Santorini's Duct – An Insignificant Variant from Normal or an Important Overflow Valve?

Ub, Mairose; Wurbs, D; Classen, Meinhard

doi:10.1055/s-0028-1098256

Cited by 24 publications

(13 citation statements)

References 12 publications

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“…Berman et al (1960) suggested that the presence of a communicating accessory duct might reduce the incidence of pancreatitis by acting as a safety valve when the main duct was obstructed. This suggestion is supported to some extent by Mairose et al (1978) who found a three-fold increase in the incidence of hyperamylasaemia after ERCP in patients with an absent accessory pancreatic duct.…”

Section: Discussionmentioning

confidence: 72%

Clinical relevance of an unfused pancreatic duct system.

Mitchell¹,

Lintott²,

Ruddell³

et al. 1979

Gut

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SUMMARY In man, the main pancreatic duct is normally derived from ventral and dorsal embryological buds of the pancreas. In a minority of people, failure of fusion of the two buds results in separate drainage of the dorsal and ventral pancreas, so that the accessory duct provides the main drainage for the gland. Patients with this anomaly demonstrated at endoscopic retrograde pancreatography (ERP) have been investigated to assess whether non-fusion of the main pancreatic duct predisposes to the development of pancreatitis. A failure of fusion of the pancreatic ducts was seen in 21 out of 449 (4-7 %) successful pancreatograms; four of these 21 patients had definite clinical evidence of pancreatitis and two patients had possible pancreatic disease, but in the remainder the anomaly was not considered to be clinically relevant. An abnormal pancreatogram suggesting pancreatitis was present in 116 out of the 428 patients (27.1 %) with a normally fused duct system. The anomaly was found as frequently in the whole series as it was seen in patients with pancreatitis. These findings suggest that embryological failure of pancreatic duct fusion does not predispose to the development of pancreatitis. However, the presence of this anomaly may lead to misinterpretation of ultrasonographic and CT scan findings.The pancreas is formed embryologically from distinct ventral and dorsal buds which arise from the duodenal diverticulum after rotation of the ventral bud and have fused by the seventh week of life (Meckel, 1812). Wirsung (1642) first demonstrated the main pancreatic duct in man and Santorini (1775) accurately described the duct system and demonstrated the accessory pancreatic duct.Normally, the main pancreatic duct is derived from both embryological parts of the pancreas; the dorsal pancreas provides the main duct in the tail and body of the gland with the ventral anlage providing the main duct in the head of the gland. The accessory duct (of Santorini) is the remaining portion of the duct in the dorsal pancreas which may drain through an accessory papilla more proximally in the duodenal loop.It is thus not surprising that anomalies of the pancreatic duct system occur and their frequency has been documented in large systematic necropsy studies by Baldwin

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Section: Discussionmentioning

confidence: 72%

Clinical relevance of an unfused pancreatic duct system.

Mitchell¹,

Lintott²,

Ruddell³

et al. 1979

Gut

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“…Accordingly, the reported patency of the APD of the typical pancreatic duct system (excluding cases of unfused pancreatic duct systems) has ranged widely, from 12% to 82% (Table 1). [2][3][4][5][6][7][8][9][10][11][12][13][14]37 Recently, some endoscopic retrograde pancreatography (ERP) studies have evaluated patency of the APD by observing the leakage of contrast medium from the MIP on fluoroscopy or radiography. 11,12,14 However, in many cases, the orifice of the MIP is very small and precise evaluation of patency of the APD is practically impossible using these methods.…”

Section: Patency Of the Apdmentioning

confidence: 99%

“…[46][47][48][49] Patency of the APD in control cases, as determined by dye-injection ERP, was 43% 49 , consistent with the average reported patency (46%; 624/ 1351). [2][3][4][5][6][7][8][9][10][11][12][13][14]37 In addition, Millbourn 4 reported that the APD was considered capable of relieving the function of the MPD in 33% of 182 cases.…”

