False pancreas divisum. Acquired pancreatic duct obstruction simulating the congenital anomaly.

Eight patients with recurrent acute pancreatitis were found by ERCP to have foreshortening of the duct of Wirsung simulating the radiographic appearance of the congenital anomaly pancreas divisum. In contrast to 44 patients with true pancreas divisum, who were predominantly young (mean 32 years), nonalcoholic (42/44), and female (34/44), patients with false pancreas divisum were older (mean 48 years), male (7/8), and alcoholic (5/8). False pancreas divisum is most often an acquired obstructing lesion resulting from irremediable injury to the pancreatic duct during acute pancreatitis, often associated with pseudocyst formation and subsequent healing by scar at the site of duct injury. Appreciation of the radiographic differences between pancreatograms in true and false pancreas divisum and the different findings at operation allow for proper selection of therapy. Whereas accessory papilla sphincteroplasty appears to be effective for recurrent pancreatitis associated with true pancreas divisum, false pancreas divisum requires distal pancreatectomy or pancreaticojejunostomy to overcome the irreversible obstruction of the main pancreatic duct.     

Pancreas divisum and the dominant dorsal duct syndrome

Pancreas divisum, the most frequent congenital malformation of the pancreas, results from the absence of embryologic fusion of the dorsal and ventral pancreatic ducts which keep an autonomy of drainage. The dorsal pancreatic duct is dominant and drains the major part of the pancreatic fluid through a non adapted accessory papilla. The high prevalence of pancreas divisum in patients presenting recurrent acute pancreatitis, the presence of obstructive pancreatitis electively located on the dorsal pancreatic duct and the results of the treatments targeted on the accessory papilla are the arguments pleading for the pathogenic character of the pancreas divisum. Currently, the diagnosis of pancreas divisum is based on magnetic resonance imaging. For symptomatic patients (after exclusion of patients with intestinal functional disorders), results of endoscopic sphincterotomy or surgical sphincteroplasty are favourable in 75% of patients with recurrent acute pancreatitis. They are worse in patients with chronic pain. Surgical sphincteroplasty must be discussed in the same manner as the endoscopic treatment for sometimes avoiding multiplication of the procedures.     

Dorsal duct sphincterotomy is effective long-term treatment of acute pancreatitis associated with pancreas divisum

Nonbiliary, nonalcoholic pancreatic inflammatory disease was investigated by biochemical investigation, ultrasonography, endoscopic retrograde cholangiopancreatography, and secretin tests. Twenty-five consecutive cases were followed up for 12 months to 10 years after treatment of disease associated with pancreas divisum, diagnosed by endoscopic retrograde cholangiopancreatography. Thirteen patients had no recurrence of acute pancreatitis after dorsal duct sphincterotomy alone, during long-term follow-up (mean, 54 months); one patient had recurrent pancreatitis during 33 months after failed sphincterotomy. Eight patients had variable results 12 months to 8 years (mean, 49 months) after dorsal duct sphincterotomy for pancreatic pain syndrome (without amylase elevation), three were pain free, and one had recurrent pancreatitis. For 10 years after dorsal duct sphincterotomy for chronic pancreatitis, one patient had no pain relief; after subtotal pancreatectomy and pancreaticojejunostomy of the dorsal duct, both for chronic pancreatitis, one patient each was pain free and normoglycemic after 54 and 12 months, respectively. Dorsal duct sphincterotomy alone is successful in achieving long-term freedom from recurrence of acute pancreatitis associated with pancreas divisum. Pancreatic pain syndrome is not consistently improved by dorsal duct sphincterotomy. Chronic pancreatitis associated with pancreas divisum should be treated by resection or drainage procedures, not by dorsal duct sphincterotomy.     

