Groove pancreatitis associated with true pancreatic cyst

Groove pancreatitis: From enigma to future directions-A comprehensive review

Groove pancreatitis (GP) is a rare and clinically distinct form of chronic pancreatitis affecting the pancreaticoduodenal groove comprising the head of the pancreas, duodenum, and the common bile duct. It is more prevalent in individuals in their 4-5th decade of life and disproportionately affects men compared with women. Excessive alcohol consumption, tobacco smoking, pancreatic ductal stones, pancreatic divisum, annular pancreas, ectopic pancreas, duodenal wall thickening, and peptic ulcers are significant risk factors implicated in the development of GP. The usual presenting symptoms include severe abdominal pain, nausea, vomiting, diarrhea, weight loss, and jaundice. Establishing a diagnosis of GP is often challenging due to significant clinical and radiological overlap with numerous benign and malignant conditions affecting the same anatomical location. This can lead to a delay in initiation of treatment leading to increasing morbidity, mortality, and complication rates. Promising research in artificial intelligence (AI) has garnered immense interest in recent years. Due to its widespread application in diagnostic imaging with a high degree of sensitivity and specificity, AI has the potential of becoming a vital tool in differentiating GP from pancreatic malignancies, thereby preventing a missed or delayed diagnosis. In this article, we provide a comprehensive review of GP, covering the etiology, pathogenesis, clinical presentation, radiological and endoscopic evaluation, management strategies, and future directions. This article also aims to increase awareness about this lesser known and often-misdiagnosed clinical entity amongst clinicians to ultimately improve patient outcomes.

A case of groove pancreatitis with duodenal stenosis successfully treated by endoscopic ultrasonography‐guided pancreaticogastrostomy

One of the reasons for groove pancreatitis is caused by the leakage of pancreatic juice into the space between the pancreatic head, descending duodenum, and common bile duct. Endoscopic drainage of Santorini's duct (SD) via the minor papilla is reportedly efficacious but can be difficult due to duodenal stenosis. We report Santorini's duct drainage using endoscopic ultrasonography‐guided pancreaticogastrostomy (EUS‐PGS) for a case of groove pancreatitis with gastric outlet obstruction. Gastric outlet obstruction was improved after 7 months of EUS‐PGS with internal drainage through the Santorini's duct/minor papilla. EUS‐PGS may be effective for treating groove pancreatitis with duodenal stenosis. This is the first report of groove pancreatitis with duodenal stenosis, the symptoms of which were improved by EUS‐PGS.

Duodenal stenosis associated with an ectopic opening of the common bile duct into the duodenal bulb: a case report

Background

Ectopic opening of the common bile duct is a rare congenital biliary anomaly. Herein, we present a case of duodenal stenosis with ectopic opening of the common bile duct into the duodenal bulb.

Case presentation

A 54-year-old man was referred with fever, nausea, and vomiting. He had experienced epigastric pain several times over the past 30 years. Endoscopy showed a post-bulbar ulcer, a submucosal tumor of the duodenum, and a small opening with bile secretion. Contrast duodenography revealed duodenal stenosis and bile reflux with a common bile duct deformity. Pancreatoduodenectomy was performed because of the clinical suspicion of a biliary neoplasm or groove pancreatitis. The resected specimen showed an ectopic opening of the common bile duct into the duodenal bulb and no tumor.

Conclusions

Ectopic opening of the common bile duct into the duodenal bulb is complicated by a duodenal ulcer, deformity, and stenosis mimicking groove pancreatitis or pancreatic tumors. Although rare, we should be aware of this anomaly for an accurate diagnosis.

Pancreaticoduodenectomy and Outcomes for Groove Pancreatitis

BACKGROUND/AIMS

The operative management of groove pancreatitis (GP) is still a matter of controversy and pancreaticoduodenectomy (PD) can be a high-risk procedure for patients. The aim of this study was to report our 9-year experience of surgical resection for GP and to review relevant literature.

METHODS

A retrospective review of patients undergoing pancreatectomy for GP from August 1, 2008, through May 31, 2017 was performed. Patients with clinical, radiologic, and final pathologic confirmation of GP were included. Literature on the current understanding of GP was reviewed.

