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Pancreas-preserving approach to "paraduodenal pancreatitis" treatment: why, when, and how? Experience of treatment of 62 patients with duodenal dystrophy.

Egorov VI, Vankovich AN, Petrov RV, Starostina NS, Butkevich ATs, Sazhin AV, Stepanova EA - Biomed Res Int (2014)

Bottom Line: To assess the results of different types of treatment for PP.Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded.  Preoperative diagnosis was correct in all the cases except one (1.9%).PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not "paraduodenal," origin.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Oncology, Moscow City Hospital No. 5, Sechenov First Moscow State Medical University, Stromynka Street 7, Moscow 107076, Russia.

ABSTRACT

Background: The term "paraduodenal pancreatitis" (PP) was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis, but it is still unclear what organ PP originates from and how to treat it properly.

Objective: To assess the results of different types of treatment for PP.

Method: Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded. 

Results: Preoperative diagnosis was correct in all the cases except one (1.9%). Patients presented with abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Ten patients were treated conservatively, 24 underwent pancreaticoduodenectomies (PD), pancreatico- and cystoenterostomies (8), Nakao procedures (5), duodenum-preserving pancreatic head resections (5), and 10 pancreas-preserving duodenal resections (PPDR) without mortality. Full pain control was achieved after PPRDs in 83%, after PDs in 85%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD.

Conclusions: PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not "paraduodenal," origin.

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Duodenal dystrophy with moderate chronic orthotopic pancreatitis. Multidetector computed tomography. Frontal view. Patient, 32 y.o. (a) Arterial phase. Deformation and thickening of the medial wall of the duodenum with septated cyst (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (b) patient 44 y.o. Venous phase. Deformed and thickened medial duodenal wall with multiple cysts (arrow), separated from moderately changed pancreatic head (thick arrow), is narrowing the duodenal lumen (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (c) patient 49 y.o. Arterial phase. Deformation and thickening of the medial wall of the duodenum with contrasted pancreatic tissue inside (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (black arrow). The scheme of the lesion and the unaffected main pancreas is in the upper right corner. (d) Isolated form of the duodenal dystrophy. Multidetector computed tomography. (d) Male, 57 y.o. Arterial phase. Sagittal view. Deformation and thickening of the medial wall of the duodenum (D) with septated cysts (DD). The gastroduodenal artery (GDA) is shifted forward and to the left, lying in the groove between the unaffected pancreatic head (P) and duodenal wall. (e) Isolated form of the duodenal dystrophy with unchanged orthotopic pancreas. (a) Male 57 y.o. Arterial phase. Sagittal view. Septated cysts in the submucosa and muscularis of the diffusely thickened duodenal wall surround the major papilla.
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fig13: Duodenal dystrophy with moderate chronic orthotopic pancreatitis. Multidetector computed tomography. Frontal view. Patient, 32 y.o. (a) Arterial phase. Deformation and thickening of the medial wall of the duodenum with septated cyst (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (b) patient 44 y.o. Venous phase. Deformed and thickened medial duodenal wall with multiple cysts (arrow), separated from moderately changed pancreatic head (thick arrow), is narrowing the duodenal lumen (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (c) patient 49 y.o. Arterial phase. Deformation and thickening of the medial wall of the duodenum with contrasted pancreatic tissue inside (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (black arrow). The scheme of the lesion and the unaffected main pancreas is in the upper right corner. (d) Isolated form of the duodenal dystrophy. Multidetector computed tomography. (d) Male, 57 y.o. Arterial phase. Sagittal view. Deformation and thickening of the medial wall of the duodenum (D) with septated cysts (DD). The gastroduodenal artery (GDA) is shifted forward and to the left, lying in the groove between the unaffected pancreatic head (P) and duodenal wall. (e) Isolated form of the duodenal dystrophy with unchanged orthotopic pancreas. (a) Male 57 y.o. Arterial phase. Sagittal view. Septated cysts in the submucosa and muscularis of the diffusely thickened duodenal wall surround the major papilla.

Mentions: MRI and MRCP were performed in 26 (41.6%) patients. The main CT and MRI findings in DD patients included thickening, infiltration, and cystic structures in the duodenal wall (Figures 13(a)–13(e)). Endoscopic ultrasound (EUS) was performed in 40 (64%) patients, and the main signs of DD were duodenal wall thickening and presence of hypoechoic cavities (100%) in the muscular and/or submucosal layer of the duodenal wall (Figures 14(a)–14(d)) [32]. The sensitivity of CT, MRI, and EUS was 95%, 84%, and 94%, and specificity was 94%, 86%, and 98%, respectively.


Pancreas-preserving approach to "paraduodenal pancreatitis" treatment: why, when, and how? Experience of treatment of 62 patients with duodenal dystrophy.

