Diagnosis and treatment of pancreas divisum: A literature review

Background:Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis.Recurrent acute pancreatitis,chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5%of the patients with pancreas divisum.This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum.Data sources:We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum.Results:There are limited reports available on this topic in the literature.We analyzed and described the main indications in the treatment of pancreas divisum,focusing on surgical treatment and a discussion of the different approaches.Furthermore,we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy(the Nakao procedure).Conclusions:Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease.Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications.Many techniques,of greater or lesser complexity,have been proposed.

Pancreatitis in patients with pancreas divisum:Imaging features at MRI and MRCP

AIM:To determine the magnetic resonance cholangiopancreatography(MRCP)and magnetic resonance imaging(MRI)features of pancreatitis with pancreas divisum(PD)and the differences vs pancreatitis without divisum.METHODS:Institutional review board approval was obtained and the informed consent requirement was waived for this HIPAA-compliant study.During one year period,1439 consecutive patients underwent successful MRCP without injection of secretin and abdominal MRI studies for a variety of clinical indications using a 1.5 T magnetic resonance scanner.Two experienced radiologists retrospectively reviewed all the studies in consensus.Disputes were resolved via consultation with a third experienced radiologist.The assessment included presence and the imaging findings of PD,pancreatitis,and distribution of abnormalities.The pancreatitis with divisum constituted the study group while the pancreatitis without divisum served as the control group.MRCP and MRI findings were correlated with final diagnosis.Fisher exact tests and Pearson × 2 tests were performed.RESULTS:Pancreatitis was demonstrated at MRCP and MRI in 173 cases(38 cases with and 135 cases without divisum)among the 1439 consecutive cases.The recurrent acute pancreatitis accounted for 55.26%(21 of 38)in pancreatitis patients associated with PD,which was higher than 6.67%(9 of 135)in the control group,whereas the chronic pancreatitis was a dominant type in the control group(85.19%,115 of 135)when compared to the study group(42.11%,16 of 38)(χ 2 = 40.494,P < 0.0001).In cases of pancreatitis with PD,the dorsal pancreatitis accounted for a much higher percentage than that in pancreatitis without PD(17 of 38,44.74% vs 30 of 135,22.22%)(χ 2 = 7.257,P < 0.05).CONCLUSION:MRCP and MRI can depict the features of pancreatitis associated with divisum.Recurrent acute pancreatitis and isolated dorsal involvement are more common in patients with divisum.

Rare variant of pancreaticobiliary maljunction associated with pancreas divisum in a child diagnosed and treated by endoscopic retrograde cholangiopancreatography: A case report

BACKGROUND Pancreaticobiliary maljunction(PBM) is an uncommon congenital anomaly of the pancreatic and biliary ductal system, defined as a union of the pancreatic and biliary ducts located outside the duodenal wall. According to the Komi classification of PBM, the common bile duct(CBD) directly fuses with the ventral pancreatic duct in all types. Pancreas divisum(PD) occurs when the ventral and dorsal ducts of the embryonic pancreas fail to fuse during the second month of fetal development. The coexistence of PBM and PD is an infrequent condition.Here, we report an unusual variant of PBM associated with PD in a pediatric patient, in whom an anomalous communication existed between the CBD and dorsal pancreatic duct.CASE SUMMARY A boy aged 4 years and 2 mo was hospitalized for abdominal pain with nausea and jaundice for 5 d. Abdominal ultrasound showed cholecystitis with cholestasis in the gallbladder, dilated middle-upper CBD, and a strong echo in the lower CBD, indicating biliary stones. The diagnosis was extrahepatic biliary obstruction caused by biliary stones, which is an indication for endoscopic retrograde cholangiopancreatography(ERCP). ERCP was performed to remove biliary stones. During the ERCP, we found a rare communication between the CBD and dorsal pancreatic duct. After clearing the CBD with a balloon, an 8.5 Fr 4-cm pigtail plastic pancreatic stent was placed in the biliary duct through the major papilla. Six months later, his biliary stent was removed after he had no symptoms and normal laboratory tests. In the following 4-year period, the child grew up normally with no more attacks of abdominal pain.CONCLUSION We consider that ERCP is effective and safe in pediatric patients with PBM combined with PD, and can be the initial therapy to manage such cases,especially when it is combined with aberrant communication between the CBD and dorsal pancreatic duct.