Evaluation and treatment of the dominant dorsal duct syndrome (pancreas divisum redefined)

The controversial association of pancreatitis and pancreas divisum was studied in 100 patients (77 women, 23 men, median age 35) with episodic acute pancreatitis (49%) or "pancreatic pain" (51%). Seventy-one had classic pancreas divisum (type 1); 23 had only a dorsal duct with an absent Wirsung's duct (type 2); and 6 had a filamentous connection between the two duct systems (type 3). Accessory papilla sphincteroplasty was performed in 88 patients, with a mean follow-up of 53 months. The orifice was stenotic at the mucosal level in 66 patients. Seventy percent of patients have shown improvement: 85% if the accessory papilla was stenotic, compared with 27% if it was not (p less than 0.0001); and 82% with discrete attacks, compared with 56% with chronic pain (p = 0.002). Judged against intraoperative calibration of accessory papilla orifice diameter, ultrasonography with secretin stimulation was 78% sensitive for accessory papilla stenosis, with 3% false-positive results. Ultrasonography with secretin stimulation was the best predictor of surgical success: positive = 92% success (attacks or pain) versus negative = 40% success (64% with attacks; 21% with pain). There have been seven restenoses with six reoperations. We conclude that (1) pancreas divisum is but one variety of pancreatic anatomy characterized by a dominant dorsal duct and dependence on secretion through the accessory papilla; (2) accessory papilla stenosis appears to be a necessary cofactor to produce a morbid state, whether episodic pancreatitis or pancreatic pain; (3) presentation with pancreatitis and a positive result on the ultrasound-secretin test are the best predictors of successful accessory papilla sphincteroplasty.     

Surgical treatment of pancreas divisum causing chronic pancreatitis: The outcome benefits of duodenum-preserving pancreatic head resection

Pancreas divisum (PD) represents a duct anomaly in the pancreatic head ducts, leading frequently leading to recurrent acute pancreatitis (rAP) or chronic pancreatitis (CP). Based on endoscopic retrograde cholangiopancreatography, pancreas divisum can be found in 1% to 6% of patients with pancreatitis. The correlation of this abnormality with pancreatic disease is an issue of continuing controversy. Because of the underlying duct anomalies and major pathomorphological changes in the pancreatic head, duodenumpreserving pancreatic head resection (DPPHR) offers an option for causal treatment. Thirty-six patients with pancreatitis caused by PD were treated surgically. Thirty patients suffered from CP, 6 from rAP. The mean duration of the disease was 47.5 and 49.8 months, respectively. The age at the time of surgery was 39.2 years in the CPgroup, and 27.6 years in the rAP group. Median hospitalization since diagnosis was 18.8 weeks for CP patients and 24.6 weeks for rAP patients. Previous procedures performed in these patients included endoscopic papillotomy (30%), duct stenting (14%), and surgical treatment (17%). The median preoperative pain score was 8 on a visual analog scale. According to the classification of pancreas divisum, 10 patients demonstrated a complete PD, 25 had a functionally incomplete PD, and 1 had a dorsal duct type. The pain status as well as the endocrine (oral glucose tolerance test) and exocrine (pancreolauryl test) function were evaluated preoperatively and early and late postoperatively with a median follow-up time of 39.3 months. There was no operative-related mortality. The follow-up was 100%; 4 patients died (1 from suicide, 1 from cardiac arrest, and 2 from cancer of the esophagus). Fifty percent of the patients were completely pain-free,31%hada significant reduction of pain with a median pain score of 2 (P < 0.001). Six patients (5 CP, 1 rAP) had further attacks of acute pancreatitis with a need for hospitalization. DPPHR reduced pain and preserved the endocrine function in the majority of patients with pancreas divisum. Therefore, DPPHR is an alternative to other resective or drainage procedures after failure of interventional treatment.     

Surgical treatment of pancreas divisum causing pancreatitis in children

Although controversial, pancreas divisum has been implicated as a cause of acute pancreatitis when there is stenosis of the accessory papilla that drains the duct of Santorini. Over the past 5 years, four children with pancreas divisum and recurrent pancreatitis were successfully treated surgically. The diagnosis was made by endoscopic retrograde cholangiopancreatography (ERCP) in each case. Surgical treatment included sphincteroplasty to the accessory papilla to improve drainage of the duct of Santorini, opening the ampulla of Vater to expose the ostium of the duct of Wirsung to enlarge it, and cholecystectomy.     

Pancreas divisum, pancreatic pseudocyst, and choledochal cyst in an 8-year-old child

An 8-year-old American Indian girl presented with acute pancreatitis. Ultrasonography and computerized tomography (CT) showed two large cystic masses near the head of the pancreas. During 4 weeks of complete bowel rest and total parenteral nutrition, she had multiple exacerbations of pancreatitis without resolution of the cysts. There were no symptoms of biliary ductal obstruction. Endoscopic cholangiopancreatography (ERCP) showed an 8-cm pancreatic pseudocyst, pancreas divisum, and a 10-cm choledochal cyst. The junction of the common bile duct and the pancreatic duct of Wirsung had a normal relationship. She underwent a Roux-en-Y pseudocyst-jejunostomy and an accessory sphincteroplasty. Three months later, a choledochal cyst excision was performed with biliary reconstruction. The patient is well and asymptomatic 1 year later. This case suggests that pancreatic juice reflux into the common bile duct may not be the only etiology of choledochal cyst formation.     

