1. Incomplete fusion of the dorsal and ventral pancreatic
ducts results in pancreas divisum, but a variety of ductal anomalies
can be seen. Magnetic resonance cholangiopancreatography as well
as endoscopic retrograde cholangiopancreatography can identify these
ductal anomalies, and clarification of the ductal pattern of the
pancreas is important before attempts at interventions.
2. The “replaced right hepatic artery” occurs
in 15% of patients and needs to be identified preoperatively
to prevent inadvertent injury with resulting hepatic necrosis. Anomalous
hepatic arterial anatomy can result in hepatic ischemia during dissection
of the porta hepatis as well. “Thin cut” multidetector
computed tomographic images are usually able to identify the relevant
arterial and venous patterns around the pancreas.
3. Regardless of the etiology, the management of the early phase
of acute pancreatitis is critical to achieve a successful outcome. “Resting
the pancreas” means eliminating oral nutrients, and resumption
of diet should be limited to liquids and low-fat/low-protein foods.
Patients who do not improve spontaneously within 24 to 48 hours
are at risk for developing severe disease with its risk of life-threatening
4. Surgical intervention in acute pancreatitis is reserved for patients
with infected collections or infected necrosis only, or to relieve
an impacted gallstone in the ampulla if endoscopic or radiologic
treatments are unavailable or unsuccessful. Infection is usually
confirmed by a pattern of air in the retroperitoneum on computed
tomographic scan, or by documentation of bacteria on Gram’s
stain or culture from fine-needle aspiration of a suspected infected
fluid collection. Fine-needle aspiration of suspicious fluid collections should
not be converted to percutaneous drainage unless infection is confirmed,
and the consensus decision has been made that percutaneous drainage
is appropriate for the individual patient.
5. The appearance of chronic pancreatitis on computed tomographic
scan varies dramatically, and multiple diagnostic studies are usually
needed to establish the extent of disease. Calcific pancreatitis
is not a marker of alcoholic pancreatitis alone, and rarely indicates
autoimmune pancreatitis. Endoscopic ultrasound provides a better
assessment of the disease than computed tomography and is useful
to disclose indolent or unsuspected cancer, which can occur in up
to 10% of patients.
6. The nidus of inflammation in chronic pancreatitis due to any
cause is the head of the gland. Therefore, treatment approaches
that address the disease in the head have the best long-term results.
The Whipple procedure, the Beger procedure, and the Frey procedure,
with or without longitudinal duct drainage, are the best surgical
options, as all three approaches remove all or most of the disease
in the head of the gland.
7. The precursor lesion that probably leads to most cases of ductular
adenocarcinoma is the ductal epithelial hyperplasia/dysplasia
process described by the pancreatic intraepithelial neoplasia classification system.
Pancreatic intraepithelial neoplasia 2 and pancreatic intraepithelial
neoplasia 3 lesions may be associated with other, nonspecific changes
in pancreatic morphology seen on imaging studies, or may only be
seen histologically. ...