Cases Of Pancreas Divisum Research Articles

Preoperative Endoscopic Minor Papilla Sphincterotomy for Pancreas Divisum in a Patient with Pancreatic Cancer Who Underwent Laparoscopic Distal Pancreatectomy.

Pancreas divisum (PD) is a congenital anomaly that occurs due to failure of fusion of the dorsal and ventral pancreatic ductal systems.1-3 In PD, pancreatic juice drains mainly through the minor papilla via the dorsal duct, leading to high intraductal pressure, which can cause pancreatitis.1-3 We report a case of PD that underwent preoperative decompression using endoscopic minor papilla sphincterotomy (EMPS) before laparoscopic distal pancreatectomy (LDP) for pancreatic cancer.3 METHODS: The patient was a 74-year-old woman with pancreatic tail cancer, measuring 35 mm in size, in PD with an entirely dilated dorsal duct, implying high, intraductal pressure caused by minor papillary dysfunction. We performed EMPS to prevent postoperative pancreatitis and pancreatic fistula before LDP using a left-posterior approach, as previously described.4 As the pancreatic transection margin was positive for high-grade pancreatic intraepithelial neoplasia on intraoperative pathology, an additional resection of the pancreatic head to the right side of the portal vein was performed after the liberation of the gastroduodenal artery with both the dorsal and ventral pancreatic ducts ligated and divided. The operative time was 421 min, and blood loss was 70 mL. The postoperative course was uneventful, with no evidence of pancreatitis or pancreatic fistula. The patient was discharged on postoperative Day 10. Postoperative computed tomography revealed reduced dilatation of the dorsal duct. Preoperative EMPS may be effective in preventing pancreatic fistula after LDP in patients with PD.

Pancreatic ductal adenocarcinoma in a patient with pancreas divisum and gastrointestinal duplication cyst: a case report

BackgroundThe complication of duplication of alimentary tracts and pancreas divisum (PD) is a rare malformation and the development of pancreatic ductal adenocarcinoma (PDAC) in this malformation is also extremely rare. There have been some reports of complication of malignancy in a gastric duplication cyst (GDC) and PD. However, there have been no reports of complication of PDAC in cases with GDC and PD.Case presentationA 54-year-old woman was followed up at the previous hospital due to a history of ovarian endometrial adenocarcinoma. She also had a surgical history of partial excision for a GDC and pancreatic tail of PD in her childhood. A gynecological follow-up computed tomography (CT) examination revealed the pancreatic body tumor and the bifurcated main pancreatic duct dilatation. Furthermore, magnetic resonance cholangiopancreatography also revealed that the ventral main pancreatic duct communicated with the GDC. The initial levels of tumor markers were high, but we could not achieve preoperative histopathological diagnosis. The preoperative diagnosis was PDAC occurring in a case with PD and GDC. She received two courses of neoadjuvant chemotherapy with gemcitabine and nab-paclitaxel. A CT examination after neoadjuvant chemotherapy revealed the shrinkage of the tumor, and then we performed distal pancreatectomy with splenectomy and GDC resection. A histopathological examination revealed invasive PDAC and lymph node metastases; pathological staging was T1N1M0, stage III. Furthermore, PD and GDC were also histopathologically detected. The postoperative course was uneventful, and she was discharged on the postoperative day 25. She received S-1 monotherapy for 6 months, and no recurrence has been detected at 1 year after radical resection.ConclusionsWe herein presented an extremely rare combined case of PD, GDC and PDAC. We successfully treated it by neoadjuvant chemotherapy and distal pancreatectomy with GDC resection, and postoperative chemotherapy.

Successful cruciate incision of the minor papilla in a patient with acute pancreatitis due to pancreas divisum: A case report

Pancreas divisum is a congenital anatomical anomaly characterized by a lack of fusion of the ventral and dorsal parts of the pancreas, which sometimes causes pancreatitis. Most cases of pancreas divisum are difficult to treat, and no established guidelines are currently available. Here we describe the case of patient with acute recurrent pancreatitis caused by pancreas divisum who was successfully treated with cruciate sphincterotomy of the minor papilla. A 70-year-old female was admitted to our hospital due to an emergency of acute abdominal pain, which was subsequently diagnosed as acute pancreatitis caused by pancreas divisum. The patient, recalcitrant to conservative endoscopic management of minor papilla, underwent the cruciate incision of the minor papilla, which allowed drainage of the pancreatic duct. Following this intervention, the patient’s clinical condition and serum amylase level promptly improved. No recurrence was observed over a follow-up period of 48 months. Cruciate incision of the minor papilla is an effective and safe technique for minimally invasive treatment of pancreas divisum.

