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Skandalakis’ Surgical Anatomy > Chapter 21. Pancreas >

History

The anatomic and surgical history of the pancreas is summarized in Table 21-1.

Table 21-1. Anatomic and Surgical History of the Pancreas

Egypt ca. 1500 B.C. The Ebers Papyrus described diabetes
Herophilus of Chalcedon (334-280 B.C.)   Noted the existence of the pancreas
Erasistratus of Chios (319-250 B.C.)   Also mentioned the pancreas but was unsure of its function
Aretaeus (A.D. 81-138)   First to use the term diabetes
Rufus of Ephesus ca. A.D. 100 Thought the pancreas was part of the omentum. First to use the term “pankreas” (all flesh).
Galen (131-200 A.D.)   Described the pancreas as glandular and identified its arterial and venous supplies
Da Carpi 1522 Wrote of a glandular pancreas that in the pig was edible (“Brisaro” or sweetbreads)
Edwardes 1532 Thought that lymphatic vessels were physically supported by the pancreas
Massa 1536 Wrote that the pancreas served as a pad “upon which the mouth of the stomach rests lest it touch the hard surface of the vertebrae without a buffer between.”
Vesalius 1541 Provided illustrations of the pancreas offering pictures of its vasculature. Agreed with Galen on its glandular nature and disagreed with Rufus on its relationship with the omentum.
Wirsung 1642 Discovered the main pancreatic duct (Wirsung’s duct)
Wharton 1656 Noted that the pancreas was similar to salivary glands
DeGraaf 1664 Collected pancreatic juices through a cannulated duct of a dog in order to study pancreatic function
Willis 1674 Noted that patients suffering from what he called “diabetes mellitus” produced sweet urine
Brunner 1683 Partially pancreatectomized dogs in vivisection experiments
Bidloo 1685 Provided a description of the duodenal papillae, the junction of the pancreatic and common bile ducts, and the hepatopancreatic ampulla
Vater 1720 Redescribed the duodenal papilla originally described by Bidloo; it is now commonly called the papilla of Vater
Santorini 1724 Observed the main and accessory duodenal papillae along with their associated pancreatic ducts. The accessory duct now bears his eponym (Santorini’s duct).
Winslow 1732 Described the epiploic (omental) foramen (foramen of Winslow)
Morgagni 1769 First described pancreatoadenocarcinoma
Soemmering 1791 Described the glandular nature of the pancreas. Labeled it “Bauchspeicheldrüse” (abdominal salivary gland).
Bernard 1849 to 1856 Performed several experiments establishing the role of the pancreas during digestion. Showed that pancreatic juice emulsifies fatty foods into fatty acids and glycerin, converts starches into sugars, and breaks down proteins that pass undissolved through the stomach. 
Treitz 1853 Located the retropancreatic fascia and Treitz’s band
Langerhans 1869 Noted the presence of small polygonal, non-granulated cells with round nuclei scattered (like islands) throughout the parenchyma. These were named the islets of Langerhans by Laguesse in 1893.
Danilevsky 1872 Discovered trypsin
Kühne 1874 Isolated trypsin
MacBurney 1878 Used a duodenotomy and papillotomy to remove calculi in the papilla
Thiersch 1881 Drained a fluctuating tumor of the abdomen resulting in a spontaneously closing pancreatic fistula
Kühne and Lea 1882 Described the capillary network surrounding pancreatic islet cells
Bozeman 1882 Removed a 20 pound pancreatic cyst
Trendelenburg 1882 In the process of excising a sarcoma he removed the tail of the pancreas and the spleen
von Winiwarter 1882 First operation for pancreatic adenocarcinoma
Capparelli 1883 Drained a pancreatic cyst using an external fistula
Gussenbauer 1883 Marsupialized a pancreatic pseudocyst
Oddi 1887 Observed and described the sphincter of the hepatopancreatic ampulla (sphincter of Oddi)
Toldt 1889 Described the Toldt fascia
Fitz 1889 Provided the first complete description of acute pancreatitis
von Mering and Minkowski 1889 Discerned that pancreatectomized dogs developed fatal diabetes
Ruggi 1889 Removed an adenosarcoma in the tail of the pancreas
Minkowski 1892 Implanted autogenous pancreatic grafts in pancreatectomized dogs. They did not develop glycosuria until the grafts were removed.
Laguesse 1893 Suggested that hormones were secreted from the “islots de langerhans” in discussing their capillary networks
Kocher 1895 Advocated using a choledochoduodenostomy after removing periampullary and choledochal calculi
Halsted 1898 Removed part of the duodenum along with the pancreas to treat an ampullary carcinoma. Implantation of the pancreatic and common bile duct into a portion of the duodenum followed.
Codivilla 1898 Treated pancreatic cancer with a pancreatoduodenectomy (resected the duodenum, head of the pancreas, and pylorus, then closed the duodenal stump) followed by a cholecystojejunostomy and a gastroenterostomy-en-Y
Mayo-Robson 1900 Removed a cylindrical portion of the duodenum along with a carcinoma of the ampulla
Opie 1901 Established the common-channel theory of pancreatitis stating that Wirsung’s duct entered the common bile duct proximal to their duodenal entrance. Hypothesized that any stone wedged against the sphincter of this channel could cause bile to flow into the pancreas and pancreatic juice to flow into the biliary tract producing pancreatitis or cholecystitis. In the same report he noted that the islets of Langerhans were associated with diabetes because patients with hyalinized islet cells developed the disease.
Ssoboleff 1902 Observed that acinar tissue atrophied after ligation of the pancreatic duct while islet tissue remained unchanged
Bayliss and Starling 1902 Discovered secretin 
Nicholls 1902 Reported a simple pancreatic adenoma involving islet tissue
Kocher 1903 Developed a method of duodenal mobilization (Kocher’s maneuver) later used to enhance access to the duodenal papilla of Vater
Fabozzi 1903 First to describe islet cell carcinoma
Desjardins 1907 Performed a cadaveric two-stage procedure to excise the head of the pancreas and the duodenum
Svelzer 1908 Induced hypoglycemia using an isolated pancreatic extract
Lane 1908 Differentiated alpha and beta islet cells
Sauvé 1908 Advocated a one-stage procedure similar to Desjardins’
Navarro 1908 Performed a papillectomy
De Meyer 1909 Named Laguesse’s hypothetical islet hormone “insuline”
Coffey 1909 Advocated the implantation of the pancreatic stump (the tail in this case) into the distal end of the resected duodenum after pancreatoduodenectomy
Kausch 1909 Performed the first successful pancreatoduodenectomy
Ombredanne 1911 Anastomosed a pancreatic cyst to the duodenum
Kausch 1912 First successful two-stage pancreatoduodenectomy
Hirschel 1914 Connected the common bile duct to the duodenum using a rubber tube after a one-stage partial pancreatoduodenectomy. The patient died one year later.
Dragstedt 1918 Proved that experimental animals could survive total duodenectomy
Banting and Best 1922 Isolated “insuline” from islet secretions of dog pancreas
Tetani 1922 Performed a successful two-stage pancreatoduodenectomy involving a posterior gastrojejunostomy and division of the common duct with a choledochoduodenostomy in the lower end of the duodenum in the first stage. After jaundice subsided, the second stage brought about the resection of duodenum and pancreas 2 cm beyond the ampullary growth with the head of the pancreas implanted into the lower end of the duodenum.
S. Harris 1923 Suggested that spontaneous hyperinsulinism was possible after noticing it in non-diabetic patients given an overdosage of insulin
Wilder 1927 Noticed a case of hyperinsulism in a patient with an islet cell tumor
Elman 1927 Invented the serum amylase test
Mayo 1927 First operated on a nonresectable metastatic malignant insulinoma
R. Graham 1929 Removed a benign pancreatic adenoma to successfully treat hyperinsulism
Whipple 1930 Offered his triad in insulinoma: 1) symptoms of hypoglycemia during fasting; 2) serum glucose less than 50 mg/dL; 3) with administration of exogenous glucose the hypoglycemic symptoms disappear 
Whipple/Parsons/ Mullins 1935 Published the results of their two-stage procedure for ampullary carcinoma. A cholecystogastrostomy was done in the first stage while a duodenectomy was done in the second. They were among the first to use silk suture instead of catgut (which was dissolved by pancreatic enzymes).
Whipple 1935 Performed a two-stage operation involving a cholecystojejunostomy in the first stage and a total duodenectomy and excision of much of the head of the pancreas in the second
Brunschwig 1937 Successfully performed a radical pancreatoduodenectomy for carcinoma of the head of the pancreas
Whipple 1940 Performed a one-stage excision of the entire head of the pancreas with total duodenectomy with 10-year survival
Waugh and Clagett 1943 Implanted the tail of the pancreas into the posterior wall of the stomach augmenting Whipple’s procedure
Rockey 1943 Performed the first total pancreatectomy
Fallis and Szilagyi 1944 Performed the first successful total pancreatectomy for pancreatic cancer
Clagett 1944 Unsuccessfully treated pancreatitis with a total pancreatectomy
Zollinger and Ellison 1955 Reported four cases in which patients possessed an exaggerated gastric acidity as well as tumors of the alpha islet cells (producing gastrin)
Barrett and Bowers 1957 Described the 95% pancreatectomy
Watts 1963 Successfully treated acute fulminant pancreatitis with a total pancreatectomy
Doubilet and Mulholland 1965 Advocated sphincterectomy to treat acute pancreatitis
Kelly and Lillehei 1966 First clinical pancreas transplant
Fortner 1973 Introduced the regional pancreatectomy (total pancreatectomy, resection of the pancreatic segment of the portal vein, subtotal gastrectomy and regional lymph node dissection for type I, and extending to resect the hepatic and superior mesenteric arteries in type II)
Kelly, Acosta 1974 Reported gallstone migration through the ampulla of Vater initiating pancreatitis
Traverso and Longmire 1978 Introduced the pylorus-preserving pancreatoduodenectomy
Safrany 1980 Performed early endoscopic papillotomy to remove calculi in the papilla
Ishida et al. 1981 Early report of laparoscopic pancreatic biopsy
Jordan 1987 Advocated anastomosis of the first and third portions of the duodenum after resection of the head of the pancreas
Beger et al. 1988 Described necrosectomy in management of necrotizing pancreatitis
Neoptolemos et al. 1988 Randomized trial of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy
Warshaw et al. 1990 Study showed that laparoscopy for assessment of pancreatic cancer compared favorably with other methods
Sarr et al. 1991 Described necrosectomy in management of necrotizing pancreatitis

Source: McClusky DA III, Skandalakis LJ, Colborn GL, Skandalakis JE. Harbinger or hermit? Pancreatic anatomy and surgery through the ages. Part III. World J Surg 2002; 26:1512-1524; with permission.

References

Beger HG, Büchler M, Bittner R, Block S, Nevalainen T, Roscher R. Necrosectomy and postoperative local lavage in necrotizing pancreatitis. Br J Surg 1988;75:207-212.

Cameron JL. Current Surgical Therapy (5th ed). St. Louis: Mosby, 1995, pp. 414, 465.

Ishida H, Furukawa Y, Kuroda H, Kobayashi M, Tsuneoka K. Laparoscopic observation and biopsy of the pancreas. Endoscopy 1981;13:68-73.

Lo CY, van Heerden JA, Thompson GB, Grant CS, Söreide JA, Harmsen WS. Islet cell carcinoma of the pancreas. World J Surg 1996;20:878-884.

Neoptolemos JP, Carr-Locke DL, London NJ, Bailey IA, James D, Fossard DP. Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet 1988;2:979-983.

