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Background: It is widely believed that the prerequisite for safely performing enucleation is that the distance between the tumor and the main pancreatic duct (MPD) is at least 2–3 mm. However, enucleating a deep pancreatic tumor adjacent to the MPD remains challenging, particularly when exposure or repair of the MPD is necessary. This study reported our initial experience with this procedure and demonstrated the feasibility and safety of the MPD exposure or repair. Methods: Patients who underwent laparoscopic enucleation (LapEN) with exposing the MPD from January 2017 to August 2023 were collected and analyzed in this retrospective cohort study. Data from procedures of laparoscopic middle pancreatectomy (LMP) and LapEN for superficial tumors were collected for comparative analyses. Results: A total of 26 patients were enrolled, 27 tumors were enucleated. Tumor located in the pancreatic head and neck (n = 20), and the body (n = 7). The mean tumor size, operating time, and blood loss were 2.3 cm, 163 min, and 63 ml, respectively. MPD injuries occurred in 8 cases due to the need for complete tumor resection, which were repaired or reconstructed using 6–0 PDS-II with or not inserting a plastic stent. 10 cases (38.5%) developed surgical‐related complications, seven (26.9%) were classified as Clavien-Dindo grade I, and three (11.5%) were Clavien-Dindo grade IIIa. Biochemical leakage occurred in 16 cases (61.5%), clinically relevant pancreatic fistula (CR-POPF) occurred in 10 cases (38.5%). Two patients (7.7%) experienced post-pancreatectomy hemorrhage. Further analyses indicated LapEN with MPD exposure had a longer operating time and higher incidence of CR-POPF compared to LapEN for superficial tumors, but a shorter operating time and less blood loss compared to LMP (P < 0.05). Conclusion: Laparoscopic enucleation with exposing the MPD is feasible and safe with the support of precise preoperative assessments, meticulous intraoperative dissection, well familiarity with the anatomy of the MPD, and excellent surgical skills. [ABSTRACT FROM AUTHOR]

Background: For premalignant main duct intraductal papillary mucinous neoplasms (MD-IPMN), laparoscopic duodenum and spleen-preserving subtotal or total pancreatectomy (LDSP-STP/TP) seems to be a viable option for parenchyma-sparing pancreatectomy. Patients and Methods: On the basis of the imaging features, family history, genomic alterations, intraoperative ultrasound examination, and frozen section evaluation, we have proposed patient selection strategies for the LDSP-STP/TP technique for the first time. Additionally, a comprehensive step-by-step overview of this technique has been provided. To date, we have performed five LDSP-STP procedures and one LDSP-TP procedure. Results: We successfully performed selective resection of the affected pancreatic parenchyma while preserving the duodenum, common bile duct (CBD), spleen, and splenic artery and vein. The operation time ranged from 295 to 495 min, with blood loss ranging from 100 to 300 mL. Postoperative pathological results revealed low-grade dysplasia in the resected pancreatic samples and margins. The patients resumed eating within 3–5 days after surgery, and all postoperative complications were classified as grade I according to the Clavien–Dindo classification. At the 3-month follow-up, there were no cases of CBD ischemic stenosis, splenic ischemia, or pseudocyst formation observed. For patients who received LDSP-STP, the longitudinal diameter of the remaining pancreatic tail ranged from 2.2 to 4.6 cm, and they demonstrated satisfactory long-term blood glycemic control. Conclusions: LDSP-STP/TP demonstrates technical feasibility and safety. It allows for the selective resection of the affected pancreatic parenchyma, thereby minimizing the impact of pancreatic functional impairment. However, it is crucial to validate this technique through long-term prospective observations. [ABSTRACT FROM AUTHOR]

This study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure. Clinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed. There were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001). The improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis. [ABSTRACT FROM AUTHOR]

This is a case of a 67-year-old woman diagnosed with a 35-mm pancreatic body cancer with a chief complaint of epigastric discomfort. Computed tomography demonstrated invasion of the common hepatic artery, portal vein, and stomach, and chemotherapy was initiated for locally advanced pancreatic cancer. After 9 months of chemotherapy, the tumor remained stable on imaging, and the tumor markers were within the normal range. After additional chemoradiotherapy, the patient underwent a conversion surgery, a pancreaticoduodenectomy. Magnetic resonance cholangiopancreatography (MRCP) at the time of diagnosis demonstrated main pancreatic duct (MPD) dilatation on the tail side of the tumor; however, most of the MPD signal disappeared on MRCP after chemotherapy. Surgical findings failed to identify MPD on the first pancreatic resection plane, and additional resection was conducted; however, no MPD was found. As a pancreatic duct anastomosis was not available, pancreatic reconstruction was selected for pancreaticogastric anastomosis using the invagination method. Pathologically, the pancreatic tissue on the tail side of the tumor was replaced by fibrotic tissue, and MPD could not be identified. To the best of our knowledge, this is the first case report of the disappearance of a dilated pancreatic duct on the tail side accompanied by exocrine tissue loss during preoperative treatment for pancreatic cancer. [ABSTRACT FROM AUTHOR]

Background: Intraductal papillary mucinous neoplasms (IPMNs) have the potential to evolve into pancreatic adenocarcinoma (PDAC). While main-duct IPMNs (MD-IPMNs), involving the main pancreatic duct (MPD), are less common than side-branch IPMNs (SB-IPMNs) or mixed-type IPMNs (mixed-IPMNs), their malignant transformation potential is far greater. Controversy exists between different guidelines in terms of recommended management strategies. This study was aimed at assessing the utility of the radiological follow up of MD-IPMNs and mixed-type IPMNs, including prevalence of worrisome radiological findings as well as clinical and laboratory parameters, and their correlation with the development of progression or pancreatic adenocarcinoma. Methods: Eighty-four patients with MD-IPMNs or mixed-type IPMNs who underwent at least one magnetic resonance cholangiopancreatography (MRCP) were included. Clinical and laboratory data were obtained retrospectively. A cross-sectional analysis was carried out to establish clinical and laboratory parameters associated with development of PDAC. A retrospective cohort analysis was performed on 44 patients who had at least six months of follow up, trying to identify factors correlating with worrisome radiological features. Results: Nine cases (10.7%) of PDAC were recorded in this cohort. The laboratory and imaging factors associated with cyst size progression greater than 5 mm during follow up were elevated alanine transaminase (ALT) levels, the maximal cyst size, and the MPD diameter. Cross-sectional analysis indicated that PDAC was associated with nausea (p = 0.01), as well as increased levels of aspartate aminotransferase (AST) (p = 0.05), gamma glutamyl transpeptidase (GGT) (p = 0.01), and alkaline phosphatase (ALP) (p = 0.01). Conclusions: Elevated levels of liver enzymes were associated with IPMN progression and, subsequently, the development of PDAC. ALT levels, maximal cyst size, and MPD diameter are associated with the progression of cyst size. These data may aid in risk-stratifying patients when determining the follow up approach for IPMNs. [ABSTRACT FROM AUTHOR]

