Dorsal Duct Research Articles

Larval development in the apodid sea cucumber Chiridota gigas, with a focus on coelom development and the serotonergic nervous system during metamorphosis

AbstractA unifying feature of echinoderm larvae is the development of a left anterior coelom, which consists of an undivided left axocoel and hydrocoel. Although the axocoel is a key deuterostome trait, the presence of this coelom in holothurians has been the subject of debate. Here, we focus on the development of the coelom in a basal holothuroid, the apodid Chiridota gigas (F. Chiridotidae). The dorsal pore and dorsal duct develop first, just after gastrulation, followed by expansion into an axohydrocoel in the auricularia. The left somatocoel was first evident adjacent to the stomach ~30 days post‐fertilization. The axohydrocoel differentiated into two distinct parts: the hydrocoel adjacent to the stomach, and a thin‐walled axocoel that was mid‐dorsal between the hydrocoel and the dorsal pore. This left axocoel extended to both the anterior and posterior but did not cross the larval midline. Out‐folding of the hydrocoel to form the primary tentacles was first observed at 58 days. Transition to a doliolaria with four‐rings was rapid (24 hr) and similar to the transition in other holothurians, with the hydrocoel encircling the esophagus. This transition involved a posterior shift of elements of the auricularia ciliary band and associated nervous system. The ciliary band of the auricularia was rearranged to form transverse bands of the doliolaria larva, and at the same time, the serotonergic cells and fibers that had been at the anterior end moved with the portions of the ciliary band with which they were associated. These serotonergic cells and fibers were still present in the pentactula. The first pentactula was observed at 66 days. Coelom development in C. gigas showed two differences from that in other holothurians, including the development of the left axocoel and the extension of the anterior coelom into the preoral lobe. Description of the full larval development in C. gigas also revealed highly variable morphology in the late auricularia stage, which may aid in identifying apodid holothurians from plankton samples.

Anatomical, Radiological, and Corrosion Casting of the Liver, Gallbladder, and Biliary Duct System of Local Breed Cattle (Bos ttaurus)

Local breed cattle's liver, reddish-brown, occupies the right hypochondriac region with 35.2 ± 3.24 cm long and 5.5 ± 0.5 kg weight. Connected by left and right triangular ligaments; and falciform ligaments with the diaphragm, and hepatorenal ligament with the right kidney. While the coronary ligament encompassing the caudal vena cava divides into dorsal and ventral branches, enclosing the nuda region. The round ligament connects the umbilical fissure to the umbilicus. The lesser omentum on the liver's visceral surface connects the stomach and duodenum through hepatogastric and hepatoduodenal ligaments, respectively. The liver has, parietal and visceral surfaces; right, left, ventral, and dorsal borders; and left, right, caudate, and quadrate liver lobes that are not clearly separated, except for the caudate. The gallbladder has a dark green color and pear-shaped morphology, measures 16 ± 1.5 cm, and is located in a shallow cystic fossa. Consisting of the neck, forms an inverted funnel shape, body, and fundus. The diameters were 2 ± 0.3, 6 ± 1.2, and 4 ± 1.3 cm, respectively. The biliary tract consists of extrahepatic and intrahepatic ducts. The extrahepatic ducts have a left duct of 3 ± 0.5 cm and a right duct of 2 ± 0.25 cm. Converging to form a common hepatic duct 8 ± 0.5 cm. The cystic duct is 3± 0. cm, joins with the common hepatic duct ventrally. The intrahepatic ducts consisted of primary, secondary, tertiary, interlobular, intralobular, and intercalated ducts. The left hepatic duct received 9 ± 1 of dorsal primary ducts and 8 ± 2 ventral primary ducts. The right hepatic duct receives 4 ± 1 dorsal ducts and 2 ± 1 ventral ducts.

Modified double-wire technique for deep cannulation of dorsal duct in incomplete pancreas divisum

Modified double-wire technique for deep cannulation of dorsal duct in incomplete pancreas divisum

A possible manifestation of pancreas divisum–pancreatic pseudocyst in an infant with no apparent history of pancreatitis: a case report

