Outcomes After Conservative, Endoscopic, and Surgical Treatment of Groove Pancreatitis: A Systematic Review

Chronic pancreatitis for the clinician: complications and special forms of the disease. Interdisciplinary position paper of the Catalan Society of Digestology (SCD) and the Catalan Pancreatic Society (SCPanc)

Chronic pancreatitis tends to develop a number of complications that may constitute the form of presentation of the disease. Some societies have issued guidelines for diagnosis and treatment of chronic pancreatitis complications, but the level of evidence for any topic is usually low and recommendations tend to be weak. We aimed to provide defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The goal was to propose defined terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 14 sections related to complications and special forms of chronic pancreatitis (early chronic, groove and autoimmune pancreatitis) were reviewed by 21 specialists from 6 different fields to generate 32 statements. Featured statements assert common bile duct stenosis does not require invasive treatment (endoscopic or surgical) unless cholestasis, cholangitis, lithiasis or other symptoms develop. Pancreatic duct strictures and calculi should be approached (after ruling out malignancy) if causing pain, pancreatitis, pseudocysts or other complications. Treatment of symptomatic pseudocysts must be individualized, considering associated main duct stenosis, vascular and pericystic complications. Higher risk conditions for pancreatic cancer are advance age, smoking, genetic background, recent diagnosis of chronic pancreatitis or diabetes, and appearance of new symptoms. Groove pancreatitis can initially be treated with conservative measures. Both prednisolone or rituximab can induce remission and maintenance of autoimmune pancreatitis. Internal fistula, vascular complications, bacterial overgrowth, osteoporosis and renal lithiasis require specific therapeutic approaches.

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.

Duodenojejunostomy treatment of groove pancreatitis-induced stenosis and obstruction of the horizontal duodenum: A case report

BACKGROUND

Groove pancreatitis (GP) is a rare condition affecting the pancreatic groove region within the dorsal-cranial part of the pancreatic head, duodenum, and common bile duct. As a rare form of chronic pancreatitis, GP poses a diagnostic and therapeutic challenge for clinicians. GP is frequently misdiagnosed or not considered; thus, the diagnosis is often delayed by weeks or months. The treatment of GP is complicated and often requires surgical intervention, especially pancreatoduodenectomy.

CASE SUMMARY

A 66-year-old man with a history of long-term drinking was admitted to the gastroenterology department of our hospital, complaining of vomiting and acid reflux. Upper gastrointestinal endoscopy showed luminal stenosis in the descending part of the duodenum. Abdominal computed tomography showed slight exudation in the descending and horizontal parts of the duodenum with broadening of the groove region, indicating local pancreatitis. The symptoms of intestinal obstruction were not relieved with conservative therapy, and insertion of an enteral feeding tube was not successful. Exploratory laparoscopy was performed and revealed a hard mass with scarring in the horizontal part of the duodenum and stenosis. Intraoperative frozen section analysis showed no evidence of malignancy, and side-to-side duodenojejunostomy was performed. Routine pathologic examination showed massive proliferation of fibrous tissue, hyaline change, and the proliferation of spindle cells. Based on the radiologic and pathologic characteristics, a diagnosis of GP was made. The patient presented with anastomotic obstruction postoperatively and took a long time to recover, requiring supportive therapy.

CONCLUSION

GP often involves the descending and horizontal parts of the duodenum and causes duodenal stenosis, impaired duodenal motility, and gastric emptying due to fibrosis.

Groove Pancreatitis: Clinical Cases and Review of the Literature

Introduction

Groove pancreatitis (GP) is a type of chronic segmental pancreatitis that affects the pancreatoduodenal groove area, and it is often misdiagnosed. Outflow obstruction of the minor papilla associated with alcohol consumption seems to be the main pathophysiological mechanism, and it affects mainly middle-aged males. Symptoms include nausea and postprandial vomiting from gastric outlet obstruction, weight loss, and abdominal pain. Despite modern advances, such as radiological and endoscopic methods, distinction between GP and pancreatic cancer remains a challenge, and histological examination is sometimes necessary. When a diagnosis can be obtained without a surgical specimen, management can be conservative in the absence of acute or chronic complications.

