Anatomy and Cell Biology

Korean Association of Anatomists (대한해부학회)
권호 표지
DOI QR코드

DOI QR Code

Exploring the variations of the pancreatic ductal system: a systematic review and meta-analysis of observational studies

  • Received : 2023.05.22
  • Accepted : 2023.12.24
  • Published : 2024.03.31
Download PDF
⟨ Previous Next ⟩

Abstract

The exocrine part of the pancreas has a duct system called the pancreatic ductal system (PDS). Its mechanism of development is complex, and any reorganization during early embryogenesis can give rise to anatomical variants. The aim of this study is to collect, classify, and analyze published evidence on the importance of anatomical variants of the PDS, addressing gaps in our understanding of such variations. The MEDLINE, Web of Science, Embase, and Google Scholar databases were searched to identify publications relevant to this review. R studio with meta-package was used for data extraction, risk of bias estimation, and statistical analysis. A total of 64 studies out of 1,778 proved suitable for this review and metanalysis. The meta-analysis computed the prevalence of normal variants of the PDS (92% of 10,514 subjects). Type 3 variants and "descending" subtypes of the main pancreatic duct (MPD) predominated in the pooled samples. The mean lengths of the MPD and accessory pancreatic duct (APD) were 16.53 cm and 3.36 cm, respectively. The mean diameters of the MPD at the head and the APD were 3.43 mm and 1.69 mm, respectively. The APD was present in only 41% of samples, and the long type predominated. The pancreatic ductal anatomy is highly variable, and the incorrect identification of variants may be challenging for surgeons during ductal anastomosis with gut, failure to which may often cause ductal obstruction or pseudocysts formation.

