Endotherapy for paraduodenal pancreatitis: a large retrospective case series

Background and study aims: Paraduodenal pancreatitis is histologically well defined but its epidemiology, natural history, and connection with chronic pancreatitis are not completely understood. The aim of this study was to review the endoscopic and medical management of paraduodenal pancreatitis.

Patients and methods: Medical records of all patients with paraduodenal pancreatitis diagnosed by magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasonography (EUS) between 1995 and 2010 were retrospectively reviewed. Clinical features, imaging procedures, and treatments were investigated. The primary end point was the rate of clinical success, and the secondary end points were the radiological or endoscopic improvement, complication rate, and overall survival rate.

Results: A total of 51 patients were included in the study (88.2 % alcohol abuse; median age 49 years [range 37 – 70]; 50 men). The most frequent symptoms at presentation were pain (n = 50; 98.0 %) and weight loss (n = 36; 70.6 %). Chronic pancreatitis was present in 36 patients (70.6 %), and 45 patients (88.2 %) had cysts. Other findings included stricture of the pancreatic duct (n = 37; 72.5 %), common bile duct (n = 29; 56.9 %), and duodenum (n = 24; 47.1 %). A total of 39 patients underwent initial endoscopic treatment: cystenterostomy (n = 20), pancreatic and/or biliary duct drainage (n = 19), and/or duodenal dilation (n = 6). For the patients with available follow-up (n = 41), 24 patients required repeat endoscopy and 9 patients required surgery after the initial endoscopic management. After a median follow-up of 54 months (range 6 – 156 months), complete clinical success was achieved in 70.7 % of patients, and the overall survival rate was 94.1 %.

Conclusions: This is the largest series concerning the management of paraduodenal pancreatitis using endotherapy as the first-line intervention. Although repeat endoscopic procedures were required in half of the patients, no severe complication was observed and surgical treatment was ultimately needed in less than 25 % of the patients.

• References

• 1 Vijungco JD, Prinz RA. Management of biliary and duodenal complications of chronic pancreatitis. World J Surg 2003; 27: 1258-1270
• 2 Becker V, Mischke U. Groove pancreatitis. Int J Pancreatol 1991; 10: 173-182
• 3 Potet F, Duclert N. Cystic dystrophy on aberrant pancreas of the duodenal wall [in French]. Arch Fr Mal App Dig 1970; 59: 223-238
• 4 Klöppel G, Solcia E, Longnecker D et al. Histological typing of tumours of the exocrine pancreas. World Health Organization International Histological Classification of Tumours. . 2nd.. edn. Berlin, Germany: Springer-Verlag; 1996: 23
• 5 Frulloni L, Gabbrielli A, Pezzilli R et al. Chronic pancreatitis: report from a multicenter Italian survey (PanCroInfAISP) on 893 patients. Dig Liver Dis 2009; 41: 311-317
• 6 Adsay NV, Zamboni G. Paraduodenal pancreatitis: a clinico-pathologically distinct entity unifying “cystic dystrophy of heterotopic pancreas,” “para-duodenal wall cyst,” and “groove pancreatitis”. Semin Diagn Pathol 2004; 21: 247-254
• 7 Pezzilli R, Santini D, Calculli L et al. Cystic dystrophy of the duodenal wall is not always associated with chronic pancreatitis. World J Gastro 2011; 17: 4349-4364
• 8 Rebours V, Lévy P, Vullierme MP et al. Clinical and morphological features of duodenal cystic dystrophy in heterotopic pancreas. Am J Gastro 2007; 102: 871-879
• 9 Axon AT, Classen M, Cotton PB et al. Pancreatography in chronic pancreatitis: international definitions. Gut 1984; 25: 1107-1112
• 10 Etemad B, Whitcomb DC. Chronic pancreatitis: diagnosis, classification, and new genetic developments. Gastroenterology 2001; 120: 682-707
• 11 Delhaye M, Arvanitakis M, Verset G et al. Long term clinical outcome after endoscopic pancreatic ductal drainage for patients with painful chronic pancreatitis. Clin Gastroenterol Hepatol 2004; 2: 1096-1106
• 12 de Parades V, Roulot D, Palazzo L et al. Treatment with octreotide of stenosing cystic dystrophy on heterotopic pancreas of the duodenal wall. Gastroenterol Clin Biol 1996; 20: 601-604
• 13 Basili E, Allemand I, Ville E et al. Lanreotide acetate may cure cystic dystrophy in heterotopic pancreas of the duodenal wall. Gastroenterol Clin Biol 2001; 25: 1108-1111
• 14 Zamboni G, Capelli P, Scarpa A et al. Nonneoplastic mimickers of pancreatic neoplasms. Arch Pathol Lab Med 2009; 133: 439-453
• 15 Stolte M, Weiss W, Volkholz H et al. A special form of segmental pancreatitis: “Groove pancreatitis”. Hepatogastroenterology 1982; 29: 198-208
• 16 Itoh S, Yamakawa K, Shimamoto K et al. CT findings in groove pancreatitis: correlation with histopathological findings. J Comput Assist Tomogr 1994; 18: 911-915
• 17 Andrieu J, Palazzo L, Chikli F et al. Cystic dystrophy on aberrant pancreas. Contribution of ultrasound-endoscopy. Gastroenterol Clin Biol 1989; 13: 630-633
• 18 Procacci C, Graziani R, Zamboni G et al. Cystic dystrophy of the duodenal wall: radiologic findings. Radiology 1997; 205: 741-747
• 19 Kloppel G. Pseudocysts and other non-neoplastic cysts of the pancreas. Semin Diagn Pathol 2000; 17: 7-15
• 20 Casetti L, Bassi C, Salvia R. “Paraduodenal” pancreatitis: results of surgery on 58 consecutives patients from a single Institution. World J Surg 2009; 33: 2664-2669
• 21 Leger L, Lemaigre G, Lenriot JP. Cysts on heterotopic pancreas of the duodenal wall. Nouv Presse Med 1974; 3: 2309-2314
• 22 Wind P, Pardies P, Roullet MH et al. Cystic dystrophy of the duodenal wall in aberrant pancreas. Ann Chir 1999; 53: 164-167
• 23 Vullierme MP, Vilgrain V, Fl’ejou JF et al. Cystic dystrophy of the duodenal wall in the heterotopic pancreas: radiopathological correlations. J Comput Assist Tomogr 2000; 24: 635-643
• 24 Irie H, Honda H, Kuroiwa T et al. MRI of groove pancreatitis. J Comput Ass Tomogr 1998; 22: 651-655
• 25 Castell-Monsalve FJ, Sousa-Martin JM, Carranza-Carranza A. Groove pancreatitis: MRI and pathologic findings. Abdom Imaging 2008; 33: 342-348
• 26 Blasbalg R, Baroni RH, Costa DN et al. MRI features of groove pancreatitis. AJR Am J Roentgenol 2007; 189: 73-80
• 27 Triantopoulou C, Dervenis C, Giannakou N. Groove pancreatitis: a diagnostic challenge. Eur Radiol 2009; 19: 1736-1743
• 28 Kalb B, Martin DR, Sarmiento JM et al. Paraduodenal pancreatitis: clinical performance of MR imaging in distinguishing from carcinoma. Radiology 2013; 269: 475-481
• 29 Koh DM, Collins DJ. Diffusion-weighted MRI in the body: applications and challenges in oncology. AJR Am J Roentgenol 2007; 188: 1622-1635