Partial annular pancreas as an incidental finding in a patient with intermittent bowel obstruction: A case report

Complete annular pancreas (AP) is a congenital anomaly, in which the duodenum is either completely or partially encircled by the ring of pancreatic tissue, which eventually becomes continuous with the head of the pancreas. The incidence of AP is estimated to be around 0.02%. Reports from endoscopic retrograde cholangiopancreatography show an incidence of 0.4%. Partial AP (PAP) is a rarer entity, in which a band of pancreatic tissue in continuity with the head of the pancreas, incompletely encircles the duodenum. It may be asymptomatic or may present later in life with complications. We report a case of a 72-years old male with features of intermittent bowel obstruct which was later found to be having PAP on contrast-enhanced computed tomography imaging at the level of renal hilum characterized by "crocodile-jaw appearance." The possibility of PAP should also be considered at the back of mind of the treating physician, if a patient presents with a long-term history of postprandial abdominal discomfort.

Successful Management of a Child with Bronchoesophageal Fistula Associated with Other Anomalies

Bronchoesophageal fistulas (BEFs) are rare malformations characterized by abnormal communication between the bronchus and the esophagus. Herein, we report a successful management of a child with BEF discovered as an intraoperative surprise and associated with the short gut, annular pancreas, and disorder of intestinal fixation.

Diamond-shaped versus side-to-side anastomotic duodenoduodenostomy in laparoscopic management of annular pancreas in children: a single-center retrospective comparative study

Background

Annular pancreas is a rare congenital disorder that requires surgical management once diagnosed. Diamond-shaped and side-to-side duodenoduodenostomy are both popular worldwide nowadays in the surgical management of annular pancreas. Here we present our experience with laparoscopic management of annular pancreas in the last 5 years and compare the clinical results of the diamond-shaped versus side-to-side anastomotic techniques.

Methods

Fifty-two patients diagnosed with annular pancreas who underwent duodenoduodenostomy at our medical center between January 2016 and April 2021 were included in the study. Forty-four patients underwent laparoscopic diamond-shaped duodenoduodenostomy (DS group) and eight underwent laparoscopic side-to-side duodenoduodenostomy (STS group). Clinical data, including surgical indices and early outcomes after surgery, with at least 19 months of follow-up, were collected and analyzed.

Results

Of the 52 patients, 61.5% were prenatally diagnosed, and vomiting was the most common clinical manifestation after birth. The operative time and bleeding volume were 187.5 [interquartile range (IQR), 150-228)] min and 2 (IQR, 2-5) mL in the DS group, compared to 175 (IQR, 155-270) min and 2 (IQR, 2-4.25) mL in the STS group (P=0.89 and 0.32 respectively). The mean time from surgery to initial oral feeding and full oral feeding was 6 (IQR, 4-10) and 12 (IQR, 10-15) days in the DS group, compared to 8 (IQR, 4.75-11.25) and 14.5 (IQR, 13-16.75) days in the STS group (P=0.61 and 0.46 respectively). The mean hospital stay was 16 (IQR, 14-19) and 20 (IQR, 17.75-26) days in the DS and STS groups respectively (P=0.13). No severe complications such as anastomotic leakage, anastomotic stenosis, reoperation or unsuspected rehospitalization were noted in either group. Feeding intolerance was revealed in six cases in the DS group and two cases in the STS group, and there was no significant difference between the two groups (P=0.50).

Conclusions

Both laparoscopic diamond-shaped and side-to-side techniques showed good clinical results in treating annular pancreas. The surgical technique, trans-anastomotic tube and early feeding are not likely to increase the risk of postoperative feeding intolerance.

Pancreaticoduodenectomy in the Portal Annular Pancreas-Mesopancreas Triangle Approach (with Video)

BACKGROUND

Portal Annular Pancreas (PAP) is a relatively uncommon entity with 4% reported incidence. Pancreaticoduodenectomy is challenging in cases with PAP and is associated with higher postoperative pancreatic fistula rate and overall morbidity. PAP is classified according to the pattern and location of fusion around the portal vein as-supra-splenic, infra-splenic & mixed fusion type. Also, the ductal anatomy can vary as pancreatic duct present only in the ante-portal portion or only in the retro-portal portion or ducts in both ante and retro-portal portion. At present, ideal surgical strategy is not defined as per the PAP types.

METHODS

The case demonstrated in the video presented with a localized, large duodenal mass with type IIA PAP (supra-splenic fusion with both ante and retro-portal ducts) detected on the preoperative triphasic CT scan. To achieve a single pancreatic cut surface with a single pancreatic duct for anastomosis, an extended pancreatic resection was performed using meso-pancreas triangle approach.

RESULTS

Patient had a smooth intraoperative course & the postoperative recovery was also uneventful. Pathology reported pT3 duodenal cancer with negative margins and uninvolved lymph nodes.

CONCLUSION

A preoperative knowledge of PAP and its various types is extremely important in order to tailor intraoperative management, specially of the retro-portal portion. In patients with retro-portal duct or both ante and retro-portal ducts (as the case presented in the video), an extended resection is recommended to mitigate postoperative pancreatic fistula.