BackgroundPancreas divisum (PD), the most common pancreatic anomaly, is caused by the failure of pancreatic bud fusion in the embryo. Although most cases are asymptomatic, it can cause pancreatitis or epigastric pain. We report an unusual case of PD in an infant.Case presentationThe patient was a 9-month-old girl with no pertinent medical history. She had suffered vomiting and diarrhea for 1 week before transfer to our hospital. Her general condition was poor, and abdominal distention was noted. Blood tests revealed microcytic anemia with normal chemical markers. The parents reported no episode of pancreatitis. Ultrasonography revealed massive ascites, which was later found to be bloody. Enhanced computed tomography and magnetic resonance imaging depicted a cystic lesion, approximately 2 cm in size, anterior to the second portion of the duodenum. During exploratory laparotomy, a pinhole was identified on the cyst wall, which was mistakenly identified as a duodenal perforation, and direct closure was performed. Postoperative levels of serum amylase and inflammation markers were elevated, and the amount of ascites increased, impairing oral feeding. The level of pancreatic enzymes in the ascites was high. Imaging studies were repeated, but the cause of pancreatic fistula was not identified. Conservative therapy, including administration of total parenteral nutrition, antibiotics, and octreotide, was initiated, but the situation did not improve. Three months after admission, endoscopic retrograde cholangiopancreatography showed a thick dorsal pancreatic duct communicating with a hypoplastic ventral duct, which was indicative of PD. Contrast medium leaking from the dorsal duct near the minor ampulla revealed the presence of a pseudocyst. Stenting via the minor papilla was impossible because the minor papilla was obstructed. Instead, a stent was inserted into the ventral pancreatic duct. Endoscopic transgastric drainage of the cyst was effective, and the patient was discharged, 7 months after admission. The patient is healthy, but the gastric stent needs to be replaced regularly.ConclusionIn children, PD can manifest with pancreatic pseudocyst that causes pancreatic ascites, even in the absence of pancreatitis. This may be a previously unrecognized manifestation of PD in children, and clinicians need to be aware of it.

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.

MP60-14 A CELLULAR ATLAS OF THE NORMAL ADULT HUMAN FEMALE URETHRA

You have accessJournal of UrologyCME1 Apr 2023MP60-14 A CELLULAR ATLAS OF THE NORMAL ADULT HUMAN FEMALE URETHRA John Lafin, Alicia Malewska, Philippe Zimmern, Maude Carmel, Gary Lemack, Douglas Strand, and Ramy Goueli John LafinJohn Lafin More articles by this author , Alicia MalewskaAlicia Malewska More articles by this author , Philippe ZimmernPhilippe Zimmern More articles by this author , Maude CarmelMaude Carmel More articles by this author , Gary LemackGary Lemack More articles by this author , Douglas StrandDouglas Strand More articles by this author , and Ramy GoueliRamy Goueli More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003318.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary voiding dysfunction is highly prevalent in aging women. A deeper understanding of the cellular composition of female urethra in the non-diseased state could provide insights into the etiology of dysfunction. Single cell RNA sequencing was performed on female urethra to generate a cellular atlas. METHODS: Urethra from female organ donors aged 18-45 (N=4) was collected fresh from surgery and enzymatically digested into a single cell suspension. Single cell RNA sequencing was performed using 10x Genomics V3 chemistry. Data were analyzed in Seurat for cell type annotation. Immunohistochemical validation of cell types was performed on FFPE sections using differentially expressed genes from clustered data. RESULTS: The female proximal urethral lumen is lined with a stratified urothelium composed of KRT5+/KRT14- basal cells with KRT13+ hillock epithelia and KRT4+ luminal epithelia. Ducts emerging from dorsal urethra (Skene's glands) contain basal and club cells similar to prostatic urethra. The urethral lumen is surrounded by two discrete layers of fibroblasts (peri-urethral and interstitial) and circumferential smooth muscle and skeletal muscle. CONCLUSIONS: The identification of 1) specialized fibroblasts surrounding the urethra, and 2) club cells in dorsal ducts could yield new insight into the regulation of infection, inflammation and obstruction, which are the putative etiologies of most urethral dysfunction. Source of Funding: DK115477, DK104310, DK129994 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e848 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Lafin More articles by this author Alicia Malewska More articles by this author Philippe Zimmern More articles by this author Maude Carmel More articles by this author Gary Lemack More articles by this author Douglas Strand More articles by this author Ramy Goueli More articles by this author Expand All Advertisement PDF downloadLoading ...

Uncinate Duct Dilatation Predicts Additional Risk for High-Grade Dysplasia or Invasive Carcinoma Among Fukuoka-Positive Intraductal Papillary Mucinous Neoplasms.