Imaging of pancreas divisum by linear-array endoscopic ultrasonography.

Pancreas divisum (PD) is the most common developmental anatomic variant of pancreatic duct. Endoscopic ultrasound (EUS) is often performed to evaluate idiopathic pancreatitis and has been shown to have high accuracy in diagnosis of PD. The different techniques to identify PD by linear EUS have been described differently by different authors. If EUS is done with a proper technique it can be a valuable tool in the diagnosis of PD. The anatomical and technical background of different signs has not been described so far. This article summarizes the different techniques of imaging of pancreatic duct in a suspected case of PD and gives a technical explanation of various signs. The common signs seen during evaluation of pancreatic duct in PD are stack sign of linear EUS, crossed duct sign on linear EUS, the dominant duct and ventral dorsal duct (VD) transition. Few other signs are described which include duct above duct, short ventral duct /absent ventral duct, separate opening of ducts with no communication, separate opening of ducts with filamentous communication, stacking of duct of Santorini and indirect signs like santorinecele. The principles of the sign have been explained on an anatomical basis and the techniques and the principles described in the review will be helpful in technical evaluation of PD during EUS.

Acute Recurrent Pancreatitis; Relative Risk Factors, Etiology ,Diagnosis Procedure And Treatment In the Pancreatic disease Institute of Wuhan Union Hospital Of China

This study describes the relative risk factors, etiology and treatment option of recurrent acute pancreatitis. The data of 71 patients with acute recurrent pancreatitis were retrospectively studied from January 2010 to December 2014. Of 71 patients, 41 were male and 30 were female with a sex ratio of 1.4:1 with a mean age of 49 years. Their age ranged from 14 to 85 years. After reviewing the clinical data, the risk factors were analyzed using univariate and multivariate analysis. The etiology was investigated in each case using specialized laboratory analysis, ERCP, EUS and MRCP. Their pain was labeled severe, moderate and mild by using the Analgesic Ladder by World Health Organization. Subsequent to the investigation reports, therapeutic ERCP and endoscopic sphincterotomy were performed. Of the 71 patients, 52 cases were biliary pancreatitis, 13 were idiopathic pancreatitis, 3 were alcohol induced pancreatitis and 3 were hyperlipidemia pancreatitis. The univariate analysis showed easy recurrence with obstructive jaundice, hepatic function injury and local complication of pancreas (P=0.016< 0.05 P= 0.003<0.05 and P= 0.024< 0.05 correspondingly). Multivariate analysis showed no single factor related to recurrence. Upon definition of etiology, there were 33 cases of common bile duct stones, 14 cases of pancreatic duct stones, 5 cases of gallbladder stones, 3 cases of pancreas divisum, 2 cases of ampullary tumor, 4 cases of sphincter of Oddi dysfunction, 6 cases of chronic pancreatitis, 1 cases of post liver transplant complication and 3 cases of duodenal diverticulum. The 71 patients performed ERCP followed by either endoscopic sphincterotomy in 69 cases or endoscopic resection in 2 cases. The procedure was curative and successfully performed. A complication rate of 2.8% with no mortality was observed. Post-therapy, a decline in pain intensity was observed in 56 cases of the patients. ERCP and endoscopic sphincterotomy has a curative effect in diverse etiology of acute recurrent pancreatitis.

