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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.

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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.

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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 sepsis.

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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.

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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.

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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.

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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. ...

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