Annular pancreas: Beneath the intestinal obstruction-A case report

Annular pancreas is an uncommon congenital anomaly which is a rare cause of congenital duodenal obstruction. It is normally identified during the neonatal period, but may also be identified in adolescence or adulthood. This diagnosis is often overlooked in adult patients who present with symptoms suggestive of duodenal obstruction. We present a case of AP detected in a 23-year-old man, with complaints of continuous vomiting and abdominal discomfort over the last 6 months. An upper gastrointestinal study revealed a constricted second part of the duodenum. A computed tomography scan revealed a complete ring of pancreatic tissue around the second part of the duodenum. Diagnostic and therapeutic surgery decompresses the external obstruction. The patient had an early post-operative activation. No specific guidelines and protocols exist about the management of such cases. Given the rarity of this congenital anomaly, presenting with chronic partial duodenal obstruction, and its successful surgical treatment, have prompted us to report the case along with a brief review of literature about the subject.

Recurrent non-bilious vomiting in a child: A case report of an uncommon diagnosis

Annular pancreas (AP) is a congenital anomaly and a recognised cause of duodenal obstruction which can affect all age groups. It may manifest early in the neonatal period, but it may also have varied and often delayed symptoms. We report the case of AP in an 18-month-old girl with a long history of recurrent post-prandial non-bilious vomiting treated for a long time with the clinical diagnosis of gastroesophageal reflux. Upper gastrointestinal study was suggestive of partial duodenal obstruction and computed tomography revealed a complete ring of pancreatic parenchyma surrounding the second part of the duodenum. Diamond-shaped duodenoduodenostomy was achieved successfully and the post-operative period was uneventful. Although rare, AP must be kept in mind of any paediatric surgeon while confronted to symptoms of partial duodenal obstruction.

Annular pancreas causing duodenal obstruction in a 23 year old women managed surgically for gastrojejunostomy; a case report

INTRODUCTION

Annular pancreas is an uncommon congenital abnormality characterized by a ring of pancreatic tissue around the duodenum descending part. It is exceptionally rare in adults and is increasingly detected after the investigation of symptoms caused by its consequences, which include recurrent pancreatitis, duodenal stenosis at the site of the annulus, or duodenal or gastric ulcers. In this study, we present a case report of symptomatic annular pancreas in an adult patient.

PRESENTATION OF CASE

A 23-year-old woman hospitalized for epigastric pain and recurrent vomiting. Radiological examination was consistent with an annular pancreas. At operation, a partial obstruction of the second part of the duodenum was found, caused by an annular pancreas. No other congenital anomaly of the intra-abdominal organs was noted. A gastrojejunostomy was performed and she was discharged after 8 days with good recovery.

CONCLUSION

Because annular pancreas in adults is a rare clinical scenario, it should be included in the differential diagnosis of adult patients with gastrointestinal obstructive symptoms for a prolonged period of time, given that surgical intervention has a reliable outcome.

Annular Pancreas: A Rare Cause of Upper Gastrointestinal Bleeding in Adults

Annular pancreas is a rare congenital anomaly in which a thin band of pancreatic tissue partially or completely surrounds the duodenum. It is challenging to diagnose due to its variable clinical presentation. Approximately two-thirds of patients have no symptoms in their lifetime, and most symptomatic cases are seen in neonates and infants. Symptomatic adult patients present with upper gastrointestinal symptoms, such as epigastric pain, vomiting, and postprandial fullness associated with gastric outlet obstruction. Complications associated with annular pancreas include peptic ulcer disease, pancreatitis, pancreatic head carcinoma, and biliary obstruction. Annular pancreas is also a rare cause of upper gastrointestinal bleeding in adults, but it should be considered as one of the differential diagnoses in patients presenting with a peptic ulcer and duodenal stricture. Here, we report the case of a 60-year-old man who presented with melena and was subsequently diagnosed with an annular pancreas.

VACTERL syndrome with late presentation of annular pancreas with duodenal web: Case report

VACTERL Syndrome affects multiple body systems and can include various anomalies of the Vertebral column, Anus and/or rectum, heart (Cardiac), Tracheo-Esophagus, kidneys (Renal), and Limbs. Patients with VACTERL syndrome are at increased risk of having a congenital duodenal obstruction that may be extrinsic in the form of an annular pancreas or intrinsic in the form of duodenal atresia, stenosis or web. Simultaneous presentation of both the annular pancreas and duodenal web is a rare clinical entity and typically presents in neonates. However, late presentation of annular pancreas combined with a duodenal web is exceedingly uncommon. We present a case of late diagnosis of annular pancreas with duodenal web resulting in an entrapped ingested foreign body.

Is postoperative transanastomotic feeding beneficial in neonates with congenital duodenal obstruction?

PURPOSE

We aimed to evaluate possible positive and negative effects of postoperative use of transanastomotic feeding tube (TAFT) in neonates operated for congenital duodenal obstruction (CDO).

METHODS

This is a retrospective study reviewing medical records of neonates operated for CDO during 2003-2020 and comparing postoperative feeding outcomes and complications in patients with and without TAFT. Approval from the hospital's data protection officer was obtained.

RESULTS

One hundred patients, 59% girls, were included, and 37% received TAFT. Mean birth weight and gestational age were 2628 (675.1) grams and 36.6 (2.4) weeks, respectively. Furthermore, 45% had no other malformations, and 36% had Down syndrome. Patient demographics were similar for TAFT and not-TAFT patients, except that not-TAFT neonates weighed median 335 g less (p = 0.013). The TAFT group got parenteral nutrition 2 days shorter (p < 0.001) and started enteral feeds 1.5 days earlier (p < 0.001) than the not-TAFT group. Fewer neonates with TAFT got a central venous catheter [65 vs 89%, (p = 0.008)]. In the TAFT group, 67% were breast fed at discharge compared to 49% in the not-TAFT group (p = 0.096).