False pancreas divisum: a complication of post-endoscopic retrograde pancreatography pancreatitis

Pancreas divisum (PD) and meandering main pancreatic duct (MMPD) are common developmental variants of the pancreatic ductal system. They always appear in the head of the pancreas and are associated with idiopathic pancreatitis. The condition of these variants is rarely reported to have changed after birth. We present a rare case of false PD that occurred with alteration of loop-type MMPD after endoscopic retrograde pancreatography (ERP) and brush cytology followed by post-procedural pancreatitis. A 76-year-old female underwent pre-surgical ERP and brush cytology for an incidentally detected, expanding branch-type intraductal papillary mucinous neoplasm in the body of pancreas. The guidewire was inserted along the main pancreatic duct (MPD) and had uncoiled the loop-shaped MPD into a linear shape; soon afterwards, the patient developed post-procedural acute pancreatitis. Follow-up magnetic resonance cholangiopancreatography study 1 month later revealed the morphology of PD with an absent ventral duct. We hypothesize that inflammatory synechia had occluded the uncoiled ventral duct. This single case provides evidence that pancreatic ductal anatomy is flexible in some situations.

A case of pancreas divisum with a waveform like sphincter muscle by manometry of minor duodenal papilla

症例は52歳女性。45歳時に膵管非癒合による急性膵炎の既往あり。心窩部痛にて当院救急搬送され，急性膵炎と診断された。軽快後，膵管非癒合の精査目的にERPを施行した。経副乳頭的に行った圧測定で，膵管内圧上昇と副乳頭部で括約筋様収縮波を認めた。副乳頭切開を施行し，その後膵炎の再発はない。経副乳頭的内圧測定は膵管非癒合による再発性膵炎に対して，副乳頭切開を行う際の指標として有用である可能性が考えられた。

A Case of Pancreas Divisum With Stenosis of the Pancreatic Duct

A Case of Pancreas Divisum With Stenosis of the Pancreatic Duct

Secretin-stimulated magnetic resonance cholangiopancreatography of patients with unclear disease in the pancreaticobiliary tract

To explore the usefulness of secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) on different pathological entities in the pancreaticobiliary tract (PBT) MATERIAL AND METHODS: Sixty-two patients with unclear disease in the PBT were examined with S-MRCP as the final radiological procedure. Nine groups of referral diagnoses were identified, and clinical outcome was evaluated. In five patients with suspected pancreatic duct injury after blunt abdominal trauma, a negative predictive value of 100% was found after a median of 3.5 months of follow-up. In 22 patients with residual pain after cholecystectomy, investigated for sphincter of Oddi dysfunction (SOD), delayed dilatation of the PD and pain were documented in four patients. Three of these were treated with endoscopic papillotomy (EPT), and no recurrences were found during an average of 13.6 months of follow-up. Five cases of pancreas divisum not previously seen were identified, and of 12 patients with suspected postoperative stenosis, five were successfully treated after being identified with S-MRCP. Useful information was obtained in most of the patients, i.e., findings not observed in previous radiological examinations or clarifying uncertain previous findings. Nine patients were referred to other non-radiological examinations, identifying that the origin of disease was outside the PBT. S-MRCP has the potential to become the final part of diagnostic workup in difficult PBT diseases, but further investigation of usefulness regarding different referral reasons is mandatory.

Does Moderate Celiac Axis Stenosis Identified on Preoperative Multidetector Computed Tomographic Angiography Predict an Increased Risk of Complications After Pancreaticoduodenectomy for Malignant Pancreatic Tumors?

To identify any association between celiac artery compromise found on computed tomographic angiography and the incidence of postoperative and perioperative complications. The computed tomographic angiograms of 36 patients who underwent the Whipple procedure for pancreatic adenocarcinoma were examined retrospectively. The association between the results and surgical course was investigated. Twelve patients (33%) had significant postoperative complications. Ten (28%) had evidence of celiac artery stenosis. Stenosis ranged from 20% to 60%. There was no evidence of a difference between the 2 groups. There seems to be no evidence of an increased risk of postoperative or perioperative complication in patients undergoing the Whipple procedure, with a celiac stenosis of up to 60%.