Praderi RC. History of pancreatic surgery. In: Trede M, Carter DC (eds). Surgery of the Pancreas. New York: Churchill Livingtone, 1993, pp. 3-15.

Rhoads JE, Folin LS. The history of surgery of the pancreas. In: Howard JM, Jordan GL, Reber HA (eds.) Surgical Diseases of the Pancreas. Philadelphia: Lea and Febiger, 1987, pp. 3-10.

Sarr MG, Nagorney DM, Mucha P Jr., Farnell MB, Johnson CD. Acute necrotizing pancreatitis: management by planned, staged pancreatic necrosectomy/debridement and delayed primary wound closure over drains. Br J Surg 1991;78:576-581.

Tan HP, Smith J, Garberoglio CA. Pancreatic adenocarcinoma: An update. J Am Coll Surg 1996;183:164-184.

Warshaw AL, Gu ZY, Wittenberg J, Waltman AC. Preoperative staging and assessment of resectability of pancreatic cancer. Arch Surg 1990;125:230-233.

Whipple AO. A historical sketch of the pancreas. In: Howard JM, Jordan GL (eds.) Surgical Diseases of the Pancreas. Philadelphia: JB Lippincott, 1960, pp. 1-8.

Embryogenesis

Normal Development

Two pancreatic primordia (anlagen), the dorsal and ventral (Fig. 21-1), are responsible for the genesis of the pancreas. At the end of the fourth week, on the 26th day, the dorsal pancreatic primordium arises from the dorsal side of the duodenum. The ventral primordium arises somewhat later, on the 32nd day, from the base of the hepatic diverticulum, near the bile duct. Contact between the two pancreatic primordia takes place at about 37 days. Their fusion occurs at the end of the sixth week, the ventral primordium locating below and behind the dorsal. The ventral primordium differentiates into part of the head and uncinate process of the pancreas.

Fig 21-1.

Embryogenesis of proximal and distal pancreatic duct (highly diagrammatic). S, Duct of Santorini; W, Duct of Wirsung; M, Main pancreatic duct. (From Skandalakis LJ, Rowe JS Jr., Gray SW, Skandalakis JE. Surgical embryology and anatomy of the pancreas. Surg Clin North Am 1993;73:661-697; with permission.)

After the fusion of the two primordia, their principal ducts anastomose. This allows the proximal part of the duct of Wirsung from the ventral pancreas to join the common bile duct (CBD), perhaps on the 32nd day, also contributing to the formation of the ampulla of Vater. The terminal portion of the duct of Wirsung is therefore formed by the duct of the ventral pancreas. The distal portion of the duct of the dorsal pancreas is retained as most of the main duct (Fig. 21-1). The duct of Santorini represents the proximal part of the duct of the dorsal pancreas. Remember, the ventral pancreas forms the duct of Wirsung and part of the uncinate process and head.

The dorsal pancreas forms the remainder of the uncinate process and head, plus the body and tail. The secretory acini appear during the third month, and the islands of Langerhans arise from the acini approximately at the end of the third month. Secretion of insulin is taking place around the 5th month. Parenchymal cells are also responsible for glucagon-secreting cells and somatostatin-secreting cells.

Two populations of endodermal cells develop: those that form ducts and acini, and those that form islet cells. Ducts and acini form first, but islet primordia bud off ducts as soon as they are formed. The approximate time of functional awakening of both endocrine and exocrine components is perhaps 10 to 12 weeks.

Polak et al.2 stated that the patterns of endocrine differentiation and epithelial proliferation observed within the human pancreas early in development suggest that the mesenchyme plays a role in these phenomena.

Debas3 hypothesizes that the endocrine pancreatic cells derive from the endodermal lining of the primitive gut (mesenchyme of the foregut), not from the endodermal neural crest. The presence of mesenchyme regulates the development of a pancreas with exocrine structures, ducts, and mature islet cells.

The only critical morphologic events are rotation and fusion of the pancreatic primordia. Malrotation of the ventral primordium in the fifth week results in an anular pancreas. Fusion in the seventh week produces several possible variations of ductal patterns. Around the sixth week, the pancreas lies within the dorsal mesentery.

The classic concept of ansa pancreatica (that is, that a loop is formed between an inferior branch of the dorsal pancreatic duct and an inferior branch of the ventral duct) is challenged by Suda et al.4 There was, from the observations of Suda and colleagues, fusion between an inferior branch of the dorsal pancreatic duct and the ventral pancreatic duct.

We include here Table 21-2 from Embryology for Surgeons5 and the quotation that accompanies it:

It is not within the scope of this book to give details on fetal physiology nor to discuss ontogeny and phylogeny; however, we wish to include in the form of a table the ontogeny of the gastrointestinal peptides from the excellent chapter of Leung and Lebenthal.6 This shows the approximate time of appearance of the peptides in various tissues of the human fetus.

Table 21-2. Ontogeny of the Gastrointestinal Peptides

  Age of Earliest Appearance
Peptide (Weeks)  
Glucagon  6 (pancreas)
Insulin 10 (pancreas)
Somatostatin 8 (pancreas)
Somatostatin 9-11 (intestine)
Pancreatic polypeptide 8-9 (pancreas)
Gastrin 10-11 (duodenum)
Cholecystokinin 10 (duodenum)
Secretin  8 (duodenum)
GIP* 8-10 (duodenum and jejunum)
VIP 
 
8-9 (fundus and duodenum)
VIP 10 (VIP-nerve fibers)
Neurotensin 12 (jejunum, ileum, colon)
Motilin 8-11 (duodenum, jejunum)
Substance P 18-25 (brainstem)
Bombesin 12 (bronchus)

*Gastric inhibitory polypeptide.

 Vasoactive intestinal peptide.

Source: Leung YK, Lebenthal E. Gastrointestinal peptides: physiology, ontogeny, and clinical significance. In: Lebenthal E (ed). Human Gastrointestinal Development. New York: Raven, 1989, pp. 41-98; with permission.

Congenital Anomalies

There are many congenital anomalies of the pancreas (Table 21-3). This chapter cannot present all of them but will briefly discuss the following: pancreas divisum, anular pancreas, pancreatic gallbladder, ectopic and accessory pancreas, intraperitoneal pancreas, gastrinomas, and insulinomas. The interested student is advised to study Embryology for Surgeons.5

Table 21-3. Congenital Anomalies of the Pancreas

Aplasia-hypoplasia Pancreatic gallbladder
Hyperplasia-hypertrophy Cystic fibrosis
Dysplasia Pancreatic cysts
Variations and anomalies of the ducts—pancreas divisum Rotational anomalies
Anular pancreas Ectopic pancreatic tissue
  Vascular anomalies
  Intraperitoneal pancreas

Source: Modified from Skandalakis LJ, Rowe JS Jr, Gray SW, Skandalakis JE. Surgical embryology and anatomy of the pancreas. Surg Clin North Am 73(4): 661-697, 1993; with permission.

Pancreas Divisum

Failure of the dorsal and ventral pancreatic primordia (anlagen) to fuse may result in separate draining of the ducts of Wirsung and Santorini. This condition is called “pancreas divisum” or “isolated ventral pancreas.” About 12 percent of patients with pancreatitis have pancreas divisum demonstrated on ERCP (endoscopic retrograde cholangiopancreatography), but only 3 percent of patients who have pancreatography for other reasons have the anomaly. This suggests that pancreas divisum predisposes to attacks of acute pancreatitis.7-10 Pancreatitis may occur secondary to stenosis or obstruction of one or both ducts. Stenting may relieve the symptoms of patients with chronic pancreatitis.11,12 To avoid the formation of stones, sphincteroplasty of both ducts and cholecystectomy is the current procedure of choice. Neblett and O’Neill13 advised that patients with more distal ductal obstruction or ductal ectasia may benefit from pancreaticojejunostomy. Kamisawa et al.14 presented what may be the first report of carcinoma associated with anular pancreas coexistent with pancreas divisum.

Anular Pancreas

An anular pancreas (Fig. 21-2) is a thin, flat band of normal pancreatic tissue surrounding the second part of the duodenum and continuing into the head of the pancreas on either side. The band may be partially or wholly free from the duodenum, or the pancreatic tissue may penetrate the duodenal muscularis. The ring of pancreatic tissue contains a large duct that usually enters the main pancreatic duct. This, however, occasionally enters the duodenum independently.

Fig 21-2.

Anular pancreas; duodenum under anulus is usually stenosed. SMV, superior mesenteric vein; SMA, superior mesenteric artery. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15(5):17-50; with permission.)

The anular pancreas’ developmental course is not known. Is the ventral anlage totally responsible because of its early division into two parts? Perhaps the left part follows an opposite direction and produces the constricting ring. Or is early fusion of the ventral pancreatic tip with the dorsal pancreas responsible for this anomaly? Nobukawa et al.15 described an anular pancreas originating from paired ventral pancreata, with a ring formation originating from the left lobe.

Duodenal stenosis at the level of the pancreatic ring is typical. If obstruction at the site of the anulus exists before birth, hydramnios is frequently present.16 However, half of the patients with anular pancreas do not have symptoms until adulthood,17 when they present with signs of duodenal obstruction. Currently, the procedures of choice to treat duodenal obstruction caused by anular pancreas are duodenoduodenostomy, first proposed by Gross and Chisholm,18 or duodenojejunostomy.

Pancreatic Gallbladder

In 1926, Boyden19 described gallbladder duplications in cats in which the accessory organ arose from the ventral pancreatic bud instead of from the cystic primordium. He suggested that some duplications in humans might be of this type. Wrenn and Favara20 reported the presence of a human pancreatic gallbladder. This was confirmed by Boyden.21 Pancreatic tissue in the wall of an otherwise normal gallbladder22 does not indicate origin from the ventral pancreatic primordium.23

Ectopic Pancreas, Heterotopic Pancreatic Tissue, and Accessory Pancreas

It is not unusual to have pancreatic tissue in the stomach (Fig. 21-3), duodenal wall or ileal wall, Meckel’s diverticulum, or at the umbilicus. Less common sites are the colon,24 appendix,25 gallbladder,26 omentum or mesentery,27 and in anomalous bronchoesophageal fistula.28

Fig 21-3.

Chief sites of heterotopic pancreatic tissue. Fifty percent of these structures occur in the duodenum or pylorus. (Modified from Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994; with permission.)

Most ectopic pancreatic tissue is functional. Islet tissue is often present in gastric and duodenal heterotopia, but it is usually absent in accessory pancreatic tissue elsewhere in the body.

Accessory duodenal pancreas may occur as lobules of normal pancreas in the submucosa sequestered beneath the muscularis externa. In other cases, pancreatized Brunner’s glands might be considered to be a potential anlage. Development of accessory pancreatic tissue is usually suppressed by the earlier maturing normal pancreas, but may occasionally escape from such suppression.

Feldman and Weinberg29 found duodenal pancreatic tissue in 13.7 percent of 410 necropsy specimens. Pearson30 estimated that heterotopic pancreatic tissue could be found in as many as 2 percent of autopsies if it were sought carefully. About 6 percent of Meckel’s diverticula can be expected to contain pancreatic tissue.31 Fékété et al. reported six cases of a pseudotumor with cystic dystrophy developing in heterotopic pancreas.32

Atypical metaplasia of pluripotential endodermal cells of the embryonic foregut may account for the presence of pancreatic tissue in the stomach, Meckel’s diverticulum, and intestinal duplications. Asymptomatic ectopic pancreatic tissue in the intestine is increasingly recognized as a potential source of pyloric obstruction, disruption of normal peristalsis, production of peptic ulcer, or neoplasm. Ravitch33 wrote that the presence of an ulcerated nodule of ectopic pancreas in the stomach or duodenum may give rise to ulcerlike symptoms that are relieved by removal of the nodule. According to Rosai,34 if a patient with heterotopic pancreas develops acute pancreatitis, the inflammatory process will also affect the heterotopic foci.

