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World Journal of Surgical Oncology Apr 2019Portal annular pancreas (PAP) is a rare congenital anatomical abnormality of the pancreas in which the portal vein is encircled by aberrant parenchyma, and special...
BACKGROUND
Portal annular pancreas (PAP) is a rare congenital anatomical abnormality of the pancreas in which the portal vein is encircled by aberrant parenchyma, and special attention is needed for pancreatic resections. This is the first report of central pancreatectomy (CP) in a PAP for metastatic renal cell carcinoma (RCC).
CASE PRESENTATION
A 76-year-old man who had a history of left nephrectomy for renal cancer not otherwise specified 36 years earlier and radical cystectomy for bladder cancer 4 years earlier was incidentally found to have a pancreatic tumor and a liver tumor. The pancreatic tumor was diagnosed as metastasis of clear cell RCC, and the liver tumor was diagnosed as moderately differentiated hepatocellular carcinoma (HCC) on preoperative histological evaluation. Preoperative computed tomography imaging showed a type 3A PAP, in which the main pancreatic duct (MPD) ran ventral to the portal vein (anteportal type), and the aberrant parenchyma was located cranial to the confluence of the portal vein and splenic vein (suprasplenic type). After adhesiotomy and partial liver resection, CP was performed. With intraoperative ultrasound guidance, the aberrant parenchyma of the PAP could be preserved, avoiding additional resection. Thus, two pancreatic transections were performed, creating a single-cut margin that contained the MPD in the distal pancreas. Oncologically safe margins were confirmed by intraoperative pathological diagnosis. The distal pancreas was reconstructed by pancreatojejunostomy in the routine procedures. The pathological diagnosis of the surgical specimens was identical to the preoperative diagnosis. A postoperative pancreatic fistula (POPF) developed from the proximal stump of the head of the pancreas, necessitating no specific treatment other than drainage. The patient showed no signs or symptoms of recurrent RCC or abnormal pancreatic function for 2 years after the operation, although a histologically proven new HCC lesion developed distant from the initial site 8 months after the operation.
CONCLUSIONS
Precise preoperative evaluation of the tumor features and PAP allowed adequate surgical strategies to be planned. Intraoperative ultrasound was useful to minimize parenchymal resections of the PAP. CP is still a challenging procedure in terms of the development of POPF.
Topics: Aged; Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Male; Pancreas; Pancreatectomy; Pancreatic Diseases; Portal Vein; Postoperative Complications; Prognosis
PubMed: 31039791
DOI: 10.1186/s12957-019-1622-8 -
Asian Journal of Surgery Jun 2019
Topics: Anatomic Variation; Female; Humans; Middle Aged; Pancreas; Pancreatic Diseases; Portal Vein; Tomography, X-Ray Computed
PubMed: 30852073
DOI: 10.1016/j.asjsur.2019.02.001 -
Surgical Case Reports Feb 2019Although annular pancreas concurrent with pancreaticobiliary maljunction has rarely been reported, some reports have pointed out a possibility that both anomalies have a...
BACKGROUND
Although annular pancreas concurrent with pancreaticobiliary maljunction has rarely been reported, some reports have pointed out a possibility that both anomalies have a common pathogenesis in pancreatic development. We herein report a case with pancreaticobiliary maljunction diagnosed long after surgical treatment for annular pancreas.
CASE PRESENTATION
A 34-year-old female, with a surgical history of duodenal obstruction due to annular pancreas in the neonatal period, was referred to our hospital for further examination of chronic pancreatitis. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography revealed choledocholithiasis, pancreatic lithiasis, and pancreaticobiliary maljunction without biliary dilatation. Choledocholithotomy and cholecystectomy were performed, and highly elevated levels of amylase in bile from the common bile duct were found intraoperatively.
CONCLUSION
The present case highlights a possible association of pancreaticobiliary maljunction in a patient with annular pancreas.
PubMed: 30707318
DOI: 10.1186/s40792-019-0572-2 -
Journal of Radiology Case Reports Oct 2018Annular pancreas is a rare congenital condition in which tissue from the head of the pancreas partially or completely surrounds the second part of the duodenum. This...
Annular pancreas is a rare congenital condition in which tissue from the head of the pancreas partially or completely surrounds the second part of the duodenum. This condition has a variable clinical presentation in adults and children. Radiologists should be aware of the imaging findings in adults as an annular pancreas can be overlooked or misdiagnosed in this patient population. In this case report we describe an adult patient with pancreatitis associated with the computed tomography findings of a complete annular pancreas and discuss additional imaging techniques and findings for differential diagnoses of this condition.
Topics: Contrast Media; Diagnosis, Differential; Humans; Imaging, Three-Dimensional; Iopamidol; Male; Middle Aged; Pancreas; Pancreatic Diseases; Pancreatitis; Tomography, X-Ray Computed
PubMed: 30651906
DOI: 10.3941/jrcr.v12i10.3461 -
Journal of Minimal Access Surgery 2020Annular pancreas is a rare, congenital, rotational anomaly of pancreas, seen usually in newborns who present with features of duodenal obstruction. However, in adults,...