Case Presentation

The authors present 2 clinical cases which portray the diagnostic workup and management decisions of this entity.

Discussion/Conclusion

GP is a clinical entity, offering diagnostic and therapeutic challenges. Imaging exams are crucial in the diagnosis and follow-up, but surgery may be necessary in a significant number of cases due to the incapacity to rule out malignancy.

Systematic review on groove pancreatitis: management of a rare disease

BACKGROUND

Groove pancreatitis is a focal form of chronic pancreatitis affecting the area of the paraduodenal groove. The aim of this systematic review was to assess the clinical presentation, diagnosis and treatment of patients with groove pancreatitis.

METHODS

Medical literature databases (Embase, Medline via PubMed and Cochrane Central Register of Controlled Trials) were systematically searched for data recorded between 1 January 1990 and 31 August 2022 regarding patient characteristics, diagnosis, surgical treatment and outcomes. The following inclusion criteria were applied: RCTs, observational studies (cohort and case-control studies) and case studies with >3 cases including patients with groove pancreatitis undergoing medical, endoscopic or surgical treatment with available clinical and diagnostic data. Fisher's exact test for binary data and Mann-Whitney U test or Student t-test for continuous data were adopted for statistical analysis.

RESULTS

Of 649 studies, 44 were included, involving reports on 1404 patients with a mean age of 49 years. In 41 of the 44 studies in which patient gender was described, 86 per cent (N = 1023) of patients were male. Information on the risk factors of alcohol and nicotine was available in 37 and 23 studies, respectively. Seventy-nine per cent (N = 886) of patients had a history of excessive alcohol consumption and 83 per cent (N = 595) were smokers. Information on clinical symptoms was available in 37 of the 44 included studies and 78.5 per cent (N = 870) presented with abdominal pain. Some 27 studies comprising 920 groove pancreatitis patients were treatment oriented. Seventy-four per cent (N = 682) of patients were treated conservatively, 26.4 per cent (N = 134) underwent endoscopic treatment and 54.7 per cent (N = 503) required surgery. There was complete relief of symptoms in 35.6 per cent (N = 243) after conservative treatment, 55.2 per cent (N = 74) after endoscopic treatment and 69.6 per cent (N = 350) after surgical treatment. The median follow-up time was 42 months (range, 1-161 months).

CONCLUSION

Groove pancreatitis shows on imaging a typical triad: cystic lesions in the pancreatic duct or duodenal wall, calcifications, and thickenings of the duodenal wall. Surgery appears to be the most effective treatment modality.

Duodenum-preserving pancreatic head resection or pancreatoduodenectomy for the surgical treatment of paraduodenal pancreatitis: a retrospective cohort study

PURPOSE

Paraduodenal pancreatitis (PDP) is an uncommon yet well-described type of focal chronic pancreatitis. The aim of our study was to compare the outcomes of surgical treatment of patients with PDP using pancreatoduodenectomy and duodenum-preserving pancreatic head resection (DPPHR).

METHODS

A retrospective analysis of 153 consecutive patients with PDP was performed. Patients who were treated with either DPPHR or PD were enrolled. The primary endpoint of the study was pain control achieved at the time of follow-up. The secondary endpoints of the study were complication rate (Clavien-Dindo > 2), hospital length of stay, and 90-day mortality. All patients were followed up after discharge for the assessment of pain cessation for a minimal period of 10 months.

RESULTS

The final study population consisted of 71 patients. A total of 14 patients (19.7%) underwent pancreatoduodenectomy, and 57 (80.3%) were managed with DPPHR. Complication rate was significantly lower in DPPHR group at χ² = 4.2677, p < 0.05. Mean hospital length of stay was 9.3 days (range 3-29) in DPPHR group and 13.9 days (range 7-35) in PD group (p < 0.05). No postoperative mortality was recorded. The mean follow-up period of the patients after surgery was 41.8 ± 20.6 months (range 10-88). Pain scores at the time of operation were calculated as 50.9 ± 12.1 in DPPHR group and 56.1 ± 11.4 in PD group. At the time of follow-up, pain scores improved significantly in both groups and were 10.3 ± 8.8 and 10.9 ± 8.6, respectively.

