory duct cannulation.