Keywords

References

  1. Anand BS, Vij JC, Mac HS, Chowdhury V, Kumar A. Effect of aging on the pancreatic ducts: a study based on endoscopic retrograde pancreatography. Gastrointest Endosc 1989;35:210-3.  https://doi.org/10.1016/S0016-5107(89)72760-7
  2. Arora A, Piplani M, Kapoor S, Bhatia B, Singh R, Verma P, Piplani S. A research study of santorini duct. J Clin Diagn Res 2011;5:1510-3. 
  3. Abdelkareem H, Ali R, Jibrini M, Nazzal Z, Maree M, Hamaida J, Demyati K. A study of the anatomic variations of the pancreatico-biliary system in Palestine: a national study. Int Surg J 2019;6:1020-8.  https://doi.org/10.18203/2349-2902.isj20191066
  4. Covantsev S, Chicu C, Mazuruc N, Belic O. Pancreatic ductal anatomy: more than meets the eye. Surg Radiol Anat 2022;44:1231-8.  https://doi.org/10.1007/s00276-022-03002-w
  5. Renzulli M, Pagano N, Golfieri R. Pancreas divisum inversus. Clin Anat 2020;33:646-52.  https://doi.org/10.1002/ca.23475
  6. Jagielski M, Smoczynski M, Adrych K. The anatomical variations of pancreatic duct in the patients with pancreatic diseases. Eur J Transl Clin Med 2018;1:63-6.  https://doi.org/10.31373/ejtcm/92069
  7. Dimitriou I, Katsourakis A, Nikolaidou E, Noussios G. The main anatomical variations of the pancreatic duct system: review of the literature and its importance in surgical practice. J Clin Med Res 2018;10:370-5.  https://doi.org/10.14740/jocmr3344w
  8. Dugic A, Nikolic S, Muhldorfer S, Bulajic M, Pozzi Mucelli R, Tsolakis AV, Lohr JM, Vujasinovic M. Clinical importance of main pancreatic duct variants and possible correlation with pancreatic diseases. Scand J Gastroenterol 2020;55:517-27.  https://doi.org/10.1080/00365521.2020.1760345
  9. Adibelli ZH, Adatepe M, Isayeva L, Esen OS, Yildirim M. Pancreas divisum: a risk factor for pancreaticobiliary tumors - an analysis of 1628 MR cholangiography examinations. Diagn Interv Imaging 2017;98:141-7.  https://doi.org/10.1016/j.diii.2016.08.004
  10. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res 2014;14:579. 
  11. Bulow R, Simon P, Thiel R, Thamm P, Messner P, Lerch MM, Mayerle J, Volzke H, Hosten N, Kuhn JP. Anatomic variants of the pancreatic duct and their clinical relevance: an MR-guided study in the general population. Eur Radiol 2014;24:3142-9.  https://doi.org/10.1007/s00330-014-3359-7
  12. Turkvatan A, Erden A, Turkoglu MA, Yener O. Congenital variants and anomalies of the pancreas and pancreatic duct: imaging by magnetic resonance cholangiopancreaticography and multidetector computed tomography. Korean J Radiol 2013;14:905-13.  https://doi.org/10.3348/kjr.2013.14.6.905
  13. Kamisawa T. Clinical significance of the minor duodenal papilla and accessory pancreatic duct. J Gastroenterol 2004;39:605-15.  https://doi.org/10.1007/s00535-004-1390-1
  14. Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, Tugwell P. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa Hospital Research Institute; 2011. 
  15. De Filippo M, Calabrese M, Quinto S, Rastelli A, Bertellini A, Martora R, Sverzellati N, Corradi D, Vitale M, Crialesi G, Sarli L, Roncoroni L, Garlaschi G, Zompatori M. Congenital anomalies and variations of the bile and pancreatic ducts: magnetic resonance cholangiopancreatography findings, epidemiology and clinical significance. Radiol Med 2008;113:841-59.  https://doi.org/10.1007/s11547-008-0298-x
  16. Bang S, Suh JH, Park BK, Park SW, Song SY, Chung JB. The relationship of anatomic variation of pancreatic ductal system and pancreaticobiliary diseases. Yonsei Med J 2006;47:243-8.  https://doi.org/10.3349/ymj.2006.47.2.243