Intraperitoneal Pancreas

Tuncel et al.35 presented a case of intraperitoneal pancreas where the head and a part of the body of the pancreas were found intraperitoneally. They summarized their findings as follows.

The pancreas was covered by the peritoneum within the omental bursa except its tail. Additionally, the anterior layer of the hepatogastric ligament turned over the hepatoduodenal ligament and continued behind the head of the pancreas together with the peritoneum which formed the posterior wall of the epiploic foramen (Winslow). The peritoneum also covered a part of the posterior surface of the body and directed to the right, forming a recessus just behind the pancreas.

Gastrinoma and Insulinoma

In all honesty, we do not know whether the gastrinoma is an embryologic phenomenon. We hope the reader will forgive us for mentioning this tumor and the insulinoma together with other “bona fide” congenital anomalies.

Gastrinoma, a benign or malignant tumor, is located primarily in the pancreas. It is responsible for the Zollinger-Ellison syndrome (ZES): acid and pepsin supersecretion by the parietal and chief cells of the mucosa of the fundus of the stomach. This syndrome is named for the two researchers who associated islet cell tumor, hormone hypersecretion, and the resulting severe clinical manifestations.36 We agree with Stabile37 that their work “served as the defining moment for the entire field of gastrointestinal endocrinology.”

According to Stabile et al.,38 most gastrinomas (90%) are anatomically located within the so-called gastrinoma triangle (Fig. 21-4). The boundaries of this triangle are the cystic duct, the border of the 2nd and 3rd portion of the duodenum, and the junction of the neck and body of the pancreas.

Fig. 21-4.

Gastrinoma triangle. (Modified from Yeo CJ. Neoplasms of the endocrine pancreas. In: Greenfield LJ (ed). Surgery: Scientific Principles and Practice, 2nd Ed. Philadelphia: Lippincott-Raven, 1997, pp. 918-929; with permission.)

Passaro and colleagues,39 fathers of the gastrinoma triangle, hypothesize that some gastrinomas are embryologically of ventral pancreatic bud stem origin. These authors postulate a very interesting conjecture that stem cells from the ventral bud disperse and are enveloped by lymphoid tissue and the duodenal wall. We agree with Townsend40 that Passaro el al. “removed the mystery from the ‘ectopic’ gastrinomas,” and add our encomiums to his.

 Read an Editorial Comment

According to Townsend and Thompson,41 pancreatic gastrinomas have an anatomic distribution in the head, body, and tail of 4:1:4. Fewer than 25% of patients have a single tumor. Two pancreatic areas are affected in 30% of patients, and 20% have tumors in all three areas.

Surgery is the procedure of choice for gastrinoma, benign or malignant, despite the occasional good result with careful conservative treatment. Table 21-4 presents the tumor characteristics of patients with ZES.

Table 21-4. Pathology, Location, and Extent of Tumor in Patients with Zollinger-Ellison Syndrome

Tumor Characteristics % of Patients with Indicated Characteristica 
 
Range (%)
Extent of tumor    
  No tumor found 30 7-48
  Localized tumor 36 23-51
  Metastatic tumor 34 13-52
Tumor location    
  Pancreas 42 21-65
  Duodenum 15 6-32
  Otherb 
 
2 0-18
  Metastases only 2 0-11
Pathology    
  Gastrinoma 90 87-100
  Malignant   60-90
  Benign   10-39
  Islet cell hyperplasia 10c 
 
0-13

aData from 12 studies (see source)

bOther locations include lymph nodes primarily, but also in the stomach, liver, mesentery, renal capsule, ovary

cIn recent studies islet cell hyperplasia is felt not to be a cause of ZES

Source: Jensen RT, Gardner JD. Gastrinoma. In: Go VLW, DiMagno EP, Gardner JD, Lebenthal E, Reber HA, Scheele GA. The Pancreas: Biology, Pathobiology, and Disease, 2nd Ed. New York: Raven Press, 1993; with permission.

Norton et al.42 stated that surgical resection of localized liver gastrinoma provides a cure rate similar to that of extrahepatic gastrinoma with excellent long-term survival.

Kisker et al.43 advised intraoperative ultrasonography in association with pancreatic and duodenal exploration for localization of gastrinomas. They reported detection and excision of the tumor in 96% of their cases.

Proye et al.44 advised including intraoperative gastrin measurement in the surgical treatment of gastrinoma.

Remember

Occasionally, the student is confused by the differences between gastrinomas and insulinomas. We add a few comments about insulinomas to separate these two clinical entities, one perhaps congenital and the other acquired.

Insulinoma syndrome, an overproduction of insulin, is caused by a -cell tumor. Located at the islets of Langerhans, these small (less than 2 cm) tumors are solitary in 90% of cases.7 Unlike gastrinomas, insulinomas are equally distributed in the head, body, and tail of the pancreas. Less than 10%45 of insulinomas are malignant. After preoperative localization, surgery is the treatment of choice.

Kuzin et al.46 advised the use of intraoperative ultrasonography, and selective celiac arteriography in combination with arterial stimulated venous sampling, for precise localization of organic hyperinsulinism. Boukhman et al.47 found intraoperative ultrasonography more sensitive than preoperative ultrasonography or any other intraoperative localization study for localization of insulinomas.

We quote from Hashimoto and Walsh:48

The diagnosis of an insulinoma does not require extensive localization studies before operation. The combination of surgical exploration and intraoperative ultrasonography identified more than 90% of insulinomas. When technically feasible, enucleation is curative and can be accomplished with low morbidity.

Simon et al.49 described operative strategies for reoperation in patients with organic hyperinsulinism with diffuse or multiple disease (multiple tumors, MEN I syndrome [multiple endocrine neoplasia type I], and diffuse nodular hyperplasia).

Jordan50 gave an excellent summary of his 35-year experience in treating pancreatic and duodenal neuroendocrine tumors (gastrinomas, insulinomas, somatostatinomas, glucagonomas, amphicrine tumors) (Table 21-5):

Patients with duodenal gastrinoma with lymph node metasteses were curable, and cures were achieved occasionally after resection of liver metastases. Results of operation were similar for those with and without MEN I. MEN I and metastases were not contraindications to operation; instead, these patients should be operated on aggressively. Gastrinomas not found at operation were likely to be small duodenal gastrinomas. Gastrinomas can arise in a lymph node and can be cured by its removal. Parietal cell vagotomy is recommended after operation for gastrinomas in the event of residual tumor. With the exception of patients with MEN I or microadenomata, insulinomas were treated best by tumor enucleation. Otherwise, Whipple operation or distal pancreatectomy and enucleation of tumor in the remaining pancreas was indicated.

Table 21-5. Distribution of Neuroendocrine Tumors

Tumor n
Pancreatic gastrinoma  
  Without MEN I 9
  With MEN I 3
Duodenal and lymph node gastrinoma 13
Pancreatic and duodenal gastrinoma 5
Duodenal gastrinoma 7
Primary lymph node gastrinoma 3
Nonfunctioning neuroendocrine tumor 16
Neuroendocrine tumor not found 11
Insulinoma 11
Pancreatic amphicrine tumor 2
Glucagonoma 1
Somatostatinoma 1

Source: Jordan PH Jr. A personal experience with pancreatic and duodenal neuroendocrine tumors. J Am Coll Surg 189:470-482, 1999; with permission.

Surgical Applications

 

The embryologic and anatomic relationships between the pancreas, stomach, esophagus, duodenum, and spleen may have potential implications with respect to some surgical questions.

The embryology of the stomach and related organs is such that the body and tail of the pancreas (derived from the dorsal pancreatic anlage), together with the spleen, lie in the dorsal mesogastrium. They share both a common blood supply (left gastric and splenic arteries) and a common lymphatic drainage with the proximal portion of the stomach.

The head of the pancreas (derived from the ventral pancreatic anlage) lies in the mesoduodenum. The pancreatic head shares its blood supply (pancreaticoduodenal and gastroduodenal arteries) and lymphatic drainage with the duodenum, the distal CBD, and the distal stomach.

 

Cancer of the proximal stomach can theoretically be treated effectively by en bloc resection of the distribution of the left gastric and splenic arteries (Fig. 21-5A). This includes the distal esophagus, the proximal two-thirds of the stomach and greater omentum, the spleen, and the body and tail of the pancreas.

Similarly, cancer of the distal stomach can be treated by en bloc resection of the distribution of the common hepatic artery, sparing, of course, the artery itself (Fig. 21-5B). This resection includes the head of the pancreas, the distal stomach and greater omentum, the duodenum, and the distal bile duct.

Visalli and Grimes51 believe that the en bloc resections described above will check metastatic spread more effectively than will extirpation of peripheral lymph nodes only. Perhaps this will be the case in the future, but the procedure should be accompanied by lymphadenectomy. The reader is reminded of the high morbidity and mortality that accompany such procedures.

Doglietto et al.52 advocated pancreas-preserving total gastrectomy for cancer of the stomach due to its low incidence of postoperative complications and high survival rates.

Duodenoduodenostomy is the best procedure for anular pancreas. Duodenojejunostomy also may be utilized. Both procedures avoid the formation of pancreatic fistula due to the presence of pancreatic ductules and an inability to relieve the stenosis due to mingling of the pancreatic tissues within the duodenal wall musculature.

Ectopic or accessory pancreas should be removed to avoid future problems such as ulceration, bleeding, pancreatitis, intussusception, or even formation of benign or malignant neoplasms and other related problems.

Chung et al.53 reported duodenal ectopic pancreas complicated by chronic pancreatitis and pseudocyst formation. Allison et al.54 reported ectopic pancreas in the gastric antrum with gastroduodenal prolapse. Salman et al.55 reported ileocolic intussusception secondary to an ectopic pancreas located at the antimesenteric border of the terminal ileum. Kovari et al.56 reported papillary cystic neoplasms in ectopic pancreas located in the omentum. Roshe et al.57 presented a case of anaplastic carcinoma arising in ectopic pancreas located in the distal esophagus. Guillou et al.58 reported ductal adenocarcinoma originating in an ectopic pancreas which was located in a hiatal hernia at the gastroesophageal junction.

Fig. 21-5.

Highly diagrammatic presentation for en bloc resections of (A) proximal stomach and related organs sharing a common blood supply and lymphatic drainage, and (B) distal stomach and related organs. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Surgical Anatomy

The precise anatomy of the pancreas, its ducts, and its adjacent blood vessels achieves great importance in operating on the pancreas. Failure to be wary of the implications of surgical procedures on the pancreas is often followed by a string of complications that are serious at best and are not unlikely to be fatal. In this regard, the pancreas is one of the most treacherous organs to operate on.—R.J. Baker59

Topography and Relations

The pancreas is neither striking in appearance nor obvious in function. Its early history is hardly more than a list of the names of those who noticed it in their dissections before passing on to more interesting organs. It was only with demonstration of the digestive enzymes by Claude Bernard in 1850 that the pancreas became a complete organ with an important function and thus an object worthy of study.

In spite of the apparent accessibility of the pancreas, several anatomic relations combine to make its surgical removal difficult. In 1898, Halstead was the first to successfully remove the head of the pancreas and a portion of the duodenum for ampullary cancer. Several surgeons, in the United States and elsewhere, subsequently developed two-stage operations for removal of the head of the pancreas. These efforts culminated in 1940 with the one-stage operation of Allen O. Whipple. A major factor in Whipple’s success was the use of silk sutures, which tend to resist digestion by enzymes that destroy catgut sutures.