CONCLUSION

Neonates with TAFT had earlier first enteral feed, fewer days with parenteral nutrition and fewer placements of central venous catheters.

The development of zebrafish pancreas affected by deficiency of Hedgehog signaling

The pancreas development depends on complex regulation of several signaling pathways, including the Hedgehog (Hh) signaling via a receptor complex component, Smoothened, which deficiency blocks the Hh signaling. Such a defect in birds and mammals results in an annular pancreas. We showed that in developing zebrafish, the mutation of Smoothened or inhibition of Hh signaling by its antagonist cyclopamine caused developmental defects of internal organs, liver, pancreas, and gut. In particular, the pancreatic primordium was duplicated. The two exocrine pancreatic primordia surround the gut. This phenomenon correlates with a significant reduction of the gut's diameter, causing the annular pancreas phenotype.

Annular pancreas mimicking hypertrophic pyloric stenosis in a female infant

Annular pancreas is a rare congenital intestinal obstruction to be found in infants. It is characterized by nonbilious vomiting, abdominal distention, and feeding intolerance that share similar symptoms with other intestinal obstructions. We reported a case of 11-month-old female infant with a history of nonbilious vomiting after coughing as much as 6 times per day 1 day before admission. The patient had an incorrect provisional diagnosis of hypertrophic pyloric stenosis based on ultrasound. Later on, an upper gastrointestinal series showed dilatation of the second part of the duodenum which was successfully treated by a duodenostomy during laparotomy procedure. It is suggested that treating an intestinal obstruction needs a further investigation when the symptoms were continuously repeated.

Extraordinary first jejunal arterial variation associated with annular pancreas undergoing pancreaticoduodenectomy for pancreatic cancer: a case report

Purpose

Annular pancreas encountered in adults and jejunal arterial variations are rare. Anatomical variations can cause conflicts between oncology and surgical safety.

Methods

Case report of a 68-year-old man suffering from vomiting because of an annular pancreas and a ductal adenocarcinoma of the pancreas head invading the second portion of the duodenum.

Results

Contrast-enhanced computed tomography showed multiple arterial variations describing the absence of the coeliac trunk such that the left gastric artery (LGA), splenic artery and superior mesenteric artery (SMA) were arising separately from the aorta. The accessory left hepatic artery arose from the LGA; and both the common hepatic artery and combined trunk of the replaced right hepatic artery with the higher replaced first jejunal artery separately arose close to the root of the SMA. The patient underwent curative pancreaticoduodenectomy which achieved 3 years of recurrence-free survival.

Conclusion

This was an extraordinary case of annular pancreas with first jejunal arterial variation detailing an embryological interpretation as well as considerations for balancing short- and long-term outcomes.

Portal Annular Pancreas (PAP): an Underestimated Devil in Pancreatic Surgery-Systematic Review of Literature and Case Report

INTRODUCTION

Portal annular pancreas (PAP) is an anatomic variation due to aberrant fusion of the ventral and dorsal pancreatic buds around the portal vein. In this article, we present a case report with a systematic review of literature of patients undergoing major pancreatic surgery with associated PAP. We also intend to discuss and suggest possible surgical strategies to minimise major postoperative complications.

METHODS

A systematic literature search was conducted using the terms "circumportal," "periportal," "pancreas," "annular pancreas," "portal annular pancreas" and "pancreas anomaly." All articles describing portal annular pancreas with surgical resection were included.

RESULTS

We identified a total of 53 patients of PAP from 29 articles, who underwent pancreatic resection with a median age of 65 years. POPF (postoperative pancreatic fistula) was demonstrated in 42.55% of patients and 34% had CR (clinically relevant)-POPF. Following pancreaticoduodenectomy, pancreatic stump was reconstructed in all patients with either pancreaticojejunostomy or pancreaticogastrostomy. Standard line of pancreatic transection, i.e., division of anteportal portion at the pancreatic neck and stapling of the retroportal process, resulted in 71% incidence of CR-POPF, whereas it was only 16% when extended resection was performed to achieve single pancreatic stump and 12.5% when retroportal portion was sutured or ligated. Amongst distal pancreatic resections, 66% had POPF and 33% developed CR-POPF.

CONCLUSION

It is of utmost importance for pancreatic surgeons to diligently look for and identify PAP in the preoperative imaging. Additional imaging in the form of MRCP helps to define abnormal pancreatic ductal anatomy. Surgeons need to be cognisant of pancreatic stump management in patients with PAP to reduce associated higher rates of POPF.

Clinical characteristics of adult-type annular pancreas: A case report

BACKGROUND

Annular pancreas (AP) is a rare congenital abnormal rotation of the pancreas. AP rarely occurs in adults. Pancreatic tumors and ampullary tumors are related to AP, so the discovery and treatment of AP are essential.

CASE SUMMARY

This study investigated the clinical manifestations, imaging features, complications, and treatment of six patients diagnosed with AP at the Department of Hepatobiliary and Pancreatic Surgery, First Hospital of Jilin University from January 2010 to June 2020. There were four males and two females, with an average age of 56.00 ± 9.86 years old. In this study, abdominal pain and jaundice were the main clinical manifestations. Imaging can show the “crocodile jaw sign” or “double bubble sign”.

