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Annular pancreas causing duodenal obstruction
ANNULAR
PANCREAS
CAUSING
DUODENAL
OBSTRUCTION ALFRED J. GOLDYNE, M.D. Resident Surgeon, hlary’s Help Hospital
AND
EVERETT
CARLSON,
Chief Surgeon, Mary’s
M.D.
HeIp Hospital
SAN FRANCISCO, CALIFORNIA
A
NNULAR pancreas causing duodena1 obstruction is of rare occurrence and its importance from a surgicocIinica1 aspect is such that any case in which the patient is operated upon warrants reporting so that this condition may become known as a cIinica1 entity and a suitable approach for its correction ma?; be estabhshed. This is especiaIIy desirable since the data on operative intervention are Iimited to thirteen cases incIuding this report. Because of the rarity of this anomaIy and the unusua1 features of this case, we make this presentation: CASE
REPORT
Father R. C., a twenty-six-year oId priest, was admitted to the hospital on January 26, 1945, with the foIlowing complaints: Pain of a d&I and persistent nature in the pit of the stomach coming on one hour after a meal and relieved by more food or baking soda. The pain recurred on and off for the past year. It IateIy became unrelieved by food or soda, but bending or doubling over did reIieve the pain. There was no characteristic radiation. BeIching was present for two years. The patient, before seeking medical advice, treated himseIf for an entire year with baking soda and food ingestion with some reIief. Vomiting occurred on two occasions. The first time, ten to eIeven months preceding the hospital admission and the second time, two months before entrance. Both episodes of vomiting reIieved the pain. There was Ioss of appetite for the past nine months, but unassociated with Ioss of weight. When the patient finally sought medical advice a vear ago, he was put on an uIcer diet and aIkaii therapy which relieved him of his discomfort until three months ago when the pain reappeared.; Further medica management was unsatisfactory. Two weeks before his hospita1 admission he consented to a compIete gastrointestina1 x-ray investigation at which 429
time.he was advised to be operated upon for an obstruction of his bowel. The past history and family history as we11 as the system review were non-contributory. Physical examination on entry, revealed a well developed, we11 nourished, white, twentysix-year old male, who was not acuteIy iI1. Blood pressure was 120/70; temperature 98.6”~.; pulse 86. There was no evidence of weight Ioss or dehydration. The heart and Iungs were normal. The upper part of his abdomen was prominent. There was no guarding or rigidity of the recti, but there was slight tenderness in the epigastrium to the right of the midIine. No abnormal masses could be palpated. Roentgenologic examination of the gastrointestinal tract reveaIed a moderate diIatation of the stomach and first part of the duodenum and a retention in both at the end of six and twenty-four hours. No other abnormalities were noted except the presence of a scoliosis. A diagnosis of marked obstruction in the second part of the duodenum was sufficiently estabIished to justify surgical expIoration for its relief. Operation w-as performed under general anesthesia. A midline incision was made. On entering the abdomen, the stomach was found to be moderately diIated to about one and a half times the normal. The first and second portion of the duodenum were markedly diIated to about three times the normal diameter. The pyIoric ring couId be feIt as a band between the diIated portions of the stomach and duodenum; the opening was moderateIy Iarge. Adjacent to the right of the ascending coIon, the incompIeteIy rotated cecum was found with the appendix densely embedded in it. The dista1 third of the appendix was bound down to the underIying area of duodenal construction. Its tip was enlarged, and showed evidence of past inflammatory reactions. Adhesions were present between it and the gaIIbIadder. It was removed and its base inverted. Further dissection uncovered
430
American Journal
of
Surgery
GoIdyne,
CarIson-Annular
FIG. I. Anteroposterior view of immediate stomach, showing defmite constriction of the second portion of duodenum with diIatation of the first portion.
FIG. 3. Six-hour examination showing definite residue in stomach and duodenum.
Pancreas
FIG. 2. Postero-anterior view of immediate stomach, showing diIatation of the first portion of the duodenum. There is scoIiosis of the lumbar spine.
FIG. 4. Twenty-four-hour examination showing residue in first portion of the duodenum.
945
VOL..