ERCP and CT diagnosis of pancreas divisum and its relation to etiology of chronic pancreatitis

AIM To inquire into the ERCP and CT features of pancreas divisum (PD) and its role in the etiology of chronic pancreatitis. METHODS Fourteen patients with PD were analyzed in regard to the findings in ERCP and CT, the activities of serum amylase and the incidence of pancreatitis. Dorsal ductography via minor papilla cannulation was performed in six of them. RESULTS The length of dorsal and ventral pancreatic duct was 16 56cm±2 52cm and 5 55cm±1 46cm. Most of the patients had dilatation of dorsal (10/14) and ventral (8/14) duct and the stenosis of dorsal duct terminal (10/14). Delayed clearance of contrast in dorsal duct was found in 8 patients. The size and contour of the pancreas were normal in all the patients at conventional CT. Pancreatitis was identified in 13 patients. CONCLUSION Dorsal ductography was necessary in the diagnosis of PD. Conventional CT play little role in the diagnosis of PD. Patients with PD run a higher risk of pancreatitis due to the stenosis of the minor papilla.

Choledochocele with pancreas divisum:A rare cooccurrence diagnosed on magnetic resonance cholangiopancreatography

We report a case of a 42-year-old male with symptomatic choledochocele and incidental pancreas divisum diagnosed with magnetic resonance cholangiopancreatography (MRCP). Small choledochocele is rare congenital malformation associated with non-specific symptoms and a delay in diagnosis. The coexistence of choledochocele and pancreas divisum is extremely rare with only two case reports published in literature. In both cases MRCP failed to diagnose any biliary or pancreatic abnormality. This case suggests that the patients with recurrent abdominal pain and pancreas divisum should not be presumed to be suffering from pancreatitis. Careful evaluated for additional anomalies in the biliary tree should be sought for refractory symptoms. MRCP is a useful one-stop-shop for diagnosing pancreatic and biliary ductal anomalies.

Endoscopic papillectomy of minor papillar adenoma associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare.We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy.A 64-year-old man was admitted to our hospital for treatment of an asymptomatic mass in the minor papilla detected by upper gastrointestinal endoscopy.Endscopic analysis showed an 18-mm,whitish,sessile mass,located in the duodenum proximal to a normal-appearing major papilla.Endoscopic retrograde pancreatography did not reveal the pancreatic duct.Magnetic resonance cholangiopancreatography showed a lack of the ventral pancreatic duct.We suspected this case was associated with pancreatic divisum;therefore,we performed endoscopic papillectomy of the minor papilla tumor.Subsequently,endoscopic pancreatic stent placement in the minor papilla was done to prevent drainage disturbance.The patient has been asymptomatic without recurrence of tumor or stenosis of the Santorini orifice upon endoscopic examination for the past 2 years.

Research advance in the diagnosis of pancreas divisum

Pancreas divisum is a kind of congenital anatomic abnormality;its diagnostic basis depends mainly on imaging examination. With the development of medical science, imaging technology has been improved and added, and a complete examination system including ERCP, B-Ultrasound, MRCP, S-MRCP and CT, etc. has been formed. There are even researcher, through further analysis of pancreas divisum on the level of genes, found that CFTR is a risk factor causing such disease. This paper is focused on the value of these examination methods in the diagnosis of pancreas divisum.

Gastric duplication associated with pancreas divisum diagnosed by a multidisciplinary approach before surgery

We report a unique case of communicating gastric duplication associated with pancreas divisum,diagnosed with a multidisciplinary approach,including X-rays,computed tomography,magnetic resonance imaging,esophagogastro duodenoscopy,ultrasound endoscopy and histology. We believe that this approach constitutes a fuller diagnostic evaluation,resulting in better and safer surgery.

Duodenal duplication cyst and pancreas divisum causing acute pancreatitis in an adult male

Duodenal duplication cysts are rare congenital abnormalities which are more commonly diagnosed in infancy and childhood.However,in rare cases,these lesions can remain asymptomatic until adulthood.The combination of duplication cyst and pancreas divisum is extremely rare and both conditions have been linked with acute recurrent pancreatitis.We present the case of a 37 years-old patient who presented with repeated episodes of acute pancreatitis.By means of magnetic resonance imaging and endoscopic ultrasonography we discovered a duplication cyst whose cavity received drainage from the dorsal pancreas.After opening the cyst cavity to the duodenal lumen with a needle knife the patient presented no further episodes in the clinical follow-up.Comparable literature findings and therapeutic options for these abnormalities are discussed with regard to the presented case.

Antegrade bowel intussusception after remote Whipple and Puestow procedures for treatment of pancreas divisum

To date, antegrade intussusception involving a Roux-en-Y reconstruction has been reported only once. We report a case of acute bowel obstruction due to an intussusception involving two Roux-en-Y limbs in a 40-year-old woman with a history of chronic pancreatitis due to pancreas divisum. Four years preceding this event, the patient had undergone a Whipple procedure, and three years prior to that, a Puestow operation. The patient was successfully treated with bowel resection and a side-to-side anastomosis between the most distal aspect of the bowel and the most distal Roux-en-Y reconstruction, which preserved both Roux-en-Y reconstructions.

