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Case Reports in Gastroenterology 2024Portal annular pancreas (PAP) is a congenital anomaly resulting from aberrant fusion of the ventral and dorsal pancreatic buds around the portal vein (PV). PAP was...
INTRODUCTION
Portal annular pancreas (PAP) is a congenital anomaly resulting from aberrant fusion of the ventral and dorsal pancreatic buds around the portal vein (PV). PAP was classified into three types by Joseph et al., based on the location of the main pancreatic duct around the PV. The presence of PAP is important for the surgical procedure because it is associated with the postoperative pancreatic fistula. There are no standardized surgical procedures of resection and reconstruction for PAP.
CASE PRESENTATION
We report 2 cases of subtotal stomach-preserving pancreatoduodenectomy in patients with PAP. One case of PAP was discovered coincidentally intraoperatively, and the other case was diagnosed before surgery. The first case was an 84-year-old male patient who underwent surgery for distal bile duct cancer. PAP was noticed intraoperatively when the uncinate process of the pancreas was detached from behind the PV. The second case was an 84-year-old female patient who also underwent surgery for distal bile duct cancer. We recognized PAP from preoperative computed tomography images. In both cases, the ductal anatomy was consistent with type IIIA PAP, and the dorsal pancreas was resected using a stapling device. During the postoperative period, there was no clinically relevant postoperative pancreatic fistula.
CONCLUSION
PAP is rarely encountered intraoperatively; however, it is important to recognize it before surgery and take it into consideration when deciding upon the procedures for resection and reconstruction.
PubMed: 38628808
DOI: 10.1159/000538370 -
African Journal of Paediatric Surgery :... 2023Annular pancreas (AP) is a congenital anomaly and a recognised cause of duodenal obstruction which can affect all age groups. It may manifest early in the neonatal...
Annular pancreas (AP) is a congenital anomaly and a recognised cause of duodenal obstruction which can affect all age groups. It may manifest early in the neonatal period, but it may also have varied and often delayed symptoms. We report the case of AP in an 18-month-old girl with a long history of recurrent post-prandial non-bilious vomiting treated for a long time with the clinical diagnosis of gastroesophageal reflux. Upper gastrointestinal study was suggestive of partial duodenal obstruction and computed tomography revealed a complete ring of pancreatic parenchyma surrounding the second part of the duodenum. Diamond-shaped duodenoduodenostomy was achieved successfully and the post-operative period was uneventful. Although rare, AP must be kept in mind of any paediatric surgeon while confronted to symptoms of partial duodenal obstruction.
Topics: Female; Infant, Newborn; Humans; Child; Infant; Duodenal Obstruction; Duodenum; Pancreas; Vomiting
PubMed: 36722572
DOI: 10.4103/ajps.ajps_86_21 -
Gastroenterology Sep 2019
Topics: Adult; Diagnosis, Differential; Duodenal Obstruction; Endoscopy, Digestive System; Female; Gastroparesis; Gastrostomy; Humans; Pancreas; Pancreatectomy; Pancreatic Diseases; Predictive Value of Tests; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 31063781
DOI: 10.1053/j.gastro.2019.04.045 -
Medicine Dec 2021Portal annular pancreas (PAP) is a rare pancreatic anomaly characterized by portal vein encasement in the pancreatic parenchyma. Due to its rarity, PAP may often be...
RATIONALE
Portal annular pancreas (PAP) is a rare pancreatic anomaly characterized by portal vein encasement in the pancreatic parenchyma. Due to its rarity, PAP may often be missed on preoperative computed tomography (CT) review, and surgeons may face challenges in dealing with an unexpected intraoperative encounter with PAP. We documented 2 such intraoperatively diagnosed cases and illustrated their surgical management.
PATIENTS CONCERNS
In case 1, a 70-year-old man was found to have a 15-mm mass in the pancreatic body and dilatation of the peripheral main pancreatic duct on enhanced CT. Case 2 involved a 46-year-old woman with a history of familial adenomatous polyposis, and rectal cancer with a mass in the duodenal papilla.
DIAGNOSES
The patient in case 1 was diagnosed with resectable pancreatic cancer. In case 2, the patient was diagnosed with duodenal papillary carcinoma.
INTERVENTIONS
In case 1, the patient underwent distal pancreatectomy with lymph node dissection. In case 2, the patient underwent pancreaticoduodenectomy. Intraoperatively, PAP was observed in both cases. In case 1, after the usual transection at the right border of the portal vein, an additional dissection was performed on the dorsal pancreas using a powered linear stapler. In case 2, an additional section was made in the pancreatic body caudal to the cricoid pancreatic junction so that the pancreatic cross-section was oriented in 1 plane.
