Pancreas Divisum Research Articles

A rare case of autoimmune pancreatitis with pancreatic divisum

Chronic pancreatitis has a fibro-inflammatory subtype called autoimmune pancreatitis. A combination of imaging tests, including a CT scan and pancreatography, lab tests that check for IgG4 and/or autoantibodies, histological analysis, and a favourable response to corticosteroid treatment are used for diagnosis. Hereby we present a case of a young boy who presented to our hospital with recurrent abdominal pain and on further investigation was found to have elevated levels of IgG4 as well as a developmental abnormality of pancreatic duct known as pancreatic divisum.

Rendezvous-assisted endoscopic retrograde pancreatography in a patient with annular pancreas and coexisting pancreas divisum.

An 18-year-old female was hospitalized for chronic pancreatitis of unknown origin. No history of alcohol abuse and hereditary diseases were found. Enhanced computed tomography (CT) and magnetic resonance cholangiography revealed dilated pancreatic duct system and abnormal pancreatic tissue incompletely wrapping around the second portion of the duodenum ([Fig. 1], [Fig. 2]). Endoscopic retrograde pancreatography (ERP) with intended minor papilla cannulation was attempted and yet failed due to the polypoid nodular papilla ([Fig. 3]).

Correction: Endoscopic ultrasonography successfully diagnosed pancreas divisum and santorinicele.

Correction to: Endoscopic ultrasonography successfully diagnosed pancreas divisum and santoriniceleEndoscopy 2023; 55(S 01): E527-E528DOI: 10.1055/a-2037-5436

Endoscopic ultrasonography successfully diagnosed pancreas divisum and santorinicele.

Endoscopic ultrasonography successfully diagnosed pancreas divisum and santorinicele.

Endoscopic ultrasound-guided rendezvous in pancreas divisum with a nondilated pancreatic duct.

Pancreas divisum is the most common congenital malformation of the pancreas, in which a single pancreatic duct does not form in the 7th week of gestation. It usually causes no symptoms or complications, but a small percentage of persons with this malformation develop recurrent acute pancreatitis. Patients with recurrent acute pancreatitis may benefit from endoscopic sphincterotomy of the minor papilla to open up the outflow of the dorsal pancreatic duct [1] [2].

A shot in the light: rendezvous endoscopic ultrasonography-guided pancreatic duct drainage in treatment of recurrent pancreatitis with pancreas divisum.

A 34-year-old man with recurrent pancreatitis was referred for endoscopic retrograde cholangiopancreatography (ERCP) [1], but cannulation of the main pancreatic duct (MPD) repeatedly failed at several teaching hospitals owing to pancreas divisum and invisible minor papilla orifice ([Fig. 1]) [2]. Thus, we decided to perform rendezvous endoscopic ultrasonography (EUS)-guided pancreatic duct drainage (EUS-PD-RV) ([Video 1]).

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.

Laparoscopic Sleeve Gastrectomy following Pylorus-Preserving Pancreaticoduodenectomy

Background: A 35-year-old married female (68 kg, 150 cm, BMI: 30.2) with pancreatic divisum complicated chronic pancreatitis and underwent pylorus-preserving pancreaticoduodenectomy in 2010. After that, her condition was well. However, body weight gained progressively to 76 kg (BMI: 33.7) and hypertension developed. During these two years, tried exercise and medication control for hypertension, but in vain. She received a laparoscopic sleeve gastrectomy in October 2013. The post-operative course was uneventful. Methods: We applied three ports for laparoscopic operation, including two 12 mm and one 5 mm trocars. The liver was not needed to be elevated due to adhesion. The operative time was 75 minutes. Results: The patient’s body weight was 10 kg reduced in the first two months and reduced to 59 kg 6 months later. Conclusions: We report a case that received laparoscopic sleeve gastrectomy following pylorus-preserving pancreaticoduodenectomy due to pancreatic divisum. This case encourages us to extend the indication of laparoscopic sleeve gastrectomy.

DOUBLE COMMON BILE DUCT ASSOCIATED WITH PANCREATIC DIVISUM: A CASE REPORT

Double common bile duct type I is a rare anomaly. Moreover, the association of double common bile duct and Pancreatic divisum is an even less common malformation. We reported a case of a combined double common bile duct type I and pancreatic divisum presented after complicated with a large common bile duct calculus. Classification and investigations for the double common bile duct are briefly discussed.