CONCLUSION

For patients with duodenal or biliary obstruction, physicians should give priority to AP when imaging examinations suggest that the duodenum is wrapped with tissue similar to the density of the pancreas. Symptomatic patients should actively undergo surgical treatment.

Case report: Neonatal pancreatitis, chromosomal abnormality and duodenal stenosis in a newborn. A new syndrome?

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Neonatal jaundice and abdominal symptoms may be a pointer to pancreatitis.

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Prenatal diagnosis of duodenal obstruction should raise suspicions of annular pancreas and other abnormalities.

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Prenatal diagnosis of one congenital abnormality should necessitate referral to specialist centres for delivery.

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History of maternal infection must be obtained even in resource constrained settings.

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Imperative to investigate cause of jaundice extensively in neonatal acute abdomen.

Introduction

Pancreatitis is a dire clinical diagnosis with variable presentation in the paediatric population. Moreover, neonatal pancreatitis has been rarely reported in the English literature.

Presentation of case

A newborn, product of a poorly supervised, pre-term gestation with pre-natally diagnosed intestinal obstruction, and post-natal clinical features of jaundice, vomiting, abdominal distension, aphonation and suspected chromosomal abnormalities. There was maternal hepatitis which was untreated. Diagnosed as duodenal atresia, the baby was investigated, resuscitated and had surgery. Intra-operative findings were of an omental bubble, duodenal stenosis with annular pancreas, coagulative necrosis of the pancreas and multiple intra peritoneal cheesy deposits. Following an unfortunate demise, autopsy confirmed pancreatitis and multiple congenital abnormalities.

Discussion

Paediatric caregivers should be aware of the possibility of neonatal pancreatitis in jaundiced newborns with intestinal obstruction especially with a background of maternal viraemia.

Conclusion

A constellation of unusual presentations as highlighted could be a pointer to an emerging syndrome. All paediatric caregivers should entertain a high index of suspicion of pancreatitis in such a case, investigate and expedite appropriate interventions to prevent mortality.

Pancreatitis in the developmentally anomalous pancreas

Developmental anomalies of the pancreas include more common entities such as pancreas divisum and annular pancreas, and unusual entities such as heterotopic pancreas. While these anomalies can present a diagnostic challenge to the radiologist, when the pancreatic tissue involved in these processes develops pancreatitis, the radiographic appearance can present a diagnostic dilemma. Awareness of these pancreatic anomalies and familiarity with their appearance when inflamed is necessary to distinguish pancreatitis in the developmentally anomalous pancreas from other inflammatory or neoplastic processes.

Modified Puestow Procedure for Chronic Pancreatitis in a Child Due to Annular Pancreas and Duodenal Duplication: A Case Report

An 18-year-old woman with annular pancreas and duodenal duplication presented with recurrent acute pancreatitis and underwent a resection of duodenal duplication. However, the patient experienced recurrent abdominal pain after resection. Abdominal computed tomography and magnetic resonance imaging showed a dilatation of the peripheral pancreatic duct and stenosis and malformation of both the Wirsung's and Santorini's duct due to multiple stones. The modified puestow procedure was performed. The main pancreatic ducts in the body and tail were opened, and the intrapancreatic common bile duct was preserved. A Roux-en-Y pancreatico-jejunostomy was performed for reconstructing the pancreaticobiliary system after removing the ductal protein plug. The patient experienced no abdominal pain, no significant elevation of the serum amylase and lipase levels, and no stone formation during the 2 years of follow-up. This procedure is considered to be beneficial for pediatric patients with chronic pancreatitis due to annular pancreas and duodenal duplication.

Clinical spectrum of adult patients with annular pancreas: Findings from a large single institution cohort

BACKGROUND AND AIMS

Annular pancreas (AnnP) is a rare congenital abnormality that results from the presence of a complete or partial ring of pancreatic tissue surrounding the descending portion of the duodenum. While the clinical presentation and management of AnnP in neonates and infants has been well described, the complete spectrum of clinical presentation of AP in adults is not very clear. We aimed to describe the clinical spectrum of presentation and management of adult patients with AnnP.

METHODS

Using the electronic medical record, we identified 198 patients with radiologically and/or surgically confirmed AnnP evaluated at Mayo Clinic between 1995 and 2017.

RESULTS

The mean age of the study population at diagnosis was 55.1 (±18.3) years (60% female). 60% of patients did not have symptoms attributable to pancreatic disease at the time of diagnosis and were diagnosed incidentally. Computed tomography (CT) was the most common modality (64%) of diagnosis. Among symptomatic patients, abdominal pain (50%), duodenal obstruction (31%) and acute pancreatitis (16%) were the most common symptoms (non-exclusive). While most patients with duodenal obstruction required surgery, all patients with acute pancreatitis could be managed conservatively in the absence of competing indications for intervention.

CONCLUSION

AnnP may remain asymptomatic well into adulthood and be incidentally detected on abdominal imaging done for other indications. While surgery remains the mainstay of treatment in patients presenting with duodenal obstruction, a majority of these adult symptomatic patients with AnnP, including those with acute pancreatitis require no further treatment.

Pancreaticobiliary maljunction diagnosed long after laparotomy in the neonatal period for annular pancreas: report of a case

BACKGROUND

Although annular pancreas concurrent with pancreaticobiliary maljunction has rarely been reported, some reports have pointed out a possibility that both anomalies have a common pathogenesis in pancreatic development. We herein report a case with pancreaticobiliary maljunction diagnosed long after surgical treatment for annular pancreas.