Background/Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is one of the useful treatment for treating diseases that cause pancreatic duct stenosis. However, if the stenosis is severe, accessories other than the guide wire cannot pass through. This makes the ERCP procedure difficult. At this time, cystotome, a type of diathermic dilator seems to be an option. In this paper, we would like to discuss the experience of treatment procedures using cystotome. Methods: Patients who underwent ERCP at a single tertiary hospital from November 2019 to October 2022 were analyzed retrospectively. Among them, cystotome was used in eight procedures in seven patients who passed the guide wire but failed to pass the stenosis. Results: Technical success was achieved in all eight times. All the balloon catheter smoothly passed through the stenosis after cystotome was performed. In the second ERCP, it was a functional success for the balloon catheter to pass through stenosis without further treatment. This was achieved in 6 out of 8 (75.0%). In the case of complications, only one of the total successful procedures developed mild pancreatitis, which led to additional hospitalization for about two days after the procedure, and improved after conservative treatment. Conclusions: Based on this, cystotome seems to be a good option as an alternative treatment to severe stenosis of the pancreatic duct. [ABSTRACT FROM AUTHOR]

Abstract Background and Aim Pancreatic ductal adenocarcinoma (PDAC) is a lethal cancer, partly because its early detection is difficult. This study aimed to identify computed tomography (CT) findings associated with PDAC prior to diagnosis. Methods Past CT images were retrospectively collected from the PDAC group (n = 54) and the control group (n = 90). The following imaging findings were compared: pancreatic mass, main pancreatic duct (MPD) dilatation with or without cutoff, cyst, chronic pancreatitis with calcification, partial parenchymal atrophy (PPA), and diffuse parenchymal atrophy (DPA). In the PDAC group, CT findings were examined during the pre‐diagnostic period and 6–36 months and 36–60 months before diagnosis. Multivariate analyses were performed using logistic regression. Results MPD dilatation with cutoff (P

IntroductionPancreatic necrosis is one of the most severe acute abdominal conditions, accounting for 15%–20% of all patients with acute pancreatitis and characterized by significant rates of postoperative complications and mortality. Patients with pancreatic necrosis, in which pathological changes are localized in the proximal pancreas and retroperitoneal space, deserve special attention. This form of the disease includes patients with disconnected main pancreatic duct (MPD) syndrome who have a difficult prognosis.AimThe aim of the study was an improvement of treatment results in patients with necrotizing pancreatitis and signs of the dissociation of the pancreas duct system using the endoscopic transpapillary stent placement method.Material and methodsThis study was a retrospective cohort study. There were 32 patients with acute necrotizing pancreatitis who were managed using the endoscopic transpapillary stent placement method between 2019 and 2021. Disconnected MPD syndrome was diagnosed in all 32 patients. In total, 26 patients were admitted to hospital in the first 72 h, while 6 patients were admitted after 72 h. We diagnosed the necrotizing process located in the proximal and central areas of the pancreas and peripancreatic space in all these patients (“model III”).ResultsPositive results related to transpapillary stent placement were noted in 24 (75%) patients (first cohort). A total of 20 patients from this group were admitted to hospital in the first 48 h, and 4 patients were admitted later than 72 h from the onset of disease. Moreover, 8 patients (25%; second cohort) failed to succeed in transpapillary stent placement. Complications in the first cohort occurred in 3 (12.5%) patients: dislocation of the stent into the duodenum occurred in 1 patient, and bleeding after papillosphincterotomy took place in 2 patients. Meanwhile, infected necrotized pancreatitis developed in 5 patients, and 1 patient (5%) died. Complications among the second cohort occurred in 2 (25%) patients: erosive bleeding (after debridement). Infected necrotized pancreatitis developed in 4 patients, and 2 patients (25%) died.ConclusionsEndoscopic transpapillary stent placement is an effective minimally invasive approach in the management of patients with necrotizing pancreatitis.

Background: Intraductal papillary mucinous neoplasms (IPMNs) have the potential to evolve into pancreatic adenocarcinoma (PDAC). While main-duct IPMNs (MD-IPMNs), involving the main pancreatic duct (MPD), are less common than side-branch IPMNs (SB-IPMNs) or mixed-type IPMNs (mixed-IPMNs), their malignant transformation potential is far greater. Controversy exists between different guidelines in terms of recommended management strategies. This study was aimed at assessing the utility of the radiological follow up of MD-IPMNs and mixed-type IPMNs, including prevalence of worrisome radiological findings as well as clinical and laboratory parameters, and their correlation with the development of progression or pancreatic adenocarcinoma. Methods: Eighty-four patients with MD-IPMNs or mixed-type IPMNs who underwent at least one magnetic resonance cholangiopancreatography (MRCP) were included. Clinical and laboratory data were obtained retrospectively. A cross-sectional analysis was carried out to establish clinical and laboratory parameters associated with development of PDAC. A retrospective cohort analysis was performed on 44 patients who had at least six months of follow up, trying to identify factors correlating with worrisome radiological features. Results: Nine cases (10.7%) of PDAC were recorded in this cohort. The laboratory and imaging factors associated with cyst size progression greater than 5 mm during follow up were elevated alanine transaminase (ALT) levels, the maximal cyst size, and the MPD diameter. Cross-sectional analysis indicated that PDAC was associated with nausea (p = 0.01), as well as increased levels of aspartate aminotransferase (AST) (p = 0.05), gamma glutamyl transpeptidase (GGT) (p = 0.01), and alkaline phosphatase (ALP) (p = 0.01). Conclusions: Elevated levels of liver enzymes were associated with IPMN progression and, subsequently, the development of PDAC. ALT levels, maximal cyst size, and MPD diameter are associated with the progression of cyst size. These data may aid in risk-stratifying patients when determining the follow up approach for IPMNs.