Endoscopic interventions for pancreas malformations and diseases in children

Introduction. Malformations and diseases of the pancreas are associated with the risk of complications. Interventional endoscopy is one of the ways to solve this problem.Material and methods. 24 patients (3–17 y.o.) were included in the study. 36 interventional endoscopic interventions were performed. Results. Transpapillary interventions were performed in 10 patients, all of them had anomalies of the ductal system. Stenosis of the distal pancreatic ducts was detected in 3 cases, in which stenting of the Wirsung duct was performed. Virsungolithiasis was confirmed in 3 cases, in which an anomaly of the ducts in the form of an incomplete split gland was detected in 2 patients. Pancreas divisum was detected in 1 patient, which required sphincterotomy of the minor duodenal papilla. Transmural interventions were performed in 13 cases: puncture – in 7 patients with intra- or parapancreatic cystic formations; drainage – in 6 patients with pancreatic pseudocysts. One child with traumatic rupture of the pancreas had a combined intervention (transpapillary and transmural). Discussion. The etiology of pancreatitis in children is associated with developmental anomalies and genetic factors. The leading pathogenetic factor in the development of complications is hypertension in the ducts of the gland. Traditional surgical interventions for pancreatitis are often traumatic and are accompanied by a high risk of complications. The introduction of minimally invasive techniques, such as interventional endoscopy, can solve the problem in some diseases of the pancreas.Conclusion. Transpapillary interventions can effectively eliminate hypertension in the pancreatic ducts in case of their dilatation and virsungolithiasis. Transmural interventions can be used to clarify the etiology of pancreatic cysts, as well as to drain pancreatic pseudocysts.

Safety and efficacy of minor papillotomy in children and adolescents with pancreas divisum

IntroductionPancreas Divisum (PD) is a common pancreatic ductal variant which is twice as common in pediatric patients with acute recurrent pancreatitis (ARP) relative to the general population (14% vs. 7%). Endoscopic retrograde cholangiopancreatography (ERCP) with minor papillotomy has been performed to facilitate drainage of pancreatic juice from the diminutive minor papilla to prevent pancreatitis and pancreatic damage. MethodsWe searched our prospectively-maintained endoscopy databases for patients 18 and younger who underwent ERCP with minor papillotomy between 2009 and 2019. Demographic data, indications, procedural interventions and findings, as well as available clinical outcomes data were analyzed. Results54 ARP/PD patients underwent ERCP with minor papillotomy. Median age was 14 (range 7–18) years, and 26 (48.1%) patients were female. Post-ERCP pancreatitis developed in 10/54 patients (18.5%). 12-month post-ERCP clinical trajectory was available in 47/54 (87%) patients and most patients (38/47, 80.8%) improved clinically after minor papillotomy, with 9/47 (19.1%) experiencing resolution of pancreatitis episodes and none indicated worsening severity or frequency of pancreatitis episodes following ERCP. ConclusionThe majority of children and adolescents with PD and ARP who underwent ERCP with minor papillotomy experienced subjective improvement in their symptoms following the intervention. These data suggest that ERCP with minor papillotomy for pediatric patients with PD and ARP is beneficial and may be curative in a subset of patients—higher rates of improvement than have been previously reported in adults.

Acute Pancreatitis; New Methods for Understanding an Old Problem

Acute pancreatitis is responsible of considerable amount of hospital admissions, and therefore, significant morbidity and mortality in the modern world. The disease poses a significant burden to healthcare systems since its incidence have been rose to as high as 45 subjects in every 100000 population since early 1990s. Excessive alcohol consumption and biliary tract disorders are two most common causes of acute pancreatitis. Other etiological factors include dyslipidemia, surgery or traumatic injury of abdomen, hypercalcemia, infections, inflammation related to vasculitis, tumors of pancreas or ampulla and various drugs. Drugs that cause acute pancreatitis are anti-neoplastic agents (i.e., asparaginase, azathioprine, mercaptopurine), antibiotics (i.e., tetracycline, isoniazid, sulfonamides, metronidazole), anti-inflammatory drugs (i.e., celecoxib, meselamine, leflunomide), thiazide diuretics, anti-diabetic treatments (i.e., exenatide, sitagliptin), and anti-hypertensive and anti-hyperlipidemia therapies (methyl dopa, enalapril, fenofibrate, simvastatin). Medical interventions such as enteroscopy, peritoneal dialysis, endoscopic retrograde colangio-pancreatography, may also induce acute pancreatitis. Cystic fibrosis and pancreas divisum are also contributing conditions to acute pancreatitis.

Gastrointestinal: Ampullary tumor growing into ventral pancreatic duct in incomplete pancreas divisum.

Gastrointestinal: Ampullary tumor growing into ventral pancreatic duct in incomplete pancreas divisum.

膵管癒合不全に合併した膵管内乳頭粘液性腫瘍に対して尾側膵亜全摘を行った1例

膵管癒合不全に合併した膵管内乳頭粘液性腫瘍に対して尾側膵亜全摘を行った1例

Pancreatic duct stents.

Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.