LXXI, No.3
GoIdyne,
CarIson-AnnuIar
the hard, annular band over the distal portion of the second part of the duodenum. It was about one inch wide and one-half inch thick,
FIG. 5. Postoperative six-hour examination showing residue in stomach and duodenum.
and completely surrounded the duodenum, constricting its lumen to a very narrow diameter of about one-fourth inch. Its identity was established as pancreatic tissue. The duodenum was mobilized by cutting the mesentery to the right of it and the annular band was dissected free and cut transverseIy to the right of the head of the pancreas. It was further freed from the duodenal wall and a portion of about one inch was resected. This reIeased the duodena1 Iumen so that it was possible to insert the index finger through its most constricted portion. FoIlowing this, the abdomen was cIosed in Iayers and not drained. The pathoIogica1 examination of the tissue resected showed it to be pancreatic tissue with al1 of the histologic characteristics of a norma pancreas, incIuding normal acini, ducts, and many islets. The appendix varied from 8 to 12 mm. in diameter, being Iarger at its tip. The tip was distended with fecaIiths. PostoperativeIy, the course was fairly uneventfu1. The patient was slightly nauseated, but free from vomiting the first day. Food and
Pancreas
American
JournalofSurgery43 I
fIuids were taken freeIy on the second day. He had to be catheterized severa times. Due to an upper respiratory infection, a temperature of
FIG. 6. Postoperative twenty-four-hourexamination showing gastric and duodenal residue.
102.6~~. was recorded on the evening of the second day. This graduaIly subsided, the patient being temperature free on the eigth day. At no time were there any signs of peritoneal irritation from possible pancreatic secretions, nor did any pancreatic fistuIa form as has been the experience in severa reported cases (8, IO, 17). There was no wound infection. Eight weeks foIIowing surgery, aIthough entirely symptom free and abIe to eat an unrestricted diet, the patient was routinely x-rayed. The fiIms reveaIed a persistence of a twenty-four and forty-eight hour residue in the stomach and duodenum.
Embryology. ExceIIent detailed accounts of the embryologica deveIopment of the annuIar pancreas have been presented by Howard,8 McNaught,“,12 and others.l,“l 1 The anomaIy is thought to be the result of fixation of the ventral pancreatic bud which assumes an annular configuration when rotation of the duodenum occurs, Chapman and Mossman,” however, be-
432
American
~““~“~1
“f surgery
GoIdyne,
CarIson-AnnuIar
lieve that the ventraI pancreatic tissue spreads dorsaIIy in a subperitonea1 position around both sides of the duodenum rather than on one side as it normaIIy does, As proof of this, they cite the presence of three pancreatic ducts and Iobes as the normal condition found in birds. The former theory, however, is the one most accepted. Clinical data, to date, revea1 a total of fifty-two cases of annuIar pancreas reported in the Iiterature. Thirteen of the cases, incIuding our report, have been surgica1 probIems; the others were incidentaIIy found at postmortems or in anatomic Iaboratories. There were four deaths in the patients operated upon, a mortaIity of 31 per cent. The presence of an annular pancreas with a greater or Iesser degree of duodena1 obstruction is not incompatibIe with Iong Iife as is shown by the upper age group in which this anomaIy was found. The oIdest patients operated upon being seventy-four years oId (Smetana I3 Custer and Waugh”). Excepting two cases found in three-day oId infants, (VidaI16 Cross and ChishoIm’), the ages varied from twenty-three to seventy-four years. The majority of the cases were asymptomatic throughout Iife and attention was caIIed to the anomaIy by the presence of pathoIogic processes in the same or continguous organs. In some,“” an acute pancreatitis or a duodena ulcer or as in our case, a pathoIogic appendix precipitated the investigation Ieading to the discovery of the annuIar pancreas.