Abstract Background Main pancreatic duct (MPD) dilation is a high-risk stigmata/worrisome feature of malignancy in intraductal papillary mucinous neoplasms (IPMNs). The threshold of MPD diameter in predicting malignancy may be related to the lesion location. This study aimed to separately identify the thresholds of MPD for malignancy of IPMNs separately for the head-neck and body-tail. Materials and methods A total of 185 patients with pathologically confirmed IPMNs were included. Patient demographic information, clinical data, and pathological features were obtained from the medical records. Those IPMNs with high-grade dysplasia or with associated invasive carcinoma were considered as malignant tumor. Radiological data including lesion location, tumor size, diameter of the MPD, mural nodule, and IPMN types (main duct, MD; branch duct, BD; and mixed type, MT), were collected on computed tomography or magnetic resonance imaging. Serum carbohydrate antigen 19-9 levels, serum carcinoembryonic antigen levels, and the medical history of diabetes mellitus, chronic cholecystitis, and pancreatitis were also collected. Results Malignant IPMNs were detected in 31.6% of 117 patients with lesions in the pancreatic head-neck and 20.9% of 67 patients with lesions in the pancreatic body-tail. In MPD-involved IPMNs, malignancy was observed in 54.1% of patients with lesions in the pancreatic head-neck and 30.8% of patients with lesions in the pancreatic body-tail (p

A wide spectrum of anomalies of the pancreas, the pancreatic ductal system and the biliary tree are commonly encountered at radiologic evaluation. Pancreas bifidum, also known as bifid pancreas or fish-tail pancreas, is an extremely rare congenital branching anomaly of the main pancreatic duct characterized by its duplication. These 2 separate ducts are laid from the pancreatic tail to neck and they generally join at the pancreas body-tail draining via the major papilla; the pancreatic parenchyma is also bifurcated with separated dorsal and caudal buds. The clinical impact of this condition is not well established: although some authors sustained that probably does not cause or contribute to abdominal pain or overt pancreatic diseases, others argued that could be considered as a possible cause of acute pancreatitis.We herewith describe the case of a 51-year-old woman presenting to our hospital with epigastric pain, nausea, and vomiting. Biochemical tests were suspicious for acute pancreatitis. Ultrasound examination was negative. MRI, including MR cholangiopancreatography revealed bifid pancreas characterized by duplication of the main pancreatic duct with 2 separate ducts that join at the pancreas head and draining via the minor papilla. On T2-weighted images the ventral bud of the pancreas was enlarged and characterized by slightly hyperintensity without peripancreatic fluid collections. The MRI findings were consistent with acute pancreatitis limited to the ventral bud of a bifid pancreas. Patient was treated with intravenous fluid resuscitation, pain control and institution of early enteral nutrition and discharged on the seventh day after admission.

Background and Aim: Pancreatic ductal adenocarcinoma (PDAC) is a lethal cancer, partly because its early detection is difficult. This study aimed to identify computed tomography (CT) findings associated with PDAC prior to diagnosis. Methods: Past CT images were retrospectively collected from the PDAC group (n = 54) and the control group (n = 90). The following imaging findings were compared: pancreatic mass, main pancreatic duct (MPD) dilatation with or without cutoff, cyst, chronic pancreatitis with calcification, partial parenchymal atrophy (PPA), and diffuse parenchymal atrophy (DPA). In the PDAC group, CT findings were examined during the pre‐diagnostic period and 6–36 months and 36–60 months before diagnosis. Multivariate analyses were performed using logistic regression. Results: MPD dilatation with cutoff (P < 0.0001) and PPA (P = 0.023) were identified as significant imaging findings 6–36 months before diagnosis. DPA was identified as a novel imaging finding at 6–36 months (P = 0.003) and 36–60 months (P = 0.009) before diagnosis. Conclusion: DPA, MPD dilatation with cutoff, and PPA were identified as imaging findings associated with pre‐diagnostic PDAC. [ABSTRACT FROM AUTHOR]

Objective: Intraductal papillary mucinous neoplasm (IPMN) is a rare pancreatic lesion. The identification of malignancy is critical for the establishment of treatment strategies. Main pancreatic duct (MPD) diameter is one critical feature for malignant IPMNs. However, the threshold of 1.0 cm is challenged. In this study, we explored independent risk factors and further calculated the threshold of MPD in identifying malignant IPMNs. Method: A total of 151 IPMN patients were included in this retrospective study. Demographic information, clinicopathological features, laboratory testing, and preoperative radiological characteristics by magnetic resonance imaging were collected. The receiver operating characteristic (ROC) curves were performed to determine the MPD diameter's cutoff levels and evaluate the predicted factors' diagnostic ability. Results: A cutoff value of 0.77 cm MPD (an area under the curve (AUC) = 0.746) in all IPMNs and 0.82 cm (AUC = 0.742) in the main duct involved IPMNs was obtained. MPD diameter (odds ratio (OR), 12.67; 95% confidence interval (CI), 4.80–33.48) and the mural nodule (OR, 12.98; 95% CI, 3.18–52.97) were the independent associated factors with high-risk IPMNs. The combined model with MPD and mural nodule showed a better predictive performance than mural nodule or MPD diameter alone (AUC = 0.803 vs 0.619, 0.746). A nomogram was developed and showed good performance (C index = 0.803). Conclusion: Our data show that mural nodule and MPD diameter are independent risk factors in identifying malignant intraductal papillary mucinous neoplasms. A cutoff value of 0.77 cm of MPD diameter may be a threshold value in identifying malignant intraductal papillary mucinous neoplasms or undergoing surgical resection. [ABSTRACT FROM AUTHOR]