Prevalence of pancreatic and biliary tract tumors in pancreas divisum

The present study was undertaken to evaluate the prevalence of pancreatic and biliary tract tumors in pancreas divisum (PD). A retrospective single-center study was performed, and a total of 118 cases of complete PD and 7850 cases of fused pancreas were identified among the 8537 consecutive new endoscopic retrograde cholangiopancreatography (ERCP) examinations performed between 1980 and 2002. The prevalence of pancreatic cancer (PCA), intraductal papillary mucinous neoplasms (IPMNs), other pancreatic tumors, and biliary tract cancer in the patients with PD and the patients with a fused pancreas were compared. The prevalence of the pancreatic tumors in the PD patients was: PCA, 10%; IPMN, 5.1%; other pancreatic tumors, 2.5%. The prevalence of pancreatic tumors in the patients with a fused pancreas was: PCA, 4.8%; IPMN, 2.6%; and other pancreatic tumors, 1.1%. The prevalence of PCA was significantly higher in the patients with PD than in those with a fused pancreas (P = 0.008; OR, 2.24). The percentages of PD patients with PCA who had pancreatic-type pain and a serum pancreatic enzyme elevation were significantly higher than among the PD patients without PCA. The prevalence of biliary tract cancer was 0.8% in the PD group and 5.3% in the fused pancreas group, and it was significantly lower in PD than in fused pancreas (P = 0.031). The results of this study showed a significantly higher prevalence of PCA in PD than in fused pancreas. We concluded that patients with PD, especially patients presenting with pancreatic-type pain and pancreatic enzyme elevation, should be carefully followed up because of the risk of developing PCA.

7015 The role of endoscopic ultrasonography for the pancreatobiliary diseases in medical checkup.

Introduction: EUS is considered to be useful modality for the pancreatobiliary(PB) disorders.We evaluated the efficiency of EUS for PB disorders. Subjects and Methods: Subjects consisted of 874 cases suspicious of PB disorders by US-performed for 82436 persons( 4/1994 - 12/1998 at Aichi Health Care Center.). Check up criteria of US were in table 1. We made EUS exam. for above listed 874 cases, and evaluated following points ; 1.True negative rate. 2. Coincidence rate between EUS diagnosis and definite diagnosis(Table-2). 3.Unchanged period from the point diagosed as benign. Every 6 month observasion by US was done, if there was any change on US, the case was re-examined by EUS, and once a year, individual prognosis inquiry was made by mail. Results: 1. 100%. Also, the cases followed by only US remained under US criteria. 2. 96.7%, 2 cases of pancreas divisum was misdiagnosed. 3.All the cases diagosed as benign remained unchanged. Conclusion: Using EUS , we could restrict to only 0.07%(60/82436) necessary to be sent to special hospital. EUS is an efficient and accurate examination of PB diseases in mass screening.

4564 Endoscopic ultrasound in idiopathic acute pancreatitis.

Background: EUS is a sensitive method of diagnosing biliary microlithiasis and chronic pancreatitis. The aim of this study was to determine how often EUS establishes an etiology for unexplained acute pancreatitis, and whether ERCP is subsequently needed. Methods: Thirty-one patients who underwent EUS for assessment of idiopathic acute pancreatitis were identified from an EUS database. Follow-up data were collected from inpatient and outpatient records, and subjects were contacted for a telephone interview. Idiopathic pancreatitis was defined as a greater than 2 fold elevation of amylase or lipase with a compatible clinical picture and no identified cause on imaging and biochemical studies. Bile was obtained for microscopy at the conclusion of EUS when appropriate. ERCP was subsequently performed only when symptoms recurred or if requested pre-operatively. Results: Of the 31 subjects (mean age 49 years), seventeen had had recurrent bouts whereas 14 were referred after one attack of pancreatitis. Twenty-nine patients had undergone transabdominal ultrasonography and 30 had undergone CT scanning prior to referral. Twelve ERCP's had been attempted at other institutions with successful completion in only 4 patients. Twenty-three patients had a history of occasional or habitual alcohol use. EUS revealed previously undiagnosed microlithiasis in 5 (16%) patients. Chronic pancreatitis (CP) based on 3 or more sonographic features was found in 14 (45%) patients, one of whom also had an EUS diagnosis of pancreas divisum. Twelve of the 14 patients with CP had a history of alcohol use. In the remaining 12 patients, EUS diagnosed one T1 pancreatic cancer, one additional pancreas divisum, and was not diagnostic in 10 (32%) cases. During a mean follow-up of 16 months, 12 of the 31 patients subsequently underwent ERCP, 3 pre-operatively and 9 for evaluation of recurrent symptoms, including 5 with EUS diagnosis of CP and 4 with non-diagnostic EUS. ERCP changed final diagnosis in 4 patients, detecting one additional case of pancreas divisum, one previously unidentified pancreatic duct stone, one intraductal polyp, and one case of sphincter of Oddi dysfunction. Conclusion: EUS, a less invasive test than ERCP, demonstrated a potential etiology in two-thirds of patients with idiopathic acute pancreatitis. Most patients did not require ERCP during the followup period. EUS is an attractive alternative to ERCP in patients with unexplained acute pancreatitis.

