Q1 Which of the following is true regarding pancreatic embryology?

A The ventral pancreatic bud arises from the dorsum of the foregut just distal to the stomach.

B The dorsal pancreas arises from the biliary diverticulum.

C Fusion of the ducts of the two buds is typically complete by 7 weeks of gestation.

D The islet cells make up 10% of the pancreas during fetal life but only 1% during adult life.

E The major arterial blood supply to the pancreas is from the superior mesenteric artery (SMA) and
inferior mesenteric artery.

A1 D The dorsal pancreatic bud arises from the dorsum of the foregut just distal to the stomach and the
ventral pancreas arises from the biliary diverticulum. Fusion of the parenchyma of the two buds is
typically complete by 7 weeks’ gestation but duct fusion is delayed until the perinatal period. The major
arterial blood supply is from the coeliac axis and the SMA, which gives rise to the superior and inferior
pancreaticoduodenal vessels.

Q2 Which of the following is not associated with annular pancreas?

A oesophageal atresia

B hypertrophic pyloric stenosis

C duodenal web

D trisomy 21

E complex congenital heart disease

A2 B Duodenal atresia or stenosis is seen in as many as 50% of patients with annular pancreas. Trisomy
21 and malrotation occurs in about 20% of patients each. Complex congenital heart disease and tracheo-
oesophageal fistula are also associated with annular pancreas.

Q3 A 2-day-old male presents with bilious emesis and a ‘double-bubble sign’ on abdominal plain X-ray.
Which of the following is the best surgical management for an intraoperative finding of annular
pancreas?

A lateral duodenotomy with duodenal web excision

B division of the annular pancreatic segment anteriorly

C pancreaticoduodenectomy

D gastrojejunostomy

E duodenoduodenostomy

A3 E In annular pancreas, frequently a thin, flat band of pancreatic tissue arising from the head of the
pancreas surrounds the second portion of the duodenum. Typically there is coexisting duodenal stenosis
or atresia and the pancreatic tissue may penetrate the duodenal muscularis. Bypass of the duodenal
obstruction should be performed without mobilising the annular pancreas because injury to the
pancreas could result in production of a chronic fistula.

Q4 Which of the following is true regarding pancreas divisum (PD)?

A The frequency of PD in the general population is less than 1%.

B PD results when the dorsal and ventral pancreatic ducts fail to fuse properly and there is inadequate
drainage through a small dorsal duct (Santorini).

C The majority of patients with PD present with recurrent pancreatitis.

D Endoscopic sphincterotomy is the procedure of choice in children with symptomatic PD.

E CT scan is the diagnostic modality of choice to evaluate patients with suspected PD.

A4 B The frequency of PD in the general population is between 5% and 10%. The majority of patients
with PD are asymptomatic. Endoscopic retrograde cholangiopancreatography (ERCP) is the most helpful
preoperative imaging study in patients with PD. For symptomatic patients, operative sphincteroplasty
seems to have the greatest benefit. There is little data to support endoscopic sphincterotomy in
children.