Sir Andrew Watt Kay60 wrote in 1978, “For me, the tiger country is removal of the pancreas. The anatomy is very complex and one encounters anomalies.”

The embryogenesis of the pancreas and its deep retroperitoneal anatomy are responsible for the tiger country. No other organ is so closely surrounded by so many anatomic entities, including the duodenum, stomach, spleen, left adrenal, transverse mesocolon and colon, left kidney, right ureter, and jejunum. Figures 21-6, 21-7, 21-8, and 21-9 show anterior and posterior relations of the pancreas.

Fig. 21-6.

Anterior relationships. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Fig. 21-7.

Bare areas of duodenum. Pancreas is in intimate contact with the duodenum along the concave surface. Attachment of transverse mesocolon produces an additional bare area. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15: 17-50; with permission.)

Fig. 21-8.

Posterior relationships of the pancreas. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Fig. 21-9.

Five parts of pancreas. Line dividing body and tail is entirely arbitrary. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

The proximity of the pancreas to so many organs means it is prone to local invasion by carcinoma. Z’graggen et al.61 reported metastasis to the pancreas from carcinoma of the kidney and lung. Isolated metastases may be amenable to palliation and even long term survival with resection. Similarly, pancreatic cancer is likely to invade other organs.

Two tables show important considerations in pancreatic cancer: organs directly invaded by pancreatic duct cancer (Table 21-6) and areas most likely to involve metastatic lesions from pancreatic cancer (Table 21-7).

Table 21-6. Organ Directly Invaded (at Autopsy) by Pancreas Duct Cancer (75 Patients)

    Primary Site
    Head Body Tail
Anatomical Site Invaded Total No. Patients No. (%) No. (%) No. (%)
Duodenum 30 24 (67) 6 (24) 0 (0)
Stomach 20 9 (25) 10 (40) 1 (7)
Spleen 8 0 (0) 3 (12) 5 (36)
Left adrenal 5 0 (0) 1 (4) 4 (29)
Transverse colon 6 1 (3) 3 (12) 2 (14)
Left kidney 2 0 (0) 1 (4) 1 (7)
Jejunum 3 1 (3) 1 (4) 1 (7)
Ureter (right) 1 1 (3) 0 (0) 0 (0)
Total (%) 75 36 (48) 25 (33) 14 (19)

Source: Cubilla AL, Fitzgerald PJ. Metastasis in pancreatic duct adenocarcinoma. In: Day SB, Meyers WPL, Stanley P, et al. (eds). Cancer Invasion and Metastasis: Biologic Mechanisms and Therapy. New York, Raven Press, 1977; with permission.

Table 21-7. Sites of Metastases from Carcinoma of the Pancreas as Seen at Autopsy

  Location of Tumor
Site of Metastasis Head (%) Body and Tail (%)
Regional nodes 75 76
Liver 65 71
Lungs 30 14
Peritoneum 22 38
Duodenum 19 5
Adrenals 13 24
Stomach 11 5
Gallbladder 9 0
Spleen 6 14
Kidney 6 5
Intestines 4 5
Mediastinal nodes 4 5
Other 19 28
No metastasis 13 0

Source: Howard JM, Jordan JL Jr. Cancer of the pancreas. Curr Probl Cancer 2: 5-52, 1977; with permission.

Location and Parts of the Pancreas

The pancreas lies transversely in the retroperitoneal sac, between the duodenum on the right and the spleen on the left. It is related to the omental bursa above, the transverse mesocolon anteriorly, and the greater sac below. For all practical purposes, the pancreas is a fixed organ.

Busnardo et al.62 studied the segmental anatomy of the human pancreas in 30 corrosion casts. Two anatomic segments were found (Figs. 21-10, 21-11), perhaps similar to the segmentation that can be found in the liver, spleen, kidneys, and other organs. The right segment (cephalocervical) and the left (corporocaudate) are separated from each other by a poorly vascularized area. They are connected by the main pancreatic duct and often, according to these authors, by a small artery.

Fig. 21-10.

Diagram of the arteries surrounding the human pancreas. The intersegmental plane has been drawn on the left of the superior mesenteric artery. The right and left pancreatic anatomicosurgical segments are united intraparenchymally only by the inferior pancreatic artery which corresponds, in this case, to the left terminal branch of the dorsal pancreatic artery. The pancreatic ducts are not shown in their entire extension until their termination in the major and minor duodenal papilla. A, Aorta; Lg, Left gastric artery; Pg, Posterior gastric artery; Dp, Dorsal pancreatic artery; S, Splenic artery; Pm, Pancreatica magna artery; Ip, Inferior pancreatic artery; Sm, Superior mesenteric artery; Rg, Right gastroepiploic (gastromental) artery; Aipd, Anterior inferior pancreaticoduodenal artery; Pipd, Posterior inferior pancreaticoduodenal artery; Aspd, Anterior superior pancreaticoduodenal artery; Pspd, Posterior superior pancreaticoduodenal artery; Gd, Gastroduodenal artery; H, Hepatic artery; P (arrow), Pancreatic duct. (Modified from Busnardo AC, DiDio LJA, Thomford NR. Anatomicosurgical segments of the human pancreas. Surg Radiol Anat 10:77-82, 1988; with permission.)

Fig. 21-11.

Diagrams of the anatomicosurgical segments of the pancreas: RS, right (cephalocervical) and LS, left (corporocaudate). The right and left pancreatic segments are artificially separated at the level of the pauci-arterial area. CA, Caput (head); CE, Cervix; CO, Corpus; CAU, Cauda pancreatica. (Modified from Busnardo AC, DiDio LJA, Thomford NR. Anatomicosurgical segments of the human pancreas. Surg Radiol Anat 10:77-82, 1988; with permission.)

The parts of the pancreas as traditionally accepted are discussed below and shown in Figure 21-9.

Head

The head of the pancreas is flattened and has an anterior and a posterior surface. The anterior surface is adjacent to the pylorus and the transverse colon. The anterior pancreaticoduodenal arcade can be seen upon the ventral surface of the head of the pancreas, coursing roughly parallel with the duodenal curvature. The posterior pancreaticoduodenal vascular arcade is a major entity on the posterior surface of the head. This surface of the pancreatic head is close to the hilum and medial border of the right kidney, the right renal vessels and the inferior vena cava, the right crus of the diaphragm, and the right gonadal vein.

The head of the pancreas adheres to the duodenal loop. Osler offers a very poetic description of this junction: “The abdominal area of romance where the head of the pancreas lies folded in the arms of the duodenum.”

The head the pancreas may be related to the third part of the common bile duct in a variety of ways.63Figures 21-12A and 21-12B show the most frequent conditions: the bile duct is partially covered by a tongue of pancreatic tissue (44 percent). In Figure 21-12C, the bile duct is completely covered (30 percent). The duct is uncovered on the posterior surface of the pancreas in 16.5 percent of cases (Fig. 21-12D). In 9 percent of cases, the third part of the common bile duct is covered by two tongues of pancreatic tissue (Fig. 21-12E).

Fig. 21-12.

Five variations of relation of third part of common bile duct to head of pancreas. (Data from Smanio T. Varying relations of the common bile duct with the posterior face of the pancreas in negroes and white persons. J Int Coll Surg 22:150, 1954; drawing modified from Skandalakis JE, Gray SW. Embryology for Surgeons (2nd ed). Baltimore: Williams & Wilkins, 1994; with permission.)

Uncinate Process

The uncinate (“hooklike”) process is an extension of the head of the pancreas and is highly variable in size and shape. It passes downward and slightly to the left from the principal part of the head. It further continues behind the superior mesenteric vessels and in front of the aorta and inferior vena cava. In sagittal section, the uncinate process (Fig. 21-13) lies between the aorta and the superior mesenteric artery, with the left renal vein above and the duodenum below. If the junction of the superior mesenteric vein with the portal vein is low, the anterior surface of the uncinate process is related to the superior mesenteric vessels and the portal vein.

Fig. 21-13.

Sagittal section through neck of pancreas. Uncinate process and third portion of duodenum lie posterior to superior mesenteric artery (SMA) and anterior to aorta. Middle colic artery (MCA) leaves SMA to travel in transverse mesocolon. (Modified from Akin JT, Gray SW, Skandalakis JE. Vascular compression of the duodenum: Presentation of ten cases and review of the literature. Surgery 1976;79:515-522; with permission.)

The uncinate process may be absent or may completely encircle the superior mesenteric vessels (Fig. 21-14). If the process is well developed, the neck of the pancreas must be sectioned from the front to avoid injury to the vessels. Short vessels from the superior mesenteric artery and vein supply the uncinate process and must be carefully ligated.

Fig. 21-14.

Uncinate process may or may not extend under superior mesenteric vessels. A, Does not reach superior mesenteric vessels. B, Reaches across superior mesenteric vein almost to superior mesenteric artery. C, Reaches beyond superior mesenteric artery. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

In an unpublished study by J.E. Skandalakis, dissection of the head of the pancreas was performed in 20 fresh cadavers. The uncinate process was observed in 18, and absent in 2. In most cases, the posterior surface of the uncinate process was in contact with the inferior vena cava and aorta and was crossed ventrally by the superior mesenteric vein and artery. Efforts to weigh the proximal and distal pancreas with or without the uncinate process did not provide any satisfactory data regarding the weight of the uncinate process.

Remember

 

The extent of resection of the head or the uncinate process is empiric.

Division at the neck is equivalent to a 60 percent to 70 percent resection.

Division at the proximal body to the left of the portal vein above and to the superior mesenteric vein below is a 50 percent to 60 percent resection.

Even with an 80 percent pancreatectomy, good exocrine and endocrine activity are present.

We cannot predict whether the physiology of the in situ remaining pancreas after pancreatectomy will be normal because we do not know how much pancreatic disease is present within the remaining part of the pancreas.

We have seen the ligament of the uncinate process where the process ends in the vicinity of the superior mesenteric vein. In such cases, the ligament is quite dense and attaches the process to the superior mesenteric artery. Pancreatitis or cancer makes the fixation even more adherent. An anomalous right hepatic artery may pass through the uncinate process. Because the aorta is behind the uncinate process, pancreatic carcinoma can be inseparable from the aorta.

Neck

The neck of the pancreas can be defined as the site of passage of the superior mesenteric vessels and the beginning of the portal vein dorsal to the pancreas. This pancreatic segment is 1.5 to 2.0 cm long, and it is partially covered anteriorly by the pylorus.

The gastroduodenal artery passes to the right of the neck and provides origin for the anterior superior pancreaticoduodenal artery. Posterior to the neck, the portal vein is formed by the confluence of the superior mesenteric and splenic veins. Near the inferior margin of the pancreatic neck, one can often see the terminations of the inferior pancreaticoduodenal vein and right gastroepiploic vein where they drain into the superior mesenteric or splenic veins or into the portal vein proper.

The inferior mesenteric vein drains, with essentially equal frequency, into the splenic vein, the superior mesenteric vein, or the site of formation of the portal vein. Careful elevation of the neck and ligation of any anterior tributaries, if present, are necessary. Bleeding can make it difficult to evaluate the structures lying beneath the neck.

The portal vein receives the posterior superior pancreaticoduodenal, right gastric, left gastric, and pyloric veins. It is fairly common for an anomalous vein to enter the anterior surface.