The presence of main pancreatic duct (MPD) dilatation is important for diagnosing pancreatic ductal adenocarcinomas (PDACs). However, we occasionally encounter PDAC cases without MPD dilatation. The objectives of this study were to compare the clinical findings and prognosis of pathologically diagnosed PDAC cases with and without MPD dilatation and to extract factors related to the prognosis of PDAC. The 281 patients pathologically diagnosed with PDAC were divided into two groups: the dilatation group (n = 215), consisting of patients with MPD dilatation of 3 mm or more, and the non-dilatation group (n = 66), consisting of patients with MPD dilatation less than 3 mm. We found that the non-dilatation group had more cancers in the pancreatic tail, more advanced disease stage, lower resectability, and worse prognoses than the dilatation group. Clinical stage and history of surgery or chemotherapy were identified as significant prognostic factors for PDAC, while tumor location was not. Endoscopic ultrasonography (EUS), diffusion-weighted magnetic resonance imaging (DW-MRI), and contrast-enhanced computed tomography had a high tumor detection rate for PDAC even in the non-dilatation group. Construction of a diagnostic system centered on EUS and DW-MRI is necessary for the early diagnosis of PDAC without MPD dilatation, which can improve its prognosis. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to reveal the role of preoperative main pancreatic duct (MPD) stent placement in reducing the intraoperative main pancreatic duct injury rate and the incidence of postoperative pancreatic leakage following pancreatic tumor enucleation. Methods: A retrospective cohort analysis was performed for all patients with benign/borderline pancreatic head tumors who were treated with enucleation. The patients were divided into two groups (standard vs. stent) depending on whether they underwent main pancreatic duct stent placement prior to surgery. Results: Thirty-three patients were finally included in the analytical cohort. Compared with the standard group, patients in the stent group had a shorter distance between tumors and main pancreatic duct (p=0.01) and presented with larger tumors (p<0.01). The rates of POPF (grade B&C) were 39.1% (9/23) and 20% (2/10) in the standard and stent groups, respectively (p<0.01). Major postoperative complications occurred more frequently in the standard group than in the stent group (14 versus 2; p<0.01). No significant differences in mortality, in-hospital stay or medical cost were observed between the two groups (p>0.05). Conclusions: MPD stent placement prior to surgery may facilitate pancreatic tumor enucleation, minimize MPD injury and decrease the occurrence of postoperative fistula. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the accuracy and time-efficiency of newly developed software in automatically creating curved planar reconstruction (CPR) images along the main pancreatic duct (MPD), which was developed based on a 3-dimensional convolutional neural network, and compare them with those of conventional manually generated CPR ones. Materials and methods: A total of 100 consecutive patients with MPD dilatation (≥ 3 mm) who underwent contrast-enhanced computed tomography between February 2021 and July 2021 were included in the study. Two radiologists independently performed blinded qualitative analysis of automated and manually created CPR images. They rated overall image quality based on a four-point scale and weighted κ analysis was employed to compare between manually created and automated CPR images. A quantitative analysis of the time required to create CPR images and the total length of the MPD measured from CPR images was performed. Results: The κ value was 0.796, and a good correlation was found between the manually created and automated CPR images. The average time to create automated and manually created CPR images was 61.7 s and 174.6 s, respectively (P < 0.001). The total MPD length of the automated and manually created CPR images was 110.5 and 115.6 mm, respectively (P = 0.059). Conclusion: The automated CPR software significantly reduced reconstruction time without compromising image quality. [ABSTRACT FROM AUTHOR]

Background and Aim: Stent‐induced ductal change (SIDC) is a complication of endoscopic pancreatic stenting (EPS) in patients with chronic pancreatitis (CP). However, the evaluation of SIDC associated with S‐type pancreatic plastic stent (PS) and large‐caliber PS, such as 10 Fr, is limited. This study aimed to analyze the SIDC of the main pancreatic duct (MPD) associated with 10‐Fr S‐type PS in patients with CP. Methods: Between January 2008 and December 2021, 132 patients with CP in whom a 10‐Fr S‐type PS had been installed by EPS were retrospectively reviewed. The SIDC incidence rate was examined, and the clinical features of patients with and without SIDC were investigated, including the outcomes for detected SIDC. Results: Stent‐induced ductal change during EPS was confirmed in 41 patients (31.1%) of 132 patients at a site coincident with the PS tip or distal flap in the MPD. All patients were asymptomatic during the development of SIDC. Morphological changes in the MPD were detected as elevated (75.6%) or bearing stricture changes (24.4%). A total of 90.2% of SIDC developed after the first 10‐Fr PS installation. No significant differences were noted between the patients with and without SIDC. The outcomes of continued PS installment for SIDC showed persistence and secondary change. Conclusions: Stent‐induced ductal change‐associated 10‐Fr PS installation was performed in just under one‐third of the patients, indicating a substantial incidence rate and a possible development of SIDC from early stages onwards. More emphasis should be placed on SIDC as the complication. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to develop and evaluate an algorithm for calculating a shape feature to automatically detect both main pancreatic duct dilation (MPDD) and pancreatic parenchymal atrophy (PPA) in abdominal contrast-enhanced CT (CE-CT) images., Approach: The proposed algorithm for the automatic detection of MPDD and PPA is composed of five processes: coarse pancreas segmentation, fine pancreas segmentation, main pancreatic duct (MPD) segmentation, centerline estimation, and shape feature calculation. First, the pancreas region is segmented by a deep learning convolutional neural network (CNN). Then, the MPD region is segmented inside the pancreatic region by the deep learning CNN. Next, centerline estimation is performed using Dijkstra's rooting algorithm. Finally, in shape feature calculation, the cross-sectional area ratio of the pancreatic duct to the pancreatic parenchyma (DP ratio) is calculated in all cross sections perpendicular to the identified centerline, and the 90th percentile value of the DP ratio for all cross sections (90th DP ratio) is calculated. The detection performance of the 90th DP ratio for MPDD and PPA was evaluated using 56 abdominal CE-CT images available as public data., Results: The average of the 90th DP ratio was 0.059 in 48 cases with MPDD and 0.007 in eight cases without MPDD ( p < 0.001 ) and 0.074 in 31 cases with PPA and 0.023 in 25 cases without PPA ( p < 0.001 )., Conclusions: We have developed an algorithm for calculating an automatically measurable shape feature called the 90th DP ratio for the detection of MPDD and PPA., (© 2025 The Authors.)