  17. Kamisawa T, Takuma K, Tabata T, Egawa N. Clinical implications of accessory pancreatic duct. World J Gastroenterol 2010;16:4499-503.  https://doi.org/10.3748/wjg.v16.i36.4499
  18. Shahriah S, Nurunnabi ASM, Johora F, Siddiqua D, Ara S. Cadaveric study of the anatomical variations of the accessory pancreatic duct. J Bangladesh Soc Physiol 2014;9:83-8.  https://doi.org/10.3329/jbsp.v9i2.22802
  19. Kim HJ, Kim MH, Lee SK, Seo DW, Kim YT, Lee DK, Song SY, Roe IH, Kim JH, Chung JB, Kim CD, Shim CS, Yoon YB, Yang US, Kang JK, Min YI. Normal structure, variations, and anomalies of the pancreaticobiliary ducts of Koreans: a nationwide cooperative prospective study. Gastrointest Endosc 2002;55:889-96.  https://doi.org/10.1067/mge.2002.124635
  20. Oracz G, Oralewska B, Pertkiewics J, Teisseyre M, Ryzko J, Socha J. Chronic pancreatitis associated with anatomic anomalies of pancreatic duct in children. J Pediatr Gastroenterol Nutr 2006;42:E58. 
  21. Uomo G, Manes G, D'Anna L, Laccetti M, Di Gaeta S, Rabitti PG. Fusion and duplication variants of pancreatic duct system. Clinical and pancreatographic evaluation. Int J Pancreatol 1995;17:23-8.  https://doi.org/10.1007/BF02788355
  22. Prasanna LC, Rajagopal KV, Thomas HR, Bhat KM. Accessory pancreatic duct patterns and their clinical implications. J Clin Diagn Res 2015;9:AC05-7.  https://doi.org/10.7860/JCDR/2015/11539.5660
  23. Prasad M, Rout S, Putta T, Kurien RT, Chowdhury SD, Eapen A, Hepsy YS, Rabi S. Anatomical patterns of the pancreatic ductal system - a cadaveric and magnetic resonance cholangiopancreatography study. J Morphol Sci 2019;36:279-85.  https://doi.org/10.1055/s-0039-1698371
  24. Koshariya M, Behram S, Singour JP, Tiwari S, Khare V. Anomalous anatomical variation in extrahepatic biliary tree and pancreas and its related vessels: a cadaveric study. Int Surg J 2019;6:3111-6.  https://doi.org/10.18203/2349-2902.isj20193658
  25. Gonoi W, Akai H, Hagiwara K, Akahane M, Hayashi N, Maeda E, Yoshikawa T, Kiryu S, Tada M, Uno K, Okura N, Koike K, Ohtomo K. Santorinicele without pancreas divisum pathophysiology: initial clinical and radiographic investigations. BMC Gastroenterol 2013;13:62. 
  26. Darnis E, Cronier P, Mercier P, Moreau P, Pillet J, Boyer J. A radio-anatomical study in vivo on pancreatic ducts. Anat Clin 1984;6:109-16.  https://doi.org/10.1007/BF01773162
  27. Schmitt F, Maignan A, Ploteau S, Hamel A, Lagier S, Blin Y, Rogez JM, Le Borgne J. New anatomical data on the drainage patterns of the uncinate process of the pancreas. Surg Radiol Anat 2010;32:777-81.  https://doi.org/10.1007/s00276-010-0680-y
  28. Smanio T. Proposed nomenclature and classification of the human pancreatic ducts and duodenal papillae. Study based on 200 post mortems. Int Surg 1969;52:125-41. 
  29. Dawson W, Langman J. An anatomical-radiological study on the pancreatic duct pattern in man. Anat Rec 1961;139:59-68.  https://doi.org/10.1002/ar.1091390109
  30. Berman LG, Prior JT, Abramow SM, Ziegler DD. A study of the pancreatic duct system in man by the use of vinyl acetate casts of postmortem preparations. Surg Gynecol Obstet 1960;110:391-403. 
  31. Ishaque I, Ilyas A, Khan O, Kazmi QH, Ladak AH, Rafay A. Role of magnetic resonance cholangiopancreatography (MRCP) in learning anatomical variations in pancreatic duct. J Pak Med Assoc 2020;70:472-6.  https://doi.org/10.5455/JPMA.15767
  32. Johansson K, Mustonen H, Seppanen H, Lehtimaki TE. Anatomical pancreatic variants in intraductal papillary mucinous neoplasm patients: a cross-sectional study. BMC Gastroenterol 2022;22:394. 
  33. Malathi K, Kishan Reddy C. The study of anatomy of main pancreatic duct and its variations. Perspect Med Res 2019;7:31-7. 