RESULTS

Eight patients from total 449 pancreatectomies met inclusion criteria. Four male and 4 female patients (mean age, 51.9 years; mean body mass index, 25.3) underwent pylorus-preserving pancreatoduodenectomy (3 by laparoscopy and 5 by open approach). Mean (range) operative time and blood loss was 343 (167-525) min and 218 (40-500) mL respectively. Pancreatic fistula and delayed gastric emptying were noted in one patient each. No major complications occurred, but minor complications occurred in 5 (62%) patients. Mean hospital stay was 6.1 (range 3-14) days. At median follow-up of 18.15 (interquartile range 7.25-33.8) months, all patients experienced a resolution of pancreatitis and improvement in symptoms.

CONCLUSIONS

PD is a safe procedure for GP. Short-term surgical outcomes are acceptable and long-term outcomes are associated with improved symptom control.

Laparoscopic spleen-preserving distal pancreatectomy in a solitary true pancreatic cyst

BACKGROUND

Solitary true pancreatic cysts (STPCs), or epithelial cysts, are benign lesions that are extremely rare in adult patients. Advances in radiographic techniques have improved the ability to identify pancreatic cystic lesions. We report a case of a large and symptomatic STPC in a 47-year-old female patient who was treated successfully with spleen-preserving laparoscopic distal pancreatectomy. We also review the clinical and pathologic features of all reported STPCs within the past 25 years.

DATABASE

To compose the review, we did a search of the international literature for STPCs that had occurred in adults. Fourteen related articles were found describing cases of STPCs. Clinical and pathologic information was collected for all of the reported pancreatic cysts, and a database was formed. STPCs are detected more frequently in women than in men. The mean age of occurrence is 43.2 years, and the mean cyst size is 5.6 cm. Fifty percent of true cysts are located in the head of the pancreas. Size and site are responsible for the symptoms caused, although 22.8% were asymptomatic. Diagnosis was made postoperatively in all cases by histopathologic studies. No case of malignancy was reported in any STPC.

CONCLUSIONS

STPCs are rare and benign lesions commonly discovered incidentally during abdominal imaging. Surgical treatment is considered the appropriate therapy for large and symptomatic STPCs. The definitive diagnosis is established by histopathologic and immunohistochemical studies.

Malignant potential in incidental pancreatic cysts

Although pancreatic cysts are being diagnosed with greater frequency, a uniform agreement on management is still lacking. This is mainly because accurate and reliable preoperative determination of the exact pathology of a pancreatic cyst remains elusive. Although ultrasound-guided fine needle aspiration represents a significant advancement in our ability to characterize pancreatic cysts preoperatively, significant limitations persist. In this article, we review the roles of clinical characteristics, imaging features and biochemical markers in the correct classification of incidental pancreatic cysts. The correct diagnosis and management of these cysts still hinges, to a large extent, on clinical experience and multidisciplinary cooperation.

Cystic dystrophy of the duodenal wall is not always associated with chronic pancreatitis

Cystic dystrophy of the duodenal wall is a rare form of the disease which was described in 1970 by French authors who reported the presence of focal pancreatic disease localized in an area comprising the C-loop of the duodenum and the head of the pancreas. German authors have defined this area as a “groove”. We report our recent experience on cystic dystrophy of the paraduodenal space and systematically review the data in the literature regarding the alterations of this space. A MEDLINE search of papers published between 1966 and 2010 was carried out and 59 papers were considered for the present study; there were 19 cohort studies and 40 case reports. The majority of patients having groove pancreatitis were middle aged. Mean age was significantly higher in patients having groove carcinoma. The diagnosis of cystic dystrophy of the duodenal wall can now be assessed by multidetector computer tomography, magnetic resonance imaging and endoscopic ultrasonography. These latter two techniques may also add more information on the involvement of the remaining pancreatic gland not involved by the duodenal malformation and they may help in differentiating “groove pancreatitis” from “groove adenocarcinoma”. In conclusion, chronic pancreatitis involving the entire pancreatic gland was present in half of the patients with cystic dystrophy of the duodenal wall and, in the majority of them, the pancreatitis had calcifications.