CONCLUSION

DPPHR achieves similar results in pain control as PD with a lower complication rate and shorter hospital LOS.

Cystic dystrophy in heterotopic pancreas

Cystic dystrophy in heterotopic pancreas, or paraduodenal pancreatitis, is a rare and complicated presentation involving heterotopic pancreatic tissue in the duodenal wall. This condition is present in 5% of the general population but disease mainly affects middle-aged alcoholic-smoking men with chronic pancreatitis (CP). It may be purely duodenal or segmental (pancreatico-duodenopathy). Its pathophysiology arises from alcohol toxicity with obstruction of small ducts of heterotopic pancreatic tissue present in the duodenal wall and the pancreatic-duodenal sulcus, leading to repeated episodes of pancreatitis. The symptomatology includes episodes of acute pancreatitis, weight loss, and vomiting due to duodenal obstruction. Imaging shows thickening of the wall of the second portion of the duodenum with multiple small cysts. A stepwise therapeutic approach is preferred. Conservative medical treatment is favored in first intention (analgesics, continuous enteral feeding, somatostatin analogues), which allows complete symptomatic regression in 57% of cases associated with a 5% rate of complications (arterial thrombosis and diabetes). Endoscopic treatment may also be associated with conservative measures. Surgery achieves a complete regression of symptoms in 79% of cases but with a 20% rate of complications. Surgery is indicated in case of therapeutic failure or in case of doubt about a malignant tumor. Pancreaticoduodenectomy and duodenal resection with pancreatic preservation (PPDR) seem to be the most effective treatments. PPDR has also been proposed as a first-line treatment for purely duodenal location of paraduodenal pancreatitis, thereby preventing progression to an extended segmental form.

Paraduodenal Pancreatitis: A Case Report

Pancreatitis of the groove, or paraduodenal pancreatitis, is a rare form of chronic segmental pancreatitis, located between the head of the pancreas, the inner wall of the duodenum, and the common bile duct. Alcohol abuse is misoften found in the history. The diagnosis is made on the basis of CT and MRI data. Clinical signs usually regress under symptomatic medical treatment. The main differential diagnosis is pancreatic carcinoma, which sometimes requires surgical exploration. We report the case of a 51 years old man presenting paraduodenal pancreatitis with heterotopic pancreas revealed by epigastric pain.

CT imaging patterns of paraduodenal pancreatitis: a unique clinicoradiological entity

AIM

To analyse the computed tomography (CT) findings of paraduodenal pancreatitis (PP) in patients treated at Amrita Institute of Medical Sciences.

MATERIALS AND METHODS

Clinical, laboratory, and CT findings of 30 patients with PP treated from July 2007 to December 2020 were reviewed retrospectively.

RESULTS

The average age of the patients was 45.9 years (19-60 years), which included 29 (96.7%) men, and 90% had a history of alcohol abuse. The majority [22 (73.3%)] presented with recurrent abdominal pain. Serum amylase was elevated in 21 (70%) patients and serum lipase was elevated in 25 (83.3%) patients. Carbohydrate antigen (CA 19-9) was elevated in three (10%) patients. The cystic pattern was seen in three (10%), solid pattern in 13 (43.3%), and solid-cystic pattern in 14 (46.7%) patients. The pure form of the disease was seen in seven (23.3%) patients, whereas the segmental form was seen in 23 (76.7%) patients. Descending duodenal wall thickening and enhancement was seen in 25 (83.3%) and 18 (60%) patients, respectively. The gastroduodenal artery was displaced medially in 12 (40%) patients and encased in five (16.7%) patients; however, it was not occluded in any of the patients. Calcifications were seen in the groove lesion in nine (30%) patients. The pancreas showed atrophic changes in 14 (46.6%) patients and calcifications in 12 (40%) patients. Distal common bile duct strictures were seen in three (10%) patients.

