CONGENITAL PANCREATICOBILIARY ANOMALLIES IN AN URBAN MEDICAL CENTER
Naresh Sundaresan*, Choichi Sugawa, Andrew Hollenbeck, Aftab Jafri, Adnan Malik, Charles E. Lucas
Surgery, Wayne State University, Detroit, MI
Purpose: Pancreaticobiliary anomalies are rare. Patients affected by these anomalies often present with cryptic signs and symptoms which can be poorly appreciated, thus delaying or preventing appropriate treatment. Our results are presented, along with the types of anomalies and appropriate treatments.
Methods: Endoscopic retrograde cholangiopancreatography (ERCP) was used to define pancreaticobiliary anomalies. A retrospective review was performed of 5522 ERCPs done at a tertiary care center by a single surgical endoscopist from 1972 to 2015.
Results: There were 297 (5%) patients with pancreaticobiliary anomalies including 179 patients with pancreas divisum (PD), 44 patients with choledochal cyst (CC) (Todani's classification Type I: extrahepatic cyst 31, Type III; choledochocele 9, Type V: Caroli's disease 4), 20 patients with anomalous pancreaticobiliary ductal union (APDU), and 6 patients with other abnormalities. Among 179 patients with pancreas divisum, 59 patients (33%) had pancreatitis, and 8 (4.5%) required minor sphincterotomies for multiple unexplained acute pancreatitis. Among 31 patients with Type I CC, 7 had an associated APDU, and 4 had an associated PD. Fifteen of the 31 (48%) patients underwent an operation including 4 who had choledochectomy and hepatico-jejunostomy, 3 who had cholecystectomy with choledochoduodenostomy, 3 who had major sphincterotomies, and 5 who had a cholecystectomy alone. Thirteen were observed non-operatively. In patients with Type III CC (choledochocele), 7 of the 9 were treated by endoscopic sphincterotomy and 2 patients were treated by transduodenal cyst excision and surgical sphincteroplasty. 4 patients with Type V CC (Caroli's disease) were managed non-operatively. Of the 20 patients with APDU, 7 (35%) had associated Type I CC and 2 (10%) had associated PD. 8 (40%) required operative intervention, which was comprised of 3 cholecystectomies, 2 endoscopic sphincterotomies,2 choledochectomies with hepatico-jejunostomy and 1 cholecystectomy with lymphadenectomy. Six patients were found to have other anomalies; 2 with pancreas bifidum, 1 with a duplication of the gallbladder, 1 with a cystic duct diverticulum, 1 with an annular pancreas, and 1 with an abnormal cystic duct origin. These patients were treated based on their etiology.
Conclusion: Pancreaticobiliary anomalies are rare, and can be defined using ERCP. When symptomatic, these anomalies require surgical or endoscopic therapies. Minor sphincterotomy for pancreas divisum is performed for selected patients with recurrent bouts of acute pancreatitis. Asymptomatic APDU and CBD do pose increased risk of malignancy, and when identified, benefit from prophylactic interventions. The appreciation of these abnormalities is important for the proper diagnosis and treatment of these rare biliary and pancreatic disorders.
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