OUTCOMES
The patient in case 1 was discharged without complications. In case 2, although the patient had a grade-B pancreatic fistula (International Study Group of Pancreatic Fistula Classification), the patient recovered conservatively and was discharged without significant complications. In both cases, a retrospective review identified PAP in patients' preoperative CT images.
LESSONS
Both cases required ingenuity during pancreatectomy. Awareness about PAP and its management will enable surgeons to prepare for unexpected encounters with the condition. Moreover, surgeons (especially pancreatic surgeons) should consider the possibility of PAP while managing pancreatic anomalies to make appropriate treatment decisions.
Topics: Aged; Female; Humans; Lymph Node Excision; Male; Middle Aged; Pancreas; Pancreatectomy; Pancreatic Diseases; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Portal Vein; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 34918681
DOI: 10.1097/MD.0000000000028204 -
Revista Medica Del Instituto Mexicano... Jul 2019Annular pancreas is a congenital abnormality which causes duodenal obstruction in neonates. It befalls upon 1 patient amongst every 12 000-15 000 newborns. It often...
BACKGROUND
Annular pancreas is a congenital abnormality which causes duodenal obstruction in neonates. It befalls upon 1 patient amongst every 12 000-15 000 newborns. It often appears in adulthood. Clinical traits include abdominal pain, intestinal obstruction, vomiting, and pancreatitis. The diagnosis requires image studies and surgical exploration.
CLINICAL CASE
Female patient, 11 years of age, presenting intermittent chronic abdominal pain, underweight for her age. Treated by a private physician with ranitidine (4 mg/kg/day) and ibuprofen (5 mg/kg/dose) orally, for one month, due to acid-peptic disease. On December 31, 2017, she was attended at Pediatric Emergency presenting epigastric pain, and nausea. She vomited bile contents 4 times over a 24 hour span. Other symptoms included painful reaction to epigastric palpation, positive pancreatic points, negative Murphy’s sign, no hepatomegaly or splenomegaly, decreased peristaltic noises. Reported: amylase 2163 U/L, lipase 821 U/L, lactic dehydrogenase 461 U/L. Pancreatic ultrasound: 19.3 mm head, 23.2 mm body and 10 mm tail. She was admitted to pediatrics, where the annular pancreas condition was confirmed through ultrasound and computed tomography scan. She then underwent conservative treatment.
CONCLUSION
The patient displayed typical annular pancreas symptoms. Image studies were key to the diagnosis.
Topics: Abdominal Pain; Child; Female; Humans; Pancreas; Pancreatic Diseases; Radiography, Abdominal; Stomach; Tomography, X-Ray Computed; Ultrasonography
PubMed: 31618567
DOI: No ID Found -
Journal of Pediatric Surgery Feb 2024Paediatric pancreatic pathology and its management is rarely described. We present our experience.
BACKGROUND
Paediatric pancreatic pathology and its management is rarely described. We present our experience.
METHODS
A retrospective case-note review of all patients with pancreatic disease from 1995 to 2021 was completed. Data are quoted as median (range).
RESULTS
Two hundred and twelve patients were identified with 75.9% presenting with pancreatitis. Referrals for pancreatitis increased during the study period and affected a wide age range (2 months-15.6 years). Acute pancreatitis (n = 118) (age 10.6 (0.18-16.3) years). The most common causes were idiopathic (n = 60, 50.8%) and biliary (n = 28, 23.8%). About 10% required treatment for complications or underlying biliary causes. Recurrent pancreatitis (n = 14) (11.6 (0.3-14.3) years). The most common cause was hereditary pancreatitis (n = 6, 42.9%). One patient required endoscopic drainage of pseudocyst. Chronic pancreatitis (n = 29) (16 (0.38-15.5) years). The underlying diagnosis was idiopathic (n = 14, 48.4%) or hereditary pancreatitis (n = 10, 34.5%). 13 patients required active management, including pancreaticojejunostomies (n = 5). Blunt Trauma (n = 34) was managed conservatively in 24 (70.5%). 6 patients required open surgery, but 4 were managed by either endoscopy or interventional radiology. Pancreatic tumours (n = 13) presented at 11.2 (2.3-16) years. Pathology included pancreaticoblastomas (n = 3), solid pseudopapillary tumours (n = 3), neuroendocrine tumours (n = 2), acinar cell cystadenoma (n = 1), intraductal papillary mucinous neoplasm (n = 1), pancreatic insulinoma (n = 1), pancreatic ductal adenocarcinoma (n = 1), and embryonal rhabdomyosarcoma (n = 1). OTHERS (N = 4): Pancreatic cyst (n = 3) and annular pancreas (n = 1).
CONCLUSION
Paediatric pancreatic disease spans a wide spectrum of both benign and malignant disease and benefits from access to specialist medical, surgical, endoscopic, and interventional radiology expertise. Referrals for paediatric pancreatitis are increasing, but aetiology is different to that seen in adults.