Biliopancreatic reflux—pathophysiology and clinical implications

The common bile duct and the main pancreatic duct open into the duodenum, where they frequently form a common channel. The sphincter of Oddi is located at the distal end of the pancreatic and bile ducts; it regulates the outflow of bile and pancreatic juice. In patients with a pancreaticobiliary maljunction, the action of the sphincter does not functionally affect the junction. Therefore, in these patients, two-way regurgitation (pancreatobiliary and biliopancreatic reflux) occurs. This results in various pathological conditions of the biliary tract and the pancreas. Biliopancreatic reflux could be confirmed by: operative or postoperative T-tube cholangiography; CT combined with drip infusion cholangiography; histological detection of gallbladder cancer cells in the main pancreatic duct; and reflux of bile on the cut surface of the pancreas. Biliopancreatic reflux occurs frequently in patients with a long common channel. Although the true prevalence, degree, and pathophysiology of biliopancreatic reflux remain unclear, biliopancreatic reflux is related to the occurrence of acute pancreatitis. Obstruction of a long common channel easily causes bile flow into the pancreas. Even if no obstruction is present, biliopancreatic reflux can still result in acute pancreatitis in some cases.     

Pancreatic intubation ifn pancreas divisum

AIM: Long-term results of endoscopic pancreatic stenting in pancreas divisum is still debated. The aim of this retrospective study was to evaluate the efficacy of dorsal duct stenting in patients presenting with acute recurrent pancreatitis. PATIENTS AND METHODS: Between 1980 and 1998, among 34 patients presenting with recurrent acute pancreatitis associated with pancreas divisum, 21 were treated by pancreatic stenting during a mean time of 11 months. There were 13 men and eight women (mean age: 50 years). RESULTS: The median follow-up was 50 (range 11-105) months. The number of patients presenting with acute pancreatitis before pancreatic stenting, at the end of stenting and at the end of the follow-up was respectively 21/21 (100%), 2/19 (10%) and 2/18 (11%) (P < 0.01). The number of patients presenting with chronic pain before stenting, at the end of stenting and at the end of the follow-up was respectively 17/21 (80%), 6/19 (31%) and 5/18 (27%) (P = 0.07). The overall morbidity rate was 8/21 patients (38%) including mainly acute pancreatitis (three cases); all but one complication were managed conservatively. CONCLUSION: In patients with pancreas divisum, dorsal duct stenting decreases the rate of recurrent acute pancreatitis but the improvement of chronic pain appears less obvious.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.

Abstract：

Objective To explore the diagnostic methods and reasonable surgical interventions for the chronic obstructive pancreatitis due to the inflammatory lesions at the opening of the pancreatic duct Methods From January 2002 to November 2010 the data of 28 patients who were diagnosed as the chronic obstructive pancreatitis (COP) was retrospectively reviewed. Out of the 28 patients, it was analyzed that the clinical manifestations, diagnostic methods, surgical finding and surgical interventions of the 13 patients who were diagnosed as COP due to the inflammatory lesions at the opening of the pancreatic duct in the exploratory operation accompanying recurrent acute abdominal pain with increased serum amylase and lipase,dilation of entire pancreatic duct on imaging before surgery. The conditions included pain recrudescence,quality of life, pancreatic changes on imaging and the serum amylase and lipase after surgery were recorded.Results All the 13 patients had clinical manifestations of COP. However, 12 patients had different manifestations on imaging from those chronic pancreatitis imaging due to tumors at the duodenal papilla,ampulla or inner pancreatic duct. Via exploratory operation and magnetic resonance cholangiopancreatography (MRCP) , there were short pancreaticobiliary common channel or pancreas divisum existing in most patients. There was no acute abdominal pain with the increased serum amylase and lipase in the 12 patients who receiving the transduodenal mastoid, ampulla and pancreatic ductal opening incision and plasty, the paramastoideus incision and plasty in the visit Conclusions The imaging character of COP due to the inflammatory lesions at the opening of the pancreatic duct is the dilation of the pancreatic duct without the chronic obstruction in the bile duct The patients with short pancreaticobiliary common channel or pancreas divisum easily suffer COP due to the stenosis of the pancreatic ductal opening caused by the duodenal mastoiditis or paramastoiditis. The local plasty surgery to correct the stenosis at the pancreatic ductal opening and improve the drainage of the pancreatic duct is an easy and effective management.     

