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EUS features of annular pancreas (with video).Gastrointest
Endosc. 2007 Feb;65(2):340-4.
BACKGROUND:
An annular pancreas is a rare congenital anomaly that results in a
band of pancreatic tissue, either partially or completely
encircling the duodenum. OBJECTIVES: In patients referred for an
upper-GI (UGI) EUS (1) to determine the prevalence of an annular
pancreas identified by EUS versus CT and (2) to describe the EUS
features of an annular pancreas. DESIGN: After review of UGI EUS
procedures from January 1, 2000, through June 1, 2006, we
conducted a retrospective review of EUS annular pancreas images to
identify characteristic EUS features. PATIENTS: This is the
largest report describing the EUS findings in 5 patients. RESULTS:
Of 9776 patients undergoing UGI EUS, 5 patients (0.05%) (2 men;
median age, 64 years; range, 44-69 years) were found to have an
annular pancreas. EUS detected a band of pancreatic tissue that
encircled the duodenum by 360 degrees (n = 3), 270 degrees (n =
1), or 180 degrees (n = 1). Within this band of tissue, the
pancreatic duct was identified in 4 of 5 patients. The ductal and
parenchymal features within the annular band were identical to
those within the remaining pancreas in all patients. None of the
patients had hypoechoic ventral anlage. LIMITATIONS: Whereas, firm
EUS criteria of an annular pancreas cannot be established based on
5 patients, certain features may prove useful for diagnosis.
CONCLUSIONS: Although a diagnosis of an annular pancreas is rare,
it should be considered in situations when a patient with possible
associated symptoms has a normal CT.
Ampullary carcinoma associated with an annular pancreas.JOP.
2007 Jan 9;8(1):50-4.
CONTEXT:
Annular pancreas is an uncommon congenital abnormality.
Co-existence of this condition with a pancreaticobiliary
malignancy is an exceptionally rare occurrence. CASE REPORT: We
present a case report of a 78-year-old woman with jaundice due to
an ampullary carcinoma associated with an annular pancreas treated
by pancreaticoduodenectomy. CONCLUSIONS: A collection of
previously reported cases is reviewed together with the relevant
literature. Obstructive jaundice is an uncommon feature of annular
pancreas; hence the possibility of co-existent pancreaticobiliary
malignancy should be excluded.
Annular
pancreas in identical twin newborns.J
Pediatr Surg. 2006 Aug;41(8):e19-21.
Annular
pancreas is a rare congenital anomaly occurring in 1 of every
12,000 to 15,000 live births [Nerwich N, Shi E. Neonatal duodenal
obstruction: a review of 30 consecutive cases. Pediatr Surg Int
1994;9:47-50]. It may remain asymptomatic throughout life, present
in adulthood, or present in infancy as a high intestinal
obstruction. Review of the literature demonstrates only 8 cases of
familial annular pancreas and no case of twins exhibiting the
disease. We will describe a case of identical (monochorionic
diamniotic) female twins with neonatal presentation of duodenal
obstruction and annular pancreas, and discuss data supportive of a
genetic etiology.
Annular
pancreas in the adult: management with laparoscopic
gastrojejunostomy.Am
Surg. 2006 Jan;72(1):71-3.
Annular
pancreas is an uncommon congenital anomaly associated with
duodenal atresia in neonates. Rarely, the condition may manifest
later in life. These symptoms include abdominal pain, nausea, and
vomiting and usually arise due to obstruction to gastric emptying.
Abdominal CT scan with high resolution and angiography protocol
and magnetic resonance imaging are useful in confirming the
presence of annular pancreas. Operative management involves
bypassing the obstructed duodenum. Duodenoduodenostomy is
routinely performed in neonates with annular pancreas. In adults,
the duodenum is less mobile, and duodenojejunostomy or
gastrojejunostomy are recommended. We report two cases of annular
pancreas in adults treated with laparoscopic gastrojejunostomy.
Annular
pancreas - a rare cause of gastric obstruction in an 82-year-old
patient.
Ann R Coll Surg Engl. 2005
Jan;87(1):W13-5.
Annular
pancreas is an uncommon and rarely reported congenital anomaly and
thus is rarely suspected. A case is reported of an 82-year-old
patient who presented with a 3-month history of nausea and
vomiting associated with weight loss who at laparotomy was found
to have an annular pancreas.
Annular
pancreas combined with distal stenosis. A report of four cases and
review of the literature.Pediatr
Med Chir. 2004 Jul-Aug;26(4):256-9.
