Annular pancreas in adults: embryological development, morphology and clinical significance

Abstract: Three cases (two male, one female) of annular pancreas are presented, which were found and operated on within the last three decades. Diagnosis was made using imaging techniques, especially ultrasonography and computed tomography. In two cases there was incomplete obstruction, while in the other obstruction was complete. It is characteristic that in the case of complete obstruction the annular portion of the pancreas attached to a circular band of connective tissue, while in the two cases of incomplete obstruction there was a complete ring of pancreatic tissue. In all cases surgical intervention was needed in order to create a bypass. In the first case gastroenterostomy and truncal vagotomy was performed, in the second latero-lateral duodeno-jejunostomy and in the third latero-lateral antropyloroduodeno-jejunostomy. The embryology and morphology of the annular pancreas, the morphology of its duct system, diagnosis, differential diagnosis and the surgical treatment of this rare condition are reviewed.     

Heterotopic Ossification of annular ligament: A case report and review of literature

Heterotopic Osification (HO) commonly occurs in the hip and elbow joint post, trauma, surgery or dislocation. HO can occur anywhere in the body, and the term Heterotopic Ossification of Ligaments and Tendon (HOTL) is specifically used to denote HO occurring in ligaments and tendons. HOTL of an annular ligament is reported rarely in the literature. Here we describe a case of calcified annular ligament in a neglected monteggia fracture (Bado Type – 1), which was managed by excision and reconstruction of the same using triceps fascia. Post-op review after 2.5 years showed a stable elbow, with some restriction in pronation.     

Tricuspid annular plane systolic excursion (TAPSE) can predict the outcome of isolated tricuspid valve surgery in patients with previous cardiac surgery?

Background

Isolated tricuspid valve replacement is rare when performed as a re-operation after a left side operation. It is important to know the factors that determine mortality and morbidity. Tricuspid Annular Plane Systolic Excursion (TAPSE) is a scoring system that is used with non-invasive Doppler echocardiography to determine right ventricular (RV) function. This study analyzed TAPSE scores and adverse outcomes of isolated tricuspid valve surgery in patients with previous cardiac surgery.

Methods

All patients who underwent tricuspid valve replacement between January 2014 and December 2015 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. These patients were divided into two groups: TAPSE >14 mm and TAPSE ≤14 mm. In-hospital outcomes were compared.

Results

A total of 26 patients with severe tricuspid valve regurgitation underwent tricuspid valve replacement. There were 5 males (19.2%) and 21 females (80.8%). The average age at operation was 54.77±9.61 years (range, 27–69 years). There were 16 patients in the TAPSE >14 mm group and 10 patients in the TAPSE ≤14 mm group. The BNP in the TAPSE >14 mm group was significant (TAPSE >14 mm 672.34±229.98 versus TAPSE ≤14 mm 1,054.79±684.69, P=0.03). The median cardiopulmonary bypass (CPB) time and red blood cell (RBC) transfusions in the two groups were not different. The need for prolonged ventilatory support (>48 h) in the two groups was also not different (TAPSE> 14 mm 91.2±12.31 vs. TAPSE ≤14 mm 39.00±36.80, P=0.46). Moreover, hospital stays were similar between the two groups. No differences were found in postoperative renal and respiratory complications.

Conclusions

It is important to determine the right ventricule function quantitatively. The TAPSE score is an important parameter that determines the cardiac index and right ventricle function. It should be used for the prediction of mortality and morbidity with all the other parameters as a whole.     

Annular pancreas associated with carcinoma in the dorsal part of pancreas divisum

Summary A carcinoma in the dorsal part of the pancreas divisum with an annular pancreas in the anterior part is reported. A 79-yr-old female was admitted in our hospital complaining of epigastralgia. Computed tomography (CT) and ultrasound (US) showed an irregular mass in the pancreatic body. A pancreatogram obtained through the major duodenal papilla demonstrated only the ventral pancreatic duct that encircled the duodenum. Contrast medium injected from the minor duodenal papilla showed Santorini’s duct obstruction at the neck portion of the pancreas without communication with the ventral pancreatic duct. The patient died with liver metastases. Autopsy confirmed annular pancreas and a 6-cm tumor in the pancreatic body extending to the pancreatic head and pancreas divisum. Pancreatic carcinoma; histologically a moderately differentiated adenocarcinoma; originated from the dorsal part of pancreas divisum. To our knowledge this is the first report of pancreatic carcinoma associated with annular pancreas coexistent with pancreas divisum.     