胰腺分裂症的内镜微创治疗研究进展

胰腺分裂症是胰腺的一种先天性解剖变异性疾病,内镜微创治疗疗效好、恢复快、并发症少.本文就胰腺分裂症的发病机制、诊断及治疗方法做一综述.

胰腺分裂症的诊断及内镜治疗研究进展

胰腺分裂是最常见的胰腺先天性发育异常,大多数患者无症状,但少数患者合并胰腺炎、慢性腹痛等临床表现,称为胰腺分裂症。近年来,随着医学影像学和内镜技术的不断发展,胰腺分裂症的诊疗取得了一系列进展,无创诊断已成为可能,“超级微创”的治疗理念日益深入人心。尽管胰腺分裂症的诊疗水平不断提高,但临床中仍存在一些挑战和问题,需要进一步研究和探讨。本文总结了当前胰腺分裂症诊断与内镜治疗研究的最新进展,旨在加深临床医师对胰腺分裂症的认识并提高诊疗能力。

胰腺分裂症的内镜治疗

对长海医院 1993年 1月～2 0 0 1年 12月行内镜治疗的 5例PD患者的临床资料进行回顾分析。5例PD患者中 ,1例在导丝引导下用气囊导管对副乳头行扩张成形术 ;1例在导丝引导下行副乳头括约肌切开术 ,切开大小约 5mm ;3例行副乳头塑料探条 (7及8 5F)扩张。 3例行副胰管支架置入治疗 ,支架外径均为 7F ,长度分别为 3 5cm、5cm及 6cm。术后 2例 2 4h内血清淀粉酶高于正常 ,4 8h后恢复正常水平 ,未发现严重胰腺炎、出血及穿孔等并发症 ,近期腹痛缓解率为 10 0 %。随访 5～ 36个月 (平均 18个月 ) ,除 1例 8个月后因胰管支架阻塞再发腹痛 ,经更换支架后腹痛缓解 ,其余患者未再发腹痛 ,亦未发生支架移位及阻塞等远期并发症。提示对有症状的PD患者应积极行内镜治疗 ,尤其副胰管支架置入 ,可达到较好的胰液引流效果 ,缓解患者腹痛等症状。

胰腺先天异常的影像诊断

在胰腺的发育过程中,少数人将会产生胰腺的先天异常,主要有胰腺分裂和环状胰腺,只有提高对他们的认识,才能作出正确的CT和MRI诊断。

十二指肠副乳头插管在ERCP中的应用价值

目的：探讨十二指肠副乳头插管在ERCP操作中的价值。方法2008年11月～2015年9月，我院行副乳头插管造影及治疗52例，其中胰腺分裂18例，慢性胰腺炎24例，胰管增宽原因待查6例，胰腺假性囊肿1例，怀疑胰腺导管内乳头状肿瘤（ intraductal papillary mucinous neoplasm ，IPMN）2例，胰腺占位性质待查1例。结果52例行63次副胰管插管操作，成功46次，副乳头插管成功率73％（46／63）。35例副乳头插管成功，其中1例接受外科手术，其余34例1个月随访时症状缓解率91％（31／34），半年以上随访时症状缓解率82％（28／34）。结论十二指肠副乳头插管对于主胰管插管失败、胰腺分裂患者是ERCP胰管插管中的一种重要手段，值得推广。

磁共振胰胆管成像对胰腺分裂症的诊断价值

目的:比较磁共振胰胆管成像(MRCP)与内镜逆行胰胆管造影术(ERCP)对胰腺分裂的诊断价值。方法:回顾8例行MRCP及ERCP的胰腺分裂病例,分析比较胰腺分裂MRCP及ERCP的胰胆管表现及MRCP诊断的准确性。结果:8例经ERCP诊断为胰腺分裂的患者中,MRCP诊断的准确性为87.5%(7/8),ERCP显示了所有8例患者的背侧胰管及6例患者的腹侧胰管。MRCP显示8例患者的背侧胰管及3例患者的腹侧胰管。结论:作为一种无创伤性检查,MRCP对胰腺分裂诊断有重要临床价值。