BACKGROUND: Congenital duodenal obstruction (CDO) in combination
with more distal duodenal obstructions is a rare anomaly occurring
in 4% of neonates with duodenal atresia. The experience of two
European Pediatric Centers in treatment of congenital double
duodenal obstruction (CDDO) is reported and the pertinent
literature is reviewed. MATERIALS AND METHODS: During the last 15
years a total of 86 neonates were operated upon for CDO at the
department of pediatric surgery of "St. Sophia" Children's
Hospital of Athens in Greece and the department of pediatric
surgery of "Federico II" Children's University Hospital of Naples
in Italy; four of them had a CDDO. These ones presented with
nonbilious vomiting and the plain film of the abdomen showed the
typical "double bubble". Our cases with CDDO presented annular
pancreas causing complete obstruction of the second part of the
duodenum and dilatation of the duodenum distal to this obstruction
due to an additional congenital stenosis (two cases) or a
membranous web (two cases). A diamond shaped duodeno-duodenal (DDD)
anastomosis was carried out to relieve the proximal obstruction
and a Heinecke-Mikulicz plasty was used to relieve the distal
stenosis. RESULTS: All patients with double obstruction underwent
successful surgery with no complications. The postoperative course
was uneventfuL An upper gastrointestinal barium study at one month
postoperatively showed no blind loop, megaduodenum, anastomotic
stenosis or malfunction. CONCLUSIONS: a) The combination of
duodenal atresia with annular pancreas and distal duodenal
stenosis or web is extremely rare. b) Patency of the duodenum
distal to the usual obstruction should always be checked in order
to avoid misdiagnosis of this combination.
Annular pancreas in two consecutive siblings: an extremely rare
case.Eur
J Pediatr Surg. 2005 Oct;15(5):364-8.
Annular pancreas is the rare congenital anomaly where the pancreas
forms a full or incomplete ring around the second segment of the
duodenum, causing various degrees of stenosis or atresia. It is
estimated that it appears in 1 out of 12 000-15 000 births of
living neonates and until now, in the literature, only 6 cases
have been reported among individuals of the same family. We
present the case of two siblings, a boy and a girl, with annular
pancreas from consecutive pregnancies of the same couple. Both
neonates had a prenatal diagnosis of duodenal obstruction and they
underwent duodenoduodenal, proximal transverse to distal
longitudinal anastomosis. Furthermore, the girl had a mobile
ascending colon. Their postoperative condition was perfect. The
case we are reporting is an addition to the other 6 cases of
familial presentation of annular pancreas and is similar to one of
them. In these families, a total of 16 persons present this
congenital anomaly while 14 are seemingly healthy. Twelve of the
affected persons are female and 4 male. In conclusion, it can be
stated that female individuals seem to have a greater propensity
to transmit the disease to their descendants, compared to males,
suggesting the possible action of an autosomal recessive
sex-influenced gene. The recording of such rare family cases
should be encouraged, in order to fully recognize a possible type
of inherited transmission.
Symptomatic adult annular pancreas: report of two cases and a
review of the literature.Hepatobiliary
Pancreat Dis Int. 2005
Aug;4(3):468-71.
BACKGROUND: Annular pancreas in adults is a rare embryologic
abnormality detected after development of complications.
Embryology, diagnosis and treatment strategies for symptomatic
adult annular pancreas remain controversial. In this paper we
reevaluated these problems in view of the technological and
theoretical advances. METHODS: In 2 patients with annular
pancreas, one(36-year-old male patient) presenting with duodenal
obstruction and duodenal ulcer associated with duodenocolic
fistula underwent Billroth II gastrectomy and fistula ectomy and
the other(17-year-old male patient) presenting with duodenal
obstruction and duodenal ulcer underwent Billroth II gastrectomy.
English language literature about annular pancreas etiology,
diagnosis and treatment was reviewed. RESULTS: Both of the
patients had uneventfully recovered. Abdominal computed
tomography, endoscopic retrograde cholangiopancreatography and
magnetic resonance cholangiopancreatography showed typical images
of annular pancreas. Duodenal bypass procedure,
choledochojejunostomy, endoscopic sphincterotomy or biliary
stenting, and pancreatic resection were alternative to treat this
sort of anomaly. CONCLUSIONS: Annular pancreas in adults is a rare
congenital abnormality, while newer imaging modalities and an
index of suspicion may assist in finding more cases. The
management of this congenital anomaly should be individualized
according to the associated complications.
Islet isolation and transplantation from an annular pancreas: a
case report.JOP.