Recurrent acute pancreatitis: a diagnostic and a therapeutic dilemma

Although uncommon, surgeons and physicians are sometimes confronted with patients who presents with recurrent episodes of acute pancreatitis. When two or more episodes of acute pancreatitis occur without an identifiable cause, it is referred to as Recurrent Acute Pancreatitis (RAP). In such patients, selecting the most appropriate management strategy continue to pose a challenge due to multiple aetiological factors, associated conditions, microanatomical and pathological processes and complex immunological mechanisms of this condition. The identifiable causes of RAP such as bile duct stones, biliary sludge or crystals, Sphincter of Oddi Dysfunction (SOD), pancreatic duct obstructions due to benign and malignant neoplasms, genetic mutations, Pancreatic Divisum (PD), metabolic disorders, alcohol consumption and smoking may be identified in some patients. There are several other rare conditions which may be associated with RAP. However, in about 30%, no cause/s can be identified. Diagnosis is further complicated by the fact that, although the gland may appear morphologically normal following the initial episode of Acute Pancreatitis (AP), in some patients, evidence of Chronic Pancreatitis (CP) may manifest later. Furthermore, there is an ongoing debate as to whether, recurrent bouts of pancreatitis following the first; the Sentinel Acute Pancreatitis episode in patients who are 'immunologically' predisposed may lead to Chronic Pancreatitis. In such patients who subsequently develop acute episodes, i.e., Acute on Chronic Pancreatitis will further complicate recognition of aetiological factors of RAP. The recognition of possible causes, associated factors, and understanding of pathological progressions are therefore important in the management of such patients. Detailed clinical assessment and clinical reasoning, standard haematological and biochemical workup and basic and advanced imaging studies will help identify patients who can be selected for specific invasive and medical therapy to prevent acute episodes. This brief review is a clinical update to guide clinicians, the best way forward in the management of RAP.

ANNULAR PANCREAS DIVISUMTREATED WITH WHIPPLE PROCEDURE: A CASE REPORTAND UPDATE OF ARARE CONDITION

There are two distinct congenital anomalies of the pancreas-annular pancreas and pancreas divisum-both of which have the potential to manifest in infancy with symptoms that are taken to indicate duodenal blockage. However, symptoms such as stomach discomfort, postprandial fullness, and pancreatitis may not appear until maturity. An annular pancreatic divisum that required duodenopancreatectomyin a 32-year-old woman with a history of hyperthyroidism treated with carbimazole was admitted in our department. The MRCP was important in making the accurate diagnosis. This article describes the symptoms and potential treatments for annular pancreas divisum.

A successful endoscopic pancreatic stone extraction in a patient with pancreatic divisum with cholangiojejunostomy reconstruction.

A successful endoscopic pancreatic stone extraction in a patient with pancreatic divisum with cholangiojejunostomy reconstruction.

Clinical characteristics and endoscopic treatment of pancreatitis caused by pancreaticobiliary malformation in Chinese children.

We aimed to describe the clinical characteristics of pediatric patients with pancreatitis caused by pancreaticobiliary malformation and to evaluate the efficacy and safety of magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of the disease. Medical records of pediatric patients with pancreatitis related to pancreaticobiliary malformation diagnosed by ERCP and treated in our hospital between April 2008 and December 2020 were retrospectively reviewed. Clinical manifestations, laboratory indicators, genetic testing results and imaging findings including MRCP were collected. Of the 148 patients with pancreaticobiliary malformation-related pancreatitis, 90 (60.8%) had pancreaticobiliary maljunction (PBM), 52 (35.1%) had pancreatic divisum (PD), and six (4.1%) had annular pancreas (AnnP). Compared with the PD group, patients with PBM were younger (P < 0.001), and were more likely to have jaundice (P < 0.001) and fever (P = 0.034). Genetic mutation was found in 51.6% of patients with PD, 50.0% with AnnP, and 15.0% with PBM. Diagnostic rate of PBM, PD, and AnnP using MRCP was 46.7%, 15.4%, and 100%, respectively. In total, 87.8% of patients had symptomatic improvement after endoscopic treatment. ERCP-related complications were observed in 28 out of the 260 procedures, including post-ERCP pancreatitis (7.7%), infection (2.3%), and gastrointestinal bleeding (0.8%). PBM should be considered when jaundice and fever occur in pediatric patients. Genetic testing is recommended for those with PD and AnnP. The role of MRCP is limited in identifying pancreaticobiliary malformation in children. ERCP is effective and safe for the diagnosis and treatment for pediatric pancreatitis caused by pancreaticobiliary malformation.

S1837 Successful Use of Minor Papillotomy in Pancreas Divisum With Walled-Off Necrosis: Ready for Prime Time?

S1837 Successful Use of Minor Papillotomy in Pancreas Divisum With Walled-Off Necrosis: Ready for Prime Time?