CASE PRESENTATION

A 34-year-old female, with a surgical history of duodenal obstruction due to annular pancreas in the neonatal period, was referred to our hospital for further examination of chronic pancreatitis. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography revealed choledocholithiasis, pancreatic lithiasis, and pancreaticobiliary maljunction without biliary dilatation. Choledocholithotomy and cholecystectomy were performed, and highly elevated levels of amylase in bile from the common bile duct were found intraoperatively.

CONCLUSION

The present case highlights a possible association of pancreaticobiliary maljunction in a patient with annular pancreas.

Laparoscopic Roux-en Y duodenojejunostomy: A safe and physiological treatment for symptomatic annular pancreas in adults

Background:

Annular pancreas is a rare, congenital, rotational anomaly of pancreas, seen usually in newborns who present with features of duodenal obstruction. However, in adults, only 24% of cases are present with duodenal obstruction. Surgery remains the procedure of choice in patients in whom symptoms can be attributed to duodenal obstruction and the goal of surgery is to relieve obstruction by bypassing the annulus. Laparoscopic Roux-en Y duodenostomy (DJ) is our preferred bypass approach for this condition. Literature search revealed that very few case reports have been published about laparoscopic management of annular pancreas, especially about duodenojejunal anastomosis. We present our experience in the laparoscopic management of symptomatic annular pancreas in adults and technique of the laparoscopic Roux-en Y DJ for annular pancreas.

Materials and Methods:

Between 1996 and 2016, a total of six adult patients underwent laparoscopic management for symptomatic annular pancreas. The demographic, perioperative and follow-up details were documented.

Results:

All surgeries were successfully performed by laparoscopic approach with no conversion to open. Five cases underwent Roux-en Y DJ and one underwent gastrojejunostomy. No major perioperative events occurred. The mean length of hospital stay was 5.6 days. Five out of six patients were followed up for 24 months, and no symptom recurrence was seen.

Conclusion:

Laparoscopic Roux-en Y duodenojejunostomy could be used as a safe and physiological treatment for annular pancreas in adult patients and should be preferred for the treatment of duodenal obstruction due to annular pancreas.

Annular pancreas in China: 9 years' experience from a single center

To summarize the clinical characteristics, diagnosis, treatment and prognosis among 152 children with annular pancreas (AP). A retrospective review of 152 patients with AP who were treated with surgical repair between January 2009 and August 2017 was performed at our pediatric surgical units. Presenting symptoms, birth weight, radiological findings, associated anomalies, the type of surgery performed were analyzed. (1) 152 patients were identified, out of which 82 were males, and 70 were females; (2) the average birth weight of children with AP was less than that of healthy newborns. The birth weights of 5.4% premature infants were less than 1500 g; the birth weight of 17% full-term infants, 69% premature infants and 50% post-term infants were less than 2500 g. (3) 100 (66%) patients presented symptoms during neonatal period and 43 (28%) patients had duodenal obstruction diagnosed by prenatal ultrasound scan. (4) All cases were managed surgically by open laparotomy, and all patients were duly discharged. AP most commonly presents symptoms in early neonatal period. Infants with AP are associated with a higher rate of low birth weight, and it was because swallowed amniotic fluid could not be absorbed and impaired insulin secretion caused by abnormal pancreas. Ultrasonography, abdominal plain film and upper gastrointestinal series (UGI) are helpful, but cannot make the diagnosis, and surgery is the only effective way to diagnose and treat AP.

Laparoscopic Roux-en-Y duodenojejunostomy for annular pancreas in adults: case report and literature review

Annular pancreas is in adults is a rare congenital anomaly which incidence varied from 0.005% to 0.015%. Although 33% of the cases are symptomatic, the symptoms are most commonly associated with gastric outlet obstruction. Here we presented an adult diagnosed with annular pancreas treated by laparoscopic Roux-en-Y side to side duodenojejunostomy.

A rare cause of vomiting: annular pancreas

Annular pancreas is a rare congenital anomaly that consists of a ring of pancreatic tissue partially or completely encircling the second part of the duodenum. It can affect anyone from neonates to adults, and is difficult to diagnose because it can present in a wide range of clinical conditions. Although cases have also been reported in adults, symptomatic cases are often referred in infancy or early childhood. A 17-year-old female patient who was diagnosed as having annular pancreas is reported. The patient had had non-bilious vomiting accompanied by abdominal pain, especially 5-10 minutes after meals, for seven years. Annular pancreas, which may be seen at any age, should be considered in the differential diagnosis of patients with non-bilious vomiting, particularly after meals, over a long period.

A case of annular pancreas with Wirsung's duct encircling the duodenum: embryological hypothesis based on cholangiopancreatographic and immunohistochemical findings

We present a resected case of annular pancreas in which Wirsung's duct encircled the duodenum and continued directly to the main pancreatic duct in the body and tail. Furthermore, Wirsung's duct coursed along the right side of the lower bile duct near the major duodenal papilla. Histologically, the islets of Langerhans in the annular pancreas were irregular in shape and were characterized by a striking abundance of pancreatic polypeptide (PP)-positive cells. The PP-rich area that encircled the duodenum was fused with the PP-poor area in the head of the pancreas. The following embryological hypothesis is proposed. The tip of the ventral pancreatic anlage adhered to the duodenal wall and stretched to form a ring during clockwise rotation. The rotation was incomplete, and the pancreatic duct did not cross over the lower bile duct. Since there was adequate ventral anlage in the lower part of the head of the pancreas, fusion between the ducts of the ventral and dorsal anlagen did not occur. The tip of the ventral anlage overgrew and adhered to the dorsal anlage, and the annular duct fused with the main duct of the dorsal anlage.