胰管开口炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗

目的 探讨胰管开口部位炎性病变导致的慢性阻塞性胰腺炎的诊断和外科治疗方式.方法 对我院自2002年1月至2010年11月收治的28例慢性阻塞性胰腺炎患者的临床资料进行回顾性总结.其中13例患者血清淀粉酶和脂肪酶升高伴有反复急性腹痛,经影像学检查显示胰管全程扩张改变,外科探查明确诊断为胰管开口部位炎性病变导致的慢性阻塞性胰腺炎.对此13例患者的临床表现、诊断方法、手术探查发现和治疗方法进行分析,并对术后的状况包括疼痛复发、生活质量、胰腺的影像学变化和血清胰腺酶学进行随访观察.结果 13例患者均具有典型的慢性阻塞性胰腺炎的临床表现,但12例患者的影像学表现有别于十二指肠乳突、壶腹或胰腺导管内肿瘤导致的慢性阻塞性胰腺炎的图像特征,手术探查和影像学揭示多数患者的胆胰共同通道过短或存在胰腺分裂畸形,对12例患者实施十二指肠乳突、壶腹及胰管开口切开成形术或副乳突切开成形术,术后随访结果显示均未再伴有胰腺酶学升高的急性腹痛发作.结论 以胰管扩张为主而不伴有胆管慢性梗阻是胰管开口炎性病变导致的慢性阻塞性胰腺炎的影像学特征,十二指肠乳突炎症或副乳突炎症时容易在过短的胆胰共同通道或胰腺分裂畸形的患者中引发胰管开口的狭窄而发生慢性阻塞性胰腺炎,纠正胰管开口狭窄、改善胰管引流的局部成形术是简单、有效的治疗方法.     

Surgical management of pancreas divisum

Pancreas divisum is a congenital anatomic variant characterized by nonunion of dorsal and ventral pancreatic ducts in an otherwise fused pancreas. Of 21 patients with divisum documented by endoscopic retrograde cholangiopancreatography, 6 (28 percent) were found to have no reason other than divisum to account for multiple attacks of pancreatitis. Cholelithiasis was present in one patient, who remains free of recurrent pancreatitis after cholecystectomy only. The remaining five patients underwent surgical treatment directed at pancreas divisum in the belief that stenosis of the duct of Santorini at the entrance into the duodenum is responsible for recurrent attacks of pancreatitis. Four of five have done well with follow-up of 12, 13, 18 and 28 months. Successful sphincteroplasty of the duct of Santorini appears to prevent recurrent attacks of pancreatitis due to pancreas divisum. Pancreaticojejunostomy is reserved for those with markedly dilated ducts secondary to chronic pancreatitis.     

Pancreatitis and pancreas divisum: aetiological and surgical considerations

It has been suggested that acute pancreatitis occurs more commonly in patients with pancreas divisum and that these patients may respond to surgery aimed at improving pancreatic ductal drainage. We have studied the incidence of pancreas divisum in patients referred for endoscopic retrograde cholangio pancreatography (ERCP) and the results of surgical sphincteroplasty in a separate series of such patients. Twenty-three patients with pancreas divisum were identified among 336 successful pancreatograms (Group A), an incidence of 6.8%. The incidence of pancreas divisum in patients having ERCP for documented pancreatitis was 13% (11 of 86) compared with 4.8% (12 of 250) in those having ERCP for other indications. This difference was statistically significant (P less than 0.05). However, pancreas divisum was not the sole risk factor for pancreatitis in the majority of our patients; most also had one of the commonly recognized causes for their pancreatitis. There is dispute about the indications for surgery in patients with recurrent acute pancreatitis and pancreas divisum, but without any other risk factor. We have reviewed the results of operations on 13 patients with pancreas divisum (Group B) treated in four different hospitals. Surgical sphincteroplasty was carried out on 10 patients with documented pancreatitis and seven of these had good results. Three patients who had operations for pain without documented pancreatitis were not improved.     