A number of surgica1 procedures have been suggested for the correction of the obstruction caused by the anomaIy. Of the thirteen patients operated upon and by
othersI>
2~5~6~7~8~9~10~13r15~16~17
in_
eluding ours, a partia1 resection or division of the ring was performed in five. AI1 had a compIete recovery with the exception of Lehman’s case9 which had persistent postoperative symptoms. Posterior
MARCH, 1946
gastroenterostomy was performed in five cases of which three died of intercurrent infections or associated pathoIogic processes. Duodenojejunostomy was performed on a three-day oId femaIe by Gross and ChishoIm’ with compIete cure. In the case reported by Custer and Waugh” a gastric resection incIuding the upper 8 cm. of duodenum was performed for an associated gastric uIcer. An anterior Iong Ioop gastroenterostomy was done. The reported resuIt was good. TABLE CASES
OF
ANNULAR
Reported bY
AgeSex
Male
1905 dos Sante: 1906 Lerat 1908 Smetana 1928 Howard
3 days Female 36 yr. Female
74 YT. Fe”l&
193” Brines
46 YT. Male
193” Zech
35 YI. Female
1931
27 YI.
46 YI. Male
Brines
Malt:
1931
44 Yr.
I*
PANCREAS
Vidal
Male 35 Yr.
TREATED
BY
Operation
Result
Cure
Posterior gastroenter osto”Iy Posterior gastroenter ostomy Resection of pan creatic ring Posterior gastroenter ostomy Division of ring Drainage of pancreat tis Division of ring Heineke-Mikulicz plastic on duodenun Posterior gastroenter ostomy
OPERATION
Died (pneumonia) Cure Died CUT”
i-
Died CUT”
_, Died _
Posterior gastroentcr “stomy plastic “1 duodenum Partial resection 0 ring
(respiratory infection) CUE
f! Recovery,
Lehman
Male
1943
23 Yr.
Gross and Chisholm
Female 3 days
Duodenjejunostomy
but persistent symptoms Cure
I944 Custer an< Waugh
Male
Gastric
Cure
72 yr.
1944 Goldyne and Carl son * After
COMMENTS
reported
Pancreas
Male
resection
Resection
of ring
CUE
26 yr.
Gross and Chisholm.
Considering the Iack of mortaIity, resection of the pancreatic ring appears to be the safest method, thus far, despite the hazard associated with cutting through pancreatic ducts, and the consequent deveIopment of pancreatic cysts and fistuIas. However, it is readiIy conceded that because of the meager Iiterature and experience with this anomaIy, the safest procedure is yet to be determined. The
VOL.
I.XXI.
No.
GoIdyne,
3
CarJson- -Annular
fact, called attention to by other investigators,“,J.7’. 11.I-1 concerning the association of other anomalies with this condition is further substantiated by this case. The diagnosis of annuJar pancreas has not been made preoperativeIy in our case or in any of those reported. The lesion being difficult to differentiate from other causes of duodenal obstruction. We have personaIJyencountered three cases which couid not be differentiated roentgenoIogicaIly from the obstruction caused by an annular pancreas. These were, two cases of congenita1 duodenal atresia in the newborn, and one case of a constricting carcinoma of the second portion of the duodenum. SUMMARY
AND
CONCLUSION
A case is presented in which the patient had duodenal obstruction due to an annular pancreas. It was treated by division of the ring and resection of a part of it. A short summary of its embryoIogy is given. It is deduced that annular pancreas is compatible with life and may not give rise to any symptoms. Its presence is often caIIed attention to by an associated inflammatory reaction in the pancreas itself, or a contiguous organ. Resection of the ring may not reheve the obstruction entireJy, yet the patient may be symptom free. Attention is again called to the associated anomahes with this condition ; in this case an incompIeteJy rotated cecum and a pathoIogic superThis is the first case imposed appendix. a reported which ha s not developed pancreatic cyst or fistuJa foIIowing resection of the annular tissue, and the first that is symptom free despite evidence of gastric and duodenal retention. We beIieve that resection of the annuIar band, in
Pancreas
American
JOMWI
OCS~~~~W~
433
spite of the objectionabIe deveIopment of pancreatic cysts and fistulas, merits consideration as the operation of choice because of the lack of mortaIity associated with this procedure. REFERENCES BRINES, 0. A. Annular pancreas, invoIved in acute hemorrhagic pancreatitis. Ann. SW-S., 9.2: 241, T93”. 2. BRINES, 0. A. AnnuIar pancreas-associated with peptic ulcer. Am. J. Sirg., 12: 483, 1931. J. L. and MOSSMAN. H. W. Annular pan3. CHAPMAN. creas; accompanied by an aberrant pancreatic nodule in the duodenum. Am. J. Surg., 60: 286, I.