Distal Duodenal Obstruction: a Surgical Enigma

The postbulbar segment also known as the distal duodenum is a separate clinical entity in terms of the intrinsic pathologies of this region and its varied anatomical relations. The common bile duct and the pancreatic duct open through the major papilla, which marks the beginning of this segment. Distal duodenal obstruction can be defined as a clinicoradiological entity that is characterized by features of gastric outlet obstruction with recurrent bilious vomiting and a radiological evidence of postbulbar obstruction. A Medline search for distal duodenal obstruction revealed 1409 entries, mostly in the form of case reports. In the last 10 years, 310 cases are reported. Clinical features like abdominal pain, nausea, and vomiting are non-specific and quite similar to gastric outlet obstruction. Clinical findings are also non-specific and do not aid in diagnosis. Laboratory findings also do not add much. Contrast-enhanced CT scan and MR enterography are diagnostic modalities of choice. Distal duodenal obstruction is a clinical entity that has a wide list of differential diagnosis which requires due consideration in terms of its management and follow-up. Most of these lesions require adequate workup with the help of a multidisciplinary team consisting of radiologists, gastroenterologists, and pathologists to adequately diagnose and stage the disease before a treatment plan is formulated. A thorough knowledge is a must regarding the treatment options available for each of the conditions so that the management can be personalized leading to better results.

A case report of laparoscopic duodenal atresia repair in a neonate using a novel miniature stapling device

INTRODUCTION

Laparoscopic duodenal atresia repair is an advanced procedure performed in select pediatric surgical centers. Recently, sub-6mm endosurgical staplers have been introduced, facilitating and accelerating the creation of intracorporeal intestinal anastomoses.

PRESENTATION OF CASE

We performed a laparoscopic duodenojejunostomy in a one-day-old child with duodenal atresia due to annular pancreas using a novel 5.8mm articulating endostapler with excellent outcome. The technical details are reported.

DISCUSSION

Laparoscopic duodenojejunostomy is a technically demanding procedure due to difficulty in hand-sewn anastomosis in a small and restricted space. With this novel 5.8mm articulating endostapler, we were able to perform a quicker and easier anastomosis.

CONCLUSION

We report a case of laparoscopic duodenal atresia repair in a neonate using a novel miniature stapling device. This new technique is a safe, quick and easier way to perform laparoscopic duodenal atresia repair.

Incomplete Annular Pancreas with Ectopic Opening of the Pancreatic and Bile Ducts into the Pyloric Ring: First Report of a Rare Anomaly

The patient was a 56-year-old woman who had experienced epigastralgia and dorsal pain several times over the last 20 years. She was admitted for a diagnosis of acute cholecystitis, and severe intra- and extrahepatic bile duct dilatation with inner air density was noted. No papilla of Vater was present in the descending duodenum, and 2 small holes were present in the pyloric ring. Bile excretion from one of the small holes was observed under forward-viewing endoscope. It was considered that the pancreatic and bile ducts separately opened into the pyloric ring. Based on these findings, malformation of the pancreaticobiliary duct was diagnosed. She did not wish treatment, but the obstruction associated with duodenal stenosis was noted after 2 years. Pancreatoduodenectomy was performed as curative treatment for duodenal stenosis and retrograde biliary infection through the bile duct opening in the pyloric ring. The ventral pancreas encompassed almost the entire circumference of the pyloric ring, suggesting a subtype of annular pancreas. Generally, lesions are present in the descending part of the duodenum in an annular pancreas, and the pancreatic and bile ducts join in the papillary region. However, in this patient, (1) the pancreas encompassed the pyloric ring, (2) the pancreatic and bile ducts opened separately, and (3) the openings of the pancreatic and bile ducts were present in the pyloric ring. The pancreas and biliary tract develop through a complex process, which may cause various types of malformation of the pancreaticobiliary system, but no similar case report was found on a literature search. This case was very rare and could not be classified in any type of congenital anomaly of the pancreas. We would classify it as a subtype of annular pancreas with separate ectopic opening of the pancreatic and bile ducts into the pyloric ring.

Carcinoma of the Ampulla of Vater Associated with Annular Pancreas

Carcinoma of the ampulla of Vater associated with annular pancreas is a rare entity. Only seven cases have been reported so far in the English literature. We herein report one such case in a 42-year-lady who presented with progressively increasing jaundice and pain in the upper abdomen for past 2 months. A magnetic resonance cholangiopancreaticography (MRCP) and MRI revealed an annular pancreas with an ampullary mass and a dilated CBD. An upper gastrointestinal endoscopic biopsy from the ampullary mass revealed a moderately differentiated adenocarcinoma. She was diagnosed as having annular pancreas with periampullary cancer that was subsequently confirmed at laparotomy. Histological examination confirmed a complete annular pancreas with a 2 cm × 2 cm moderately differentiated adenocarcinoma of the ampulla of Vater. The management, however, remains as in any case of periampullary malignancy. This highlights the importance that obstructive jaundice in an adult patient presenting with annular pancreas may be associated with a coexisting periampullary malignancy.

Neonatal Duodenal Obstruction: A 15-Year Experience

BACKGROUND

Congenital duodenal obstruction is one of the commonest causes of neonatal intestinal obstruction. We are presenting our 15-year experience by analyzing clinical spectrum and outcome in neonates with duodenal obstruction admitted at our center.