Introduction: The knowledge of the variations of the abnormal anatomy of pancreaticobiliary union is of great importance for understanding various pathologies of the biliary tract, gall bladder, and pancreas as well as to avoid surgical complications and morbidity which may arise from pancreaticobiliary maljunction. Moreover, it helps in the early diagnosis and preventive treatment of pancreaticobiliary disease. The objective of this study was to find out the prevalence of abnormal anatomic variations of the pancreaticobiliary union in magnetic resonance cholangiopancreatography examinations. Methods: This descriptive cross-sectional study was done in patients referred for Magnetic resonance cholangiopancreatography examinations for various clinical indications from 1 February 2021 to 30 May 2021. Ethical approval was obtained from the Institutional Review Committee [Reference number: 306 (6-11)E 2 077/078]. The variations in the pancreaticobiliary union, length of the common channel, and angle between the common bile duct and major pancreatic duct were obtained from the 1.5T magnetic resonance scanner in 90 patients. The three‑dimensional magnetic resonance cholangiopancreaticography images were visually analyzed and classified into four categories. Convenience sampling method was used. Point estimate and 90% Confidence Interval were calculated. Results: Out of 90 patients, 73 (81.11%) (74.34-87.88, 90% Confidence Interval) patients had abnormal pancreaticobiliary union with pancreaticobiliary type as the most common occurrence seen in 33 (36.67%) patients. Conclusions: The prevalence of abnormal anatomic variation of pancreaticobiliary union was found to be higher than other studies done in similar settings.

Background: Main pancreatic duct (MPD) dilation is a high-risk stigmata/worrisome feature of malignancy in intraductal papillary mucinous neoplasms (IPMNs). The threshold of MPD diameter in predicting malignancy may be related to the lesion location. This study aimed to separately identify the thresholds of MPD for malignancy of IPMNs separately for the head-neck and body-tail.Materials and Methods: A total of 185 patients with pathologically confirmed IPMNs were included. Patient demographic information, clinical data, and pathological features were obtained from the medical records. Those IPMNs with high-grade dysplasia or with associated invasive carcinoma were considered as malignant tumor. Radiological data including lesion location, tumor size, diameter of the MPD, mural nodule, and IPMN types (main duct, MD; branch duct, BD; and mixed type, MT), were collected on computed tomography or magnetic resonance imaging. Serum carbohydrate antigen 19-9 levels, serum carcinoembryonic antigen levels, and the medical history of diabetes mellitus, chronic cholecystitis, and pancreatitis were also collected.Results: Malignant IPMNs were detected in 31.6% of 117 patients with lesions in the pancreatic head-neck and 20.9% of 67 patients with lesions in the pancreatic body-tail. In MPD-involved IPMNs, malignancy was observed in 54.1% of patients with lesions in the pancreatic head-neck and 30.8% of patients with lesions in the pancreatic body-tail (p < 0.05). The cutoff value of MPD diameter for malignancy was 6.5 mm for lesions in the head-neck and 7.7 mm for lesions in the body-tail in all type of IPMNs. In MPD-involved IPMNs, the threshold was 8.2 mm for lesion in pancreatic head-neck and 7.7 mm for lesions in the body-tail. Multivariate analysis confirmed that MPD diameter ≥ 6.5 mm (pancreatic head-neck) and MPD diameter ≥ 7.7 mm (pancreatic body-tail) were independent predictors of malignancy (p < 0.05). Similar results were observed in MPD-involved IPMNs using 8.2 mm as a threshold.Conclusion: The thresholds of the dilated MPD may be associated with IPMNs locations. Thresholds of 6.5 mm for lesions in the head-neck and 7.7 mm for lesions in the body-tail were observed. For MPD-involved IPMNs alone, threshold for lesions in the head-neck was close to that in the body-tail. [ABSTRACT FROM AUTHOR]

Purpose: Anatomical variations of the pancreas are relatively frequent and often understudied. The ductal system of the pancreas has multiple variations, which are not frequently reported in the literature. Materials and methods: The anatomy of the pancreas was studied through macroscopic anatomical dissection on 50 organ complexes (the pancreas, spleen, and duodenum) donated to the department of human anatomy, from patients, who died of causes not related to pancreatic diseases. Results: In type I, the main pancreatic duct (Wirsung's duct, MPD) and the accessory pancreatic duct (Santorini's duct, APD) were merged but most of the head was drained by the MPD (10% of cases). In type II, the MPD and APD were merged but most of the head was drained by the APD (4% of cases). In type III, the APD was absent and the head was drained by the MPD (14% of cases). In type IV, there was an inverted pancreas divisum where the ducts did not merge but each drained a part of the head (6% of cases). Classical pancreas divisum where the ducts did not merge but each drained a part of the head was considered as type V (4% of cases). In type VI, the MPD and APD merged and each drained a part of the head (48% of cases). In type VII, the MPD and APD merged but the upper part of the head was drained by the main pancreatic duct (4% of cases). In type VIII, the MPD and APD merged but the lower part of the head was drained by the main pancreatic duct (4% of cases). In the IX type, the MPD and APD merged but the head was drained by the branches of the MPD (6% of cases). Conclusions: There are several drainage patterns of the pancreas. In some cases, one of the ducts provides more drainage of the gland than the other. This is clinically relevant since blockage of the main source of drainage leads to pancreatic juice stasis. It also explains cases when partial or total blockage of the duct results in the pancreatitis of an isolated zone. [ABSTRACT FROM AUTHOR]

Abstract Background Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a new disease concept defined by the World Health Organization in 2010. ITPN progresses with tubulopapillary growth in the pancreatic duct and is known to have a fair prognosis. Localization in the main pancreatic duct (MPD) is one characteristic. There are few case reports of ITPN in a branch of the pancreatic duct (BD). Case presentation We encountered a case of ITPN localized in BD. An 85-year-old man was followed after colonic surgery for rectal carcinoma. An abdominal computed tomography scan revealed a cystic mass in the pancreatic head and further examination was done. A T2 weighted intension picture in magnetic resonance imaging showed a 20 mm cystic lesion with an internal mass of 15 mm. Duodenal papilla were slightly open and endoscopic retrograde pancreatography revealed mild and diffuse dilatation of the main pancreatic duct and mucin in the MPD. In consideration with the image examinations, we diagnosed the tumor as an intraductal papillary mucinous neoplasm with carcinoma because of its large mural nodule (> 10 mm in size) in a cyst. Consequently, a pancreaticoduodenectomy was performed. Macroscopically, a white solid tumor sized 2.5 × 1.8 × 1.0 was identified in the head of the pancreas. The cut surface of the resected pancreas showed a side-branch type intraductal tumor with tubulopapillary architecture without mucin secretion. Immunohistochemical staining was positive for MUC1, and negative for MUC2 and MUC5AC. The final diagnosis was determined to be pancreatic ITPN from BD. At the time of this report (48 months post-surgery), the patient remains disease-free without evidence of recurrence. Conclusion ITPNs localized in BD are rare and diagnosis prior to surgery is difficult. In our case, the shape was round, not papillary, and with little fluid. These characteristics are different from a branch duct type IPMN and can be a clue to suspect ITPN in BD.