Repairing the annular ligament is not necessary in the operation of Mason type 2, 3 isolated radial head fractures if the lateral collateral ligament is intact: Minimum 5 years follow-up

Introduction

The repair of annular ligament after open reduction and internal fixation of radial head fracture could produce the irritation or crepitation during range of motion exercise. The purpose of this study is to evaluate the significance of unrepaired annular ligament during fixation of isolated radial head fractures.

Materials and methods

Retrospectively we reviewed the twenty-five patients who underwent surgical fixation with a plate for Mason type 2, 3 isolated radial head fracture without annular ligament repair. All the radial head fracture did not have the associated injuries which could cause the elbow instabilities. The average length of follow-up was 6.9 years. The outcomes were evaluated clinically (range of motions, instabilities, pain VAS, Broberg & Murrey functional rating score, DASH score) and radiographically (bony union, arthritic change, lateral translation of the radial head, humero-ulnar angle with maximum varus stress of elbow, ulnar variance).

Results

The range of motions between affected and contralateral side were not significantly different at last follow-up. No one showed the instabilities of elbow. The mean pain VAS, Broberg & Murrey functional rating score, and DASH score were 2.7 ± 0.5, 95.3 ± 2.5, and 14.8 ± 5.3 points respectively. Bony union was observed for all cases. There was no significant difference in the lateral translation of the radial head, humero-ulnar angle with maximum varus stress of elbow, and ulnar variance between the affected and the contralateral arm.

Conclusion

The isolated role of the annular ligament seems overestimated. We scrutinize that the annular ligament repair is not essential in the operative treatment of isolated radial head fractures if the lateral collateral ligament is intact.     

Lumbar discectomy with annulus fibrosus closure: A retrospective series of 53 consecutive patients

IntroductionLumbar disc herniation is most common degenerative alteration of the spine. Whenever surgical therapy proves to be necessary, recurrent disc herniation is most frequent concern. Here, primary aim was to determine the percentage of patients eligible for insertion of an annular closure device (ACD). Secondary aim to evaluate 12-month incidence of recurrent disc herniation at the operated level. Our hypothesis was that ACD might help in preventing recurrent disc herniation.MethodsPatients in a single Swiss neurosurgical center underwent limited discectomy alone (n = 41, group 1) versus limited discectomy plus ACD (n = 12, group 2). Mean postoperative follow-up period was 12 months.ResultsTwelve out of 53 patients (22.6%) were eligible for ACD implantation. Patients of group 2 were significantly taller (mean 176 cm, P = 0.007) as compared with group 1 (mean 170). The only statistically significant difference of intraoperative parameters between group 1 and 2 was amount of nucleus materiel removed (P = 0.01), being greater in group 2 (mean 0.9) as compared with group 1 (mean 0.3). In group 1 six patients (6/41, 14.6%) presented with symptomatic reherniation at same level of surgery, while in group 2 only one patient experienced recurrence (1/12, 8.3%). No adverse events were reported.DiscussionIn the current study one out of five patients with lumbar disc herniation was considered suitable for ACD placement. In vast majority of these patients reherniation was precluded on the short-term basis. Patients with ACD were taller and had intraoperatively a higher volume of the nucleus pulposus materiel removed.     

Major malformations in a case of infantile myofibromatosis

A case of infantile myofibromatosis associated with oesophageal atresia, annular pancreas, additional sacral vertebra and hypoplatic right kidney in a male neonate is reported. The possibility of associated malformations in this rare disease is outlined.