CONCLUSIONS

The presence of sheet-like soft-tissue thickening in the groove with diffuse duodenal thickening and intramural/paraduodenal cysts are highly suggestive of PP. Identifying characteristic imaging findings of PP may help in prospective diagnosis and lead to conservative management of most of these patients avoiding unnecessary invasive procedures.

Upper Gastrointestinal Bleeding as a Debut Form of Groove Pancreatitis: A Diagnostic Challenge

Introduction. Groove pancreatitis (GP) is an unusual subtype of chronic pancreatitis that affects the groove area. Differential diagnosis between groove pancreatitis and pancreatic carcinoma (PC) can be challenging, both clinically and radiologically. Our aim is to report the first case of GP debut with upper gastrointestinal bleeding (UGB). Case Report. A 53-year-old man with a personal history of alcohol and tobacco abuse and chronic pancreatitis was admitted to the hospital for epigastric abdominal pain. A computed tomography scan showed a locally advanced neoformative lesion in the distal stomach. The patient presented melena, arterial hypotension, and 4.4 g/dl of hemoglobin. An upper gastrointestinal endoscopy showed a neoformative ulcerated lesion at the duodenal bulb without active bleeding. Biopsies were taken, and histopathological analysis did not show malignancy. A cephalic pancreaticoduodenectomy was performed, and the postoperative period was uneventful. Histopathological analysis revealed a segmental GP. Discussion. GP is an uncommon entity, and its clinical and radiological presentation mimics PC. However, with advances in imaging tests, several radiological criteria have been described to distinguish GP from PC preoperatively. Although some authors recommend a stepwise management with initial conservative therapy, a therapeutic strategy has not yet been established. Conclusion. GP is an uncommon type of focal pancreatitis that should be considered as a differential diagnosis of PC. We report the first clinical case of GP whose debut with UGB presented a greater diagnostic and therapeutic challenge.

Paraduodenal pancreatitis - problem in the groove

BACKGROUND

Paraduodenal pancreatitis (PDP) is a particular form of chronic pancreatitis (CP) occurring in and around the duodenal wall. Despite its low prevalence, this rare condition presents a significant challenge in clinical practice.

METHODS

We retrospectively analysed the electronic medical charts of all patients with a diagnosis of chronic pancreatitis and identified those with PDP, between January 1999 and December 2020.

RESULTS

There were 35 patients diagnosed with PDP (86% males and 14% females); median age of 56 ± 11 (range 38-80). Alcohol overconsumption was reported in 81% and smoking in 90% of patients. Abdominal pain was the leading symptom (71%), followed by weight loss, nausea and vomiting, jaundice, and diarrhoea. In 23 patients (66%), recurrent acute pancreatitis attacks were noted. Focal duodenal wall thickening was present in 34 patients (97%), cystic lesions in 80%, pancreatic duct dilatation in 54% and common bile duct dilatation in 46%. Endoscopic treatment was performed on nine patients (26%) and five patients (14%) underwent surgery. Complete symptom relief was reported in 12 patients (34%), partial symptom relief in three (9%), there was no improvement in five (14%), data were not available in three (9%) and 12 (34%) patients died before data analysis.

CONCLUSIONS

PDP is a rare form of pancreatitis, most commonly occurring in the 5th or 6th decade of life, with a predominance in males and patients with a history of smoking and high alcohol consumption. Focal thickening and cystic lesions of the duodenal wall are the most common imaging findings, followed by pancreatic duct and common bile duct dilatation. A minority of patients requires surgery.

Surgery for chronic pancreatitis: the comparison of two high-volume centers reveals lack of a uniform operative management

Purpose

Many aspects of surgical therapy for chronic pancreatitis (CP), including the correct indication and timing, as well as the most appropriate operative techniques, are still a matter of debate in the surgical community and vary widely across different centers. The aim of the present study was to uncover and analyze these differences by comparing the experiences of two specialized surgical units in Italy and Austria.

Methods

All patients operated for CP between 2000 and 2018 at the two centers involved were included in this retrospective analysis. Data regarding the clinical history and the pre- and perioperative surgical course were analyzed and compared between the two institutions.