RELEVANCE. The dependency results of draining operations on the efficcacy of drainig of ductal system of the pancreas and adequate outflow of the pancreatic juce through anastomosis are undoubtful, therefore the development of new techniques of longitudinal pancreatojejunostomy (LPJ) extending area of anastomosis is an actual challenge.AIM OF STUDY. To compare the immediate and long-term results of longitudinal pancreatojejunostomy with the expansion of the area of anastomosis in patients with chronic pancreatitis.MATERIAL AND METHODS. We analysed immediate and long-term results of LPJ in 58 patients with chronic pancreatitis with impaired patency of the major pancreatic duct (MPD) without the head enlargement.RESULTS. All patients were divided into two groups: comparison group ( n=26, operated up to 2008 ) and main group (n=32, operated stumps during the MPD diastasis and posterior pancreatic surface (n=3) into anastomosis, with resection of the anterior pancreatic surface in the form of triangular fragments (n=11), with circulation of the small intestine loop during the recovery phase (n=19). The original LPJ in the study group of patients did not lengthened the surgery (160 [135, 185]) and intraoperative blood loss (265 [175, 340]). In the main group of patients there was no postoperative complications and fatal outcomes, but the average duration postoperative hospital treatment (18 [16; 20.5]) exceeded some data of foreign and domestic authors. Pain within 5 years after surgery in patients of the main group exceeded 26.6% and the appearance of diarrheal syndrome with dependance from reception of enzyme preparations was twice lower than in patients og the comparison group. According to questionnaire EORTC QLQ-C30, 5 years after surgery statistically significant differences between groups in terms of scales CF, NV, DY (p=0.03, 0.02, 0.006 respectively), indicating the advantage of intervention performed in the mail group.CONCLUSIONS. 1. An indication for longitudinal pancreatojejunostomy in chronic pancreatitis is impaired patency of the main pancreatic duct in the absence of an increase and inflammatory mass in the pancreatic head.2. The width of the main pancreatic duct is less than 5 mm and the presence of diastasis between its proximal and distal stumps with the posterior surface of the pancreas preserved, is not a reason for refusing longitudinal pancreatic jujunostomy in favor of the resection method.3. The expansion of pancreatojejunal anastomosis when performing longitudinal pancreatojejunostomy can improve the immediate and longterm results of surgical treatment for chronic pancreatitis.

Abstract A 34‐year‐old male was referred to our hospital for a possible pancreatic mass detected by computed tomography (CT) that was performed to find the cause of acute pancreatitis. Multiple imaging tests, including contrast‐enhanced CT scan, magnetic resonance imaging, contrast‐enhanced endoscopic ultrasonography, and endoscopic retrograde pancreatography, revealed a solid mass occupying the head of the main pancreatic duct (MDP), and pancreaticoduodenectomy was performed. In the resected specimen, the tumor showed expansive growth from the pancreatic parenchyma to the MDP and formed a tumor plug. Histopathological findings together with immunostaining findings led to the diagnosis of pancreatic acinar cell carcinoma (PACC). The patient was alive and recurrence‐free for 11 years after surgery. Extension into the MDP is more common in PACC than in conventional pancreatic ductal adenocarcinoma. PACC patients with MDP extension may have less aggressive clinicopathologic characteristics, and a relatively good prognosis can be expected.

Purpose: This study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure., Methods: Clinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed., Results: There were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001)., Conclusion: The improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis., Competing Interests: Declaration of competing interest Authors certify that there is no conflict of interest related to the manuscript., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD). The effect of the location of the main pancreatic duct on POPF development is not completely elucidated. This study aimed to investigate the association between the location of the main pancreatic duct and POPF, and the effect of pancreaticojejunostomy based on the location of the main pancreatic duct on the risk of POPF., Methods: This retrospective study enrolled 871 patients who underwent PD between January 2018 and December 2021. Logistic regression analysis was performed to identify the independent risk factors associated with POPF. Predictive performance was evaluated using the receiver operating characteristic curves. In addition, a novel pancreaticojejunostomy strategy that could reduce the risk of POPF was adopted., Results: Based on the multivariate analysis, the pancreatic texture and the location of the main pancreatic duct were the independent risk factors of POPF. A threshold ratio of 0.397 was used to distinguish the central from the eccentric pancreatic ducts. Notably, patients with the central pancreatic duct had a significantly lower incidence rate of POPF than those with the eccentric pancreatic ducts (10.6% vs. 44.8%, P<0.001). The novel group exhibited a significantly lower incidence rate of POPF than the conventional group (13.7% vs. 23.0%, P=0.02), and the incidence rate of other complications was not high., Conclusions: The location of the main pancreatic duct is associated with POPF development. However, implementing the novel pancreaticojejunostomy approach can effectively reduce the risk of POPF while ensuring safety., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-235/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Introduction: The duct system of pancreas consists of two large ducts – Main pancreatic duct and Accessory pancreatic duct. Both these ducts drain the entire exocrine part of pancreas. Main pancreatic duct is always present while accessory pancreatic duct may be absent in 30% cases. The study of duct system of pancreas has wide application in pancreatitis, endoscopic retrograde cholangiopancreaticogram, pancreatic calculi, carcinoma of pancreas and even in obstructive jaundice caused by gall stone disease and also in gall bladder carcinoma. Materials & Methods: The present study was done in 50 adult formalin fixed pancreatic specimens removed during posterior abdominal wall dissection. Statistical analysis: Done using Mean, Standard deviation, Percentage Results: The study showed that the mean length and standard deviation of the main pancreatic duct was 18.4 ± 2.43 cm and the mean width and standard deviation of the duct was 2.7 ± 0.8 mm, 2.3 ± 0.5 mm 2.1 ± 0.2 mm respectively in the head, body and the tail. The main pancreatic duct coursed from tail to its opening into the duodenum through five various types Descending (46%), Vertical (4%), Loop(2%) , Sigmoid(30%) and Horizontal(18%). The main pancreatic duct opened into the major duodenal papillae in 72% specimens. Conclusion: The mean length of the main pancreatic duct varies from 13.4 to 26.cm, while the width of the duct gradually increases from tail to head. Descending type was most common while loop type was least common type of the main pancreatic duct course. The main drainage route of the pancreas was through major duodenal papilla