Pancreatic Diseases

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic modality capable of producing high-quality images of the biliary tree and pancreatic duct. We evaluated the MRCP capability of depicting the normal pancreatic duct and, based on data achieved, studied the usefulness in the pathologic pancreatic duct. MRCP was performed in 42 patients without any pancreatic lesion and in 162 patients with pancreatic diseases, including congenital anomalies of biliary tree and pancreatic duct. Results were compared with endoscopic retrograde cholangiopancreatography (ERCP) in 93 patients. The visualization of the pancreatic duct and its branches and the presence or absence of dilatation, stenosis, and filling defects were recorded. All images were interpreted retrospectively and blindly by three radiologists. Among control patients, the main pancreatic duct (MPD) was depicted in the head, body, and tail of the pancreas in 41 (98%), 39 (93%), and 31 (74%), and accessory pancreatic duct and secondary branches in the head, body, and tail of the pancreas were depicted in 11 (26%), eight (19%), four (10%), and two (5%) of these patients. Compared with ERCP, MRCP overestimated the stenosis of MPD and underestimated the dilatation of the branches and filling defects in the pancreatic duct in pancreatic diseases, especially pancreatitis. However, MRCP was distinctly advantageous over ERCP in diagnosing mucin-producing tumor of the pancreas, cystic lesions, and depicting the whole, including the part distal to the obstructed site. Four of the eight cases of pancreas divisum, and 10 of the 12 cases of anomalous pancreaticobiliary duct union also were demonstrated. MRCP can accurately demonstrate the normal pancreatic duct as well as various pancreatic duct abnormalities, including congenital anomalies of the biliary tree and pancreatic duct.

A CASE OF PANCERAS DIVISUM WHICH WAS DISCOVERED AS LDA OF PANCREAS HEAD AND PERFORMED VENTRAL PANCREATECTOMY

A case of pancreas divisum which was discovered as LDA of the pancreas head and performed ventral pancreatectomy was reported. A 74-year-old woman, was admitted to the hospital because of epigastric pain. She had been treated for diabetes mellitus for 25 years with a good control. After admission, a abdominal ultrasonography revealed LDA of the pancreas head. ERCP revealed that the pancreatic duct was interrupted in site of 5 cm apart from the Vater papilla orifice. Computed tomography revealed only dilatation of the main pancreatic duct. From these findings, pancreas divisum and SOL of the ventral pancreas were diagnosed. Ventral pancreatectomy was performed under the diagnosis of tumor of the pancreas head associated with pancreas divisum. Histological diagnosis was hyalinization and calcification of Langhans' cells. Therefore, it was presumed that the degeneration of Langhans' cells was visualized as LDA of the pancreas head on echography.

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)

Pancreas divisum

Cases of pancreas divisum (PD) were reviewed in our patients and 19 Japanese and 14 English series during the past 10 yr to see any significant association of PD with certain diseases. PD was diagnosed in 20 (0.64%) among our 3121 patients with successful endoscopic pancreatograms (ERP). Of 20 PD patients, acute pancreatitis in one, chronic pancreatitis in two, ampullary cancer in one, and cholelithiasis in five were diagnosed. Incidences of PD were 2.6% (1/38) in acute pancreatitis, 0.8% (2/248) in chronic pancreatitis, 0% (0/100) in pancreatic cancer, 20% (1/5) in ampullary cancer, and 0.8% (5/615) in cholelithiasis. The incidences were similar to overall incidences of ours and other Japanese series (0.69% of 36,171 patients). Higher incidences of acute pancreatitis (12.9% of 559) and pancreatic cancer (5.5% in 448) may result from the higher overall incidence (4.6% in 16,257) in English series. The relationship between pancreatitis and PD has been controversial, but our present data suggest that PD is a coincidental finding and not a predisposing factor to pancreatitis in Japan.