Embryological etiology of pancreaticobiliary system predicted from pancreaticobiliary maljunction with incomplete pancreatic divisum: a case report

Treatment of pancreaticobiliary maljunction by minimally invasive endoscopic common channel sphinctertomy: Analysis of 35 cases

BACKGROUND

Patients with pancreaticobiliary maljunction (PBM) have a common channel (CC) that is too long, causing the Oddi sphincter not to directly affect the pancreaticobiliary junction. As a result, reflux between pancreatic juice and bile occurs, causing various pathological changes in the bile duct or pancreas. Exploring the application and mechanism of minimally invasive endoscopic shortening of the pancreatic bile duct CC channel in PBM has become particularly important, providing patients with another treatment option.

AIM

To investigate the clinical efficacy and safety of minimally invasive endoscopic common channel sphinctertomy (CCEST) in the treatment of patients with PBM.

METHODS

The clinical data of 35 PBM patients treated by minimally invasive CCEST were analyzed, and there were BP type (n = 19) and PB type (n = 16) PBM. All 35 patients underwent CCEST with the help of endoscopic retrograde cholangiopancreatography, and the therapeutic effects and complications of minimally invasive CCEST in PBM patients were analyzed.

RESULTS

A total of 35 patients were diagnosed with PBM, of whom 12 were male and 23 were female. The patients ranged in age from 3 to 89 years, with a mean age of (46 ± 26.38) years. CCEST was performed in all patients to reduce the length of the CC. Among the 35 patients with PBM, 18 (51.43%) had combined biliary and pancreatic duct stones and underwent intraoperative lithotripsy. First-time ERCP stone extraction was successful in 14 patients, with a success rate of 78% (14/18). One week after minimally invasive intervention therapy, the serum biochemistry and C-reactive protein (CRP) and bile amylase in the 35 patients showed a significant decrease compared to the preoperative levels (P < 0.05). Post-ERCP pancreatitis was observed in five patients, but no serious complications such as postoperative bleeding, gastrointestinal perforation, and severe pancreatitis occurred after symptomatic treatment. After a mean follow-up period of (22.05 ± 10.67) mo in the 35 patients, one patient was diagnosed with carcinoma of the bile duct and treated by surgery, and four were treated by ERCP again because of stone recurrence and achieved satisfactory efficacy. The total effective rate of the treatment was 88.6% (31/35).

CONCLUSION

PBM patients often present with an insidious onset. ERCP is a valuable procedure for the diagnosis of PBM. CCEST effectively improves biliopancreatic drainage in early-stage PBM patients by reducing the length of the common biliopancreatic confluence channel. CCEST is a safe and effective minimally invasive intervention for the treatment of PBM patients.

Complex Pancreaticobiliary Maljunction with Pancreas Divisum and Obstructive Pseudocyst

Pancreaticobiliary maljunction (PBM) is the congenital junction of the bile and pancreatic ducts into a common channel located anatomically outside of the duodenal wall. The complex type (Type D) is the rarest type and occurs in conjunction with other pancreaticobiliary anomalies. We present a case of complex PBM with pancreas divisum presenting as acute pancreatitis and obstructive symptoms secondary to a pancreatic pseudocyst. Surgical management is discussed, as complex type PBM is most predisposed to post-operative complications.

Identification and management of pancreas divisum

Introduction: Pancreas divisum is the most common congenital malformation of the pancreas with the majority asymptomatic. The etiological role, pathogenesis, clinical significance and management of pancreas divisum in pancreatic disease has not been clearly defined and our understanding is yet to be fully elucidated.Areas covered: This review describes the role of pancreas divisum in the development of pancreatic disease and the ambiguity related to it. In our attempt to offer clarity, a comprehensive search on PubMed, Ovid, Embase and Cochrane Library from inception to May 2019 was undertaken using key words "pancreas divisum", "idiopathic recurrent acute pancreatitis" and "chronic pancreatitis".Expert opinion: Current research fails to define a clear association between pancreas divisum and pancreatic disease. Though debatable, several studies do suggest a pathological role of pancreas divisum in pancreatic disease and a benefit of minor papilla therapy in the setting of acute recurrent pancreatitis. Surgical and endoscopic therapeutic modalities have not been directly compared. With the current data available, it would be imprudent to advise a definitive line of management for pancreatic disease associated with pancreas divisum and should involve a comprehensive discussion with the individual patient to define expectations before embarking on any medical and/or interventional therapy.