‘943. Brir. J. 4. GLNXINGHA%+, G. J. AnnuIar pancreas. Surg., 27: 678, 1939, I g4o. hl. D., JR. and WALGH, J. hl. hoc. Stajf 5. CI:STER, Meet., Mayo C/in., Ig: 388-390, 1944. 6. DOS SANTOS, R. Deux lesions rare du duodenum. Xv Conpr. Infer. de Med. Lisbon, 9: 419, 1906. 7. GROSS, R. E. and CHISHOLM, T. C. AnnuIar pancreas producing duodenal obstruction. Ann. Sw., I 19: 759, 1944. 8. HOWARD, N. J. Annular pancreas. Sure., Gnec. t?+ Obst., 50: 533, 1930. _ 9. LE~IMAX. E. P. Annular oancreas as a clinica problem. Ann. Sure., I 15: 574, 1942. 10. L.ERAT, P. Contribution chirurgicale a I’etude du pancreas annulaire. Bull. Acad. Rq-. de med. de Belgique, 24: 290, 1910. I I. AICNAUCHT, J. B. Annular pancreas, a compilation of 40 cases, with a report of a new case. Am. J. Med. SC., ~85: 249, 1933. J. B. and Cox, A. J., JR. Annular 12. MCNAUGHT, pancreas. Report of a case with a simple method for visualizing the duct system. Am. J. Path., 1’: 179, 1935. H. Ein Beitrag zur Kenntnis der %IissbiIdugen des Pankreas. Be&. x. 1~2th. Anal. u.z. a&. Path., 80: 239, 1928. of ‘4. STOFER. B. E. Annular oancreas. A tabuIation recent literature and report of a case. Am. J. .Med. SC., 207: 430, 1944. F. Annular pancreas. Nord. Med. 15. TRLELSEP;, iHospira/stidj, 8: 226, 1940. 16. VIDAL, E. Quelques cas de chirurgic pancreatique. Assoc. franc. de chir., 18: 739, 1905. 17. ZECH, R. L. Anomalous pancreas as a cause of chronic duodenal obstruction. Report of a case of annular pancreas. West. J. Surg., 30: 917, ‘931. ‘3.
SMETANA,
PANCREAS
CAUSING
DUODENAL
OBSTRUCTION ALFRED J. GOLDYNE, M.D. Resident Surgeon, hlary’s Help Hospital
AND
EVERETT
CARLSON,
Chief Surgeon, Mary’s
M.D.
HeIp Hospital
SAN FRANCISCO, CALIFORNIA
A
NNULAR pancreas causing duodena1 obstruction is of rare occurrence and its importance from a surgicocIinica1 aspect is such that any case in which the patient is operated upon warrants reporting so that this condition may become known as a cIinica1 entity and a suitable approach for its correction ma?; be estabhshed. This is especiaIIy desirable since the data on operative intervention are Iimited to thirteen cases incIuding this report. Because of the rarity of this anomaIy and the unusua1 features of this case, we make this presentation: CASE
REPORT
Father R. C., a twenty-six-year oId priest, was admitted to the hospital on January 26, 1945, with the foIlowing complaints: Pain of a d&I and persistent nature in the pit of the stomach coming on one hour after a meal and relieved by more food or baking soda. The pain recurred on and off for the past year. It IateIy became unrelieved by food or soda, but bending or doubling over did reIieve the pain. There was no characteristic radiation. BeIching was present for two years. The patient, before seeking medical advice, treated himseIf for an entire year with baking soda and food ingestion with some reIief. Vomiting occurred on two occasions. The first time, ten to eIeven months preceding the hospital admission and the second time, two months before entrance. Both episodes of vomiting reIieved the pain. There was Ioss of appetite for the past nine months, but unassociated with Ioss of weight. When the patient finally sought medical advice a vear ago, he was put on an uIcer diet and aIkaii therapy which relieved him of his discomfort until three months ago when the pain reappeared.; Further medica management was unsatisfactory. Two weeks before his hospita1 admission he consented to a compIete gastrointestina1 x-ray investigation at which 429