MATERIAL AND METHODS

The hospital records of all neonates admitted with duodenal obstruction from June 2000 to June 2015 were reviewed. The patient records were analyzed for antenatal diagnosis, age, sex, clinical presentation, diagnosis, associated anomalies, surgical procedures performed; postoperative morbidity and mortality. We excluded from our study malrotation of gut associated with congenital diaphragmatic hernia and abdominal wall defects.

RESULTS

A total of 81 patients were admitted, out of which 56 were males and 25 were females. Polyhydramnios was detected in 24 (30%) pregnancies. Average birth weight was 2.1±1.0Kg and average gestational age was 38 (SD±1) weeks with 17 (21%) preterm neonates. Presenting features were vomiting in 81(100%) which was bilious in 81% and non-bilious in 19%, epigastric fullness in 56 (69%) and dehydration in 18 (22%) and failure to thrive in 16 (19%). Most common cause of obstruction was duodenal atresia in 38 (46.9%), followed by malrotation of gut in 33 (40.7%), and annular pancreas in 4 cases. Depending upon site of location, infra-ampullary obstruction was the most common in 64 (79%), supra-ampullary in 9 (7.4%) and ampullary 8 neonates. Both duodenal atresia and malrotation of gut was present in 4 cases. X-ray abdomen was most commonly used investigation to confirm the diagnosis. All cases were managed surgically by open laparotomy. Eleven (13.5%) patients died due to sepsis and associated congenital anomalies.

CONCLUSION

Congenital duodenal obstruction most commonly presents in early neonatal period with features of upper GIT obstruction like vomiting and epigastrium fullness as in our series. Early antenatal diagnosis and surgical interventions hold the key in achieving good outcome. Associated congenital anomalies, prematurity, sepsis and delayed presentation are the main risk factors for post-operative mortality and morbidity.

Intraductal papillary mucinous neoplasm in an annular pancreas: a case report

Annular pancreas is a rare anomaly in which a ring of pancreatic tissue encircles the second portion of the duodenum. We herein report a case involving a 79-year-old Japanese man with an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Imaging studies showed that the pancreatic tissue encircled the descending part of the duodenum and that a 30-mm-diameter cystic tumor was present in the annular segment, leading to the diagnosis of pancreatic IPMN. Limited pancreatic resection was successfully performed by careful division of the annular segment from the second portion of the duodenum. The postoperative course was uneventful, and the patient’s pancreatic function was retained without the need for supplementation. To the best of our knowledge, this is the first report of IPMN occurring in the annular segment of the pancreas. Limited resection of the pancreatic annular segment is a feasible surgical treatment for noninvasive IPMN of the annular pancreas.

Symptomatic annular pancreas in adult: Report of two different presentations and treatments and review of the literature

Annular pancreas (AP) in adults is a rare embryologic abnormality detected after development of complications or as incidental finding. Diagnosis and treatment strategies for symptomatic adult AP remain controversial.

We describe two different presentation of AP: a woman with a specific upper abdominal pain treated with medical therapy and a man with upper gastroenteric obstructive symptoms which underwent surgical duodeno-jejunal by-pass. English language literature about annular pancreas etiology, diagnosis and treatment was reviewed.

No specific guidelines and protocols exist about management of AP, therefore, treatment and operative approaches must be individualized. In consideration of the possible post-operative complications, surgical treatment should be reserved in case of failure of conservative medical therapies.

Annular pancreas in Trichorhinophalangeal syndrome type II with 8q23.3-q24.12 interstitial deletion

Background

Trichorhinophalangeal syndrome type II (TRPS II, OMIM # 150230) is a rare autosomal dominant genetic disorder characterized by craniofacial and skeletal abnormalities. Loss of functional copies of the TRPS1 gene at 8q23.3 and the EXT1 gene at 8q24.11 are considered to be responsible for the syndrome.

Case Presentation

Herewith, we report an 8-year-old girl with sparse scalp hair, bulbous nose, thin upper lip, broad eyebrows, phalangeal abnormalities of both hands/toes, multiple exostoses, mild intellectual impairment and severe malnutrition. In addition, the patient also had annular pancreas, a rare co-existing feature in patients with TRPS II.

Conclusions

A contiguous 5.47 Mb deletion involving 8q23.3-q24.12 was detected by array comparative genomic hybridization (aCGH), leading to haploinsufficiency of 10 protein coding genes, 1 long non-coding RNA and 1 microRNA. Quantitative PCR (qPCR) examination confirmed half-reduced DNA copy of the patient and normal expression of both parents, indicating a de novo origin of the deletion and complete penetrance of the mutation.

Colonic atresia associated with annular pancreas: An extremely rare and previously unreported association

Colonic atresia is the rarest entity among the all intestinal atresias and may be associated with anterior abdominal wall defect, small intestinal atresia, Hirschsprung's disease, and other anomalies. Here, we are reporting a case of colonic atresia associated with annular pancreas, which has not been reported previously to the best of our knowledge.

Annular pancreas, type I choledochal cyst and malrotation in a low-birth weight newborn: A case report

We present a low-birth weight newborn who presented with bilious vomit and had a "double bubble" sign on plain abdominal X-ray. Intraoperatively, we found annular pancreas with malrotation and type I choledochal cyst. To the best of our knowledge, this is the first reported case with a combination of these anomalies.

