Warshaw A L, Simeone J F, Schapiro R H, Flavin-Warshaw B
Gastrointestinal Radiology Unit, Massachusetts General Hospital, Boston 02114.
Am J Surg. 1990 Jan;159(1):59-64; discussion 64-6. doi: 10.1016/s0002-9610(05)80607-5.
The controversial association of pancreatitis and pancreas divisum was studied in 100 patients (77 women, 23 men, median age 35) with episodic acute pancreatitis (49%) or "pancreatic pain" (51%). Seventy-one had classic pancreas divisum (type 1); 23 had only a dorsal duct with an absent Wirsung's duct (type 2); and 6 had a filamentous connection between the two duct systems (type 3). Accessory papilla sphincteroplasty was performed in 88 patients, with a mean follow-up of 53 months. The orifice was stenotic at the mucosal level in 66 patients. Seventy percent of patients have shown improvement: 85% if the accessory papilla was stenotic, compared with 27% if it was not (p less than 0.0001); and 82% with discrete attacks, compared with 56% with chronic pain (p = 0.002). Judged against intraoperative calibration of accessory papilla orifice diameter, ultrasonography with secretin stimulation was 78% sensitive for accessory papilla stenosis, with 3% false-positive results. Ultrasonography with secretin stimulation was the best predictor of surgical success: positive = 92% success (attacks or pain) versus negative = 40% success (64% with attacks; 21% with pain). There have been seven restenoses with six reoperations. We conclude that (1) pancreas divisum is but one variety of pancreatic anatomy characterized by a dominant dorsal duct and dependence on secretion through the accessory papilla; (2) accessory papilla stenosis appears to be a necessary cofactor to produce a morbid state, whether episodic pancreatitis or pancreatic pain; (3) presentation with pancreatitis and a positive result on the ultrasound-secretin test are the best predictors of successful accessory papilla sphincteroplasty.
对100例发作性急性胰腺炎（49%）或“胰腺疼痛”（51%）患者（77例女性，23例男性，中位年龄35岁）研究了胰腺炎与胰腺分裂这一存在争议的关联。71例有典型的胰腺分裂（1型）；23例仅有背侧导管而主胰管缺如（2型）；6例两个导管系统之间有丝状连接（3型）。88例患者接受了副乳头括约肌成形术，平均随访53个月。66例患者副乳头开口在黏膜水平狭窄。70%的患者病情有改善：副乳头狭窄者改善率为85%，无狭窄者为27%（p<0.0001）；发作性疼痛者改善率为82%，慢性疼痛者为56%（p = 0.002）。与术中副乳头开口直径校准相比，促胰液素刺激下的超声检查对副乳头狭窄的敏感性为78%，假阳性结果为3%。促胰液素刺激下的超声检查是手术成功的最佳预测指标：检查结果阳性者手术成功率为92%（发作或疼痛缓解），阴性者为40%（发作性疼痛者成功率为64%；慢性疼痛者为21%）。有7例再狭窄，其中6例再次手术。我们得出结论：（1）胰腺分裂只是胰腺解剖结构的一种类型，其特征为背侧导管占主导且依赖通过副乳头分泌；（2）副乳头狭窄似乎是产生病态的必要辅助因素，无论是发作性胰腺炎还是胰腺疼痛；（3）出现胰腺炎且超声 - 促胰液素试验结果阳性是副乳头括约肌成形术成功的最佳预测指标。