time.he was advised to be operated upon for an obstruction of his bowel. The past history and family history as we11 as the system review were non-contributory. Physical examination on entry, revealed a well developed, we11 nourished, white, twentysix-year old male, who was not acuteIy iI1. Blood pressure was 120/70; temperature 98.6”~.; pulse 86. There was no evidence of weight Ioss or dehydration. The heart and Iungs were normal. The upper part of his abdomen was prominent. There was no guarding or rigidity of the recti, but there was slight tenderness in the epigastrium to the right of the midIine. No abnormal masses could be palpated. Roentgenologic examination of the gastrointestinal tract reveaIed a moderate diIatation of the stomach and first part of the duodenum and a retention in both at the end of six and twenty-four hours. No other abnormalities were noted except the presence of a scoliosis. A diagnosis of marked obstruction in the second part of the duodenum was sufficiently estabIished to justify surgical expIoration for its relief. Operation w-as performed under general anesthesia. A midline incision was made. On entering the abdomen, the stomach was found to be moderately diIated to about one and a half times the normal. The first and second portion of the duodenum were markedly diIated to about three times the normal diameter. The pyIoric ring couId be feIt as a band between the diIated portions of the stomach and duodenum; the opening was moderateIy Iarge. Adjacent to the right of the ascending coIon, the incompIeteIy rotated cecum was found with the appendix densely embedded in it. The dista1 third of the appendix was bound down to the underIying area of duodenal construction. Its tip was enlarged, and showed evidence of past inflammatory reactions. Adhesions were present between it and the gaIIbIadder. It was removed and its base inverted. Further dissection uncovered
430
American Journal
of
Surgery
GoIdyne,
CarIson-Annular
FIG. I. Anteroposterior view of immediate stomach, showing defmite constriction of the second portion of duodenum with diIatation of the first portion.
FIG. 3. Six-hour examination showing definite residue in stomach and duodenum.
Pancreas
FIG. 2. Postero-anterior view of immediate stomach, showing diIatation of the first portion of the duodenum. There is scoIiosis of the lumbar spine.
FIG. 4. Twenty-four-hour examination showing residue in first portion of the duodenum.
945
VOL..
LXXI, No.3
GoIdyne,
CarIson-AnnuIar
the hard, annular band over the distal portion of the second part of the duodenum. It was about one inch wide and one-half inch thick,
FIG. 5. Postoperative six-hour examination showing residue in stomach and duodenum.
and completely surrounded the duodenum, constricting its lumen to a very narrow diameter of about one-fourth inch. Its identity was established as pancreatic tissue. The duodenum was mobilized by cutting the mesentery to the right of it and the annular band was dissected free and cut transverseIy to the right of the head of the pancreas. It was further freed from the duodenal wall and a portion of about one inch was resected. This reIeased the duodena1 Iumen so that it was possible to insert the index finger through its most constricted portion. FoIlowing this, the abdomen was cIosed in Iayers and not drained. The pathoIogica1 examination of the tissue resected showed it to be pancreatic tissue with al1 of the histologic characteristics of a norma pancreas, incIuding normal acini, ducts, and many islets. The appendix varied from 8 to 12 mm. in diameter, being Iarger at its tip. The tip was distended with fecaIiths. PostoperativeIy, the course was fairly uneventfu1. The patient was slightly nauseated, but free from vomiting the first day. Food and
Pancreas
American
JournalofSurgery43 I
fIuids were taken freeIy on the second day. He had to be catheterized severa times. Due to an upper respiratory infection, a temperature of
FIG. 6. Postoperative twenty-four-hourexamination showing gastric and duodenal residue.
102.6~~. was recorded on the evening of the second day. This graduaIly subsided, the patient being temperature free on the eigth day. At no time were there any signs of peritoneal irritation from possible pancreatic secretions, nor did any pancreatic fistuIa form as has been the experience in severa reported cases (8, IO, 17). There was no wound infection. Eight weeks foIIowing surgery, aIthough entirely symptom free and abIe to eat an unrestricted diet, the patient was routinely x-rayed. The fiIms reveaIed a persistence of a twenty-four and forty-eight hour residue in the stomach and duodenum.