Background: Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option in technically challenging situations for extraction of pancreatic and common bile duct calculi. Common bile duct (CBD) stone fragmentation rates of 71 to 95% have been reported with ESWL, leading to final duct clearance rates of 70 to 90%. While complete clearance of 76% and partial clearance of 17% of pancreatic duct calculi have been documented with ESWL, our study was undertaken to investigate the efficacy and safety of ESWL in clearance of difficult bile duct and large pancreatic duct calculi. Methods: The study population consisted of 61 patients who had either large or difficult bile duct calculi or large pancreatic duct calculi documented on ultrasonography abdomen or magnetic resonance cholangiopancreatography (MRCP). All patients were subjected to ESWL sessions with endoscopic nasobiliary drainage (ENBD) placement till stones got fragmented. Results: A total of 1,284 patients underwent ERCP for either choledocholithiasis or pancreatic duct calculi during the study period (June 2015 to December 2016). Out of them 61 patients had either large or difficult CBD calculi or large pancreatic duct calculi. Forty (65.57%) had choledocholithiasis (Group-A) and 21 (34.42%) had chronic calcific pancreatitis (Group-B). CBD was cleared in 37 patients (92.5%) and 3 patients (7.5%) underwent surgical intervention. Main pancreatic duct (MPD) was cleared in all patients with clearance rate of 100%. Conclusions: ESWL is an effective and safe method for clearance of difficult CBD and pancreatic duct calculi. Combined efficacy of duct clearance is >90%. Complications are minimal and managed conservatively.

There is a classical conception of the anatomy of the pancreatic ducts. However, due to the embryological origin of the pancreas, these ducts can be the seat of various anatomical variations. These are not a rare entity and can be identified during cadaveric dissections or imaging studies. In the present study, two variants of the pancreatic ducts found during the dissection of cadaveric material and in a cholangioresonance are presented. In cadaveric material we observed a dominant pancreatic duct extending from the tail to the head of the pancreas, opening into the duodenum through the lesser duodenal papilla; and a smaller caliber pancreatic duct without a duodenal opening. In cholangioresonance, we found the unique presence of the main pancreatic duct, extended from the tail to the head of the pancreas, which loops prior to its opening into the duodenum through the greater duodenal papilla. Within the spectrum of variations reported in the literature, those of the present study are infrequent, but may be associated with a greater presence of pathologies related to the biliopancreatic sphere. [ABSTRACT FROM AUTHOR]

According to the revised international intraductal papillary mucinous neoplasm (IPMN) guidelines (2017), the indication for surgery is based on risk classification. However, some IPMNs with high-risk stigmata (HRS) can be observed for long periods without resection. Hence, we need to reconsider the risk stratification, and this study aimed to propose a novel risk stratification for HRS-IPMNs. We enrolled 328 patients diagnosed with IPMN using endoscopic ultrasound between 2012 and 2019. We compared clinicopathological features between HRS and worrisome features (WF) and evaluated outcomes of HRS-IPMN. Fifty-three patients (HRS 38, WF 15) underwent resection at initial diagnosis and 275 patients were observed. Following observation for 30 months, 22 patients (17 HRS, 5 WF) underwent resection. Analysis of resected IPMNs (n = 75) revealed that HRS had dominantly pancreatobiliary mucin subtype. Pancreatobiliary-type IPMN had larger nodule sizes and lymphatic invasion and high recurrence with poor prognosis. Seventy-four patients were diagnosed with HRS, 55 underwent resection, and 19 continue to be observed. The resected group had larger nodule sizes (median 8 mm vs. 5 mm; P = 0.060), whereas the observed group had more main pancreatic duct (MPD) dilation (median 10 mm vs. 5 mm; P = 0.005). In the resected HRS group, only patients with MPD dilation ≥10 mm (n = 10) had no recurrence but had a favorable prognosis compared with those nodule size ≥5 mm (n = 45). Large nodule size may be associated with pancreatobiliary subtype and poor prognosis; however, patients with MPD dilation ≥10 mm with nodule size <5 mm did not require resection. [ABSTRACT FROM AUTHOR]

Background: Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a new disease concept defined by the World Health Organization in 2010. ITPN progresses with tubulopapillary growth in the pancreatic duct and is known to have a fair prognosis. Localization in the main pancreatic duct (MPD) is one characteristic. There are few case reports of ITPN in a branch of the pancreatic duct (BD).Case Presentation: We encountered a case of ITPN localized in BD. An 85-year-old man was followed after colonic surgery for rectal carcinoma. An abdominal computed tomography scan revealed a cystic mass in the pancreatic head and further examination was done. A T2 weighted intension picture in magnetic resonance imaging showed a 20 mm cystic lesion with an internal mass of 15 mm. Duodenal papilla were slightly open and endoscopic retrograde pancreatography revealed mild and diffuse dilatation of the main pancreatic duct and mucin in the MPD. In consideration with the image examinations, we diagnosed the tumor as an intraductal papillary mucinous neoplasm with carcinoma because of its large mural nodule (> 10 mm in size) in a cyst. Consequently, a pancreaticoduodenectomy was performed. Macroscopically, a white solid tumor sized 2.5 × 1.8 × 1.0 was identified in the head of the pancreas. The cut surface of the resected pancreas showed a side-branch type intraductal tumor with tubulopapillary architecture without mucin secretion. Immunohistochemical staining was positive for MUC1, and negative for MUC2 and MUC5AC. The final diagnosis was determined to be pancreatic ITPN from BD. At the time of this report (48 months post-surgery), the patient remains disease-free without evidence of recurrence.Conclusion: ITPNs localized in BD are rare and diagnosis prior to surgery is difficult. In our case, the shape was round, not papillary, and with little fluid. These characteristics are different from a branch duct type IPMN and can be a clue to suspect ITPN in BD. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study is to determine preoperative factors that are predictive of malignancy in patients undergoing pancreatic resection for intraductal papillary mucinous neoplasms (IPMN). Summary Background Data: IPMN of the pancreas may be precursor lesions to pancreatic cancer (PC) and represent a target for early diagnosis or prevention. While there has been much effort to define preoperative risk factors for malignant pathology, guidelines are ever-changing and controversy remains surrounding which patients would benefit most from resection. Methods: We performed a retrospective analysis of 901 consecutive patients obtained from two tertiary referral centers who underwent pancreatic resection for histologically proven IPMN between 2004 and 2017. Collected data included patient demographic characteristics, preoperative symptoms, radiological findings, and laboratory data. Results: Main pancreatic duct (MPD) dilatation was the only variable that was significantly associated with increased probability of malignancy (defined high-dysplasia or invasion) on both univariate and multivariate analysis. Even middle-range MPD dilatation from 5 mm to 9.9mm (n = 286) was associated with increased odds of HG-IPMN (OR = 2.74; 95% CI = 1.80-4.16) and invasion (OR = 4.42; 95% CI = 2.55-7.66). MPD dilatation >10mm (n = 150) had even greater odds of HG-IPMN (OR = 6.57; 95% CI =3.94-10.98) and invasion (OR=15.07; 95% CI=8.21-27.65). A cutoff of 5 to 7mm MPD diameter was determined to be the best predictor to discriminate between malignant and benign lesions. Conclusions: In agreement with current IPMN management guidelines, we found MPD dilatation, even low levels from 5mm to 9.9 mm, to be the single best predictor of HG-IPMN or invasion, highlighting the critical role that MPD plays in the selection of surgical candidates. [ABSTRACT FROM AUTHOR]