To determine whether uncinate duct dilatation (UDD) increases the risk of high-grade dysplasia or invasive carcinoma (HGD/IC) in Fukuoka-positive intraductal papillary mucinous neoplasms (IPMNs). Though classified as a branch duct, the uncinate duct is the primary duct of the pancreatic ventral anlage. We hypothesized that UDD, like main duct dilatation, confers additional risk for HGD/IC. A total of 467 patients met inclusion criteria in a retrospective cohort study of surgically resected IPMNs at the Massachusetts General Hospital. We used multivariable logistic regression to analyze the association between UDD (defined as ≥4mm) and HGD/IC, controlling for Fukuoka risk criteria. In a secondary analysis, the modeling was repeated in the 194 patients with dorsal branch duct IPMNs (BD-IPMNs) in the pancreatic neck, body, or tail. Mean age at surgery was 70, and 229 (49%) patients were female. In total, 267 (57%) patients had only worrisome features and 200 (43%) had at least 1 high-risk feature. UDD was present in 164 (35%) patients, of whom 118 (73%) had HGD/IC. On multivariable analysis, UDD increased the odds of HGD/IC by 2.8-fold, even while controlling for Fukuoka risk factors (95% CI: 1.8-4.4, P <0.001). Prevalence of HGD/IC in all patients with UDD was 73%, compared with 74% in patients with high-risk stigmata and 73% in patients with main duct IPMNs. In the secondary analysis, UDD increased the odds of HGD/IC by 3.2-fold in patients with dorsal BD-IPMNs (95% CI: 1.3-7.7, P =0.010). UDD confers additional risk for HGD/IC unaccounted for by current Fukuoka criteria. Further research can extend this study to Fukuoka-negative patients, including unresected patients.

Anomalous Pancreatobiliary Ductal Union Presenting as Recurrent Acute and Chronic Pancreatitis in Children and Adolescents With Response to Endotherapy.

Introduction Anomalous pancreaticobiliary duct union (APBDU) is defined by the abnormal position of the junctional union of the common bile duct and the pancreatic duct, outside the duodenal wall above the influence of sphincter of Oddi, associated with choledochal cysts and biliary malignancies. APBDU may rarely present as recurrent acute pancreatitis (RAP) or chronic pancreatitis (CP). We aimed to study the prevalence of patients with APBDU presenting as RAP or CP and their response to endotherapy. Methods A retrospective audit of the prospectively maintained endoscopy database at our institute between January 2018 and November 2020 was conducted to identify cases of APBDU presenting as RAP or CP. Details of investigations, endoscopic retrograde cholangiopancreatography (ERCP) findings, and follow-up till six months were noted. Results We identified 26 cases of APBDU, of which five (19.2%) cases presented as RAP or CP. Of these five patients, two had RAP, while three presented with CP (median: 11 years; range: 4-25 years). Magnetic resonance cholangiopancreatography (MRCP) showed APBDU in three patients. One patient with RAP had a Komi type IIIB anomaly. Another patient with RAP had a rare anomaly with absent ventral PD, with the bile duct communicating and draining through the dorsal duct. Two patients with CP had a long common channel with Komi IIA anomaly. One patient with CP had IIIC2 anomaly. Pancreas divisum was noted in three patients, all of whom underwent minor-papilla sphincterotomy. Successful pancreatic stent placement was performed in all patients. Over one year of follow-up, patients with CP had a significant decrease in pain as measured by the visual analog scale. Those with RAP had no further episodes of pancreatitis. Conclusion APBDU is a rare cause of RAP and CP in young patients, occasionally missed on MRCP. RAP and CP caused by APBDU show good response to endotherapy.

S1922 A Twisted Plot: Pancreas Divisum With Right-Sided Pancreaticopleural Fistula

Introduction: We report on a 53-year-old male with a past medical history significant for chronic pancreatitis who presented with a right-sided pleural effusion secondary to pancreaticopleural fistula with pancreatic divisum. Pleural effusion secondary to pancreaticopleural fistula (PPF) is a rare complication of acute or chronic pancreatitis and usually presents with a left-sided pleural effusion. This case also highlights the difficulty and significant delay in diagnosing pancreas divisum on cross-sectional imaging. Case Description/Methods: A 53-year-old male with a medical history significant for chronic pancreatitis complicated by pancreatic ascites, walled-off necrosis, splenic and portal vein thrombosis, alcoholic gastritis, and polysubstance use presented with five days of dyspnea with new and worsening oxygen requirements. Chest x-ray showed a new moderate right-sided pleural effusion. Pleural fluid analysis revealed elevated lipase of >3,000 U/L and amylase of 21,008 U/L concerning for a pancreaticopleural fistula. MRI of pancreas showed a disconnected duct at the tail of the pancreas with a fistula extending into the mediastinum and peritoneum. During ERCP a bulging minor papilla was noted. After failed initial attempts at cannulating ventral duct, minor papilla was approached and dorsal duct was cannulated. Pancreatogram revealed a complete pancreatic divisum with a leak in the tail of the pancreas. A temporary plastic stent was placed in the dorsal duct after minor papilla sphincterotomy. The patient's symptoms resolved and he was discharged home with outpatient follow-up (Figure). Discussion: PPF is a rare complication of pancreatitis that typically presents as large, recurrent, left-sided pleural effusion often refractory to thoracentesis management. Transpapillary stent placement in the pancreatic duct is widely used in the management of PPF. Our case shows a rare right-sided presentation of PPF in the setting of a newly diagnosed pancreas divisum missed on numerous previous cross-sectional imaging. High clinical suspicion of underlying divisum raised by endoscopic and imaging findings led to successful endoscopic management of this complex case.Figure 1.: MRCP Pancreas showing pancreas divisum and disconnected duct.