Body

The anterior surface of the body of the pancreas is covered by the double layer of peritoneum of the omental bursa that separates the stomach from the pancreas. The omental tuberosity (tuber omentale) is a blunt upward projection from the body that contacts the lesser curvature of the stomach at the attachment of the lesser omentum. The body is also related to the transverse mesocolon. It divides into two leaves: the superior leaf covers the anterior surface; the inferior leaf passes inferior to the pancreas. The middle colic artery emerges from beneath the pancreas to travel between the leaves of the transverse mesocolon.

Posteriorly, the body of the pancreas is related to the aorta, the origin of the superior mesenteric artery, the left crus of the diaphragm, the left kidney and its vessels, the left adrenal gland, and the splenic vein. Small vessels from the pancreas enter the splenic vein and, during pancreatectomy, must be ligated in order to preserve the vein and the spleen.

Tail

The tail of the pancreas is relatively mobile. Its tip reaches the hilum of the spleen in 50 percent of cases64 (Fig. 21-15). Together with the splenic artery and the origin of the splenic vein, the tail is contained between two layers of the splenorenal ligament. If the reader will permit an analogy, the senior author of this chapter (JES) would characterize the pancreas as “playing footsie” with the spleen and behaving unfaithfully to the duodenum. As indicated earlier, Osler described the head of the pancreas as “folded in the arms of the duodenum.”

Fig. 21-15.

Relations of tail of pancreas to splenic portas. (Modified from Skandalakis JE, Colborn GL, Pemberton LB, Skandalakis PN, Skandalakis LJ, Gray SW. The surgical anatomy of the spleen. Probl Gen Surg 1990;7:1-17; with permission.)

The outer layer of the splenorenal ligament is the posterior layer of the gastrosplenic ligament. Careless division of this ligament may injure the short gastric vessels. The splenorenal ligament is almost avascular, but digital manipulation should stop at the pedicle. Commonly a caudate branch arises from the left gastroepiploic or an inferior splenic polar branch and passes to the tip of the tail of the pancreas. Anticipate this branch in the pancreaticosplenic ligament.

Baker59 wrote the following comment about the relationship of the pancreas to the kidney.

The relationship of the pancreas to the right and left kidneys is of more than passing interest when the pancreas is acutely inflamed. It is relatively common to find that patients exhibit tenderness posteriorly in the left costovertebral angle (Murphy punch) as compared with the right and also often exhibit minor (trace to 1+) albuminuria during the acute phase. The reason for these findings is that the tail of the pancreas is contiguous with the superior pole of the left kidney. With an acute inflammatory process, there is exudation of activated enzymes, particularly trypsin, into the peripancreatic space, resulting in a modest but finite inflammatory change in the left kidney. This change results in the physical finding as well as the albuminuria, similar to interstitial nephritis on the left. The right kidney tends to be protected from the inflammatory enzymes because the inferior vena cava and duodenum are interposed between the head of the pancreas and the right kidney, making bathing of the right kidney by enzymes less likely than on the left. In operations for necrotizing pancreatitis, left perirenal fat is often necrotic and must be extensively debrided if the surgeon hopes to clean out most of the retroperitoneal peripancreatic necrotic tissue. Involvement of the right perirenal space is less likely to require extensive surgical debridement.

Pancreatic Ducts

The main pancreatic and accessory ducts lie anterior to the major pancreatic vessels. The main pancreatic duct arises in the tail of the pancreas. Through the tail and body of the pancreas, the duct lies midway between the superior and inferior margins, slightly more posterior than anterior.

The main duct crosses the vertebral column between the twelfth thoracic and second lumbar vertebrae. In more than one-half of persons, the crossing is at the first lumbar vertebra.

In the tail and body of the pancreas, from 15 to 20 short tributaries enter the duct at right angles; superior and inferior tributaries tend to alternate. In addition, the main duct may receive a tributary draining the uncinate process. In some individuals, the accessory pancreatic duct empties into the main duct. Small tributary ducts in the head may open directly into the intrapancreatic portion of the common bile duct.

On reaching the head of the pancreas, the main duct turns caudad and posterior. At the level of the major papilla, the duct turns horizontally to join the caudal surface of the CBD and enters the wall of the duodenum, usually at the level of the second lumbar vertebra.

Frey65 stated that if the head of the pancreas is 5 cm thick and the distance is 3 cm from the duodenum to the point on the main pancreatic duct at which the duct courses posteriorly and inferiorly, the distance from the junction of the central and dorsal duct to the ampulla of Vater is 6 cm (Fig. 21-16). He believes that the major pancreatic duct in the head may not be drained well by filleting this portion of the surface of the gland.

Fig. 21-16.

After filleting, the anteroposterior segment of the major pancreatic duct in the head of the pancreas with dimensions shown will not be adequate for drainage from the anterior surface of the gland to the ampulla. (Modified from Frey CF. Partial and subtotal pancreatectomy for chronic pancreatitis. In: Nyhus LM, Baker RJ (eds). Mastery of Surgery, Vol II, 2nd ed. Boston: Little, Brown, 1992, pp. 1029-1049; with permission.)

Baker59 made the following observations regarding the precise location of the main pancreatic duct.

One [anatomic] variation is the precise location of the main pancreatic duct of Wirsung. Characteristically, the main pancreatic duct is slightly superior to the midpoint of the pancreas from a superoinferior standpoint. The characteristic description has been that the main pancreatic duct is at the junction of the superior one third and the inferior two thirds of the pancreas when viewed from the front. The depth of the duct from the anterior surface of the pancreas is even more variable. It may be as close to the anterior surface as one-third of the distance from the anterior to the posterior surface, but not infrequently it is at the middle of the gland or, less commonly, is located toward the posterior surface. Surgeons who have attempted to aspirate pancreatic juice from a normal or slightly enlarged duct by inserting a needle through the anterior surface of the pancreas are usually frustrated by the failure to localize the duct unless intraoperative ultrasonography is used to assist in the localization. When pancreatic ductal obstruction occurs in the head or neck, the enlarged duct may be found if the surgeon’s finger palpates over the anterior surface of the gland from the superior to the inferior aspect; the duct may be palpable as a groove or a “soft spot” in the midportion. This is a common finding in patients with carcinoma of the head of the pancreas and long-standing ductal hypertension, as well as in patients with single or multiple strictures of the pancreatic duct and ductal dilatation following or concomitant with chronic pancreatitis.

The accessory pancreatic duct (of Santorini) may drain the anterosuperior portion of the head, either into the duodenum at the minor papilla or into the main pancreatic duct (Fig. 21-1).

Because of the developmental origin of the two pancreatic ducts, several variations are encountered; most can be considered normal. The usual configuration is seen in Figure 21-17A. The accessory duct (Santorini) is smaller than the main pancreatic duct (of Wirsung) and opens into the duodenum on the minor papilla. Figures 21-17B, 21-17C, 21-17D and 21-17E show examples of progressive diminution in size of the accessory duct, and its absence. Figure 21-18, starting with the usual configuration, shows examples of prominence of the accessory duct and lessening caliber of the main duct. The relationships of the common bile duct, duct of Wirsung, and duct of Santorini are shown in Fig. 21-19.

Fig. 21-17.

Variations of pancreatic ducts. Degrees of suppression of accessory duct. A, Both ducts open into duodenum (60 percent). B, Accessory duct ends blindly in duodenal wall. C, Accessory duct ends blindly before reaching duodenum (30 percent). D, Accessory duct has no connection with main duct. E, Accessory duct absent. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979; 15:17-50; with permission.)

Fig. 21-18.

Degrees of suppression of main duct. A, Both ducts open into duodenum. B, Main duct smaller than accessory duct. C, Main duct with no connection to larger accessory duct (10 percent). D, Main duct short or absent (10 percent). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Fig. 21-19.

Relations of common bile duct, duct of Wirsung, and duct of Santorini to each other and duodenum. Upper thickest duct is common bile duct; smaller duct is duct of Wirsung; smallest duct is duct of Santorini. The white circular area indicates where the duct enters the duodenum. In rows 2 and 3, duct of Santorini is a major pancreatic duct. Injection studies of M. Stolte. (Modified from Cubilla AL, Fitzgerald PJ. Tumors of the Exocrine Pancreas. Washington: Armed Forces Institute of Pathology, 1984; with permission.)

In about 10 percent of individuals, there is no connection between the accessory duct and the main duct (Figs. 21-17D, 21-18C and 21-18D).66 This fact is important to remember when contrast medium is injected into the main duct. There is no minor papilla in 30 percent66 (Fig. 21-17B, 21-17C and 21-17E). In some individuals with a minor papilla, the terminal portion of the accessory duct is too small to permit the passage of any quantity of fluid. Three papillae have been seen67,68 (Fig. 21-20A and 21-20D). A curious loop in the main pancreatic duct (Fig. 21-20B) was found in 3 of 76 specimens examined by Baldwin;69 an identical example was reported by Rienhoff and Pickrell.67

Fig. 21-20.

Rare variations of pancreatic ducts. A, Duplication of accessory duct. B, Loop in main duct. C, Anomalous course of accessory duct. D, Triple pancreatic ducts. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Endoscopic retrograde cholangiopancreatography (ERCP) has made the determination of the length, diameter, and capacity of the pancreatic ductal system of considerable importance. Some published values are shown in Figs. 21-21 and 21-22.

Fig. 21-21.

Length of main pancreatic duct as reported by several authors; averages and extremes indicated. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Fig. 21-22.

Diameter of the main pancreatic duct as reported by several authors. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15: 17-50; with permission.)

The greatest diameter of the main pancreatic duct is in the head of the pancreas, just before the duct enters the duodenal wall. From this diameter, the duct gradually tapers toward the tail. Like the bile duct, the pancreatic duct is constricted in the wall of the duodenum.

The normal pancreatic ductal system is quite small. According to Baker,59 as little as 1.0 to 2.5 ml contrast medium fills a normal pancreatic duct, so the hazards of injecting dye into the pancreatic duct must be recognized. Kasugai and colleagues70 found that 2 to 3 ml of contrast medium would fill the main pancreatic duct in the living patient and 7 to 10 ml fills the branches and the smaller ducts. In autopsy specimens, Trapnell and Howard71 found 0.5 to 1.0 ml sufficient to fill the ductal system.

Yamaguchi et al.72 found that magnetic resonance cholangiopancreatography (MRCP), a non-invasive procedure, plays a complementary role to ERCP in diagnosis of pancreatic disorders. But MRCP has limitations in surgical application.

Since ERCP has become a valuable and frequently used diagnostic modality for numerous diseases of the pancreas and biliary tract, it is important to recognize the hazards of injecting dye into the pancreatic duct. Both volume of dye and pressure of injection are elements of concern.

If 5.0 ml or more of contrast medium is injected, the branches and smaller ducts will be visualized and sometimes ruptured, resulting in postendoscopic pancreatitis.59 In such cases, the pancreatitis can be severe (necrotizing), with consequences that are always serious.

An experienced endoscopist injects dye into the pancreatic duct under very low pressure, sufficient to fill the duct but not to overdistend the delicate ductal system, and limits the volume of dye infused. Patients with chronic pancreatitis often have large ducts and distal strictures, and the fibrosis of the gland makes the pancreas less susceptible to damage than a normal pancreas.

Papilla of Vater and Ampulla of Vater

There is confusion in the literature regarding the true definitions of the terms papilla and ampulla of Vater. The so-called papilla of Vater, which should be called the major duodenal papilla, is a nipplelike formation and projection of the duodenal mucosa through which the distal end of the ampulla of Vater passes into the duodenum (Fig. 21-23A). The ampulla of Vater (hepatopancreatic), with its several formations, is the union of the pancreaticobiliary ducts.

Fig. 21-23.