Results

Our analysis showed a progressive decrease in the annual rate of pancreatic surgical procedures performed for CP in Verona (no. = 91) over the last two decades (from 3% to less than 1%); by contrast, this percentage increased from 3 to 9% in Vienna (no. = 77) during the same time frame. Considerable differences were also detected with regard to the timing of surgery from the first diagnosis of CP — 4 years (IQR 5.5) in the Austrian series vs two (IQR 4.0) in the Italian series -, and of indications for surgery, with a 12% higher prevalence of groove pancreatitis among patients in the Verona cohort.

Conclusion

The comparison of the surgical attitude towards CP between two surgical centers proved that a consistent approach to this pathology still is lacking. The identification of common guidelines and labels of surgical eligibility is advisable in order to avoid interinstitutional treatment disparities.

Diagnosis, natural course and treatment outcomes of groove pancreatitis

BACKGROUND

Groove pancreatitis (GP) is a rare form of chronic pancreatitis with limited data on its diagnostics and treatment outcomes. The aim of this study was to assess its diagnostics, natural course, and treatment options.

METHODS

The study is a retrospective population-based study from Southern Finland, including all patients with suspected GP between January 2005 and December 2015. Two certified gastrointestinal radiologists re-reviewed the imaging studies. The radiological re-review, clinical judgment, and final histopathology confirmed the GP diagnoses.

RESULTS

Out of 67 patients with possible GP, 39 patients were considered to have high radiological certainty of GP. Out of these 39, five patients had cancer instead. Thirty-three patients with confirmed GP formed the final study cohort. Patients with GP were mostly middle-aged (median 55 years) men. All had at least moderate alcohol consumption. No intervention was needed in 14 patients. In five-year follow-up all conservatively treated patients became asymptomatic, while 10 out of 16 patients undergoing at least one intervention were asymptomatic at five years.

CONCLUSION

The radiological diagnosis of GP is difficult, and a low threshold for cancer suspicion should be kept. Symptoms of GP decrease with time and suggest conservative treatment as the first-line option.

Pancreatoduodenectomy for paraduodenal pancreatitis: a diagnostic and therapeutic challenge

Paraduodenal pancreatitis (PP) is a rare type of focal pancreatitis involving the groove space. It mimics pancreatic head carcinoma, and its diagnosis and treatment are challenging. Pancreatoduodenectomy (PD) has traditionally been the primary surgical treatment for duodenal stenosis or suspected cancer.

We herein report a case of PP in a 65-year-old man. The patient was admitted to the hospital for postprandial epigastric pain and vomiting. A low-density mass between the uncinate process of the pancreas and the horizontal segment of the duodenum was suspected based on computed tomography findings. Both upper gastrointestinal radiography and gastrointestinal endoscopy showed an obstruction of the distal part of the descending duodenum. An operation was performed to release the obstruction and obtain a definitive diagnosis. A 3-cm mass in the groove area was compressing the third part of the duodenum, and PD was empirically performed. The final histopathological diagnosis was PP. Postoperatively, the patient developed anastomotic leakage of the gastrojejunostomy site with bleeding and was eventually discharged on postoperative day 51 after emergency surgery.

PP should be considered as a differential diagnosis of pancreatic ductal adenocarcinoma or duodenal stenosis, and accurate preoperative diagnosis preserves the opportunity for conservative or endoscopic management.

Pancreas-preserving duodenal resections vs pancreatoduodenectomy for groove pancreatitis. Should we revisit treatment algorithm for groove pancreatitis?

BACKGROUND

The management of cystic dystrophy of the duodenal wall (CDDW), or groove pancreatitis (GP), remains controversial. Although pancreatoduodenectomy (PD) is considered the most suitable operation for CDDW, pancreas-preserving duodenal resection (PPDR) has also been suggested as an alternative for the pure form of GP (isolated CDDW). There are no studies comparing PD and PPDR for this disease.

AIM

To compare the safety, efficacy, and short- and long-term results of PD and PPDR in patients with CDDW.

METHODS

A retrospective analysis of the clinical, radiologic, pathologic, and intra- and postoperative data of 84 patients with CDDW (2004-2020) and a comparison of the safety and efficacy of PD and PPDR.