BACKGROUND
Annular pancreas is a rare, congenital, rotational anomaly of pancreas, seen usually in newborns who present with features of duodenal obstruction. However, in adults, only 24% of cases are present with duodenal obstruction. Surgery remains the procedure of choice in patients in whom symptoms can be attributed to duodenal obstruction and the goal of surgery is to relieve obstruction by bypassing the annulus. Laparoscopic Roux-en Y duodenostomy (DJ) is our preferred bypass approach for this condition. Literature search revealed that very few case reports have been published about laparoscopic management of annular pancreas, especially about duodenojejunal anastomosis. We present our experience in the laparoscopic management of symptomatic annular pancreas in adults and technique of the laparoscopic Roux-en Y DJ for annular pancreas.
MATERIALS AND METHODS
Between 1996 and 2016, a total of six adult patients underwent laparoscopic management for symptomatic annular pancreas. The demographic, perioperative and follow-up details were documented.
RESULTS
All surgeries were successfully performed by laparoscopic approach with no conversion to open. Five cases underwent Roux-en Y DJ and one underwent gastrojejunostomy. No major perioperative events occurred. The mean length of hospital stay was 5.6 days. Five out of six patients were followed up for 24 months, and no symptom recurrence was seen.
CONCLUSION
Laparoscopic Roux-en Y duodenojejunostomy could be used as a safe and physiological treatment for annular pancreas in adult patients and should be preferred for the treatment of duodenal obstruction due to annular pancreas.
PubMed: 30618433
DOI: 10.4103/jmas.JMAS_245_18 -
Gastrointestinal Endoscopy Feb 2019Annular pancreas is a congenital anomaly whereby pancreatic tissue encircles the duodenum. Current knowledge of endoscopic findings of annular pancreas is limited to... (Observational Study)
Observational Study
BACKGROUND AND AIMS
Annular pancreas is a congenital anomaly whereby pancreatic tissue encircles the duodenum. Current knowledge of endoscopic findings of annular pancreas is limited to small case series. The aim of this study was to describe the endoscopic and pancreatographic findings of patients with annular pancreas at a large tertiary care ERCP center.
METHODS
This is a retrospective observational study. Our Institutional Review Board-approved, prospectively collected ERCP database was queried for cases of annular pancreas. The electronic medical records were searched for patient and procedure-related data.
RESULTS
From January 1, 1994, to December 31, 2016, 46 patients with annular pancreas underwent ERCP at our institution. Index ERCP was technically successful in 42 patients (91.3%), and technical success was achieved in all 46 patients (100%) after 2 attempts, when required. A duodenal narrowing or ring was found in most patients (n = 39, 84.8%), yet only 2 (4.3%) had retained gastric contents. Pancreas divisum was found in 21 patients (45.7%), 18 of which were complete divisum. Pancreatobiliary neoplasia was the indication for ERCP in 7 patients (15.2%). Pancreatographic findings consistent with chronic pancreatitis were noted in 15 patients (32.6%) at the index ERCP.
CONCLUSION
This is the largest series describing the endoscopic and pancreatographic findings of patients with annular pancreas. We found that 45.7% of patients had concurrent pancreas divisum. Endoscopic therapy was successful in most patients at our institution after 1 ERCP, and in all patients after a second ERCP. Nearly one-third of patients had findings consistent with chronic pancreatitis at the time of index ERCP. It is unclear whether this may be a feature of the natural history of annular pancreas.
Topics: Adolescent; Adult; Aged; Bile Duct Neoplasms; Child; Child, Preschool; Cholangiopancreatography, Endoscopic Retrograde; Cholangiopancreatography, Magnetic Resonance; Endoscopy, Digestive System; Female; Humans; Male; Middle Aged; Pancreas; Pancreatic Diseases; Pancreatic Neoplasms; Pancreatitis, Chronic; Retrospective Studies; Sphincter of Oddi Dysfunction; Tertiary Care Centers; Young Adult
PubMed: 30240880
DOI: 10.1016/j.gie.2018.09.008 -
Zhejiang Da Xue Xue Bao. Yi Xue Ban =... May 2018To analyze complications after laparoscopic Ladd operation for intestinal malrotation, related causes and possible solutions.
OBJECTIVE
To analyze complications after laparoscopic Ladd operation for intestinal malrotation, related causes and possible solutions.
METHODS
Clinical data of 81 neonates who underwent laparoscopic Ladd operations for intestinal malrotation in the Children's Hospital, Zhejiang University School of Medicine between January 2015 and January 2018 were reviewed. The abdominal complications and findings during operation and reoperation were analyzed.
RESULTS
Operations were successfully completed in all patients, and there was no patient converted to open surgery. The annular pancreas in 6 cases and duodenal diaphragm in 4 cases were confirmed during the operation. The recurrent volvulus developed in 3 patients (3.7%), of whom 2 cases were confirmed to have midgut necrosis during open surgery 1 week and 3 months after laparoscopic Ladd operation, and both finally died; 1 case was corrected by second laparoscopic operation. Cecal perforation occurred in 1 patient (1.2%), which was caused by intensive high frequency coagulation of the appendiceal stump. One patient (1.2%) developed chylous ascites and improved after conservative treatment. Adhesive small bowel obstruction was observed in 3 cases (3.7%), and all relieved after conservative treatment.