胰腺分裂症的ERCP诊断与治疗价值

胰腺分裂症(Pancreatic Divisum,PD)是一种胰腺在发育过程中主、副胰管未融合的先天性发育不全,因胰液引流不畅而易导致胰腺炎;自20世纪70年代以来,随着ERCP技术的普及与提高,人们对PD的认识也渐清楚,诊断率明显提高,且可行ERCP治疗,据报告国外此病发病率为5％～7％,我院自1993年来,共诊断及治疗PD10例,占同期ERCP的2％,现就ERCP对PD的诊断与治疗价值总结如下: 1 材料和方法 1.1 材料 本组共10例,男7例,女3例,年龄18岁～71岁,平均35.5岁,病史10d～20a,主要症状有:腹痛10例,恶心、呕吐8例,腹泻3例,5例有复发性胰腺炎及反复血、尿淀粉酶升高病史(1a～7a),1例有糖尿病史;

内镜下胰管支架置入术治疗胰腺分裂症16例

目的探讨内镜下胰管支架置入术治疗胰腺分裂症的临床价值。方法 2010年1月—2011年1月间在北京电力医院就诊并经内镜下胰胆管造影(ERCP)检查后明确诊断为胰腺分裂症(PD)的患者16例,均行内镜下胰管支架置入术(EPS)。随访临床症状表现为反复发作的急性胰腺炎患者的体重及急性胰腺炎发作次数,慢性腹痛患者的体重及疼痛视觉模拟评分(VAS评分),并与术前进行比较。结果对10例反复发作的急性胰腺炎患者平均随访(16.4±2.4)个月,EPS术后患者的平均体重为(66.3±5.2)kg,显著高于术前的(58.2±8.2)kg(P<0.05);EPS术后中位急性胰腺炎发作次数为1.5次/年,显著低于术前的4.5次/年(P<0.05)。对6例慢性腹痛的患者平均随访(17.7±3.3)个月,EPS术后患者的平均体重为(62.3±8.0)kg,显著高于术前的(52.2±8.0)kg(P<0.05);EPS术后疼痛VAS评分为(1.7±0.6)分,显著低于术前的(7.2±0.8)分(P<0.05)。结论 EPS治疗PD安全有效,可有效减少急性胰腺炎的发作次数,并能减轻腹痛程度。

胰腺分裂症的ERCP诊断与治疗价值(附10例临床分析)

目的 探讨胰腺分裂症 (PancreaticDivisum ,PD)ERCP诊断与治疗价值。方法 总结分析了我院经ERCP确诊及治疗的 10例PD病人临床资料。结果 PD占我院同期ERCP的 2 % ,10例患者均有慢性腹痛症状 ,5例病人有复发性胰腺炎病史 ,10例患者ERCP所见 :主胰管长度 1.5～ 4.2cm ,平均 2 .2 9cm ,其末端呈细树枝样 ,9例副乳头膨大 ,开口明显 ,用针状或尖头形造影导管行副乳头插管 ,均显影 ,副胰管长度 8.5～ 14 .2cm ,平均 12 .1cm ,均有不同程度的扩张 ,1例乳头开口部狭窄 ,并见副胰管头部有一 6× 4mm囊性扩张 ,主、副胰管间无汇合交通支 ,本组病人中 5例经副乳头行支架引流治疗 ,3例副乳头扩张 ,1例行副乳头切开术 ,随访 3～ 36个月 ,8例病人腹痛明显缓解 ,5例有复发性胰腺炎病史者未再复发 ,1例病人术后 8月因胰管支架阻塞而更换支架。

Endoscopic approach through the minor papilla for the management of pancreatic diseases

AIM:To clarify the efficacy and safety of an endoscopic approach through the minor papilla for the management of pancreatic diseases.METHODS:This study included 44 endoscopic retrograde cholangiopancreatography(ERCP) procedures performed in 34 patients using a minor papilla approach between April 2007 and March 2012.We retrospectively evaluated the clinical profiles of the patients,the endoscopic interventions,short-term outcomes,and complications.RESULTS:Of 44 ERCPs,26 were diagnostic ERCP,and 18 were therapeutic ERCP.The most common cause of difficult access to the main pancreatic duct through the major papilla was pancreas divisum followed by distortion of Wirsung's duct.The overall success rate of minor papilla cannulation was 80%(35/44),which was significantly improved by wire-guided cannulation(P = 0.04).Endoscopic minor papillotomy(EMP) was performed in 17 of 34 patients(50%) using a needle-knife(13/17) or a pull-type papillotome(4/17).EMP with pancreatic stent placement,which was the main therapeutic option for patients with chronic pancreatitis,recurrent acute pancreatitis,and pancreatic pseudocyst,resulted in short-term clinical improvement in 83% of patients.Mild post-ERCP pancreatitis occurred as an early complication in 2 cases(4.5%).CONCLUSION:The endoscopic minor papilla approach is technically feasible,safe,and effective when the procedure is performed in a high-volume referral center by experienced endoscopists.