2005 May 10;6(3):274-6.
CONTEXT: Annular pancreas is an uncommon congenital anomaly formed
by a thin band of normal pancreatic tissue encircling the
duodenum. CASE REPORT: We report the first case of an islet
isolation and transplantation from an annular pancreas. The
pancreas together with duodenum was procured from a 32-year-old
previously healthy man after diagnosis of brain death. The
pancreas including the annular portion was distended well after
intraductal collagenase perfusion. A total of 276,064 islet
equivalent was recovered and transplanted into a type 1 diabetic
patient. CONCLUSIONS: Bearing in mind the shortage of donors,
patients with this anomalous condition should not be excluded as
potential organ donors.
A case of
annular pancreas in a male adult.Fukushima
J Med Sci. 2004 Dec;50(2):75-81.
Annular pancreas is a rare congenital anomaly, which consists of a
ring of pancreatic tissue partially or completely encircling the
descending portion of the duodenum. We reported a case of
symptomatic annular pancreas in a 40 year old man admitted to our
hospital complaining of abdominal pain, nausea and vomiting
without body weight loss in January 2000. The patient underwent
laparoscopic cholecystectomy for acalculous cholecystitis in
September 1996. Initially, he was diagnosed with duodenal stenosis
due to a duodenal ulcer scar, but laboratory data showed no
abnormalities. His symptoms did not improve with medication or
endoscopic balloon dilatation. Duodenograpy revealed a narrow
segment with a smooth mucosal surface in the 2nd portion of the
duodenal loop in the duodenum, and a computed tomography (CT) scan
demonstrated a thickened pancreas head around this narrow segment.
We were therefore able to diagnose annular pancreas. A
duodeno-duodenostomy was performed in March 2000. The patient's
postoperative course was uneventful, and he was discharged from
our hospital on the 19th postoperative day. Although define
diagnosis of annular pancreas is frequently made at laparotomy,
the development of a recurrent imaging modality might assist in
the preoperative diagnosis.
Unusual clinical presentation of annular pancreas in the adult.
Pancreatology. 2005;5(1):81-5. Epub
2005 Mar 16.
Annular
pancreas (AP) is a rare congenital anomaly, usually present in
childhood, with symptoms due to duodenal obstruction; however,
this condition can manifest in adulthood with abdominal pain,
pancreatitis and pancreatic head mass. The authors present a case
of AP observed in a 22-year-old patient that presented an unusual
dual-phase clinical manifestation of duodenal obstruction in
infancy that was treated by a duodenojejunostomy, and abdominal
pain due to chronic pancreatitis in the adult age. MRI with
cholangiopancreatography played a decisive role in achieving the
correct diagnosis. The patient was treated by a pylorus-preserving
Whipple procedure, with resection of the previous
duodenojejunostomy. Pancreatic changes characteristic of chronic
pancreatitis were demonstrated both in the AP and in the resected
pancreatic segment. A marked biliopancreatic ductal anomaly not
previously described in the literature was demonstrated by
radiologic examination of the surgical specimen. The pathogenesis
of AP, the importance of its association with benign and malignant
pancreatic disease and the treatment alternatives are discussed by
the authors.
Annular pancreas in children: a recent decade's experience.J
Pediatr Surg. 2004 Nov;39(11):1654-7.
PURPOSE:
Annular pancreas is a recognized cause of duodenal obstruction in
children. The authors sought to characterize the clinical,
radiologic, and prognostic findings in this disorder through a
10-year review of all patients with annular pancreas. METHODS: A
retrospective review of all annular pancreas cases identified
between 1993 and 2002 at 2 tertiary pediatric surgical centers was
completed. Factors analyzed included patient demographics,
presenting symptoms, associated anomalies, radiologic findings,
operation performed, postoperative outcomes, and complications.
RESULTS: Sixteen patients were identified. Four patients (25%)
were premature. Twelve patients (75%) presented during the first
week of life and the remainder within the first year. All patients
presented with vomiting, which was nonbilious in 15 (94%). Five
patients (31 %) had chromosomal anomalies, and 6 (38%) had other
major congenital malformations. Eleven patients (69%) presented
with partial duodenal obstruction. Operations performed were
duodenoduodenostomy in 14 (88%), duodenojejunostomy in 1 (6%), and
Ladd's procedure in 1 (6%). Enteral feedings were started, and
full enteral feeding was achieved at an average of 8.4 days and
15.9 days after operation, respectively. All patients survived and
were discharged after an average hospitalization of 24.0 days.
CONCLUSIONS: Patients with annular pancreas have preampullary
duodenal obstruction, which is more commonly partial.
Duodenoduodenostomy is the appropriate treatment. Prognosis is
excellent, despite the frequent association with chromosomal
anomalies and major congenital malformations.
Symptomatic annular pancreas in newborns.Med
Sci Monit. 2002 Jun;8(6):CR434-7.