Embryology. ExceIIent detailed accounts of the embryologica deveIopment of the annuIar pancreas have been presented by Howard,8 McNaught,“,12 and others.l,“l 1 The anomaIy is thought to be the result of fixation of the ventral pancreatic bud which assumes an annular configuration when rotation of the duodenum occurs, Chapman and Mossman,” however, be-
432
American
~““~“~1
“f surgery
GoIdyne,
CarIson-AnnuIar
lieve that the ventraI pancreatic tissue spreads dorsaIIy in a subperitonea1 position around both sides of the duodenum rather than on one side as it normaIIy does, As proof of this, they cite the presence of three pancreatic ducts and Iobes as the normal condition found in birds. The former theory, however, is the one most accepted. Clinical data, to date, revea1 a total of fifty-two cases of annuIar pancreas reported in the Iiterature. Thirteen of the cases, incIuding our report, have been surgica1 probIems; the others were incidentaIIy found at postmortems or in anatomic Iaboratories. There were four deaths in the patients operated upon, a mortaIity of 31 per cent. The presence of an annular pancreas with a greater or Iesser degree of duodena1 obstruction is not incompatibIe with Iong Iife as is shown by the upper age group in which this anomaIy was found. The oIdest patients operated upon being seventy-four years oId (Smetana I3 Custer and Waugh”). Excepting two cases found in three-day oId infants, (VidaI16 Cross and ChishoIm’), the ages varied from twenty-three to seventy-four years. The majority of the cases were asymptomatic throughout Iife and attention was caIIed to the anomaIy by the presence of pathoIogic processes in the same or continguous organs. In some,“” an acute pancreatitis or a duodena ulcer or as in our case, a pathoIogic appendix precipitated the investigation Ieading to the discovery of the annuIar pancreas.
A number of surgica1 procedures have been suggested for the correction of the obstruction caused by the anomaIy. Of the thirteen patients operated upon and by
othersI>
2~5~6~7~8~9~10~13r15~16~17
in_
eluding ours, a partia1 resection or division of the ring was performed in five. AI1 had a compIete recovery with the exception of Lehman’s case9 which had persistent postoperative symptoms. Posterior
MARCH, 1946
gastroenterostomy was performed in five cases of which three died of intercurrent infections or associated pathoIogic processes. Duodenojejunostomy was performed on a three-day oId femaIe by Gross and ChishoIm’ with compIete cure. In the case reported by Custer and Waugh” a gastric resection incIuding the upper 8 cm. of duodenum was performed for an associated gastric uIcer. An anterior Iong Ioop gastroenterostomy was done. The reported resuIt was good. TABLE CASES
OF
ANNULAR
Reported bY
AgeSex
Male
1905 dos Sante: 1906 Lerat 1908 Smetana 1928 Howard
3 days Female 36 yr. Female
74 YT. Fe”l&
193” Brines
46 YT. Male
193” Zech
35 YI. Female
1931
27 YI.
46 YI. Male
Brines
Malt:
1931
44 Yr.
I*
PANCREAS
Vidal
Male 35 Yr.
TREATED
BY
Operation
Result
Cure
Posterior gastroenter osto”Iy Posterior gastroenter ostomy Resection of pan creatic ring Posterior gastroenter ostomy Division of ring Drainage of pancreat tis Division of ring Heineke-Mikulicz plastic on duodenun Posterior gastroenter ostomy
OPERATION
Died (pneumonia) Cure Died CUT”
i-
Died CUT”
_, Died _
Posterior gastroentcr “stomy plastic “1 duodenum Partial resection 0 ring
(respiratory infection) CUE
f! Recovery,
Lehman
Male
1943
23 Yr.
Gross and Chisholm
Female 3 days
Duodenjejunostomy
but persistent symptoms Cure
I944 Custer an< Waugh
Male
Gastric
Cure
72 yr.
1944 Goldyne and Carl son * After
COMMENTS
reported
Pancreas
Male
resection
Resection
of ring
CUE
26 yr.
Gross and Chisholm.
Considering the Iack of mortaIity, resection of the pancreatic ring appears to be the safest method, thus far, despite the hazard associated with cutting through pancreatic ducts, and the consequent deveIopment of pancreatic cysts and fistuIas. However, it is readiIy conceded that because of the meager Iiterature and experience with this anomaIy, the safest procedure is yet to be determined. The
VOL.
I.XXI.
No.