A case of annular pancreas accompanied with intraductal papillary mucinous neoplasm-case report

OBJECTIVES

Annular pancreas is a rare congenital anomaly characterized by pancreatic tissues wrapping completely or incompletely around the descending duodenum. In most patients with annular pancreas, onset occurs in early childhood. Adults with annular pancreas are prone to duodenal ulcers and pancreatitis. Intraductal papillary mucinous neoplasm (IPMN) is a type of papillary mucinous secretory epithelial tumor, which originates in the main pancreatic duct and/or branch duct. We report a case of annular pancreas accompanied with intraductal papillary mucinous neoplasm.

METHODS

A 52-year-old male patient hospitalized due to recurrent upper abdominal pain for one and a half years was enrolled in this study.

RESULTS

One case of annular pancreas accompanied with intraductal papillary mucinous neoplasm which manifested as recurrent chronic pancreatitis was found. After pancreaticoduodenectomy, the patient died from uncontrollable gastrointestinal bleeding.

CONCLUSIONS

To the best of our knowledge, this is the first case in China and the second case worldwide of annular pancreas accompanied with IPMN in English literature.

Congenital variants and anomalies of the pancreas and pancreatic duct: imaging by magnetic resonance cholangiopancreaticography and multidetector computed tomography

Though congenital anomalies of the pancreas and pancreatic duct are relatively uncommon and they are often discovered as an incidental finding in asymptomatic patients, some of these anomalies may lead to various clinical symptoms such as recurrent abdominal pain, nausea and vomiting. Recognition of these anomalies is important because these anomalies may be a surgically correctable cause of recurrent pancreatitis or the cause of gastric outlet obstruction. An awareness of these anomalies may help in surgical planning and prevent inadvertent ductal injury. The purpose of this article is to review normal pancreatic embryology, the appearance of ductal anatomic variants and developmental anomalies of the pancreas, with emphasis on magnetic resonance cholangiopancreaticography and multidetector computed tomography.

Laparoscopic treatment of annular pancreas in adults: report of a case

The annular pancreas in adults is a rare congenital anomaly that is detected after development of complications, such as gastric outlet obstruction, recurrent pancreatitis, and peptic ulcer. Duodenal bypass is the procedure of choice for treating duodenal obstruction caused by the annular pancreas in both children and adults. Duodenoduodenostomy is routinely performed in neonates and children. In adults, duodenojejunostomy or gastrojejunostomy are recommended, because the duodenum is less mobile. We report a case of annular pancreas in a 33-year-old male that was successfully treated with laparoscopic gastrojejunostomy.

A rare cause of proximal intestinal obstruction in adults - annular pancreas: a case report

Annular pancreas is a rare congenital anomaly characterized by the presence of ectopic pancreatic tissue surrounding the descending part of the duodenum. It is one of the few congenital anomalies of the gastrointestinal tract which can produce symptoms late in life. In adults, the factors initiating symptoms are recurrent pancreatitis, duodenal stenosis at the site of the annulus, or duodenal or gastric ulceration. We report a new case involving a 24-year-old woman hospitalised for epigastric pain, nausea and vomiting. Radiological examination was consisted with an annular pancreas. At operation a complete obstruction of the second part of the duodenum was found, caused by an annular pancreas, no other congenital anomaly of the intra-abdominal organs was noted. A gastroenterostomy was performed.

Annular pancreas: a rare cause of duodenal obstruction in adults

Annular pancreas is an uncommon congenital anomaly which usually presents itself in infants and newborn. Rarely it can present in late adult life with wide range of clinical severities thereby making its diagnosis difficult. Pre-operative diagnosis is often difficult. CT scan can illustrate the pancreatic tissue encircling the duodenum. ERCP and MRCP are useful in outlining the annular pancreatic duct. Surgery still remains necessary to confirm diagnosis and bypassing the obstructed segment.We report a case of 61 year female presenting with duodenal obstruction due to annular pancreas.

Annular pancreas associated with duodenal carcinoma

Annular pancreas (AP) is a rare congenital anomaly. Coexisting malignancy has been reported only in a few cases. We report what is, to the best of our knowledge, the first case in the English literature of duodenal adenocarcinoma in a patient with AP. In a 55-year old woman with duodenal outlet stenosis magnetic resonance cholangiopancreatography showed an aberrant pancreatic duct encircling the duodenum. Duodenojejunostomy was performed. Eight weeks later she presented with painless jaundice. Duodenopancreatectomy revealed a duodenal adenocarcinoma, surrounded by an incomplete AP. Thus, co-existent malignancy with AP can be present without obstructive jaundice and without being visible through preoperative diagnostics.

Annular pancreas in an adult managed by laparobotic surgery: a case report

Annular pancreas in an adult is an uncommon and infrequently reported anomaly which is characterized by the presence of ectopic pancreatic tissue surrounding the descending part of the duodenum. It is one of the few congenital anomalies of the gastrointestinal tract, which can manifest with symptoms late in life (Ravitch and Woods in Ann Surg 132:1116-1127, 1950). In adults, the factors initiating symptoms are recurrent pancreatitis, duodenal stenosis at the site of the annulus, or duodenal or gastric ulceration (Morrell and Keynes in Br J Surg 57:814-816, 1970). Operative management of these cases involves bypassing the obstructed duodenum. Duodenoduodenostomy is routinely performed in neonates and children. We report a case of annular pancreas in a 55-year-old male that was successfully treated with robotic duodenoduodenostomy.