LEVEL OF EVIDENCE
IV.
Topics: Adult; Humans; Child; Infant; Retrospective Studies; Pancreatitis; Acute Disease; Treatment Outcome; Pancreatic Diseases; Pancreatic Neoplasms; Endoscopy, Gastrointestinal; Pancreatitis, Chronic
PubMed: 37957099
DOI: 10.1016/j.jpedsurg.2023.10.035 -
Cureus Mar 2024Lymphatic malformations frequently present as benign masses in the neck and clavicle region among infants and young children. Cystic hygroma represents an...
Lymphatic malformations frequently present as benign masses in the neck and clavicle region among infants and young children. Cystic hygroma represents an often-encountered form of lymphatic malformation. This case report details the medical history of a one-year-old girl characterized by a multifaceted medical background, initially exhibiting symptoms of persistent cough, cold, and neck swelling. Further investigations revealed more severe conditions: complex congenital heart defects, including large atrial septal defect (ASD), large ventricular septal defect (VSD), and aorta arising from the right ventricle with cystic hygroma and annular pancreas. The patient underwent various diagnostic tests, including chest X-rays, ultrasound, magnetic resonance imaging (MRI), and computed tomography pulmonary angiogram (CTPA), leading to multidisciplinary treatment involving sclerotherapy for cystic hygroma and supportive therapies. The case underscores the challenges in diagnosing and managing pediatric patients with overlapping conditions and the critical need for continuous follow-up.
PubMed: 38659571
DOI: 10.7759/cureus.56852 -
Surgical Case Reports May 2020Portal annular pancreas (PAP) is a rare pancreatic anomaly in which the uncinate process wraps annularly around the portal vein and fuses to the body of the pancreas....
BACKGROUND
Portal annular pancreas (PAP) is a rare pancreatic anomaly in which the uncinate process wraps annularly around the portal vein and fuses to the body of the pancreas. PAP is highly relevant to the development of postoperative pancreatic fistula (POPF) in pancreatic surgery. Here, we describe our experience and surgical technique of laparoscopic spleen-preserving distal pancreatectomy using Warshaw's procedure for patients with the PAP.
CASE PRESENTATION
A 49-year-old woman with PAP was referred to our hospital for a suspicious mucinous cystic neoplasms 1.5 cm in diameter in the pancreatic tail. Laparoscopic spleen-preserving distal pancreatectomy using Warshaw's procedure was performed. Mobilization of the pancreatic tail was first performed, and then, the splenic artery was cut. After dividing the pancreatic tail from the splenic hilum, the ventral pancreatic parenchyma was divided using a stapler. After cutting the splenic vein, complete mobilization of the pancreatic body and tail enabled easy division of the PAP. Finally, the PAP was also divided using the stapler. Although grade B POPF occurred, she was discharged on the 9th postoperative day.
CONCLUSIONS
Surgeons should understand the anatomical characteristics of PAP and be aware of the possibility of POPF.
PubMed: 32358636
DOI: 10.1186/s40792-020-00852-7 -
Clinical Gastroenterology and... Apr 2024
Topics: Humans; Pancreatic Neoplasms; Pancreas; Pancreatic Diseases; Carcinoma, Pancreatic Ductal
PubMed: 37730156
DOI: 10.1016/j.cgh.2023.09.005 -
Annals of Surgical Oncology Mar 2024Sufficient knowledge and surgical management of portal annular pancreas (PAP) are essential for pancreatic surgery. As PAP is a relatively rare pancreatic anomaly, few...
BACKGROUND
Sufficient knowledge and surgical management of portal annular pancreas (PAP) are essential for pancreatic surgery. As PAP is a relatively rare pancreatic anomaly, few studies have described surgical techniques for patients with PAP undergoing robotic pancreatoduodenectomy (RPD).
PATIENTS AND METHODS
An 82-year-old female patient who underwent RPD presented with distal cholangiocarcinoma and type III PAP (the fusion of the uncinate process with the anteportal main pancreatic duct). After the Kocher maneuver and stomach transection, the pancreas was transected into the neck of the anteportal portion. The retroportal portion was dissected, encircled with hanging tape, and compressed. Blood supply from the mesenteric vessels was confirmed using indocyanine green (ICG) fluorescence imaging. Subsequently, the retroportal portion was stapled.
CONCLUSIONS
This study demonstrates a unique surgical technique for type III PAP using the hanging maneuver with ICG fluorescence imaging. Surgeons should decide on the surgical strategy on the basis of the fusion and ductal anatomy of the pancreas.
Topics: Female; Humans; Aged, 80 and over; Pancreaticoduodenectomy; Indocyanine Green; Robotic Surgical Procedures; Pancreas; Optical Imaging; Pancreatic Diseases
PubMed: 38055095
DOI: 10.1245/s10434-023-14685-9