Pancreas divisum, chronic pancreatitis and diabetes mellitus. Improvement by pancreaticojejunostomy]

The relationship between pancreas divisum and chronic pancreatitis is controversial. We report the cases of two patients aged 40 and 53 years suffering from recurrent pancreatitis and known to have histologically proven idiopathic chronic pancreatitis. One patient had insulin dependent diabetes. Pancreatography demonstrated in these two cases a pancreas divisum with a dilated dorsal pancreatic duct. A pancreatico-jejunostomy was performed, associated in one case with splenopancreatectomy for pseudo-cyst. With a follow-up of 32 and 78 months, both patients were free of symptoms and the diabetic patient had normal blood glucose levels with diet alone. The clinical history of the patients suggests a relationship between pancreas divisum and chronic pancreatitis and that pancreatico-jejunostomy may improve pancreatic pain and pancreatic function.     

The cause and treatment of pancreatitis associated with pancreas divisum

Recurrent pancreatitis is more prevalent in the 4% of people with pancreas divisum (nonfused dorsal and ventral ducts), and it has been proposed that the pancreatitis is caused by stenosis at the orifice of the dorsal duct. We have treated 40 patients with pancreas divisum and proven or probable pancreatitis. The diagnoses were made by endoscopic pancreatography showing a foreshortened (less than 6 cm) ventral duct (Wirsung) and confirmed by postoperative pancreatograms showing the separate main duct (Santorini) emptying via the accessory papilla. Of these, 32 patients (25 men, 7 women, median age 30) had recurrent acute pancreatitis (22) or persistent pain (10) without chronic inflammation or fibrosis. Twenty-nine have been treated by transduodenal sphincteroplasty of the accessory papilla; 22 were stenotic (0.75 mm or less) and 7 nonstenotic. Among 25 patients observed for longer than 6 months after surgery, the relief of pain and pancreatitis has been good in 17, fair in 1, and poor in 7. There was no difference between accessory papillotomy alone (10-0-3) v papillotomies of both accessory and major papillae (7-1-4). Patients with stenosis (16-1-1) fared better (p less than 0.001) than those without stenosis (1-0-6). Those presenting with discrete attacks (12-1-2) also fared better (p less than 0.05) than those presenting with chronic pain (5-0-5). The other eight patients (two women, six men, median age 28) had chronic pancreatitis proven by pancreatography and surgical biopsy. In this group, treatment by sphincteroplasty of the accessory papilla failed, and seven patients eventually required a pancreaticojejunostomy (3), distal pancreatectomy (2), or total pancreatectomy (2). In pancreas divisum, pancreatitis is caused by stenosis at the accessory papilla of Santorini. There may be progression from recurrent acute pancreatitis to irreversible fibrosis in some cases. Sphincteroplasty is effective for recurrent acute pancreatitis, but ductal drainage or resection becomes necessary once chronic pancreatitis is established. A preoperative test for stenosis of the accessory papilla is needed to identify patients whose symptoms are genuinely caused by their pancreas divisum.     

Clinicopathological studies of anomalous arrangement of the pancreaticobiliary ductal system with pancreas divisum

We examined the morphological aspects of the pancreaticobiliary ductal system in 13 patients with both anomalous arrangement of the pancreaticobiliary ductal system (AAPB) and associated pancreas divisum (PD), and compared their clinicopathological findings with those of patients with either AAPB or PD alone. PD is classified into three types, i.e., separate pancreas, nonfusion of the ventral and dorsal pancreatic ducts, and partial fusion of the ventral and dorsal pancreatic ducts. Of the 13 patients with AAPB and associated PD, 5 were male and 8 female; their mean age was 57 years. Nine of the 13 had clinical symptoms. Five of the 13 had gallbladder cancer, 3 had cholecystolithiasis, and 2 choledochal cyst. One patient showed nonfusion of both pancreatic ducts and the others showed partial fusion of the ducts. The length of the common duct from the orifice of the papilla of Vater to the junction of the common bile duct with the ventral pancreatic duct and the location of the union varied. The presence of both AAPB and PD made the arrangement of the pancreaticobiliary ducts very complicated. Clinical aspects were similar to those of AAPB and the patients were likely to be treated for a condition other than PD. However, since relapsing acute pancreatitis and intermittent epigastric pain are typical symptoms in patients with AAPB as well as in those with PD, we should carefully follow up those patients with both AAPB and PD.     

