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Key Points

  • image 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.

  • image 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.

  • image Regardless of the etiology, the management of the early phase of acute pancreatitis is critical to achieve a successful outcome. Aggressive fluid resuscitation and early enteral feeding both reduce the risk of complications. It is no longer considered appropriate to “rest the pancreas” if the patient can tolerate enteral nutrients.

  • image 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 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.

  • image 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 it 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.

  • image 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. Although the limited pancreatic procedures (Beger/Frey) have a lower initial rate of endocrine dysfunction, the long-term risk of diabetes is more related to the progression of the underlying disease than to the effects of operation. Level 1 studies confirm that the duodenum preserving options are associated with a lower immediate morbidity and mortality and therefore, in the absence of a mass or concerns about cancer, are better options than a Whipple procedure for chronic pancreatitis.

  • image The precursor lesion that probably leads to most cases of ductular ...

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