Abstract

An annular pancreas may cause congenital duodenal obstruction (CDO) or remain asymptomatic. In our practice, we came across atypical extra pancreatic location of the Wirsung duct in a newborn patient with CDO. Such duct malformation was unique in our practice and has not been described in literature yet. We report this case and speculate on embryology mechanisms that could lead to it.

Materials: From 2017 to 2021, 27 children with duodenal obstruction were treated in our department an intraoperative complication occurred in one child-it was the injury to atypically located Wirsung duct. A male child, born on 35 weeks of gestation had abdominal distention after birth. The examination revealed duodenal obstruction, an atrial septal defect and Down’s syndrome. The child underwent laparoscopic procedure on his 6th day of life. During blunt division of transverse-duodenal ligament the abnormally located duct was damaged as it was located in the ligament tissue but not within the pancreatic parenchyma. We performed Kimura duodenal anastomosis with suturing the duct into it.
Result: After surgery the child suffered from infection with metabolic disorders and gastric bleeding, on the 5th postoperative day anastomosis leak occurred, which demanded further duodena-pancreatoneuroanastomosis with a Roux-en-Y loop and cholecystectomy. No surgical complications were seen afterwards. We consider this case is worth discussing regardless its poor outcome (the patient died on the 16th day after the last operation) as it is a unique observation of pancreatic duct anomaly.
Conclusion: We report a rare variant of the anomalous location of the Wirsung duct. Unawareness of its possible extra pancreatic location could lead to its rupture and further demand of reconstructive operation. To explain the complex embryogenesis of annular pancreas and pancreatic ducts malformations further research is needed.

Keywords: Congenital duodenal obstruction; Annular pancreas; Extra pancreatic Wirsung duct; Pancreatic embryogenesis; Children

Abbreviations: CDO: Congenital Duodenal Obstruction; AP: Annular Pancreas; CRP: C-Reactive Protein; MRI: Magnetic Resonance Imaging