  34. Shu J, Zhang XM, Zeng N. Normal pancreatic duct: evaluation with MR cholangiopancreatography. Chin J Med Imaging Technol 2006;4:2004-6. 
  35. Kasugai T, Kuno N, Kobayashi S, Hattori K. Endoscopic pancreatocholangiography. I. The normal endoscopic pancreato-cholangiogram. Gastroenterology 1972;63:217-26.  https://doi.org/10.1016/S0016-5085(19)33306-2
  36. Kreel L, Sandin B. Changes in pancreatic morphology associated with aging. Gut 1973;14:962-70.  https://doi.org/10.1136/gut.14.12.962
  37. Kang JK, Chung JB, Moon YM, Choi HJ. The normal endoscopic pancreatogram in Koreans. Korean J Intern Med 1989;4:74-9.  https://doi.org/10.3904/kjim.1989.4.1.74
  38. Vinay Kumar N, Lokanadham S. A study on incidence of accessory pancreatic duct and its clinical importance. Maedica (Bucur) 2019;14:22-5.  https://doi.org/10.26574/maedica.2019.14.1.22
  39. Hayashi TY, Gonoi W, Yoshikawa T, Hayashi N, Ohtomo K. Ansa pancreatica as a predisposing factor for recurrent acute pancreatitis. World J Gastroenterol 2016;22:8940-8.  https://doi.org/10.3748/wjg.v22.i40.8940
  40. Govindraj N, Shabna C. Variations in the duct system of pancreas: a cadaveric study. Int J Anat Res 2017;5:4136-43.  https://doi.org/10.16965/ijar.2017.269
  41. Liessi F, Manfredi R, Liessi G, Mucelli RP. Anatomical variants of the pancreatic ducts. ECR; 2010. https://dx.doi.org/10.1594/ecr2010/C-0174. 
  42. Varley PF, Rohrmann CA Jr, Silvis SE, Vennes JA. The normal endoscopic pancreatogram. Radiology 1976;118:295-300.  https://doi.org/10.1148/118.2.295
  43. Classen M, Hellwig H, Rosch W. Anatomy of the pancreatic duct a duodenoscopic-radiological study. Endoscopy 1973;5:14-7.  https://doi.org/10.1055/s-0028-1098203
  44. Cotton P. The normal endoscopic pancreatogram. Endoscopy 1974;6:65-70.  https://doi.org/10.1055/s-0028-1098599
  45. Seifert E, Wagner HH, Otto, P. Value and indication of endoscopic pancreato-cholangiography. Gastroenterol Jpn 1973;8:205-12.  https://doi.org/10.1007/BF02779900
  46. Okuda K, Someya N, Goto A, Kunisaki T, Emura T, Yasumoto M, Shimokawa Y. Endoscopic pancreato-cholangiography. A preliminary report on technique and diagnostic significance. Am J Roentgenol Radium Ther Nucl Med 1973;117:437-45.  https://doi.org/10.2214/ajr.117.2.437
  47. Sivak MV Jr, Sullivan BH Jr. Endoscopic retrograde pancreatography: analysis of the normal pancreatogram. Am J Dig Dis 1976;21:263-9.  https://doi.org/10.1007/BF01095900
  48. Ara S, Shahriah S, Begum S. The length of main pancreatic duct in Bangladeshi cadaver at different age groups. Mymensingh Med J 2011;20:298-302. 
  49. Kochhar R, Goenka MK, Nagi B, Aggarwal R, Singh K. Normal pancreatic duct morphology in a north Indian population. Trop Gastroenterol 1996;17:223-5. 
  50. Sahni D, Jit I, Harjeet. Gross anatomy of the pancreatic ducts in north Indians. Trop Gastroenterol 2001;22:197-201. 
  51. Fatima T. Anatomical variants of pancreatic duct system in human cadavers. J Fatima Jinnah Med Univ 2010;4:110-7. 
  52. Wilasrusmee C, Pongchairerks P. Pancreaticobiliary ductal anatomy in Thai people. J Hepatobiliary Pancreat Surg 1999;6:79-85.  https://doi.org/10.1007/s005340050087
  53. Pina L. Does the accessory pancreatic duct have any protective role in acute biliary pancreatitis? Anatomical findings from cadaver dissections. MOJ Anat Physiol 2016;2:180. 
  54. Hastier P, Buckley MJ, Dumas R, Kuhdorf H, Staccini P, Demarquay JF, Caroli-Bosc FX, Delmont JP. A study of the effect of age on pancreatic duct morphology. Gastrointest Endosc 1998;48:53-7.  https://doi.org/10.1016/S0016-5107(98)70129-4
  55. Akochi S, Ugwu A, Otuh I. Sonographic measurement of common bile duct diameter in apparently healthy adults in Abakaliki metropolis. Int J Sci Appl Res 2018;5:1-8. 
