Variantes anatômicas e anomalias congênitas das vias biliares e pancreáticas: análise através da colangiopancreatografia por ressonância magnética / Anatomic variants and congenital abnormalities of the biliary tree seen on magnetic resonance cholangiopancreatography

Com o objetivo de ilustrar, de maneira sistematizada, as principais variantes anatômicas e anomalias congênitas observadas em exames de colangiopancreatografia por ressonância magnética (CPRM), realizamos estudo retrospectivo em exames de CPRM com as mais diversas indicações, procurando por variantes anatômicas e anomalias congênitas das vias biliares e pancraáticas. Todos os exames foram realizados em equipamento de alto campo (1,0 T ou 1,5 T), obtendo-se imagens no plano axial ponderadas em T1 (FFE) e T2 (TSE), e no plano coronal, com técnica de CPRM. Apresentamos variantes anatômicas relacionadas à posição da vesícula biliar, à distribuição e posição das vias biliares intra-hepáticas, do ducto cístico, ducto colédoco e ductos pancreáticos. Mostramos também exemplos dos principais tipos de dilatação cística congênita das vias biliares. Reconhecer as principais variantes anatômicas e anomalias congênitas das vias biliares e pancreáticas permite otimizar a eficácia diagnóstica da CPRM.

In order to illustrate the role of magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of anatomic variants and congenital abnormalities of the biliary tree, we onducted a retrospective study of MRCP scans performed due to different indications to identify anatomic variants and congenital abnormalities of the pancreas and biliary tree. High field MR machines (1.0 T and 1.5 T) and 3D TSE sequences were used to obtain images in the axial and coronal planes with MIP reconstructions in all studies. MRCP showed low cystic duct insertion, medial cystic duct insertion, and a parallel course of the cystic and hepatic ducts as well as bile duct bifurcation abnormalities and aberrant right and left hapatica duct. We also present examples of the main types of congenital cystic dilatation of the bile ducts. The recognition of the main anatomic variants of the biliary tree and pancreatic ductshelps to optimize the diagnostic accurancy of MR cholangiopancreatography.

The Relationship of Anatomic Variation of Pancreatic Ductal System and Pancreaticobiliary Diseases

The aims of this study were to identify the morphological diversities and anatomical variations of pancreatic ductal system and to define the relationships between pancreatic ductal systems, pancreaticobiliary diseases, and procedure-related complications, including post-ERCP pancreatitis. This study included 582 patients in whom both pancreatic duct (PD) and common bile duct were clearly visible by ERCP. PD systems were categorized into four types according to the relationship between common bile duct and PD. In types A and B, Wirsung duct formed the main PD. In type C, Wirsung duct did not form the main PD. If PD system did not fall into any of these three types, it was categorized as type D. The distribution of types among pancreatic ducts examined was as follows: type A: 491 cases (84.4%), type B: 56 cases (9.6%), type C: 20 cases (3.4%), and type D: 15 cases (2.6%). The anomalous anatomic variations of PD systems were divided into migration, fusion, and duplication anomalies. PD anomalies were noted in 51 patients, of which 19 (3.3%) were fusion anomalies (12 complete pancreas divisum, 7 incomplete pancreas divisum), and 32 (5.5%) were duplication anomalies (5 number variations, 27 form variations). No significant relationships between various PD morphologies and pancreaticobiliary diseases were found. However, post- ERCP hyperamylasemia was more frequently found in types C (41.7%), D (50%) and A (19.8%) than in type B (9.4%). In summary, whether Wirsung duct forms the main PD and the presence or absence of the opening of the Santorini duct are both important factors in determining the development of pancreatitis and hyperamylasemia after ERCP.

Gross anatomy of the pancreatic ducts in north Indians.

Gross anatomy of the pancreatic ducts was studied in dissections and by preparing corrosion casts of pancreases, obtained from 218 male and 57 female adult cadavers. In addition 72 normal pancreatograms were also examined. The main pancreatic duct (MPD) started as two or more tributaries in the tail of the pancreas and crossed the body of the 12th dorsal or the first lumbar vertebra or in between in 72.5% males and 62.5% females. In 96% specimens MPD followed the usual course and opened at the major duodenal papilla. Twenty to thirty five lobular ducts opened on either side of the MPD while a few opened on the anterior or posterior walls. There was no 'herringbone' arrangement. The distance between the two ductules varied from 1 to 10 mm. Mode of formation of the accessory pancreatic duct (APD), its course and termination were also studied. In dissected specimens the embryonic type of pancreatic duct (pancreas divisum) was seen in 9 (4.5%) male and 3 (6%) female specimens. In 15.1% male and 26.3% female (p < 0.05) subjects APD will not act as a safety valve if an obstruction occurs in the distal part of MPD.