GoIdyne,
3
CarJson- -Annular
fact, called attention to by other investigators,“,J.7’. 11.I-1 concerning the association of other anomalies with this condition is further substantiated by this case. The diagnosis of annuJar pancreas has not been made preoperativeIy in our case or in any of those reported. The lesion being difficult to differentiate from other causes of duodenal obstruction. We have personaIJyencountered three cases which couid not be differentiated roentgenoIogicaIly from the obstruction caused by an annular pancreas. These were, two cases of congenita1 duodenal atresia in the newborn, and one case of a constricting carcinoma of the second portion of the duodenum. SUMMARY
AND
CONCLUSION
A case is presented in which the patient had duodenal obstruction due to an annular pancreas. It was treated by division of the ring and resection of a part of it. A short summary of its embryoIogy is given. It is deduced that annular pancreas is compatible with life and may not give rise to any symptoms. Its presence is often caIIed attention to by an associated inflammatory reaction in the pancreas itself, or a contiguous organ. Resection of the ring may not reheve the obstruction entireJy, yet the patient may be symptom free. Attention is again called to the associated anomahes with this condition ; in this case an incompIeteJy rotated cecum and a pathoIogic superThis is the first case imposed appendix. a reported which ha s not developed pancreatic cyst or fistuJa foIIowing resection of the annular tissue, and the first that is symptom free despite evidence of gastric and duodenal retention. We beIieve that resection of the annuIar band, in
Pancreas
American
JOMWI
OCS~~~~W~
433
spite of the objectionabIe deveIopment of pancreatic cysts and fistulas, merits consideration as the operation of choice because of the lack of mortaIity associated with this procedure. REFERENCES BRINES, 0. A. Annular pancreas, invoIved in acute hemorrhagic pancreatitis. Ann. SW-S., 9.2: 241, T93”. 2. BRINES, 0. A. AnnuIar pancreas-associated with peptic ulcer. Am. J. Sirg., 12: 483, 1931. J. L. and MOSSMAN. H. W. Annular pan3. CHAPMAN. creas; accompanied by an aberrant pancreatic nodule in the duodenum. Am. J. Surg., 60: 286, I.
‘943. Brir. J. 4. GLNXINGHA%+, G. J. AnnuIar pancreas. Surg., 27: 678, 1939, I g4o. hl. D., JR. and WALGH, J. hl. hoc. Stajf 5. CI:STER, Meet., Mayo C/in., Ig: 388-390, 1944. 6. DOS SANTOS, R. Deux lesions rare du duodenum. Xv Conpr. Infer. de Med. Lisbon, 9: 419, 1906. 7. GROSS, R. E. and CHISHOLM, T. C. AnnuIar pancreas producing duodenal obstruction. Ann. Sw., I 19: 759, 1944. 8. HOWARD, N. J. Annular pancreas. Sure., Gnec. t?+ Obst., 50: 533, 1930. _ 9. LE~IMAX. E. P. Annular oancreas as a clinica problem. Ann. Sure., I 15: 574, 1942. 10. L.ERAT, P. Contribution chirurgicale a I’etude du pancreas annulaire. Bull. Acad. Rq-. de med. de Belgique, 24: 290, 1910. I I. AICNAUCHT, J. B. Annular pancreas, a compilation of 40 cases, with a report of a new case. Am. J. Med. SC., ~85: 249, 1933. J. B. and Cox, A. J., JR. Annular 12. MCNAUGHT, pancreas. Report of a case with a simple method for visualizing the duct system. Am. J. Path., 1’: 179, 1935. H. Ein Beitrag zur Kenntnis der %IissbiIdugen des Pankreas. Be&. x. 1~2th. Anal. u.z. a&. Path., 80: 239, 1928. of ‘4. STOFER. B. E. Annular oancreas. A tabuIation recent literature and report of a case. Am. J. .Med. SC., 207: 430, 1944. F. Annular pancreas. Nord. Med. 15. TRLELSEP;, iHospira/stidj, 8: 226, 1940. 16. VIDAL, E. Quelques cas de chirurgic pancreatique. Assoc. franc. de chir., 18: 739, 1905. 17. ZECH, R. L. Anomalous pancreas as a cause of chronic duodenal obstruction. Report of a case of annular pancreas. West. J. Surg., 30: 917, ‘931. ‘3.
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