The duodenum-preserving resection of the head of the pancreas in patients with pancreas divisum

Summary. In 1–6 % of the patients who are investigated by endoscopic retrograde cholangio-pancreatography a pancreas divisum can be found. In some patients pancreas divisum can lead to an acute relapsing and finally chronic pancreatitis (CP). Surgical intervention in these cases seems to offer a good chance of recovery. We report our experience with the duodenum-preserving resection of the head of the pancreas in 12 patients with pancreas divisum and CP. In all patients the preoperative evaluation showed clinical, functional or radiological signs of CP. The duodenum-preserving resection of the head of the pancreas was carried out in all patients without perioperative mortality. Ten postoperative versus eight preoperative patients showed a pathological exocrine function of the pancreas. Endocrine function, measured by the oral glucose tolerance test (OGTT), improved postoperatively in two patients. Eleven patients who were investigated after a mean follow-up time of 31 months (3–75 months) were completely pain free. No late mortality occurred. OGTT revealed a diabetic endocrine function in two patients. Disturbed exocrine pancreatic function had to be substituted in nine patients. One patient had to be reoperated by duct incision and renewal of the pancreatico-jejunostomy 10 months after the first operation. In conclusion, the duodenum-preserving resection of the head of the pancreas reduced pain in all patients with pancreas divisum and CP and may lead to an improvement of endocrine pancreatic function. Other, nonresecting procedures or endoscopic interventional therapy should be avoided in these patients.      

Transgastric pancreatography and EUS-guided drainage of the pancreatic duct

Background/Purpose Endoscopic transpapillary drainage of the retained pancreatic duct in symptomatic patients with chronic pancreatitis is considered an established treatment option. The aim of this study was to investigate, as an alternative, endoscopic ultrasound (EUS)-guided transgastric pancreatography and drainage of the pancreatic duct, in terms of their feasibility and outcome. Methods All consecutive symptomatic patients with failure of the traditional approach to catheterize and drain the pancreatic duct, over a 3-year time period, were enrolled in this prospective, observational single-center study (case series). Feasibility was characterized by success rate, outcome by complication rate (frequency of bleeding or perforation), mortality, and follow-up. Results Twelve patients underwent 14 interventions (sex ratio, M/F, 10 : 4; age range, 43–77 years) from November 2002 to October 2005. The main indication was retention of the pancreatic duct associated with pain, in particular: (i) papilla not reachable because of prior gastrointestinal surgery (n = 5); and (ii) not possible to introduce the catheter through the papilla in chronic pancreatitis or “pancreas divisum” (n = 7). Pancreatography was successful in all patients (normal finding with no therapeutic consequence, n = 1 [after pancreaticojejunostomy]), whereas drainage of the pancreatic duct was achieved in 9 patients (69%; attempts, n = 13). The transgastric route was used in 5 patients and the transpapillary route (rendezvous technique with endoscopic retrograde cholangiopancreatography [ERCP]) in 4. There was a complication rate of 42.9%, comprising postinterventional pain (n = 4; 28.6%); bleeding (n = 1); and perforation because of retriever problems (n = 1). The postinterventional pancreatitis rate was 0% and mortality was 0%. The follow-up investigation (range, 4 weeks − 3 years) revealed that 4 patients (28.6%) subsequently underwent surgical intervention, because of duodenal stenosis (n = 1; 7.1%), suspicious tumor growth (n = 1; 7.1%), and insufficient drainage of the pancreatic duct (n = 2; 14.3%). In 2 subjects (14.3%), endoscopic reinterventions became necessary, which were subsequently successful. There were the following technical problems: 1) Too dense stenosis (n = 3); 2) inadequate equipment (insufficient infeed of the endoscopic tool because of its bending), in each case. Conclusions Transgastric pancreatography and EUS-guided drainage of the pancreatic duct are reasonable and feasible alternative options for diagnostic and therapeutic management for selected indications (chronic pancreatitis; anomaly of the congenital pancreatic or postoperative gastrointestinal anatomy), with an acceptable periinterventional risk, which broaden the therapeutic spectrum and may avoid surgery but need further evaluation and follow-up investigation.