RESULTS

Symptoms included abdominal pain (100%), weight loss (76%), vomiting (30%) and jaundice (18%) and data from computed tomography, magnetic resonance imaging, and endoUS led to the correct preoperative diagnosis in 98.8% of cases. Twelve patients were treated conservatively with pancreaticoenterostomy (n = 8), duodenum-preserving pancreatic head resection (n = 6), PD (n = 44) and PPDR (n = 15) without mortality. Weight gain was significantly higher after PD and PPDR and complete pain control was achieved significantly more often after PPDR (93%) and PD (84%) compared to the other treatment modalities (18%). New onset diabetes mellitus and severe exocrine insufficiency occurred after PD (31% and 14%), but not after PPDR.

CONCLUSION

PPDR has similar safety and better efficacy than PD in patients with CDDW and may be the optimal procedure for the isolated form of CDDW. The pure form of GP is a duodenal disease and PD may be an overtreatment for this disease. Early detection of CDDW provides an opportunity for pancreas-preserving surgery.

Endoscopic management of local complications of chronic pancreatitis

Endoscopic treatment of local complications in patients with chronic pancreatitis has gained ground over the surgical alternative in the last few years. The lower aggressiveness of endoscopic treatment, as well as the possibility to use it repeatedly in high-risk patients, has favored this development. In addition, the incorporation of new, highly accurate endoscopic therapeutic options such as pancreatoscopy-guided lithotripsy and endoscopic ultrasound-guided treatments make endoscopic treatment the first choice in many cases, despite discordant data in the literature. This article reviews the endoscopic treatment of the most common local complications of chronic pancreatitis, such as pancreatolithiasis, pseudocysts, and pancreatic, biliary, and duodenal ductal stenosis.

Surgical Therapy of Chronic Alcoholic Pancreatitis: A Literature Review of Current Options

Chronic pancreatitis (CP) is associated with alcohol abuse in 80% of cases. The primary treatment goals in CP are pain reduction and avoidance of pancreatitis-associated complications. CP should be treated in an interdisciplinary approach. A recent randomized clinical trial showed that early surgery compared with an endoscopy-first approach resulted in reduced pain levels. Surgical resections are, therefore, the most efficient treatment of pancreatitis-associated pain as well as other complications and should be performed early in the course of the disease. Since most of the patients pre-sent with chronic inflammation of the pancreatic head, pancreatic head resection is the most common treatment option. Duodenum-preserving pancreatic head resections are the surgical procedure of choice, but pancreaticoduodenectomies (Kausch-Whipple procedures) demonstrate similar outcome with regard to pain control, quality of life, and metabolic parameters. Other surgical procedures, including drainage procedures, pancreatic segmental resections, or left resections, are rarely indicated.

The Role of Endoscopic and Surgical Treatment in Chronic Pancreatitis

Chronic pancreatitis is a long-term illness leading to hospital admissions and readmission. This disease is often caused by heavy alcohol consumption and smoking. Patients with chronic pancreatitis suffer from acute or chronic pain episodes, recurrent pancreatitis, and complications, such as pseudocysts, biliary duct strictures, and pancreatic duct fistulas. Pancreatic duct strictures and stones may increase intraductal pressure and cause pain. Endoscopic therapy is aiming at decompressing the pressure and relieving the pain, most commonly with pancreatic duct stents and pancreatic duct stone retrieval. Early surgery is another option to treat the pain. In addition, endotherapy has been successful in treating complications related to chronic pancreatitis. The therapy should be individually chosen in a multidisciplinary meeting. Endoscopic therapy and surgery as treatment options for chronic pancreatitis are discussed in this review.

Pancreaticoduodenectomy for paraduodenal pancreatitis is associated with a higher incidence of diabetes but a similar quality of life and pain control when compared to medical treatment

BACKGROUND

Paraduodenal pancreatitis is a focal form of chronic pancreatitis that affects the groove area between the duodenum and the head of the pancreas. Consensus regarding surgical or nonsurgical management as the best treatment option is still lacking.