Variations in relation of common bile duct and main pancreatic duct at duodenal papilla. A, Minimal absorption of ducts into duodenal wall during embryonic development. Ampulla present. B, Partial absorption of common channel. No true ampulla present. C, Maximum absorption of ducts into duodenum. Separate orifices on papilla, no ampulla. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Major Duodenal Papilla

Although this structure bears the name of Abraham Vater (1720), it was first illustrated by Gottfreid Bidloo of The Hague in 1685, and perhaps should have been called the papilla of Bidloo.

The papilla is on the posteromedial wall of the second portion of the duodenum, 7 to 10 cm from the pylorus. Rarely, the papilla may be in the third portion of the duodenum.73 On endoscopy, the papilla has been reported to lie to the right of the vertebral column at the level of the second lumbar vertebra in 75 percent74 to 85 percent75 of bodies examined. It has been reported to lie at the level of the third lumbar vertebra in 57 percent of autopsy specimens.76

Viewed from the mucosal surface of the duodenum, the papilla is found where a longitudinal mucosal fold or frenulum meets a transverse mucosal fold to form a T (Fig. 21-24). No such arrangement marks the site of the minor papilla.

Fig. 21-24.

T arrangement of duodenal mucosal folds indicates site of major duodenal papilla. Mucosal fold may cover orifice of papilla in some cases. Major papilla is rarely this obvious. This was beautifully illustrated in a plate by Santorini in 1775, and reproduced by Livingston in 1932. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979; 15:17-50; with permission.)

The papilla of Vater may not be obvious. Too much traction may erase the folds, or it may be covered by one of the transverse folds. Dowdy et al.77 stated that the papilla was “prominent” and easily found in 60 percent of their specimens. During the operation, if the T is not apparent and the papilla cannot be palpated, the CBD must be probed from above. A duodenal diverticulum near the papilla may confuse the surgeon or the endoscopist.

Ampulla (of Vater)

The ampulla is a dilatation of the common pancreaticobiliary channel adjacent to the major duodenal papilla and below the junction of the two ducts (Fig. 21-23A). If a septum extends as far as the duodenal orifice, the ampulla as such does not exist (Fig. 21-23B and 21-23C).

Michels78 collected the findings of 25 investigators in 2500 specimens and concluded that an ampulla was present in 64 percent. An ampulla was said to be present if the edge of the septum between the two ducts did not reach the tip of the papilla. Actual measurements of the distance between septal edge and papillary tip range from 1 to 14 mm, 75 percent being 5 mm or less, according to Rienhoff and Pickrell.67

Ampulla Classification

The following classification of Michels78 is the most useful.

 

Type 1 (Figs. 21-23A and 21-23B). The pancreatic duct opens into the CBD at a variable distance from the opening in the major duodenal papilla. The common channel may or may not be dilated (85 percent).

Type 2 (Fig. 21-23C). The pancreatic and bile ducts open near one another, but separately, on the major duodenal papilla (5 percent).

Type 3. The pancreatic and bile ducts open into the duodenum at separate points (9 percent).

A true ampulla with dilatation is present in about 75 percent of individuals of type 1 and is absent in types 2 and 3.

Blood Supply of Ampulla of Vater

(Figs. 21-25, 21-26). What do we know about the arterial and venous networks of the ampulla? There are papers in the literature that mention some of the participating arteries and veins, but the topography of the vascular network has not been defined clearly enough to help operators avoid postoperative bleeding. Most of these writers report the blood supply of the distal CBD and the pancreatic duct; these two anatomic entities participate with the duodenal wall to form the vaterian apparatus. Further information about the blood supply of the pancreas will be found later in this chapter under the heading “Vascular System.”

Fig. 21-25.

Frequency distribution of vascular supply of ampulla of Vater. (Modified from Stolte M, Wiessner V, Schaffner O, Koch H. [Vascularization of the papilla vateri and bleeding risk of papillotomy]. Leber Magen Darm 1980;10:293-301; with permission.)

Fig. 21-26.

Schematic of papillary vascular blood supply. Posterior superior pancreaticoduodenal artery crosses bile duct and gives rise to dorsal and ventral branches. These join to form arterial plexus of papillae. (Modified from Stolte M, Wiessner V, Schaffner O, Koch H. [Vascularization of the papilla vateri and bleeding risk of papillotomy]. Leber Magen Darm 1980;10:293-301; with permission.)

What should we surgical anatomists advise the surgeon, laparoscopist, and gastroenterologist about the topography, length, and depth of the incision during sphincterotomy, sphincterostomy, or sphincteroplasty to avoid bleeding or duodenal perforation? The incision should be at 10 o’clock to 11 o’clock with an approximate length of 5 to 8 mm. Little is known about the best depth to make the incision to avoid bleeding.

Arteries

The senior author of this chapter, John E. Skandalakis, has done sphincterotomies and sphincteroplasties by the open method. He has always advised residents that the vessels responsible for bleeding are the retroduodenal artery and an anomalous right hepatic artery originating from the superior mesenteric artery (SMA). These two vessels are located between the distal CBD and the duodenum. Skandalakis agrees with Chassin79 that during the open method the area behind the ampulla should be palpated to determine whether there is pulsation. If so, an anomalous artery is present.

Posterior Superior Pancreaticoduodenal Artery. Skandalakis’ personal feeling and intuition is that the primary responsibility for the arterial blood supply of the ampulla of Vater is fulfilled by the posterior superior pancreaticoduodenal arterial branch of the gastroduodenal artery (PSPD). The PSPD arises ventrally from the gastroduodenal artery and passes in a graceful, downward spiral around the retroduodenal segment of the CBD to reach the posterior surface of the pancreatic head. In most cases, it anastomoses with the posterior branch of the inferior pancreaticoduodenal branch of the SMA, very close to the ampulla of Vater. It may give origin to a supraduodenal branch to the duodenal bulb and also to the retroduodenal artery.

Retroduodenal Artery. The so-called retroduodenal artery is a branch of the gastroduodenal artery or, variably, of the PSPD. It is located very near the superior border of the duodenum and anterior to the lower CBD (in a transverse or slightly oblique way). Arising from the retroduodenal artery are ascending branches that travel upward along the CBD.

From the cystic and right hepatic arteries, descending branches travel downward and partially supply the arterial blood of the lower CBD. Some branches of the retroduodenal artery, which ascend and anastomose with the descending branches at the lower part of the common bile duct, also contribute to the lower CBD blood supply. The so-called 3 and 9 o’clock vessels mentioned by Northover and Terblanche80 are another product of the anastomosing ascending and descending branches from the retroduodenal and right hepatic and cystic arteries.

Stolte et al.81 studied vascular supply to the ampulla of Vater (Fig. 21-25). The four major types listed below comprised 52 of their 55 cases (94.64%):

 

Equally strong ventral and dorsal branches of posterior duodenal artery (retroduodenal artery) (52.78%) (Fig. 21-26)

Dominant dorsal branch (27.30%)

Dominant ventral branch (7.28%)

No dominant branch (arterial plexus of papilla composed of several vessels entering from sides) (7.28%)

Rare variations (5.36%).

Retroportal Artery. The retroportal artery may spring from the SMA or directly from the celiac axis.82 It joins the retroduodenal artery, and in 20% of cases, it joins the right hepatic artery behind the common bile duct.

Northover and Terblanche80 reported that in almost 50 percent of cases, the retroportal artery originated from the celiac axis and its major branches. In almost 50 percent, it arose from the superior mesenteric artery and its major branches. In extremely rare cases it sprang from an aberrant right hepatic artery which arose from the SMA.

Arterial Network. How close is the anastomosis between the posterior superior and posterior inferior pancreaticoduodenal (PIPD) arteries to the ampulla of Vater? We have never done injection studies, so our knowledge depends on our sixth sense and the available literature. The caliber and branching patterns of the anastomosing vessels is often such that it is difficult to be certain of the identity and origin of the vessels exposed.

The possible arterial network of the ampullary apparatus should be carefully evaluated by the blood supply of the distal common bile duct, pancreatic head, proximal pancreas, and first, second, and third parts of the duodenum.

The classical anatomy of the area tells us that the blood supply of the second part of the duodenum and the head of the pancreas originates from several arteries that spring from the celiac axis and the SMA. This can be explained easily in view of the fact that the foregut (celiac trunk) and midgut (superior mesenteric artery) participate in the embryogenesis of the duodenum and pancreas.

The pancreaticoduodenal arcades, which are located anterior and posterior to the pancreatic head, are accepted as the chief blood supply of the pancreatic head and the second part of the duodenum. A small unnamed branch from the dorsal pancreatic artery may join the PSPD artery. We do not believe this type of connection is significant in the majority of cases.

Using kocherization of the pancreatic head, one can observe the pathway of the PSPD artery. This pathway is variable, but the artery is always close to the pancreaticobiliary junction.

Perhaps we will have some answers if we accept the notion that the arterial blood of the supraduodenal CBD is supplied by the vaterian system, or that it participates in the blood supply of the vaterian network.

Northover and Terblanche80 studied the arterial blood supply of the bile duct. They reported that the retroduodenal, retroportal, gastroduodenal, and other arteries supplied the supraduodenal CBD in 60.1% of the cases. They found that the right and left hepatic, cystic, and other arteries were responsible for 38%. A small number (1.9%) came from the common hepatic artery.

The several small, nameless vessels associated with both borders of the CBD were referred to by Northover and Terblanche80 as the 3 o’clock and 9 o’clock arteries. Therefore, both retroduodenal and retroportal arteries supply the distal part of the CBD, forming arterial and capillary plexuses around its wall.

Deltenre et al.83 assessed the distance of the retroduodenal artery from the duodenal surface by identifying the arterial blood flow in 23 out of 26 patients prior to endoscopic sphincterotomy using ultrasonic Doppler probe. They limited the papillotomy length to less than the depth of the arterial sound (12.7 mm instead of 15 mm), and observed minimal capillary bleeding.

Kimura and Nagai84 reported on duodenal preservation after resection of the pancreatic head. They stated that after the anterior superior pancreaticoduodenal artery (ASPD) departs from the gastroduodenal artery, it travels downward to a point 1.5 cm below the ampulla of Vater. At that point it turns toward the posterior aspect of the pancreas to anastomose with the anterior inferior pancreaticoduodenal artery (AIPD). They wrote that an arcade is formed between the PSPD artery and the PIPD artery in 88 percent of cases.

In our experience, the exact site of anastomosis between the ASPD and AIPD arteries varies. It depends in part upon the topography of the pancreatic head and uncinate process and in part upon the manner of origin of the AIPD and PIPD arteries. Whether independently or in combination, they take origin from the superior mesenteric artery.

Veins

Biazotto85 reported that three venous networks are associated with the papilla:

 

The deep network resides in the mucous membrane of the intramural bile duct and in the hepatopancreatic ampulla.

The intermediate network is in the deep region of the chorion of the papilla.

The superficial network is in the duodenal submucous membrane covering the papilla.

Biazotto85 stated that bleeding during papillotomies is insignificant because the thick veins lie in the body and at the base of the papilla. The location in the apex of the papilla of the many small veins draining into the duodenal submucous membrane also helps explain the diffuse and low intensity bleeding.

Kimura and Nagai84 did not find any arcade formation by the ASPD and AIPD veins. They stated that arcade formation between the PSPD and PIPD veins is not always apparent, noting that these veins become quite small near the papilla of Vater.

According to Kimura and Nagai,84 the PSPD vein crosses anterior to the CBD near the upper edge of the pancreatic head and travels toward the papilla of Vater along the right side of the bile duct. They described the anatomy of the veins of the head of the pancreas as a “complex variety of patterns.” According to the same authors, the arterial and venous pancreaticoduodenal network is situated on a membrane on the posterior of the pancreas. They advised preserving this network and avoiding injury to it.

