IPEG 2024 Round Table Discussion from East Asia - Dr. Wataru Mukai

Patient is a 6-year-old boy with abdominal pain continuous for 3 consecutive days

Patient was operated for duodenal stenosis 3 days after birth

Abdomen was slightly rigid with gastric tenderness

Amylase was elevated to 1200 units per liter

Abdominal ultrasound showed dilation of pancreatic duct up to 5.6 millimeter and isoechoic mass suspecting pancreatic calculus

Enhanced CT and MRCP showed multiple pancreatic calculi with abnormal duct

Pancreatic duct malformation shaped like barbecue fork with main and accessory ducts and branch connecting posteriorly

Conservative treatment for pancreatitis was attempted but failed

ERCP was attempted by gastroenterologists but did not work because of dense pancreatic calculus obstructing the orifice

Lithotomy was chosen considering minimal damage compared to other surgical options

Surgical approach involved opening duodenum, pulling tube through pancreatic duct, removing all pancreatic calculi, placing tube through both major and minor duodenal papillae into hepatic ducts, closing pancreatic duct with omental coverage, then closing duodenum

Pancreatic calculi resembled protein plug seen in cystic fibrosis

Intraoperative contrast study showed pancreatic calculi were removed perfectly

MRCP at 6 months showed no recurrence of pancreatitis

Malformation was not treated surgically, raising concern that calculus may recur

During surgery, no annular pancreas was visible and both ducts opened normally, with major papilla beside bile duct and minor papilla on anal side

There is a possibility of developing necrotizing pancreatitis due to recurrent pancreatic calculi

Necrotizing pancreatitis may ultimately require pseudocyst gastrostomy

Close follow-up is needed for occurrence of necrotizing pancreatitis or recurrent pancreatitis

Pancreaticojejunostomy or other drainage surgery is recommended as surgical option