METHODS

We retrospectively evaluated all patients managed for PP at The Pancreas Institute of the University Hospital Trust of Verona from 1990 to 2017. The outcomes of surgical vs. medical treatment with regard to pain control, quality of life and pancreatic insufficiency were evaluated through specific questionnaires.

RESULTS

The final study population consisted of 75 patients: 62.6% underwent surgery, and 37.4% were managed without surgery. All surgical procedures consisted of pancreaticoduodenectomy. The median follow-up from the diagnosis of paraduodenal pancreatitis was 60 (12-240) months. Patients who underwent surgery experienced a similar incidence of steatorrhea (44.7 vs. 52.6%; p = 0.4) but a significantly higher incidence of diabetes (59.6 vs. 10.7%; p < 0.01) when compared to those managed without surgery. There was no difference in terms of reported chronic pain (Graded Chronic Pain Scale, median 0 vs. 1; p = 0.1) and quality of life (Pancreatitis QoL Instrument, median 82 vs. 79; p = 0.2). However, surgical patients reported a worse level of self-care activities associated with glycemic control (Diabetes Self-Management Questionnaire, median 20 vs. 28, p = 0.02).

CONCLUSION

In patients affected by paraduodenal pancreatitis, surgery and medical therapy seem to obtain similar results in terms of quality of life and pain control. However, surgery is associated with an increased prevalence of postoperative diabetes with consequent relevant issues with self-care management. Surgery should be considered only in selected patients after adequate medical treatment.

Paraduodenal Pancreatitis: A Deceptive Abdominal Mass with Unique Histologic Findings

Paraduodenal pancreatitis (PP) is an uncommon abdominal pathology characterized by scarring of the pancreaticoduodenal space. Diagnosis of this inflammatory process is challenging as its clinical presentation is similar to that of pancreatic cancer. Currently, no definitive radiologic or pathologic features have been established to permit diagnosis of PP without surgical resection. However, the presence of eosinophilic concretions has been reported with increasing frequency in the histologic evaluation of PP. To the best of our knowledge, these concretions are distinctive for PP and not reported in neoplasms commonly involving the pancreaticoduodenal space. Herein, we discuss the case of a 60-year-old man who was found to have PP after pancreaticoduodenectomy for a paraduodenal mass with an initially nondiagnostic biopsy. Retrospective review of the preoperative FNA samples revealed eosinophilic concretions like those found in the final surgical specimen. If the identification of eosinophilic concretions in a background of inflammatory changes was to be accepted as a diagnostic criterion for PP, patients such as ours could be spared the morbidity associated with surgical resection.

Groove Pancreatitis: Endoscopic Treatment via the Minor Papilla and Duct of Santorini Morphology

Background/Aims

Groove pancreatitis (GP) is an uncommon disease involving the pancreaticoduodenal area. Possible pathogenesis includes obstructive pancreatitis in the duct of Santorini and impaired communication with the duct of Wirsung, minor papilla stenosis, and leakage causing inflammation. Limited data regarding endoscopic treatment have been published.

Methods

Seven patients with GP receiving endoscopic treatment were reviewed. The morphology of the pancreatic duct was evaluated by a pancreatogram. Endoscopic dilation of the minor papilla and drainage of the duct of Santorini were performed.

Results

There were two pancreatic divisum cases, one ansa pancreatica case and four impaired connections between the duct of Santorini and the main pancreatic duct. Three to 31 sessions of endoscopy, with 2 to 24 sessions of transpapillary stenting and dilation, were performed. Interventions through the minor papilla were successfully performed in six of seven cases. The pancreatic stenting duration ranged from 2 to 87 months. Five patients with evidence of chronic pancreatitis (CP) tended to receive more endoscopic interventions than did the two patients without CP (2–24 vs 2, respectively) for GP and other complications associated with CP.

Conclusions

Disconnection or impairment of communication between the ducts of Santorini and Wirsung was observed in all cases of GP. No surgery was required, and endoscopic minor papilla dilation and drainage of the duct of Santorini were feasible for the treatment of GP.

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.