S1888 A Curious Case of Recurrent Pancreatitis: A Case Report

Introduction: Annular pancreas, a congenital anomaly characterized by incomplete rotation of the ventral pancreatic bud, causes a ring of pancreatic tissue to encircle the duodenum. It is commonly accompanied by pancreatic divisum, which occurs when the main pancreatic duct and accessory duct fail to fuse. Patients often present with recurrent pancreatitis due to partial obstruction of the pancreatic duct caused by fibrosis. Case Description/Methods: A 72-year-old Caucasian male presented with recurrent episodes of acute pancreatitis. A CT abdomen (Figure A) revealed pancreatic tissue surrounding the second portion of the duodenum consistent with an annular pancreas. A pancreatic duct stone was also noted. An MRCP (Magnetic resonance cholangiopancreatography) was consistent with annular pancreas with persistent dilation of the main and accessory pancreatic ducts and a 6mm stone noted in the pancreatic duct (Figure B). On an initial ERCP (Endoscopic retrograde cholangiopancreatography), the pancreatic duct could not be cannulated through the major papilla and minor papilla could not be identified due to inflammation. An EUS (Endoscopic ultrasound) was performed, which was suggestive of pancreas divisum. The minor papilla was cannulated, and a stent was placed in the pancreatic duct. In a subsequent ERCP (Figure C), the patient had the pancreatic stone removed, with complete resolution of his symptoms. Discussion: Typically, patients with annular pancreas present with symptoms during childhood. While infrequent, some patients remain asymptomatic until 20-50 years of age. This case demonstrates the potential to remain asymptomatic until even 72 years of age. Thus, it is important for physicians to be aware of the clinical manifestations of annular pancreas, as they could arise at any stage in life. By increasing awareness surrounding annular pancreas and management of its complications, we hope to increase the rate of early intervention.Figure 1.: Image 1A. Contrast-enhanced axial CT of the abdomen at the level of the pancreatic head. The pancreas (white bracket) is seen surrounding the 2nd part of the duodenum (white asterisk), compatible with annular pancreas. A 6 mm calcification (circled) is present in the region of the minor papilla (arrows indicating pancreatic ducts). Image 1B. Coronal MRCP images. Annular pancreas, with only a thin rim of pancreatic tissue surrounding the duodenum. The dorsal duct is best shown to wrap completely around the duodenum on MRCP images (arrow). Image 1C. ERCP fluoro image showing the previously placed pancreatic duct stent (which does appear to have a loop-like configuration) and the pancreatic stone.

S1675 Blame It on the Bamboo Stump: A Pancreatic Ductal Disruption Successfully Managed With Two-Step Endoscopic Therapy