• Blunt trauma to the abdomen, accounts for the majority of abdominal injuries in children. • Pancreas injury from blunt abdominal trauma in children is very rare. • The emergent use of ERCP in children has not been implement widely. • Operative vs non-operative management of blunt pancreatic trauma in children. • A key is the status of pancreatic duct. Although serious trauma is rare in pediatric patients, the management of blunt force trauma to the abdomen remains a challenge for Child Surgery Departments. Pancreatic injury comprises the fourth most common injury among the solid organs and cases accompanied by rupture of the main pancreatic duct (MPD) present a further challenge for physicians (Fayza Haider et al.; Wood et al., 2010; Jobst et al., 1999; Grosfeld et al., 2006). Two adolescents, both 13 years old, where referred to our Pediatric Hospital, due to blunt force abdominal trauma. During admission, both patients were hemodynamically stable, in good general condition but suffering from abdominal pain and vomiting. After a full diagnostic check-up, grade IV pancreatic injury was diagnosed in both patients and they were taken to the operation room 3 and 6 days post-injury. Intra-operatively a distal pancreatectomy along with splenectomy was performed in both cases, with catheterization and ligation of the main pancreatic duct. Both patients were admitted to the pediatric ICU for 2 and 4 days. Both made an uneventful recovery and remain well 6 months postoperatively. While hemodynamically stable, patients with Grade IV pancreatic injury, benefit from sub-acute management, allowing for planning of the surgical intervention. Distal pancreatectomy with splenectomy, along with catheterization and ligation of the main pancreatic duct, has excellent post-operative results. The chief of the Pediatric Hospital, said that in 35 years at pediatric surgery, is the first time with the need of operative management, in pancreatic injury. The hepatobiliary surgical expert in adults, who was consulted in both cases, said that without the surgeries, both children were going to die. [ABSTRACT FROM AUTHOR]

Purpose: In the diagnosis of chronic pancreatitis (CP), definition of main pancreatic duct (MPD) dilation is challenging due to lack of commonly accepted normal values. This study assessed the diagnostic performance of MPD diameters to detect CP including the impact of age. Methods: 274 patients with ERCP-verified CP and 262 healthy controls were included. All had magnetic resonance cholangiopancreatography (MRCP) with measurement of MPD diameters in the pancreatic head, body, and tail. CP disease stage was defined as patients with and without functional (exocrine and/or endocrine) impairment. Diagnostic performance of MPD diameter and corresponding cut-offs values to diagnose CP were determined, including an age-stratified analysis. Results: In healthy controls, an effect of age on MPD diameters was seen for the pancreatic head (P < 0.001), body (P = 0.006), and tail (P = 0.03). Patients with CP had increased MPD diameter compared to controls (all segments P < 0.001). Increased pancreatic head MPD diameter was seen in patients with functional pancreatic impairment compared to patients without (P = 0.03). The diagnostic performance of MPD diameter to detect CP was high (all segments ROC-AUC > 0.92). The optimal pancreatic MPD diameter cut-off values for diagnosing CP were: < 40 years: 2.0(head) and 1.8(body) mm; 40–60 years: 2.4(head) and 2.1(body) mm; > 60 years: 2.7(head) and 2.1(body) mm. Conclusion: Age is an important factor when evaluating the diameter of the pancreatic ductal system. Our findings challenge the existing reported thresholds for defining an abnormal duct diameter and point at age-stratified assessments as an integrated part of future imaging-based diagnostic and grading systems for CP. [ABSTRACT FROM AUTHOR]

Background: Except for pancreas divisum (PD), the prevalence of anatomic variants of the main pancreatic duct (MPD) seems to be insufficiently investigated. To date, their role in the occurrence of pancreatic exocrine insufficiency (PEI) and morphological changes suggestive of chronic pancreatitis (CP) has remained unclear. Methods: A systematic review was performed, searching MEDLINE and Web of Science, limited to articles published between 1960 and 1 June 2019. Results: Our review included a total number of 3234 subjects. The most common variant of MPD was type 3, followed by type 1, indicating MPD drainage pattern into major papilla (MP) as the most frequent. A sub-variant of type 3, known as 'reverse pancreas divisum' had a prevalence of 2.2%. Type 4 variant- PD, was found in 6.4% of all cases. The most common sub-variant of PD was complete PD, followed by incomplete PD and variant with MPD as only pancreatic duct. Type 5 variant (including ansa pancreatica) was present in 2.9% of subjects. Apart from one study with a significantly higher frequency of morphological changes suggestive of CP in patients with ansa pancreatica, the studies stated no significant association between pancreatic disease and MPD variants. Furthermore, only one study examined the influence of MPD variants on exocrine pancreatic function. Although equivocal, this association is most likely found to be insignificant. Conclusion: To elucidate linkage between MPD variants and the occurrence of chronic pancreatitis and impairment of pancreatic exocrine function, further clinical investigations are warranted. [ABSTRACT FROM AUTHOR]