Wirsung and Santorini: the men behind the ducts

Chronic Pancreatitis: Landmark Papers, Management Decisions, and Future

On May 16, 2015 at the invitation of the American Gastroenterological Association Institute Council E.P.D. presented a state-of-the-art lecture at Digestive Disease Week 2015. The aims were to discuss a selection of landmark papers in chronic pancreatitis (CP) that influence modern management and to conclude by suggesting some future directions. This is based on that presentation. We will specifically review the following: duct anatomy and pancreas divisum, description of chronic relapsing pancreatitis and its differentiation from recurrent acute pancreatitis and established CP (ECP), natural histories and gene discoveries of alcoholic, idiopathic and hereditary pancreatitis, development of pancreatic cancer in CP, exocrine pancreatic insufficiency and calculation of dose and delivery of enzymes, endoscopic ultrasonography, and autoimmune pancreatitis. With some exceptions, we exclude basic science and surgery.

The Beginnings of Pancreatology as a Field of Experimental and Clinical Medicine

This review presents the history of discoveries concerning the pancreas. In antiquity and the Middle Ages knowledge about the anatomy of the pancreas was very limited and its function was completely unknown. Significant progress was first made in the seventeenth and eighteenth centuries. Johann Georg Wirsüng, the prosector of the University of Padua, discovered the main pancreatic duct, and Giovanni Santorini discovered the accessory duct. Regnier de Graaf was the first to perform pancreatic exocrine studies, and Paul Langerhans's 1869 discovery of pancreatic islets was the first step toward recognizing the pancreas as an endocrine gland. The twentieth century brought the discovery of insulin and other pancreatic hormones. To date, histochemical staining, transmission electron microscopy, and immunohistochemistry enabled the discovery of five cell types with identified hormonal products in adult human pancreatic islets. Twentieth-century pancreatic studies led to crucial advances in scientific knowledge and were recognized, among other things, with seven Nobel Prizes. The first of these went to Ivan Pavlov in 1904 for his work on the physiology of digestion. The most recent was awarded to Günter Blobel in 1999 for discovering signaling mechanisms that govern the transport and localization of proteins within pancreatic acinar cells.

Ansa pancreatica: an anatomic variation and a rare cause of acute pancreatitis

INTRODUCTION

The ansa pancreatica is a rare anatomic variation of the pancreatic ducts. It is a communication between the main pancreatic duct (Wirsung) and the accessory pancreatic duct (Santorini). Recently, the ansa pancreatica has been considered as a predisposing factor in patients with idiopathic acute pancreatitis.

CASE REPORT

\We report a case of non-alcoholic and non-biliary acute pancreatitis, in a 53-year-old patient. An ansa pancreatica was discovered in a post-operative cholangiography.

CONCLUSION

A pancreatic duct variation, as the ansa pancreatica, can be diagnosed during a severe acute pancreatitis. It is still not clear whether the presence of these two pathologies is a coincidence or if the ansa pancreatica is the cause of the acute pancreatitis. New studies are necessary to clarify these points.

Pancreatic duct diversity

OBJECTIVES

The formation of the pancreatic duct system is the result of the fusion of 2 embryonic buds, the ventral and dorsal primordia. Frequently, this fusion process is localized in the pancreatic head; variations, however, may account for the structural diversity of the duct system. Pancreatic duct anomalies and diversity of body and tail are thought to be casuistic.

METHODS

Ninety-nine consecutive adult autopsies with reference to macroscopic anomalies in the distal part of the gland were evaluated. Pancreatograms were performed after large duodenal papilla cannulation. Ducts parallel to gland axis with a diameter of at least one third of the main pancreatic duct at the junction point and aberrant duct with different shapes and/or abnormal third-degree ductuli architecture were noted.

RESULTS

Our study revealed a 9.9% frequency of main pancreatic duct diversity in the pancreatic corpus and tail. Eleven atypical ducts were visible, 9 cranially and 2 caudally from the main pancreatic duct.

CONCLUSIONS

The pancreatic duct system in the body and the tail presents abnormal configuration not described in the past.

Ruggero Ferdinando Antonio Guiseppe Vincenzo Oddi

Long forgotten in his motherland but for a single discovery-a small circular tissue whose workings are as mysterious as its discoverer-a brilliant anatomist and physiologist, Oddi, gained his fame at the age of 23 years with his identification of the sphincter that would later be named in his honor. In 1984 Ruggero Oddi, was celebrated and revered in his native town of Perugia with a monument. Ruggero Oddi lived a tumultuous life, full of grief and tragedy, only to culminate in a lonely death while exiled in a foreign land. We now review the life of this contributor to modern anatomy.

Symptoms and surgical management of a distal choledochal cyst in a patient with pancreas divisum: case report and review of the literature

We report the case of a 63-year-old woman who presented with the rare finding of a distal choledochocele in a pancreas divisum with recurrent abdominal pain and episodes of pancreatitis. She underwent successful resection with choledochectomy, papillectomy and reconstruction with a hepatico-jejunostomy and reinsertion of the uncinate pancreatic duct into the same jejunal loop. Comparable literature findings are discussed with regard to the presented case.

Benign Anatomical Mistakes: “Ampulla of Vater” and “Papilla of Vater”

The anatomy of the ampullary termination of the bile and pancreatic ducts is complex; appropriate terminology for this area is confusing and inaccurate. We examine the terms “ampulla of Vater” and “papilla of Vater” for anatomical and historical correctness. The term “ampulla” refers to a dilated part of a duct or other channel. Thus, this word is topographically correct to describe the dilatation at the confluence of the bile and main pancreatic ducts; historically, however, there is considerable reason to believe that its first description was by Santorini rather than Vater. The eponymous term “papilla of Vater” is also incorrect historically. The use of eponyms is firmly entrenched in the medical literature, but some are so problematic that they should be discarded. The eponymous terms for both the ampulla and the papilla should be replaced with the terms “hepatopancreatic ampulla” (or “biliaropancreatic ampulla”) and “major [or “greater”] duodenal papilla,” respectively.