Introduction: Non-penetrating, isolated pancreatic injuries are rare, and the management is not well-established and challenging. Most injuries are managed by surgery, but recently several case reports discuss endoscopic therapy for treatment of main pancreatic duct disruption. We report a case of pancreatic injury from falling on a bamboo stump with complete pancreatic ductal disruption and complete pancreas divisum with a dominant dorsal duct that was successfully nonoperatively managed through endoscopic therapy. Case Description/Methods: An 18-year-old male transferred for worsening abdominal pain from a grade IV pancreatic injury complicated by pancreatic ascites and massive pancreatic fluid collections (PFCs) sustained a month prior after a non-penetrating fall onto a bamboo rod in the Caribbean. He had failed conservative therapy and 2 attempts with ERCP for pancreatic duct (PD) stent placement. CT A/P and MRCP showed a 13cm cyst consistent with hemorrhagic pancreatic pseudocyst (Figure A-B). Labs showed leukocytosis, elevated lipase and LFTs, but he was hemodynamically stable. US-guided paracentesis drained 250mL of fluid consistent with pancreatic ascites. To allow for pancreatic edema reduction, we elected for a 2-step procedure with separate EUS and ERCP. EUS showed multiple PFCs s/P endoscopic cyst-gastrostomy with Axios stent (Figure C-D). Repeat CT A/P showed decrease in size of the PFCs (Figure E). He was discharged and returned in one week for ERCP that revealed a surprising complete pancreas divisum and total disrupted main dorsal PD, which was endoscopically treated with sphincterotomy of the minor papilla and a long PD stent across the disruption (Figure F-H). The Axios stent was removed a week later, and 4 weeks later we successfully removed the PD stents from both the major and minor papillae. He made an uneventful recovery and remains well. Discussion: Pancreatic disruption syndrome or Disconnected Pancreatic Duct Syndrome (DPDS) is an interruption of pancreatic duct continuity, usually from necrotizing pancreatitis, but can occur with blunt or penetrating abdominal injury, as in our patient. Endoscopic management is a minimally invasive option for DPDS and pancreatic ascites. Our patient had severe pancreatic injury managed using 2-stage endoscopic therapy, demonstrating a successful treatment strategy for pancreatic injury with total main DPDS. Further studies are required regarding the selection of patients, safety, and long-term outcomes.Figure 1.: Image A: CT A/P (coronal) demonstrating edematous pancreas with significant peripancreatic fat stranding, with a peripherally enhancing hypodense fluid collection near the body and tail of the pancreas measuring approximately 4.0 x 4.8 x 13 cm in the maximum AP, RL and SI dimensions (red arrow). Image B: MRCP (coronal) Abutting the pancreatic body is a multilobulated rim-enhancing complex fluid collection that extends from the level of the diaphragmatic hiatus to just above the level of the aortoiliac bifurcation and measures 6.8 x 9.7 x 19.1 cm (AP by TR by SI, red arrow). Image C-D: EUS demonstrating large pancreatic fluid collection (PFC, left) and s/P Axios cyst-gastrostomy (right). Image E: CT A/P (coronal) demonstrating cyst-gastrostomy placement with interval decrease in PFC. Image F-H: Pancreatogram showed extravastion of contrast material at the junction of proximal 2/3 and distal1/3 of the dorsal PD c/w disrupted dorsal PD (Complete Pancreas divisum, left). Placement of a 5 Fr 9 cm Zimmon PD stent with pigtail crossing the disruption at the minor papilla (center). Pancreatogram showing no extravasation of contrast material s/P PD stent placement.

A taxonomic study of three mealybug species (Hemiptera: Coccomorpha: Pseudococcidae) infesting dwarf bamboo in Japan, with description of a new species.

The taxonomic status of some mealybug species (Hemiptera: Coccomorpha: Pseudococcidae) found on dwarf bamboos in Japan are reviewed. A species currently placed as a junior synonym of Paraputo angustus (Ezzat McConnell 1956) was found to differ from P. angustus by having dorsal oral collar tubular ducts of two sizes rather than one, so it is revived as Formicococcus bambusiphilus (Takahashi 1958) stat. rev. and comb. nov.; it is redescribed, based on the lectotype and a paralectotype designated in this study and additional adult females collected more recently. A new species, Formicococcus kawaii sp. nov., is described; it is similar to F. bambusiphilus and Paraputo angustus (Ezzat McConnell 1956) but differs from them in having 18 pairs of cerarii, relatively large antennae and hind legs, and a dumbbell-shaped circulus. The characterization of a third dwarf bamboo-feeding species, Paraputo kaiensis (Kanda 1932), is updated based on adult females collected by the original describer and material collected more recently. Paraputo kaiensis resembles P. pauper (Danzig 1971) but differs in lacking translucent pores on the hind legs and in possessing a circulus. It also differs from most species of Paraputo Laing by having the anal opening situated on the posterior margin of the dorsum and an elongate-oval body, so the generic placement of this species remains questionable. Identification keys to separate mealybug genera with anal lobe bars and without oral rim ducts found in Asia, and to species of adult female Formicococcus in Japan and Paraputo in East Asia are provided.

A new species of the genus Luzulaspis (Hemiptera: Coccomorpha: Coccidae) from Hokkaido Island, Japan.

A new species of soft scale insect (Hemiptera: Coccomorpha: Coccidae), Luzulaspis kinakikir Tanaka sp. nov., collected from Carex miyabei (Cyperaceae), on Hokkaido Island, Japan, is described and illustrated based on adult female morphology. The new species, which belongs to the Scotica group of Luzulaspis, is similar to L. filizae Kaydan, 2015, but can be distinguished from it by possessing multilocular pores with fewer loculi; numerous dorsal tubular ducts, obviously wider than the ventral tubular ducts, and by lacking dorsal tubular ducts on the head apex. An updated diagnosis of Luzulaspis and two identification keys, one to the Japanese species of Luzulaspis and the other to the species of the Scotica group of Luzulaspis, are provided.