In another publication, Kimura et al.86 reported the following crucial points for duodenal preservation.

 

Kocherization will not cause any problem. After removing the connective tissue membrane behind the pancreatic head, the PSPD vein appears across the posterior surface of the CBD near the papilla of Vater. The PSPD vein is responsible for the venous drainage of the papilla of Vater and duodenum.

The artery travelling toward the papilla of Vater and along the right side of the CBD provides important blood supply for the papillae.

The connective tissue membrane on the posterior aspect of the pancreatic head should be kept intact because all the arterial and venous network is attached to the membrane.

Summary

Because of the limited quantity of published literature describing the blood supply of the ampulla of Vater, we asked Dr. Kimura to summarize his findings. He was kind enough to provide the following information, which we present verbatim (personal communication to John E. Skandalakis, October 31, 1996).

When investigating the vascular system of the head of the pancreas, using the autopsy cases, the artery toward the papilla of Vater can be easily detected. This artery can also be grossly detected at the operation.

After departing from the PSPD artery, this artery runs along the just right side of the CBD toward the papilla of Vater. The angiography demonstrates this artery clearly, especially in the right oblique position of patients. No such big artery toward the papilla was found. Therefore we can easily imagine that this artery is very important for the blood supply of the papilla of Vater, although some of the branches from arteries of the arcades toward the duodenal wall might be also responsible for that.

With regard to the anastomosis of arcades between the ASPD-AIPD and the PSPD-PIPD, we could not find any anastomosis with naked eyes. Branches from each arcade might supply blood to the pancreas and the duodenum directly and individually.

The posterior surface of the pancreas is covered with the connective tissue membrane. When this connective tissue membrane is removed, the PSPD vein is detected. After departing from the portal vein, the PSPD vein runs across the posterior surface of the CBD, and reaches the duodenal wall near the papilla of Vater.

The PIPD vein departs from the upper jejunal vein (J1), and runs horizontally behind the superior mesenteric vein (SMV) toward the right on the connective tissue membrane of the head of the pancreas. It runs toward the papilla of Vater.

The venous draining of the papilla of Vater and duodenum would be done by these veins. Congestion of the papilla of Vater and surrounding duodenal wall would be avoided by preserving these veins.

“Sphincter of Boyden”

As it is currently understood, the “sphincter of Boyden” (Fig. 21-27) includes several sphincters of smooth muscle fiber surrounding the intramural part of the common bile duct, the main pancreatic duct, and the ampulla, if present. This muscle complex has a separate embryonic origin from the duodenal musculature, and it functions separately.

Fig. 21-27.

Four entities composing sphincter of Boyden. (Measurements from White TT. Surgical anatomy of the pancreas. In: Carey LC (ed). The Pancreas. St. Louis: CV Mosby Co, 1973; drawing modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

While Boyden87 and others properly describe the anatomy of this area, the terminology is unsettled. We suggest naming the entire sphincter complex the sphincter of Boyden in recognition of his contribution to the anatomy of this region.

The total length of the sphincteric complex may be as little as 6 mm or as great as 30 mm, depending on the obliquity of the path taken by the biliary and pancreatic ducts through the duodenal wall. In some instances, the sphincter may extend beyond the duodenal wall into the pancreatic portion of the bile duct. It is important to be aware of this fact when sphincterotomy is done.

Flati et al.88 studied the biliopancreatic ducts and sphincteric apparatus of 49 specimens and reported the following findings:

 

1. Circular muscle fibers were found on the choledochus duct side up to 13.6 mm from the papillary pore, with more rarefied fibers present up to 20.5 mm.

2. Muscle fibers 7.3 mm from the papillary pore were noticed at the pancreatic duct with a sphincterlike formation 2-3 mm above the papillary pore.

3. There was no evidence suggesting the presence of upper, middle, and lower biliary sphincters.

4. The shape of the Wirsung-choledochus junction could be categorized as follows:

 

– Y type (with short or long common channel): 61.2%

– U type (virtually absent common channel): 22.4%

– V type (separate orifices of the Wirsung and choledochus ducts within the same papilla): 14.3%

– II type (one papilla for the choledochus and one for the Wirsung duct): 2.1%

5. The duct of Santorini with a normal papilla was present in 16% of specimens.

Flati et al.88 conclude that “these data along with other interesting observations on antireflux mechanisms (Santorini’s valves) and on the ductal space orientation appear to be useful guidelines for a physiopathological understanding of bilio-pancreatic diseases and for any therapeutic procedure on these structures.”

Perhaps these authors are right. But we, for sentimental reasons and because we believe in its scientific validity, will continue to teach the concept of our late, respected friend, Dr. Boyden.

The motility of the “sphincter of Oddi” (defined by Oddi in 1887 as a sphincter of the hepatopancreatic ampulla) is the subject of multiple debates. Shibata et al.89 found possible dysfunction of the sphincter of Oddi secondary to proximal duodenal transection, but not gastric transection.

Based on canine studies, Marks et al.90 recommend Botox injection into the sphincter of Oddi as a beneficial alternative to biliary stenting for reduction of common bile duct pressures and the treatment of biliary leaks and fistulae.

Minor Duodenal Papilla

The minor duodenal papilla sits about 2 cm cranial and slightly anterior to the major papilla. It is smaller than the major duodenal papilla and its site lacks the characteristic mucosal folds that mark the site of the major papilla. Baldwin69 found the minor papilla present in all of a series of 100 specimens. More recently, in a sample of the same size, Dowdy and associates77 could find no minor papilla in 18 specimens. Some papillae may be difficult to identify even if present.

An excellent landmark for locating the minor papilla is the gastroduodenal artery, which is situated anterior to the accessory pancreatic duct (Santorini) and the minor papilla. During gastrectomy, duodenal dissection should end proximal to or at this artery. It becomes especially important in the few patients in whom the accessory duct carries the major drainage of the pancreas.

De Prates et al.91 report that the muscular and elastic fibers of the minor papilla are arranged so that the contraction of its smooth muscle fibers opens the papillary orifice and permits pancreatic juice to flow. These authors stated that this papillary network (the sphincter of Helly) is not a typical anatomic sphincter.

Surgical Applications

 

When distal partial pancreatectomy is performed, the presence or absence of the uncinate process tends to determine how much of the pancreas is removed. A well-developed uncinate process usually belongs to a pancreas with a small head. If the uncinate process is present, a 60 percent to 65 percent pancreatectomy is done. If the uncinate process is absent, 70 percent to 80 percent of the pancreas is removed.

The cephalocervical and corporocaudate segments of the pancreas can be used for transplantation.62

Vascular System

The vascular system of the pancreas is complex and non-typical, with several different patterns. We will first present our analysis based on the excellent work of Van Damme.92 Then we will present an analysis of the pancreatic blood supply by Bertelli and colleagues.93-96 We hope the reader will benefit from both of the slightly differing presentations, remembering Sir Andrew Watt Kay’s admonition about the “tiger country” of the pancreas.60

Consideration of the blood supply of the ampulla of Vater, which has preceded this, is not repeated here.

Arterial Supply (Based on Van Damme)

Van Damme92 states: “The most important pancreatic artery is the splenic artery” (Figs. 21-28 and 21-29). The pancreas is supplied with blood from branches arising from the celiac trunk and from the superior mesenteric artery (Figs. 21-28 and 21-29). Variations are common, and differing textbook illustrations are all “correct” for at least some patients. Toni et al.97 report satisfactory sensitivity of the angiographic approach for evaluating the topography and anastomosis of pancreatic arteries.

Fig. 21-28.

Major arterial supply to pancreas (anterior view). Left and right gastric arteries not shown. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Fig. 21-29.

Major arterial supply to pancreas (posterior view). Left and right gastric arteries not shown. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

The head of the pancreas and the concave surface of the duodenum are supplied by two pancreaticoduodenal arterial arcades. These are always present. The arcades are formed by a pair (anterior and posterior) of superior arteries from the gastroduodenal branch of the celiac trunk that join a second pair of inferior arteries from the superior mesenteric artery. These vascular arcades lie upon the surface of the pancreas but also supply the duodenal wall. They are the chief obstacles to complete pancreatectomy without duodenectomy.

At the neck, the dorsal pancreatic artery (Fig. 21-28) usually arises from the splenic artery, near its origin from the celiac trunk. A right branch of the dorsal pancreatic artery supplies the head of the pancreas and usually joins the posterior arcade. It may also anastomose with the ASPD artery. One or two left branches pass through the body and tail of the pancreas, often making connections with branches of the splenic artery and, at the tip of the tail, with the splenic or the left gastroepiploic artery. The left and right branches of the dorsal pancreatic artery characteristically lie within a groove on the inferior margin of the pancreas. Here they form the transverse, or inferior, pancreatic artery. All major arteries lie posterior to the ducts.

Pancreatic Arcades

(Figs. 21-28, 21-29, 21-30)

Anterior Arcade

The gastroduodenal artery arises as one of the two terminal branches of the common hepatic artery branch of the celiac trunk. Shortly after it arises from the common hepatic artery branch, the gastroduodenal artery gives origin to the supraduodenal, retroduodenal, and posterior superior pancreaticoduodenal (PSPD) arteries. The supraduodenal and retroduodenal arteries arise, variably, as branches of the PSPD artery. The gastroduodenal artery ends by dividing into the right gastroepiploic and anterior superior pancreaticoduodenal (ASPD) arteries.

Fig. 21-30.

Arteries of the pancreas. 1, Gastroduodenal artery; 2, Right gastroepiploic artery; 3, Anterior pancreaticoduodenal arcade; 4, Posterior pancreaticoduodenal arcade; 5, Intermediary pancreaticoduodenal arcade; 6, Artery for the neck; 7, Artery for the body; 8, Arteries for the tail; 9, Transverse pancreatic artery; 10, Prepancreatic arcade; 11, Branch for the uncinate process; 12, Superior and inferior splenic branch; 13, Spleno-gastroepiploic trunk; 14, Left gastroepiploic artery; 15, Superior mesenteric artery; 16, Superior mesenteric vein; 17, Epiploic branch. (Modified from Van Damme JP, Van der Schueren G, Bonte J. Vascularisation du pancréas: Proposition de nomenclature PNA et angioarchitecture des ilots. C R Assoc Anat 1968;139:1184-1192; with permission.)

The ASPD artery lies on the anterior surface of the head of the pancreas, where it contributes eight to ten branches to the anterior surface of the pancreas and the duodenum. The main stem ends by anastomosing richly with the anterior inferior pancreaticoduodenal artery (AIPD) at the lower margin of the head of the pancreas.

Mellière98 found four instances in which the anastomosis between superior and inferior vessels appeared to be absent, but he believed this to be the result of transient spasm.

The AIPD artery arises from the SMA at or above the inferior margin of the pancreatic neck. It may form a common trunk with the posterior inferior artery. One or both vessels may arise from the first or second jejunal branches of the SMA. Even more striking are instances in which a posterior inferior artery arises from an aberrant right hepatic artery springing from the SMA. Ligation of the jejunal branch endangers the blood supply to the fourth part of the duodenum.

The supraduodenal artery regularly crosses the bile duct after arising from its gastroduodenal or other source and may supply blood to the bile duct. It and the retroduodenal artery provide arterial supply to the first part of the duodenum. Either or both of these arteries can arise separately or as branches of the PSPD artery.