Section: Dye-injection Erpmentioning

confidence: 99%

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Clinical significance of the minor duodenal papilla and accessory pancreatic duct

Kamisawa

2004

J Gastroenterol

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The accessory pancreatic duct (APD) is the main drainage duct of the dorsal pancreatic bud in the embryo, entering the duodenum at the minor duodenal papilla (MIP). As development progresses, the duct of the dorsal bud undergoes varying degrees of atrophy at the duodenal end. In cases of patent APD, smooth-muscle fiber bundles derived from the duodenal proper muscular tunics surround the APD. The APD shows long and short patterns on pancreatography, and ductal fusion in the two types appears to differ embryologically. Patency of the APD in control cases, as determined by dye-injection endoscopic retrograde pancreatography, was 43%. Patency of the APD may depend on duct caliber, course, and terminal shape of the APD. A patent APD may prevent acute pancreatitis by reducing the pressure in the main pancreatic duct. Pancreas divisum is a common anatomical anomaly in which the ventral and dorsal pancreatic ducts do not unite embryologically. As the majority of exocrine flow is routed through the MIP in individuals with pancreas divisum, interrelationships between poor function of the MIP and increased flow of pancreatic juice caused by alcohol or diet may increase dorsal pancreatic duct pressure and lead to the development of pancreatitis. Wire-guided minor sphincterotomy, followed by dorsal duct stenting, is recommended for acute recurrent pancreatitis associated with pancreas divisum.

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“…It is hypothesized that in some patients an increased resistance to flow across this small orifice results in dorsal duct hypertension and clinical symptoms [7,8]. The resulting increased dorsal duct pressure also may make the pancreas more prone to injury from alcohol and drugs [13,14]. This would explain why individuals with a relatively common anomaly rarely develop complications.…”

Section: Clinical Significancementioning

confidence: 99%

Pancreas divisum

Khalid

Slivka

2001

Curr Treat Options Gastro

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We offer endoscopic therapy for pancreas divisum only in patients with acute recurrent pancreatitis or chronic pancreatitis, based on studies delineated in this article, which results in response rates of 80% and 50% respectively. We do not offer endoscopic therapy for patients with chronic abdominal pain in the absence of morphologic abnormalities in the pancreatic duct or parenchyma or normal laboratory study results. It has been our experience that the success rate for endoscopic cannulation and therapy directed at the minor papilla in patients with symptomatic pancreas divisum is improved when the procedure is performed with primary intent to treat in patients who have a pre-existing diagnosis of pancreas divisum, as opposed to patients who undergo diagnostic ERCP for idiopathic acute recurrent pancreatitis and are diagnosed with pancreas divisum during the procedure. We cannulate the minor papilla with ultratapered 3-F catheters and 0.018-in soft wires. It is our opinion that minor papilla sphincterotomy offers advantages over chronic stent therapy in treating patients with pancreas divisum. Although both techniques have proven efficacy, chronic stenting requires repeated procedures and results in a high incidence of stent-induced chronic duct changes, both of which can be avoided by performing a minor papillotomy. We use an ultratapered papillotome with a 20-mm monofilament cutting wire and typically use blended current. The papillotomy is extended to ablate the mucosal mound of the minor papilla typically in a 2-o'clock direction for a distance between 4 and 8 mm, depending on the patient's anatomy. Following minor papillotomy, we place temporary 5-F pancreatic duct stents to reduce the incidence of postprocedural pancreatitis, which has been demonstrated in pancreatic duct sphincterotomy of the major papilla. These stents usually migrate out after 24 to 72 hours following the procedure. We offer surgical sphincteroplasty to patients in whom minor papillotomy cannot be performed or whose disease relapses after successful endoscopic therapy.

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Santorini's Duct – An Insignificant Variant from Normal or an Important Overflow Valve?

Cited by 24 publications

References 12 publications

Clinical relevance of an unfused pancreatic duct system.

Clinical relevance of an unfused pancreatic duct system.

Clinical significance of the minor duodenal papilla and accessory pancreatic duct

Pancreas divisum

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