Description of a new soft scale insect of the genus Pulvinaria Targioni Tozzetti (Hemiptera: Coccomorpha: Coccidae) from India.

A new soft scale species (Hemiptera: Coccomorpha: Coccidae), Pulvinaria kalyaniensis Talukder Das, sp. n., is described from specimens collected on twigs of Azadirachta indica A. Juss. (Meliaceae) from Kalyani, West Bengal, India. This new species is similar to P. aligarhensis Avasthi Shafee and P. ixorae Green, but can be distinguished by different character states of dorsal areolations, submarginal tubercles, dorsal tubular ducts, the number of prevulvar setae and the number of loculi in each multilocular pore. An updated identification key to the species of Pulvinaria Targioni Tozzetti found in India is provided.

Reappraisal of factors impacting the cannulation rate and clinical efficacy of endoscopic minor papilla sphincterotomy

BackgroundWe aimed to assess factors impacting the endoscopic minor papilla sphincterotomy (EMPS) success rate, clinical efficacy, and safety in a large cohort of patients with symptomatic pancreas divisum (PD). MethodsRetrospective study including patients with PD referred to the Pancreas Institute of Verona from May 2009 to May 2020 to undergo EMPS. The whole population was analyzed to assess EMPS technical success, defined as the rate of deep cannulation of the dorsal duct. Patients treated for recurrent pancreatitis (RP) with a minimum follow-up of 1 year were included to evaluate the clinical efficacy, defined as resolution or significant reduction of acute pancreatitis (AP) episodes. Safety was defined as the rate of procedure-related adverse events (AEs) according to an international lexicon. The effects of the main determinants on study outcomes were evaluated. ResultsOverall, 106 patients were evaluated. Technical success was obtained in 87 (82.1%). The presence of pancreatic calcifications was associated with failure (p < 0.0001). Clinical efficacy was evaluated in 59 patients. Resolution/reduction of AP episodes after EMPS was observed in 93% of patients over a median follow-up of 49 months (IQR 37–92). Smoking habit was associated with AP recurrence (p = 0.026). The overall AE rate was 14.9%, with post-ERCP pancreatitis as the most common complication (12.6%). ConclusionsIn our study, performed at a tertiary center, EMPS showed satisfactory technical success and an acceptable safety profile. If confirmed by prospective multicenter studies, EMPS could become the standard of care for the treatment of RP in PD.

S3321 Recurrent Acute Pancreatitis Secondary to Pancreatic Divisum Anomaly

INTRODUCTION: Pancreatic divisum (PD) is a congenital malformation that occurs when the ventral and dorsal ducts of the pancreas fail to fuse. Inadequate drainage of pancreatic secretions from the minor papilla results in ductal distension and recurrent pancreatitis. We present a patient with PD who developed acute necrotizing pancreatitis (ANP) complicated by walled off pancreatic necrosis (WOPN). CASE DESCRIPTION/METHODS: 64-year-old female with history of chronic alcohol abuse and IBD presented with epigastric abdominal pain and emesis. Labs showed normal triglycerides, elevated lipase and amylase. Abdominal US ruled out gallstones. Abdominal CT showed pancreatic inflammation with several cystic-appearing fluid collections. She was treated conservatively. Repeat abdominal CT showed multiple increased peripancreatic fluid collections with mass effect on the stomach (Figure 1). Persistent abdominal pain led to ERCP which displayed complete PD and high-grade pancreatic duct fistula in the body and tail. Ventral and dorsal duct sphincterotomies were done with stent deployment in each duct. EUS revealed 3 peripancreatic fluid collections (consistent with WOPN); the largest was adjacent to the gastric antrum. Purulent drainage was noted after 3 cystogastrostomy incisions. Antibiotics were initiated. Patient eventually had recurrent pancreatitis, requiring repeat minor papilla sphincterotomy with dorsal pancreatic duct stent exchange. DISCUSSION: WOPN is a late complication of ANP, occurring more than 4 weeks after the initial attack. It can cause obstruction and fistula. Due to her PD anatomy, we suspect the patient had previous indolent acute pancreatitis episodes however they were falsely attributed to her IBD. Thus, delaying diagnosis of acute pancreatitis and leading to ANP and WOPN. The lifetime risk of pancreatitis in PD patients is similar to the general population. Consider PD in young, female patients in whom etiologies such as, gallstones and alcohol use, have been excluded. Alcohol abuse in context of her PD anatomy could have amplified our patient’s risk of acute pancreatitis. CT and MRI scans do not reliably detect PD thus ERCP remains the diagnostic test. Minor papilla sphincterotomy, papillary dilatation, stent insertion and pancreatic resection are treatment options. Since recurrent acute pancreatitis can lead to chronic pancreatitis, it is important to detect PD early. Follow up imaging in 3-6 months after pancreatitis resolution is vital, especially in patients with WOPN, to exclude neoplasm.Figure 1Figure 2.: Fig 1. and 2: CT abdomen and pelvis with contrast showing significantly compressed gastric lumen and multiloculated collections surrounding the pancreas, along the fundus of the stomach measuring 8 × 4.3 cm with mass effect, slightly inferiorly along the fundus and body measuring 7.7 × 4.2 cm, and along the antrum measuring 7.9 × 4.3 cm with surrounding fat stranding and mass effect.

