Pancreatoduodenal junction: review of anatomy and pathologic conditions

Pancreaticoduodenectomy with Anatomical Vascular Variant in Groove Pancreatitis-A Case Report

Groove pancreatitis represents a chronic focal form of pancreatitis affecting the zone between the pancreatic head and the duodenal "C" loop, known as the groove area. This is a rare condition that affects the pancreatic periampullary part, including the duodenum and the common bile duct, which is usually associated with long-term alcohol and tobacco misuse, and is more frequent in men than in women. The most common clinical symptoms of groove pancreatitis include weight loss, acute abdominal pain, nausea, and jaundice. This report is about a 66-year-old woman with a history of heavy smoking, presenting with weight loss, nausea, and upper abdominal pain. Contrast-enhanced computed tomography revealed the existence of chronic pancreatitis as well as the dilatation of the main pancreatic duct, a cyst of the pancreatic head, and enlargement of the biliary tract. Conservatory treatment was initiated but with no improvement of symptoms. Since endoscopic retrograde cholangiopancreatography was not possible due to the local changes, we decided to perform pancreatoduodenectomy, as surgery appears to be the single effective treatment.

Paroxysmal epigastric pain 30 years after abdominal trauma surgery-a case report

A 58-year-old male was admitted to the liver surgery ward of Peking Union Medical College Hospital as the result of recurrent cholangitis in the past six months. Preoperative abdominal CT and gastrointestinal radiography showed duodenal dilatation and reconstruction of gastrointestinal tract, which might be related to the laparotomy and hemostasis performed due to traffic accident 30 years ago. The operative method of that surgery might be the reason for the patient's choledocholithiasis and duodenal dilatation.

Indicative value of pathological classification of duodenal papillary adenomas in clinical diagnosis and treatment

OBJECTIVES

The relationship between the pathological classification and recurrence of duodenal papillary adenomas (DPAs) has not been elucidated. We studied the clinicopathological characteristics of DPAs with different pathological types and conducted long-term follow-up to explore its prognosis and identify methods for appropriate clinical management of DPAs.

METHODS

In total, 95 DPA cases confirmed by postoperative pathology were enrolled, of which 58 underwent endoscopic papillectomy (EP) and 37 underwent pancreatoduodenectomy (PD). The cases were classified into three anatomical and two histomorphological types according to the histopathology and location of endoscopic features. We analyzed the clinicopathological characteristics of DPAs with different pathological types and investigated the factors associated with recurrence in the EP subgroup.

RESULTS

Although EP was associated with fewer adverse events, the complete resection rate was significantly lower (72.4% vs. 100.0%, p < 0.001) and the recurrence rate significantly higher than with PD (16.3% vs. 0.0%, p < 0.001). Among eight EP cases with recurrence, six had intra-DPA (75%). A positive resection margin (HR 23.67, 95% CI 6.42-87.27; p < 0.001) and MUC2-negative status (HR 3.47, 95% CI 1.16-10.40; p = 0.026) were independent risk factors for recurrence after EP.

CONCLUSION

We identified different pathological types within DPAs, which presented varying clinicopathological features. The majority of peri-DPAs and mixed-DPAs were of the intestinal type histologically and EP is the primary recommendation. However, intra-DPA was mainly of the pancreaticobiliary type, which tends to get positive resection margins; thus, surgical resection is more suitable.

Imaging of Ampullary and Periampullary Conditions

The ampulla of Vater is formed by the union of the pancreatic duct and the common bile duct and is also known as hepatopancreatic ampulla or hepatopancreatic duct. The ampulla is surrounded by a muscular valve known as the sphincter of Oddi, which controls the flow of bile and pancreatic juices into the duodenum in response to food. The ampulla is also an important embryological landmark as it marks the anatomical transition from foregut to the midgut. Because of this, it is a watershed zone where the blood supply changes from the celiac axis to the superior mesenteric artery. Radiologic evaluation of the ampulla and the periampullary region is challenging because it requires an understanding of the embryology, the normal appearance, and different anatomic variants. Also, a wide variety of pathologies can occur in this region. The purpose of this review is to present the normal anatomy of the ampulla and the periampullary region on different imaging modalities and to summarize the imaging features of the common variants, and benign and malignant ampullary and periampullary conditions. Understanding of the normal anatomical appearance and variants along with the knowledge of common pathologic conditions affecting the ampulla and periampullary conditions can help radiologists in making accurate diagnosis resulting in optimum patient care.

Groove pancreatitis: a challenging imaging diagnosis

Groove pancreatitis (GP) is an uncommon form of chronic pancreatitis (CP) involving the space between duodenum, pancreatic head and common bile duct (CBD) known as pancreatic-duodenal groove. Although an association with long-standing ethanol assumption is reported a definite etiology of GP is unknown. Since thickening of the duodenal wall, pancreatic head enlargement, CBD stricture and dilatation of pancreatic duct system are common findings the differential diagnosis with pancreatic head neoplasm by means of imaging can be challenging. However, some imaging findings such as fibrotic changes of the pancreatic groove and presence of duodenal wall cysts may suggest the correct diagnosis. In this paper we review clinical and imaging features of GP with emphasis on computed tomography (CT) and magnetic resonance imaging (MRI) findings.