Anatomical study the choledocho - pancreatico - duodenal junction in man

Twenty - five fresh postmortem human specimens of both sexes were utilized, in this study, for gross and microscopic dissection of the choledocho-pancreatico-duodenal junction. Histological examination of the terminal ducts, at this region, was also performed. The common bile and main pancreatic ducts have been observed to exhibit three patterns of confluences: the short Y - shaped confluence [Pattern I, 52%] with a short common channel [2 - 15 mm], the long Y - shaped confluence [Pattern II, 20%] with a long common channel [> 15 mm] and the V - shaped confluence [Pattern III, 28%] with a very short common channel [< 2 mm]. The main pancreatic duct has been observed to follow a wavy course presenting two differently directed curvatures on its way towards the duodenum. Along its course, the main pancreatic duct is joined by duct tributaries at nearly right angles. The accessory pancreatic duct has been detected in 72% of specimens. A communicating channel between the accessory and main pancreatic ducts has been observed in 48% of specimens. The accessory duct has always joined the duodenum proximal to, and at a more anterior plane than, the main duct. The major duodenal papilla is located within the middle [72%] or lower [28%] thirds of the descending part of the duodenum. It lies at the proximal end of a longitudinal mucous fold [80%], at the middle of this longitudinal fold [12%], or with absence of such a fold [8%]. Transverse mucous folds [2 - 4 in number] are noticed to converge at the longitudinal fold and the papilla. The investigation has also revealed the presence of circumferential folds partially or completely obscuring the major papilla. The minor duodenal papilla is entangled by a mucosal sling, or between two circumferential mucous folds. The mucous membrane lining of the major papillary orifice has exhibited two to four layers of folds, mucosal projections, and sometimes spiral arrangement; all are probably acting as valves controlling the biliopancreatic flow. The orifices on the major duodenal papillae are either single in 88% of specimens or double in the remaining 12%. Inner circular and outer oblique or longitudinal muscle fibers have been observed in the walls of the papillary stumps, probably offering a sphincteric action for the biliopancreatic flow. Other muscle fibers are noticed in the walls of the terminal ducts intermingling with the duodenal musculature. The present investigation has provided a detailed through description of the morphological and structural variations at the human choledocho-pancreatico-duodenal junction. An accurate knowledge of such variations might offer a helpful guide for clinicians during surgical and endoscopic procedures performed at this region

Distribuição anatômica da árvore ductal pancreática do cão: implicações para o isolamento das ilhotas de Langerhans / Anatomical distribuition of pancreatic ductal tree in dog: its implications for isolating Langerhans islets

O conhecimento da anatomia normal da árvore ductal pancreática no cão e de sua variações reveste-se de importância para a execução dos protocolos de preparação e isolamento das ilhotas de Langerhans. A proposta deste estudo é demonstrar a configuração anatômica da dutal pancreática com especial atenção para as implicações sobre as técnicas de preparação do tecido pancreático para o transplante de ilhotas de Langerhans no cão. Os autores realizaram a dissecção do duto pancreático principal (Santorini) e a cateterização dos seus ramos ascendente e descendente. Em seguida procederam à pancreatectomia total sem duodenectomia. Através destes cateteres, infundiu-se solução de acetona no interior dos ductos e solução de tinta nanquim de cor azul no ramo ascendente e de cor vermelha no ramo descendente. Posteriormente, os autores dissecaram a árvore ductal pancreática com pinças delicadas e digitoclasia. Através desta técnica, os autores verificaram a distensão universal do parênquima pancreático devido ao envolvimento de toda a glândula pelos ramos tributários do ducto pancreático principal. O ramos descendente distendeu exclusivamente a região do processo uncinado, ao passo que o ramo ascendente distendeu exclusivamente as regiões do corpo e cauda do pâncreas canino. Esta constatação enfatiza a utilização destas vias para a infusão das soluções apropriadas nos procedimentos de isolamento das ilhotas de Langerhans no modelo canino

Normal pancreatic duct morphology in a north Indian population.

Ninety three normal pancreatograms from a North Indian population were studied. The pancreatic duct (PD) was L-shaped in 47%, oblique in 5% and sigmoid in 11%. The mean length (SD) of PD was 18.2 (3.0) cm, being longer in males but not varying with age. The mean maximum diameters of PD in head, body and tail were 3.7 (0.8), 2.7 (0.6) and 1.7 (0.4) mm respectively. These did not vary with sex. The PD diameters showed a statistically significant increase with age but this variation does not appear to be of much practical importance.

Bifid pancreas: an endoscopic retrograde pancreaticographic curiosity.

Bifid pancreas, representing a major bifurcation of the main pancreatic duct, has rarely been reported. We report four such cases where this condition was picked up incidentally.

Tratamiento quirúrgico de la fístula pancreática crónica / Surgical treatment of the chronic pancreatic fistula

La fístula pancreática, complicación poco frecuente en el tratamiento de la patología pancreática como extrapancreática, puede curar con tratamiento médico conservador en un 70 por ciento y 80 por ciento de los casos. Cuando éste fracasa, es necesario recurrir al tratamiento quirúrgico, pudiendo ser de tipo resectivo o derivativo de acuerdo a la localización de la fístula. Presentamos un caso de fístula pancreática crónica de etiología traumática, en quien fracasó todo intento de tratamiento médico conservador, siendo necesario la cirugía. Se hace una revisión general del tema