S3575 A Unique Case of Acute Pancreatitis Due to Metastaic Melanoma to the Minor Papilla in a Patient With Pancreas Divisum

INTRODUCTION: Metastatic melanoma can occur in the gastrointestinal tract in patients with diagnosed metastatic malignant melanoma. We present a case of metastatic melanoma to the duodenum and minor papilla in a patient with pancreas divisum, which served as a trigger for acute pancreatitis. CASE DESCRIPTION/METHODS: A 54 yr old male presented to the emergency department with severe abdominal pain, elevated lipase 1654 U/L (0–60) and mildly elevated liver function tests (AST 40 IU/L (14–30) ALT 55 IU/L (10–52)). CT scan showed a metastatic process involving the pancreas, liver, lungs, and also worsening pancreatic duct dilation (7 mm) compared to the previous CT scan three months prior. His past medical history was significant for melanoma of the right thumb s/p amputation, metastatic melanoma (BRAF V600E negative), tobacco abuse, and recent 20 pounds weight loss. Gastroenterology was consulted for acute pancreatitis and recommended an EUS and ERCP. EUS detected multiple hypoechoic round and oval masses within the pancreatic and liver parenchyma suggesting metastasis, and also pancreas divisum, with pancreatic duct measuring 5 mm in diameter. On ERCP, the major papilla and the main biliary duct were normal. However, on the endoscopic view, we detected many 3–10 mm black and flat infiltrative masses in the first and second portion of the duodenum, very suggestive of duodenal metastasis. One of the flat masses was found in the minor papilla. Subsequently the dorsal pancreatic duct was unable to be cannulated. Supportive care was recommended and he was discharged in stable medical condition. DISCUSSION: Metastatic melanoma metastasizes to the GI tract between 1-4% of patients with diagnosed metastatic malignant melanoma. Our patient had multiple metastasis visualized in the duodenum, a common site of tumor occurrence. The patient also had pancreatic divisum, previously undiagnosed and seen on EUS. These patients have a failure of the dorsal and ventral pancreatic buds fusing and thus result in majority of the pancreas draining through the dorsal duct of Santorini through the minor papilla. The abnormal fusion causes abnormal drainage of the majority of the pancreatic juice into the naturally narrowed minor papilla, causing elevation of intraductal pressure in some patients. Our patient had no prior episodes of pancreatitis prior to his metastatic melanoma diagnosis, making the melanotic lesion the likely culprit in this case for the occurrence of acute pancreatitis.Figure 1.: Minor Papilla with Metastatic Melanoma Lesion.Figure 2.: Multiple Metastatic Melanoma Lesions in Duodenum.Figure 3.: Normal Major Papilla.

Incidence and risk factors for post-ERCP pancreatitis in pancreas divisum patients without chronic pancreatitis

Aims: The studies on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in pancreas divisum (PD) patients without chronic pancreatitis (CP) are rare. In this study, we aimed to evaluate the incidence of PEP in PD patients without CP and the risk and protective factors for PEP.Methods: Consecutive patients with symptomatic PD that underwent ERCP from January 2005 to December 2017 were retrospectively analyzed. The patients were divided into PD without CP group and CP group. The basic information and medical records of patients were collected. The risk and protective factors for PEP in PD patients without CP were analyzed by univariate logistic analysis.Results: A total of 89 ERCP procedures were performed in 51 PD patients without CP, and 249 procedures in 136 patients with CP. The incidence of PEP was significantly higher in PD patients without CP than those with CP (15.7% vs. 5.6%, p = .005). Female gender were independent risk factors for PEP, while dorsal duct stent placement was a protective factor.Conclusion: CP may be a protective factor against PEP in PD patients. Female was a risk factor for PEP in PD patients and dorsal duct stent placement was a preventive factor that reduced the incidence of PEP in PD patients without CP.