CONCLUSIONS
Laparoscopic Ladd operation for intestinal malrotation in neonates was effective, and the incidence of abdominal complications may be minimized by experienced skills and strict perioperative management.
Topics: Digestive System Abnormalities; Digestive System Surgical Procedures; Humans; Infant, Newborn; Intestinal Volvulus; Laparoscopy; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 30226329
DOI: 10.3785/j.issn.1008-9292.2018.06.10 -
Annals of Translational Medicine Jun 2018Annular pancreas is in adults is a rare congenital anomaly which incidence varied from 0.005% to 0.015%. Although 33% of the cases are symptomatic, the symptoms are most...
Annular pancreas is in adults is a rare congenital anomaly which incidence varied from 0.005% to 0.015%. Although 33% of the cases are symptomatic, the symptoms are most commonly associated with gastric outlet obstruction. Here we presented an adult diagnosed with annular pancreas treated by laparoscopic Roux-en-Y side to side duodenojejunostomy.
PubMed: 30023374
DOI: 10.21037/atm.2018.05.13 -
African Journal of Paediatric Surgery :... 2018Atypical presentation of intestinal malrotation provide a diagnostic and therapeutic dilemma for the surgeon to answer the question is it wisdom to operate or not? Upper...
BACKGROUND
Atypical presentation of intestinal malrotation provide a diagnostic and therapeutic dilemma for the surgeon to answer the question is it wisdom to operate or not? Upper gastrointestinal (UGI) contrast study is essential for diagnosis; however, 'soft' radiologic findings place the responsibility of excluding malrotation directly on the surgeon. Recently, minimally invasive surgical techniques would be able to accomplish the identical evaluation and treatment of this group of patients.
PATIENTS AND METHODS
A total of 40 patients (25 male, 15 female), age of 2-14 years, presented with symptoms of chronic abdominal pain, intermittent upper intestinal obstruction, recurrent bilious vomiting and failure to thrive. On clinical examination, none of the patients had signs of acute abdominal emergency. UGI contrast study was done and it was equivocal. All patients underwent laparoscopic evaluation.
RESULTS
A total of 36 patients (90%) were found on laparoscopy to have a discrepant finding of chronic intestinal malrotation. With narrow mesenteric base which put them at significant risk of midgut volvulus. Two patients (5%) were found to have chronic appendicitis with extensive adhesion at the right iliac fossa, one patient (2.5%) has annular pancreas and one patient has negative laparoscopic exploration. Laparoscopic findings of chronic intestinal malrotation includes, huge dilated stomach and the first part of duodenum, ectopic site of caecum central in the abdomen or under the liver, medial and low position of duodenojejunal junction, congested mesenteric veins with lymphatic oedema, generalised mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, right-sided small bowel.
CONCLUSION
Laparoscopic diagnostic finding permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. Furthermore, laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children with a narrow base should undergo laparoscopic Ladd procedure to avoid catastrophic midgut volvulus.
PubMed: 32769361
DOI: 10.4103/ajps.AJPS_132_13 -
Cureus Mar 2018Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic...
Portal annular pancreas is a rare congenital anomaly in which the portal vein and/or the splenoportal confluence are completely encircled by aberrant pancreatic parenchyma. It is an asymptomatic condition and is usually an incidental finding. It is, however, important to a surgeon because the postoperative pancreatic fistula (POPF) rates following pancreatic resection are higher in patients with this anomaly. A 47-year-old male presented with features of obstructive jaundice. He was diagnosed to have periampullary carcinoma, and pancreatoduodenectomy was planned. During surgery, uncinate process was seen extending posterior to the portal vein and was communicating with the body of pancreas to the left of the portal vein. After transection, there were two pancreatic stumps. The pancreatic duct was identified in the stump anterior to the portal vein. No duct was present in the posterior pancreatic stump. We closed the posterior pancreatic stump with interrupted polypropylene sutures and performed a duct to mucosa pancreaticojejunostomy in the anterior stump. On reviewing the preoperative computed tomography (CT) scan, we were able to identify the pancreatic tissue encasing the portal vein superior to the splenic vein. Circumportal pancreas is classified based on the orientation of pancreatic duct to the portal vein and the relationship of the aberrant pancreatic tissue with the splenoportal confluence. Following pancreatoduodenectomy, the surgeon has to manage two pancreatic stumps, one anterior and the other posterior to the portal vein. No standardised technique has been described for management of the pancreatic stumps. Every surgeon planning pancreatic surgery should be aware of this rare anomaly, and look for the same in the preoperative CT scan so that appropriate plan can be made regarding the type of pancreatic anastomosis.
PubMed: 29805935
DOI: 10.7759/cureus.2366