Endoscopic Ultrasound in the Diagnosis of Pancreatoduodenal Groove Pathology: Report of Three Cases and Brief Review of the Literature

The pancreatoduodenal groove is a small area where pathologic processes involving the distal bile duct, duodenum, pancreatic head, ampulla of Vater, and retroperitoneum converge. Despite great advances in imaging techniques, a definitive preoperative diagnosis is challenging because of the complex anatomy of this area. Therefore, surgical intervention is frequently required because of the inability to completely exclude malignancy.

We report 3 cases of patients with different groove pathologies but similar clinical and imaging presentation, and show the essential role of endoscopic ultrasound (EUS) in making a specific preoperative diagnosis, excluding malignancy in the first case, changing diagnosis in the second case, and confirming malignancy in the third case. EUS was a fundamental tool in this cohort of patients, not only because of its ability to provide superior visualization of a difficult anatomical region, but because of the ability to guide precise, real-time procedures, such as fine-needle aspiration.

Microanatomical profiles on the lymphatic system in the human ampulla of Vater (immunohistochemistry and scanning electron microscopy)

BACKGROUND

Little information is available regarding microanatomy of lymphatic system in the ampulla of Vater, though it is of critical importance for an understanding of tumor progression via the lymphatics and determination of surgical strategy. The present study, therefore, aimed to demonstrate the distribution and microanatomical profiles on the lymphatic system in the ampulla.

METHODS

The fine distribution and structure of the lymphatic vessels were investigated in the ampulla and the stomach by immunohistochemistry for lymphatic- (D2-40) and blood vascular- (CD31) specific markers and scanning electron microscopy. The densities of lymphatic and blood vessels were also compared.

RESULTS

The duodenal papilla densely developed the lymphatics with distinct aspects of lymphatic capillaries, together with blood vessels. The density of lymphatic capillaries in the extramuscular layer in the ampulla was higher than those of both the other ampullary layers and the gastric extramuscular (subserosal) layer.

CONCLUSIONS

The ampulla of Vater showed widespread lymphatic capillaries throughout the entire wall. The specific vascular system is suited to produce lymph everywhere and drain without via such a large vessel as lymphatic collector. This suggests that tumor cells invade the lymphatics and metastasize more easily in the ampulla than in the other gastrointestinal regions.

Groove resection of pancreatic head in groove pancreatitis: A case report

Groove pancreatitis (GP) is a rare type of chronic pancreatitis, which primarily affects the groove area of the pancreatic head. Surgery is considered as the ultimate method for GP if the symptoms are not improved by conservative or endoscopic treatments, and the Whipple technique is the common choice at present. The present study introduces a novel surgical procedure for GP, namely groove resection of pancreatic head (GRPH), in a 56-year-old male patient. To the best of our knowledge, this is the first report on GRPH for the surgical treatment of GP. This patient was diagnosed with typical GP without any evidence of malignancy, based on imaging studies and gastrointestinal endoscopy, and was treated with GRPH. Briefly, only the groove area of the pancreatic head was resected, while the duodenum, the main pancreatic duct and the majority of the pancreatic head were preserved. A complete relief of abdominal pain and a weight gain were achieved 2 months after surgery. Endoscopic examination indicated marked improvement of the duodenal lesions. In conclusion, GRPH is a less invasive surgical procedure for GP compared with other surgical procedures and may be an alternative for the surgical treatment of GP without severe lesions or stenosis of the duodenum.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduodenectomies in the setting of chronic pancreatitis

BACKGROUND

The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease.

METHODS

Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ).

RESULTS

No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509).

CONCLUSION

Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.

Groove pancreatitis vs. pancreatic adenocarcinoma: A review of 8 cases

INTRODUCTION

Groove pancreatitis (PS) is an uncommon clinical situation and radiologically it can mimic carcinoma of the periampullary area. The aim of this paper is to study a series of 8 patients who underwent surgery with preoperative diagnosis of pancreatic head mass and subsequent pathological diagnosis of PS.

METHODS

In our series, 6 were men and 2 women, with an average age of 51,9 years. Before surgery, all patients had epigastric abdominal pain requiring analgesia at high doses. The preoperative analytical CEA and Ca 19.9 were normal in all patients. Imaging studies showed intrapancreatic solid lesions in 6 of the 8 patients, and in the remaining 2 one papillary mass of 5 and 6cm, respectively, that caused stenosis in the duodenal luz. EUS neoplastic cells were negative in all patients.

RESULTS

The immediate postoperative evolution was satisfactory, there are no complications. In our series, no patients have died. The long-term follow-up, in 7 of the 8 patients, has been excellent with disappearance of abdominal pain and improvement of nutritional status. The remaining patient had frequent recurrent episodes of acute pancreatitis, and at 60 months, presented a pseudocyst that has required a Roux-en-Y cystojejunostomy.

CONCLUSIONS

PS must be included in the differential diagnosis of pancreatic lesions, which may include carcinoma of the periampullary area and other causes of chronic pancreatitis.