Frequency of Obliteration of the Dorsal and Ventral Ducts of the Pancreas in Islet Transplantation.

Islet isolation is an essential process in every human islet transplantation protocol. Intraductal enzyme delivery followed by adequate distention of the pancreas is the most critical step in islet isolation. Anomalies of the pancreatic duct system can significantly affect this process. Thus, identification and characterization of ductal patency is of paramount importance to achieve optimal islet isolation. To investigate the frequency of duct obliteration in the human pancreas and explore donor/patient characteristics associated with specific ductal variations. We examined ductal patency of pancreata allocated for islet allotransplantation (n = 597) and autotransplantation (n = 21) after removal of the duodenum during islet isolation procedure. Donor/patient factors were reviewed from the batch files. Among 559 deceased donor pancreata without pancreas divisum (n = 38, 6.4%), both ducts were patent in 50.1%, only ventral duct was patent in 46.7%, and only dorsal duct was patent in 3.2%. Donor age was not associated with the frequency of obliterated dorsal duct. Black race tended to have the higher frequency of patent dorsal duct. As expected, pancreas divisum was more frequent in chronic pancreatitis cases (n = 6, 28.6%). Within 7 cases of chronic pancreatitis with unknown etiology, we encountered one case of ventral duct obliteration. The minor duodenal papilla and aging do not likely play an important role in the occurrence of dorsal duct obliteration. Although frequency of obliterated ventral duct was low in our population, physicians, including gastroenterologists and endoscopists, as well as islet transplantation researchers should be aware of this possibility.

Mixed-type intraductal papillary mucinous neoplasm in a patient with pancreas divisum: pancreatoscopy through the Santorini duct with direct intraductal biopsy

View Large Image Figure ViewerDownload Hi-res image Download (PPT)A 72-year-old man with abdominal pain, hyperamylasemia/lipasemia, and dilatated main pancreatic duct shown by CT underwent MRCP (A, top left) that suggested a mixed-type intraductal papillary mucinous neoplasm (IPMN) with ectasia of multiple branch pancreatic ducts (A, top right) and of the entire dorsal duct (Santorini, 8 mm), draining the dorsal part of the pancreas through minor papilla (A, bottom left), with an incomplete ventral duct (Wirsung, A, bottom right), consistent with pancreas divisum (PD). EUS showed echoic material inside branch duct dilatations (B). Endoscopy showed a typical “fish-mouth” appearance of the minor papilla, draining mucus (C, top left). Pancreatography through the minor papilla confirmed dilatation of the Santorini duct (C, top right). Peroral pancreatoscopy through the minor papilla, with use of the SpyGlass system (Boston Scientific, Boston, Mass, USA), confirmed diffuse dorsal duct dilatation with mucinous material and papillary projections from the intraductal epithelium (C, bottom left). Histologic analysis of targeted intraductal biopsy specimens obtained with SpyBite forceps (Boston Scientific) (C, bottom right) demonstrated a mucin-producing papillary neoplasm with severely atypical cells, suggestive of malignancy (D, left: H&E, orig. mag. ×25). The patient underwent total pancreatectomy (D, middle); final pathologic examination demonstrated malignant IPMN (D, right: H&E, orig. mag. ×50). Patients with PD are at risk for the development of pancreaticobiliary tumors, including IPMN. In patients with PD and dorsal duct dilatation, the coexistence of main-duct IPMN should be considered. Our advice is to perform dorsal duct pancreatoscopy and direct biopsies to reach a final diagnosis. All authors disclosed no financial relationships. Commentary In 2020, most readers of Gastrointestinal Endoscopy should be familiar with the clinical manifestations of intraductal papillary mucinous tumors. Peroral pancreatoscopy with the use of ERCP has been performed in this setting for many years, both to confirm the diagnosis by imaging and perform biopsies and to quantify the extent of disease. Peroral pancreatoscopy can thus help to determine whether a patient would benefit most from a distal pancreatectomy, a pancreaticoduodenectomy, or a total pancreatectomy (as this patient underwent). This patient had pancreas divisum, which allowed peroral pancreatoscopy to be performed through the minor papilla, making the case even more interesting. It should be recognized that peroral pancreatoscopy carries the risk of causing post-ERCP pancreatitis, even in experienced hands, and appropriate steps should be taken to minimize the risk to the patient. Douglas G. Adler, MD, FASGE, GIE Senior Associate Editor, University of Utah School of Medicine, Salt Lake City, Utah Mohamed O. Othman, MD, Associate Editor for Focal Points