BACKGROUND: The pancreas exhibits various types of anomalies,
including aplasia, dysplasia, pancreatic cysts, duplication, and
ectopia, of which the most common is annular pancreas. This study
describes the characteristic features of 7 cases of annular
pancreas diagnosed during exploration.MATERIAL/METHODS: Seven
newborns undergoing surgery for annular pancreas from 1990 to 1998
were analyzed. The cases were evaluated according to birth weight,
sex, symptoms, methods of diagnosis, associated anomalies, and
surgical treatment modalities.RESULTS: The mean birth weight of
the patients was 2385 +/- 1002 g, the mean gestational age was
37.5 +/- 3.1 weeks. Four patients (42.8%) had associated
anomalies, including intestinal malrotation (42.8%), intrinsic
duodenal obstruction (28.5%), trisomy 21 karyotype (14.2%),
cardiac malformation (14.2%), and Meckel's diverticulum (14.2%).
Surgical treatment included duodenoduodenostomy (DD) in four
patients and DD plus tapering enteroplasty (TE) plus placement of
transanastomotic jejunal tube (TJT) in three patients.CONCLUSIONS:
Infants with annular pancreas associated with duodenal obstruction
are generally premature or small for their gestational age. The
symptoms observed in annular pancreas are related not only to
extrinsic compression of the ectopic tissue, but also the duodenal
stenosis associated with this malformation. Annular pancreas is
most commonly associated with intestinal malrotation. It does not
correlate as strongly with trisomy 21 karyotype as do the duodenal
atresias, and oral feeding tolerance time is nearly the same
between the DD and DD+TE+TJT groups.
An annular
pancreas derived from paired ventral pancreata, supporting
Baldwin's hypothesis.Pancreas.
2000 May;20(4):408-10.
An annular
pancreas is a rare malformation. It is generally accepted that the
ring formation originates from a single ventral pancreas, as
suggested by Lecco. No reports of resected and/or autopsied
annular pancreata derived from paired ventral pancreata, thus
supporting Baldwin's hypothesis, have been published. We describe
an annular pancreas originating from paired ventral pancreata,
thus supporting Baldwin's hypothesis, and attempt to clarify the
pathogenesis of an annular pancreas. The patient was a 1-day-old
Japanese male newborn, born at 32 weeks of pregnancy. He died from
respiratory failure owing to esophageal atresia the next day.
Autopsy incidentally revealed an annular pancreas that was
examined histologically. Multiple 4 microm thick serial sections
were obtained from paraffin-embedded pancreatic tissue. Sections
for histologic analysis were subjected to hematoxylin-eosin
staining and pancreatic polypeptide immunostaining. An unusually
large pancreatic duct encircled by pancreatic tissue ran around
the duodenum, and the duct was confirmed to flow into the major
papilla. The islets of the encircling pancreas were positive for
pancreatic polypeptide. A normal main and accessory pancreatic
duct were also identified. Histologic and immunohistochemical
evaluation revealed that the ring formation originated from the
left lobe of paired ventral pancreata. An annular pancreas that
was investigated histopathologically and immunohistochemically and
found to support Baldwin's hypothesis is described.
Annular pancreas associated with pancreatolithiasis: a case
report.
Hepatogastroenterology. 1999
Jan-Feb;46(25):527-31.
We present
a case of annular pancreas associated with pancreatolithiasis. A
41 year-old Japanese man with epigastric pain was admitted to the
surgical service at Miyazaki Medical College Hospital. Contrast
duodenography revealed severe stenosis of the descending duodenum.
Cholangiography showed a stenotic segment of the intrapancreatic
common bile duct surrounded by calcifications. Computed tomography
of the abdomen revealed calcifications in the posterior region of
the pancreatic head. Percutaneous cannulation of the pancreatic
ductal system, using ultrasonic guidance, demonstrated a slightly
dilated pancreatic duct in the body, stenosis of the duct of
Wirsung in the pancreatic head, a normal duct of Santorini, and
calcifications in the duct of an annular pancreas which
communicated with the duct of Wirsung. At surgery, the second
portion of the duodenum was completely encircled by the annular
pancreas, and a Whipple procedure was performed. Including this
patient, 170 adult cases of annular pancreas have been reported in
Japan since 1922. Surgery was performed on 122 patients; 106 of
these procedures were well documented. A Whipple procedure was
performed on 16 patients, including the present case. Nine of
these 16 patients had associated malignant disease, while the
others had benign pancreatic disease. This is the fifth reported
case of pancreatolithiasis associated with an annular pancreas in
Japan. This case emphasizes that an annular pancreas may
predispose to localized chronic pancreatitis and
pancreatolithiasis.
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