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RESULTS
BACKGROUND
Annular pancreas is an uncommon congenital malformation of the pancreas, characterized by a ring of
pancreatic tissue surrounding the duodenum. It typically presents during neonatal period with features of
duodenal obstruction. It is estimated that almost two thirds of patients remain asymptomatic throughout life. In
adults it is associated with peptic ulcer, duodenal obstruction, pancreatitis and obstructive jaundice.
The diagnosis may be established radiologically. In neonates a plain abdominal x-ray may show the classic
“double bubble sign”. In older patients, upper gastrointestinal series or CT scan can be suggestive.
The treatment of choice in adults is duodeno- or gastro-jejunostomy. Direct impact on the pancreatic tissue
should be avoided, as it may induce complications like pancreatitis and fistula. Duodeno-duodenostomy is the
preferred surgical approach for children, as the duodenum is more mobile than in adults.
REFERENCES
1. Urayama S. et al., Am J Gastroenterol. 1995, 90(6):995
2. Maker V. et al., AM Surg. 2003 69 (5):404
3. Fig. 1. http://www.med-ed.virginia.edu/courses/rad/gi/pancreas/congen02.html (30.03.2015)
4. Fig. 2. M. Heinrich et K. Neuhaus, Kinderchirurgie. 2012
Partial annular pancreas and duodenal
stenosis in a 10 year old boy
Sophie Lustenberger, Alexander Kühn, Barbara Peiry and Bernhard Egger
Department of Surgery HFR Fribourg - Cantonal Hospital, CH-1708 Fribourg
Image 1.
Upper gastrointestinal X-ray studies:
corkscrew sign evoking malrotation
METHODS
Figure 1.
Embryological development of annular pancreas.
The anomaly is secondary to the malrotation of the ventral bud,
which wraps around the duodenum to fuse with the dorsal bud.
A 10 year old boy suffered from abdominal pain, associated with sweating, pallor
and biliary vomiting. He also needed to divide his meals into 5-8 little portions a
day. The symptoms were present for about two years and were progressive.
Upper gastrointestinal studies were suggestive of a partial malrotation. A
gastroscopy revealed a distension of the duodenal bulb and the impression of a
duodenal stricture.
Explorative laparoscopic surgery was then performed and a partial annular
pancreas with relative duodenal stenosis causing a duodenal obstruction was
diagnosed. A laparoscopic diamond shaped duodeno-duodenostomy has been
performed.
Image 3-5.
Preparation for the diamond-shaped
duodenostomy to bypass the duodenal stenosis
and the partial annular pancreas.
Figure 2.
Schematic representation of diamond-shaped
duodenostomy. A proximal transverse to distal
longitudinal anastomosis is performed. The
midpoint of the proximal incision is approximated
to the end of the distal incision.
Image 2.
Annular pancreas in situ. Duodenum (yellow), duodenal stenosis
(black), pancreas (red arrow).
CONCLUSION
Pancreas annulare is rare and may therefore be a diagnostic challenge. It should be taken into account as a possible cause of duodenal obstruction at any age. About
40% of cases need surgery for diagnosis, like in our case, and the diagnostic gold standard remains surgery.
1,2
The postoperative course was uneventful and the boy was symptom free at the
follow up one year later.