Multimodality imaging of diseases of the duodenum

The duodenum is a unique segment of intestine, occupying both intra and extra-peritoneal locations. There is a wide spectrum of abnormalities of the duodenum that range from congenital anomalies to traumatic, inflammatory, and neoplastic entities. The duodenum may be overlooked on cross-sectional imaging due to its location and small size. Duodenal pathologies may, therefore, be missed or wrongly diagnosed. Knowledge about duodenal pathologies and optimal imaging techniques can increase diagnostic yield and permit optimal patient management. Conventionally, the duodenum was evaluated with upper GI studies on fluoroscopy; however, endoluminal evaluation is better performed with endoscopy. Additionally, a broad array of cross-sectional imaging modalities permits comprehensive assessment of the duodenum and surrounding viscera. While endoscopic sonography is increasingly used to locally stage duodenal malignancies, MDCT remains the primary modality widely used in the detection and characterization of duodenal abnormalities. MRI is used as a "problem solving" modality in select conditions. We present a comprehensive review of duodenal abnormalities with an emphasis on accurate diagnosis and management.

Groove Pancreatitis: A Brief Review of a Diagnostic Challenge

Groove pancreatitis is an uncommon, yet well-described, type of focal chronic pancreatitis, affecting “the groove”—the area between the head of the pancreas, the duodenum, and the common bile duct. Men aged 40 to 50 years are most commonly affected, with a history of alcohol abuse frequently disclosed. Clinical manifestations are similar to other forms of chronic pancreatitis, and vomiting secondary to duodenal stenosis is the main feature. It is postulated that pancreatitis in the groove area arises from obstruction of pancreatic juices in the ductal system, causing fibrosis and stasis with resultant inflammation of surrounding structures. The minor papilla is frequently the anatomic area of preferential involvement. Groove pancreatitis poses diagnostic challenges, forming a “pseudotumor” that mimics pancreatic carcinoma. The distinction is important, although often impossible to make because of their similar presentation, with groove pancreatitis usually affecting younger patients. Most patients are successfully treated with pancreaticoduodenectomy when definitive pathologic diagnoses can be made.

Paraduodenal pancreatitis

Paraduodenal pancreatitis is a distinct clinicopathological entity involving the duodenum and the pancreatic tissue in the vicinity of the minor papilla. Most afflicted patients are young alcoholic males who present clinically with upper abdominal pain, weight loss, nausea, and vomiting. Pancreatic tissue elements in the duodenal wall and impedance to exocrine pancreatic secretions at the minor papilla are key factors in the pathogenesis of this condition. On imaging, the condition may manifest as a solid fibrotic mass around the minor papilla or as cysts in the duodenum and the pancreaticoduodenal groove. Duodenal stenosis, biliary strictures, chronic calcifying pancreatitis, and pancreatic ductal dilatation are also often observed.

Groove pancreatitis: spectrum of imaging findings and radiology-pathology correlation

OBJECTIVE

Groove pancreatitis is a rare form of chronic pancreatitis affecting the "groove" between the pancreatic head, duodenum, and common bile duct. The exact cause is unknown, although there are strong associations with long-term alcohol abuse, functional obstruction of the duct of Santorini, and Brunner gland hyperplasia.

CONCLUSION

Unfortunately, differentiating groove pancreatitis from malignancy on the basis of imaging features, clinical presentation, or laboratory markers can be extraordinarily difficult, and the vast majority of these patients ultimately undergo a pancreaticoduodenectomy (Whipple procedure) because of an inability to completely exclude malignancy. In certain cases, however, the imaging features on CT and MRI can allow the radiologist to prospectively suggest the correct diagnosis.

Annular pancreas: a review of its molecular embryology, genetic basis and clinical considerations

The annular pancreas remains an intriguing congenital anomaly. Many theories have sought to explain its embryological basis; however, no consensus has yet been reached regarding the exact mechanism of aberration. More recently, molecular investigations have shed light on some of these theories, confirming the origination of annular tissue from the ventral pancreatic bud. These studies highlight the role of the hedgehog signaling pathway in the development of this anomaly. Overexpression of the ventral-specific gene transmembrane 4 superfamily member 3 (tm4sf3) has also been associated with annular formation. Moreover, isolated case reports of familial annular pancreas have also been documented, suggesting a genetic basis for the development of this anomaly. Annular pancreas can initially present in childhood or adulthood with symptoms of duodenal obstruction and is diagnosed using a variety of imaging modalities. Treatment usually involves surgical correction, with bypass procedures (e.g. duodenoduodenostomy, gastrojejunostomy or duodenojejunostomy) currently favored over annular resection due to complications associated with the latter approach.

Congenital pancreatic anomalies, variants, and conditions

Understanding pancreatic development and the congenital anomalies and variants that result from alterations in normal development allows for better recognition of these anomalies at diagnostic imaging. This article reviews normal pancreatic embryology and anatomy, and the appearance of the more common developmental anomalies and ductal variants, with emphasis on computed tomography and magnetic resonance imaging. Common mimics of masses are also covered.