Groove pancreatitis: A Case Report and Review of the Literature

Groove pancreatitis is a rare form of segmental chronic pancreatitis. It involves the anatomic space between the head of the pancreas, the duodenum and the common bile duct. It was first described in the early 1970s, but it remains largely unfamiliar to most physicians. Radiological diagnosis can be challenging, as it is often difficult to differentiate it from other entities. The differential diagnosis from pancreatic head carcinoma may be difficult and recognition of subtle differences between these two entities is extremely important as the management differs significantly. Groove pancreatitis can be managed by conservative medical treatment, and surgery is reserved only for patients with persistent and severe clinical symptoms. We present a case of a 27 year-old male with groove pancreatitis and discuss the Magnetic Resonance Imaging (MRI) appearance of this entity as well as the differential diagnosis.

Survival in cystic neoplasms of the pancreas

BACKGROUND

The natural history of pancreatic cystic neoplasms remains poorly understood despite growing evidence on the subject. Pancreatic cysts display a wide spectrum of pathological phenotypes, each associated with a different prognostic implication. Many pancreatic cysts are of undetermined malignant potential at presentation and remain so until surgically resected. While the survival rates of patients with malignant cysts are known to be poor, survival rates in patients with undetermined pancreatic cysts are unknown.

OBJECTIVE

To identify the factors associated with survival in a group of patients diagnosed with a pancreatic cyst(s).

METHODS

The present study was a retrospective multicentre review of pancreatic cystic neoplasms. All patients with a diagnosis of a neoplastic pancreatic cyst from 1994 to 2003 were identified at five different institutions in Edmonton, Alberta. The data collected included patient age, sex, imaging modality, cyst location, cyst size, number of cysts, comorbid illnesses, history of upper abdominal surgery, previous cancer, previous or concurrent metastases, symptoms (pain, upper gastrointestinal bleeding, signs of biliary obstruction, nausea/vomiting), remarkable radiological features, elevated amylase or lipase, type of pancreatic surgery, final pathology (benign or malignant) and overall survival. Survival models were used to assess whether any covariates were predictors of the survival time. Patient data were plotted using the Kaplan-Meier method. The resulting plot was used to calculate survival in the cohort.

RESULTS

In total, 64 patients were identified as having neoplastic pancreatic cysts from 1994 to 2003 at the five institutions. The median overall patient survival time was 86 months. The median age at diagnosis for the patient population was 73 years, with 40 patients being women. Univariate analysis revealed that the risk of death was associated with patient age, sex and history of major comorbid illness. Multivariate models identified increased patient age and male sex as the factors that correlated most strongly with decreased overall survival.

CONCLUSION

Overall survival in patients with neoplastic pancreatic cysts is determined by patient factors (ie, age and sex) rather than factors descriptive of the cyst such as size and morphology. No conclusions could be made regarding the relationship between cyst pathology and patient survival.

A comprehensive, case-based review of groove pancreatitis

Groove pancreatitis is an uncommon form of focal chronic pancreatitis that involves the duodenal wall or "groove" area (between the pancreas, common bile duct, and duodenum). It remains largely an unfamiliar entity to most physicians and is often misdiagnosed as pancreatic malignancy or autoimmune pancreatitis because of its "pseudotumor" formation. In this case series, we present 4 cases of groove pancreatitis which highlight important clinical aspects of this disease entity. We then provide a review of the pathophysiology, diagnosis, and treatment of this condition. We hope to clarify the salient aspects of this disease process and make groove pancreatitis a more recognized entity to the clinician.

Evaluation of unusual causes of pancreatitis: role of cross-sectional imaging

There are widely diverse causes of pancreatitis. Gallstone and alcohol have been recognized as the most common causes of pancreatitis accounting for 90% of cases. However, acute and chronic pancreatitis may also result from a variety of uncommon causes. The determination of the etiology is important for patient management and prevention of recurrence. Sludge is the most common cause of idiopathic or recurrent acute pancreatitis. Endoscopic ultrasonography is considered as the most accurate diagnostic test for this abnormality. Computed tomography (CT) and magnetic resonance imaging (MRI) have only a limited role in the diagnosis of sludge. However, papillitis observed on the contrast-enhanced CT and MR may provide clues to the detection of pancreatitis secondary to sludge, a small stone or a recently passed stone. Radiological studies, clinical presentation and laboratory data can be helpful in determining the etiology of unusual causes of pancreatitis such as anatomic anomalies, autoimmune pancreatitis, groove pancreatitis, and traumatic pancreatitis.