  56. Karak PK, Vashisht S, Tandon RK, Berry M. Normal endoscopic pancreatogram in an Indian referral hospital. Indian J Med Res 1991;94:426-9. 
  57. Hadidi A. Pancreatic duct diameter: sonographic measurement in normal subjects. J Clin Ultrasound 1983;11:17-22.  https://doi.org/10.1002/jcu.1870110105
  58. Millbourn E. Calibre and appearance of the pancreatic ducts and relevant clinical problems. A roentgenographic and anatomical study. Acta Chir Scand 1960;118:286-303. 
  59. Trapnell JE, Howard JM. Transduodenal pancreatography: an improved technique. Surgery 1966;60:1112-9. 
  60. Hand BH. An anatomical study of the choledochoduodenal area. Br J Surg 1963;50:486-94.  https://doi.org/10.1002/bjs.18005022303
  61. Ogoshi K, Niwa M, Hara Y, Nebel OT. Endoscopic pancreato-cholangiography in the evaluation of pancreatic and biliary disease. Gastroenterology 1973;64:210-6.  https://doi.org/10.1016/S0016-5085(73)80031-9
  62. Birnstingl M. A study of pancreatography. Br J Surg 1959;47:128-39.  https://doi.org/10.1002/bjs.18004720203
  63. MacCarty RL, Stephens DH, Brown AL Jr, Carlson HC. Retrograde pancreatography in autopsy specimens. Am J Roentgenol Radium Ther Nucl Med 1975;123:359-66.  https://doi.org/10.2214/ajr.123.2.359
  64. Toda J, Ueno E, Takada Y, Okawa T. [Demonstration of normal bile duct and pancreatic duct with MR cholangiopancreatography]. Nihon Rinsho 1998;56:2830-5. Japanese. 
  65. Aube C, Hentati N, Tanguy JY, Fournier HD, Papon X, Lebigot J, Mercier P. Radio-anatomic study of the pancreatic duct by MR cholangiopancreatography. Surg Radiol Anat 2003;25:64-9.  https://doi.org/10.1007/s00276-002-0082-x
  66. Mchonde GJ, Gesase AP. Termination pattern of the main and accessory pancreatic ducts among Tanzanians. Anat J Afr 2014;3:223-7. 
  67. Jirasiritham J, Wilasrusmee C, Poprom N, Larbcharoensub N. Pancreaticobiliary ductal anatomy in the normal population. Asian Pac J Cancer Prev 2016;17:4363-5.  https://doi.org/10.1016/j.pan.2017.07.034
  68. Gosavi V, Gaikwad P. The duct system of the human pancreatic gland. J Anat Soc India 1980;29:142-6. 
  69. Cremer M, Toussaint J, Hermanus A, Deltenre M, De Tceuf J, Engelholm L. [Primary chronic pancreatitis. A classification based on endoscopic pancreatography]. Acta Gastroenter Belg 1976;39:522-46. In French. 
  70. Malathi K, Chitra R. The study of anatomy of accessory pancreatic duct and its variations. Eur J Mol Clin Med 2022;9:6270-9. 
  71. Nealon WH, Walser E. Main pancreatic ductal anatomy can direct choice of modality for treating pancreatic pseudocysts (surgery versus percutaneous drainage). Ann Surg 2002;235:751-8.  https://doi.org/10.1097/00000658-200206000-00001
  72. Covantev S. Pancreas divisum: a reemerging risk factor for pancreatic diseases. Rom J Intern Med 2018;56:233-42.  https://doi.org/10.2478/rjim-2018-0022
  73. de Jong DM, Stassen PM, Poley JW, Fockens P, Timmer R, Voermans RP, Verdonk RC, Bruno MJ, de Jonge PJF. Clinical outcome of endoscopic therapy in patients with symptomatic pancreas divisum: a Dutch cohort study. Endosc Int Open 2021;9:E1164-70.  https://doi.org/10.1055/a-1460-7899
  74. Testoni PA. Endoscopic pancreatic duct stent placement for inflammatory pancreatic diseases. World J Gastroenterol 2007;13:5971-8.  https://doi.org/10.3748/wjg.v13.45.5971
  75. Elbanna KY, Jang HJ, Kim TK. Imaging diagnosis and staging of pancreatic ductal adenocarcinoma: a comprehensive review. Insights Imaging 2020;11:58. 
  76. Nealon WH, Walser E. Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis. Ann Surg 2003;237:614-20; discussion 620-2. https://doi.org/10.1097/01.SLA.0000064360.14269.EF