Egorov VI, Vankovich AN, Petrov RV, Starostina NS, Butkevich ATs, Sazhin AV, Stepanova EA - Biomed Res Int (2014)

Duodenal dystrophy with moderate chronic orthotopic pancreatitis. Multidetector computed tomography. Frontal view. Patient, 32 y.o. (a) Arterial phase. Deformation and thickening of the medial wall of the duodenum with septated cyst (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (b) patient 44 y.o. Venous phase. Deformed and thickened medial duodenal wall with multiple cysts (arrow), separated from moderately changed pancreatic head (thick arrow), is narrowing the duodenal lumen (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (c) patient 49 y.o. Arterial phase. Deformation and thickening of the medial wall of the duodenum with contrasted pancreatic tissue inside (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (black arrow). The scheme of the lesion and the unaffected main pancreas is in the upper right corner. (d) Isolated form of the duodenal dystrophy. Multidetector computed tomography. (d) Male, 57 y.o. Arterial phase. Sagittal view. Deformation and thickening of the medial wall of the duodenum (D) with septated cysts (DD). The gastroduodenal artery (GDA) is shifted forward and to the left, lying in the groove between the unaffected pancreatic head (P) and duodenal wall. (e) Isolated form of the duodenal dystrophy with unchanged orthotopic pancreas. (a) Male 57 y.o. Arterial phase. Sagittal view. Septated cysts in the submucosa and muscularis of the diffusely thickened duodenal wall surround the major papilla.
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Related In: Results  -  Collection

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fig13: Duodenal dystrophy with moderate chronic orthotopic pancreatitis. Multidetector computed tomography. Frontal view. Patient, 32 y.o. (a) Arterial phase. Deformation and thickening of the medial wall of the duodenum with septated cyst (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (b) patient 44 y.o. Venous phase. Deformed and thickened medial duodenal wall with multiple cysts (arrow), separated from moderately changed pancreatic head (thick arrow), is narrowing the duodenal lumen (arrowhead). The scheme of the lesion and the unaffected main pancreas is in the lower right corner; (c) patient 49 y.o. Arterial phase. Deformation and thickening of the medial wall of the duodenum with contrasted pancreatic tissue inside (arrow). The gastroduodenal artery is shifted forward and to the left, lying in the groove between the pancreatic head and affected duodenal wall (black arrow). The scheme of the lesion and the unaffected main pancreas is in the upper right corner. (d) Isolated form of the duodenal dystrophy. Multidetector computed tomography. (d) Male, 57 y.o. Arterial phase. Sagittal view. Deformation and thickening of the medial wall of the duodenum (D) with septated cysts (DD). The gastroduodenal artery (GDA) is shifted forward and to the left, lying in the groove between the unaffected pancreatic head (P) and duodenal wall. (e) Isolated form of the duodenal dystrophy with unchanged orthotopic pancreas. (a) Male 57 y.o. Arterial phase. Sagittal view. Septated cysts in the submucosa and muscularis of the diffusely thickened duodenal wall surround the major papilla.
Mentions: MRI and MRCP were performed in 26 (41.6%) patients. The main CT and MRI findings in DD patients included thickening, infiltration, and cystic structures in the duodenal wall (Figures 13(a)–13(e)). Endoscopic ultrasound (EUS) was performed in 40 (64%) patients, and the main signs of DD were duodenal wall thickening and presence of hypoechoic cavities (100%) in the muscular and/or submucosal layer of the duodenal wall (Figures 14(a)–14(d)) [32]. The sensitivity of CT, MRI, and EUS was 95%, 84%, and 94%, and specificity was 94%, 86%, and 98%, respectively.

Bottom Line: To assess the results of different types of treatment for PP.Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded.  Preoperative diagnosis was correct in all the cases except one (1.9%).PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not "paraduodenal," origin.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgical Oncology, Moscow City Hospital No. 5, Sechenov First Moscow State Medical University, Stromynka Street 7, Moscow 107076, Russia.

ABSTRACT

Background: The term "paraduodenal pancreatitis" (PP) was proposed as a synonym for duodenal dystrophy (DD) and groove pancreatitis, but it is still unclear what organ PP originates from and how to treat it properly.

Objective: To assess the results of different types of treatment for PP.

Method: Prospective analysis of 62 cases of PP (2004-2013) with histopathology of 40 specimens was performed; clinical presentation was assessed and the results of treatment were recorded. 

Results: Preoperative diagnosis was correct in all the cases except one (1.9%). Patients presented with abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Ten patients were treated conservatively, 24 underwent pancreaticoduodenectomies (PD), pancreatico- and cystoenterostomies (8), Nakao procedures (5), duodenum-preserving pancreatic head resections (5), and 10 pancreas-preserving duodenal resections (PPDR) without mortality. Full pain control was achieved after PPRDs in 83%, after PDs in 85%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD.

Conclusions: PD is the main surgical option for PP treatment at present; early diagnosis makes PPDR the treatment of choice for PP; efficacy of PPDR for DD treatment provides proof that so-called PP is an entity of duodenal, but not "paraduodenal," origin.

Show MeSH
Related in: MedlinePlus