The PSPD artery arises from the gastroduodenal artery. It then takes a long, spiraling course in a clockwise direction around the CBD to reach the posterior aspect of the head of the pancreas. The terminal part of the PSPD artery’s course is visible only when the pancreas is turned upward to expose its posterior surface (Fig. 21-29). This also exposes its interconnections with the PIPD artery. Branches may anastomose with other branches of the gastroduodenal artery or with the transverse (inferior pancreatic) artery. Duodenal branches supply the anterior and posterior surfaces of the second part of the duodenum.

Posterior Arcade

The course of the posterior arcade (Fig. 21-29) is farther from the duodenum than is that of the anterior arcade. It passes posterior to the intrapancreatic portion of the CBD.

The posterior arcade, like the anterior, may be doubled or tripled, with the extra arcades joining the PIPD artery or the SMA. The posterior arcade may also anastomose with an aberrant right hepatic artery (Fig. 21-31C) from the SMA, either separately or together with the anterior arcade.

Fig. 21-31.

Variations of hepatic arteries. A, Normal configuration. Common hepatic artery arises from celiac trunk. B, Aberrant common hepatic artery arises from superior mesenteric artery. C, Aberrant right hepatic artery arises from superior mesenteric artery. D, Aberrant left hepatic artery arises from superior mesenteric artery. E, Aberrant left hepatic artery arises from gastroduodenal artery. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Branches of the Splenic Artery

The splenic artery (Figs. 21-28 and 21-29) courses to the left along the posterior surface of the body and tail of the pancreas, looping above and below the superior margin of the organ. This pathway may become more tortuous as the patient ages.

Ozan and Önderoglu99 reported the case of a partially intrapancreatic splenic artery in a large pancreas. There were two pancreatic ducts and the uncinate process was absent.

If the posterior gastric artery is not present,100 the first major branch of the splenic artery is the dorsal pancreatic artery. The dorsal pancreatic artery usually joins one of the posterosuperior arcades after giving off the inferior (transverse) pancreatic artery to the left. The dorsal pancreatic artery arises rather commonly from the celiac trunk or from the common hepatic artery.

The origin of the inferior pancreatic artery varies. It may be doubled or absent. It may or may not freely anastomose with the splenic artery in the body and tail of the pancreas (Fig. 21-32). The inferior artery often joins the gastroduodenal artery or the ASPD artery to the right. If there are no anastomoses, thrombosis of the inferior pancreatic artery may produce emboli, infarction, and necrosis of the tail and perhaps partially of the distal body of the pancreas.

Fig 21-32.

Diagram of possible configurations of blood supply to distal pancreas. Type I, Blood supply from splenic artery only. Type II, Blood supply from splenic and transverse (inferior) pancreatic arteries with anastomosis in tail of pancreas. Type III, Blood supply from splenic and transverse pancreatic arteries without distal anastomosis. This type is susceptible to infarction from emboli in transverse artery. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Great Pancreatic Artery

The great pancreatic artery of Von Haller (pancreatica magna) (shown in Fig. 21-40A in following discussion by Bertelli) arises from the splenic artery and reaches the pancreas near the junction of the body and tail. This artery commonly anastomoses with the inferior pancreatic artery.

Caudal Pancreatic Artery

The caudal pancreatic artery (shown in Fig. 21-40B in following discussion by Bertelli) arises from the distal segment of the splenic artery, the left gastroepiploic artery, or from a splenic branch at the hilum of the spleen. It anastomoses with branches of the great pancreatic and other pancreatic arteries. The caudal pancreatic artery supplies blood to accessory splenic tissue when it is present at the hilum.

Van Damme studied the pancreatic arteries extensively, paying particular attention to some of the important, unnamed arteries that supply the neck, body, and tail of the pancreas, as well as the transverse pancreatic artery. The following four paragraphs about these arteries are taken verbatim from Van Damme’s work.92

The Large Artery for the Neck. Because the neck of the pancreas is lodged between the celiac and the superior mesenteric arteries, it is evident that the artery for the neck arises from the divisional branches of the celiac trunk (splenic or hepatic artery) or from the superior mesenteric artery. This important pancreatic artery runs behind the neck of the pancreas, where it divides into a right and a left branch. The right branch turns to the anterior surface of the head to anastomose with the gastroduodenal or right gastroepiploic artery (prepancreatic artery, 76% of specimens); the left branch takes part in the formation of the transverse pancreatic artery.

The Medium-Sized Artery for the Body. The artery for the body (in 37% of specimens there is more than one) arises from the splenic artery. It is a typical vessel but less voluminous than the artery for the neck. When it reaches the upper border of the pancreas, it divides into several comb-shaped branches that are perpendicular to the gland and that anastomose with the transverse pancreatic vessel.

The Smaller Arteries for the Tail. The arteries for the tail (in 68% of specimens there is more than one) arise from the splenic artery (21%) and from its divisions (the left gastroepiploic artery in 20%, the splenogastroepiploic trunk in 50%, the superior or inferior splenic branches in 9%). They enter the pancreas immediately and anastomose richly with the artery for the body and with the transverse pancreatic artery. Some of these branches for the tail have a recurrent course. These small vessels, especially the recurrent ones, can be injured during splenectomy and may cause postsplenectomy pancreatitis.

The Transverse Pancreatic Artery. This collateral vessel runs within the pancreas and usually is formed by the artery for the neck. It can be more or less important. It may continue into the prepancreatic arcade,101 which runs superficially upon the head of the pancreas and connects the anterior arcade or the gastroduodenal artery with the artery for the neck after turning around the uncinate process.

Anomalous Hepatic Arteries

The common hepatic artery (Fig. 21-31A) is usually a main branch of the celiac trunk, which arises cranial to the pancreas. The surgeon must always look for a possible anomalous hepatic artery before proceeding with a pancreatic resection. These aberrant arteries may be accessory to, or may replace, normal hepatic arteries.

In from 2.0 to 4.5 percent of persons, an anomalous common hepatic artery arises from the SMA.102,103 It is related to the head or neck of the pancreas. Occasionally, it passes through the head (Fig. 21-31B) and subsequently passes behind the portal vein. Almost all of the duodenum’s blood supply comes from the SMA.

The more frequent anomalous right hepatic artery also arises from the SMA. Its course is unpredictable, but it is related to the head and neck of the pancreas. Such an artery may pass behind the CBD or behind the portal vein (Fig. 21-31C). An aberrant right hepatic artery was present in 26 percent of bodies examined by Michels.103 It may give off the inferior pancreaticoduodenal arteries.

An anomalous left hepatic artery presents a problem in operations on the pancreas only when it arises from the right side of the superior mesenteric artery (Fig. 21-31D) or from the gastroduodenal artery (Fig. 21-31E). Michels found an anomalous left hepatic artery in 27 percent of specimens, arising most commonly from the left gastric artery.103

Anomalous Middle Colic Artery

A middle colic artery (Fig. 21-33) may pass through the head of the pancreas or between the head and the duodenum. It may arise from the superior mesenteric, dorsal pancreatic, or inferior pancreaticoduodenal arteries.

Fig. 21-33.

Anomalous middle colic artery passing through head of pancreas. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979; 15:17-50; with permission.)

Venous Drainage (Based on Van Damme)

In general, the veins of the pancreas parallel the arteries and lie superficial to them. Both lie posterior to the ducts in the body and tail of the pancreas. The drainage is to the portal vein, splenic vein, and superior and inferior mesenteric veins (Figs. 21-34 and 21-35).

Fig. 21-34.

Venous drainage of pancreas (anterior view). (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15: 17-50; with permission.)

Fig. 21-35.

Venous drainage of pancreas (posterior view) and tributaries of hepatic portal vein. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Veins of the Head of the Pancreas

Four pancreaticoduodenal veins form venous arcades draining the head of the pancreas and the duodenum. The ASPD vein joins the right gastroepiploic vein. The right gastroepiploic receives a colic vein and forms a short gastrocolic vein. This becomes a tributary to the superior mesenteric vein (SMV). The PSPD vein enters the portal vein above the superior margin of the pancreas. The anterior and posterior inferior pancreaticoduodenal veins enter the SMV together or separately. Other small, unnamed veins in the head and neck of the pancreas drain independently into the SMV and the right side of the portal vein.

White104 stated that pancreatic tributaries do not enter the anterior surface of the portal or superior mesenteric veins. This reduces the risk of bleeding when incising the neck of the pancreas. Silen,66 however, warned that in some patients the superior pancreatoduodenal vein and the gastrocolic vein may enter the portal vein and the SMV anteriorly.

We quote from a personal communication (Helge Baden to John E. Skandalakis, November 23, 1988) on the pancreatic veins:

[Y]ou mention “a short gastrocolic vein” which Hollinshead105 calls the gastrocolic trunk.

This is a very important structure in pancreatic surgery. It should be identified and divided before preceding cephalad on the anterior aspect of the superior mesenteric vein. The anterior and posterior inferior pancreaticoduodenal vein…usually enter together, forming a big vein, that enters on the dorsal aspect of the superior mesenteric vein, and the surgeon may get into trouble freeing the superior mesenteric vein, if he is not aware of this.

I have never during more than 100 Whipple procedures seen pancreatic veins enter the anterior side of the superior mesenteric vein/portal vein.

Veins of the Neck, Body, and Tail of the Pancreas

The veins of the left portion of the pancreas form two large venous channels, the splenic vein above and the transverse (inferior) pancreatic vein below. A smaller superior pancreatic vein can sometimes be identified.

The splenic vein receives from 3 to 13 short pancreatic tributaries.106 In a few instances one such tributary entered the left gastroepiploic vein in the tail of the pancreas. The inferior mesenteric vein (IMV) terminates in the splenic vein in about 38 percent of individuals, and the left gastric vein has a similar ending in 17 percent. The inferior pancreatic vein may enter the left side of the SMV, the IMV, or occasionally the splenic or the gastrocolic veins.

Portal Vein

The hepatic portal vein (Figs. 21-34 and 21-35) is formed behind the neck of the pancreas by the union of the superior mesenteric and splenic veins. The inferior mesenteric vein entered at this junction in about one third of specimens examined by Douglass and associates.106 In another third, the IMV joined the splenic vein close to the junction. In the remainder, it joined the SMV.

The portal vein lies behind the pancreas and in front of the inferior vena cava, with the CBD on the right and the common hepatic artery on the left. In the absence of disease, the portal vein and the SMV can be separated easily from the posterior surface of the pancreas.

In a dissection study of 23 cadavers,107 the left gastric (coronary) vein entered the portal vein in 17 cadavers and the splenic vein in 6 cadavers. When drainage flowed to the portal vein, the left gastric vein lay in the hepatogastric ligament.

Rarely the portal vein may lie anterior to the pancreas and the duodenum. This represents persistence of the preduodenal rather than the postduodenal plexus of the embryonic vitelline veins (Fig. 21-36). Inadvertent section of this vessel could be fatal. It is often associated with anular pancreas, malrotation, and biliary tract anomalies. A preduodenal portal vein is rare in patients of any age, and extremely rare in adults. But even though there are only 11 cases reported by Ishizaki et al.,108 the surgeon should be aware of this anomaly.

Fig. 21-36.

Diagram of embryonic origin of preduodenal portal vein. A, Embryonic extrahepatic communications between vitelline veins. B, Normal development. Persisting superior communicating vein forms part of normal, retroduodenal portal vein. C, Anomalous persisting inferior communicating vein forms part of abnormal preduodenal portal vein. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Surgical Applications

 

The right branch of the dorsal pancreatic artery anastomoses with the PSPD artery. This branch does not provide enough blood for survival of the head and duodenum after the arcades are ligated.

The PSPD artery is the main supply for the ampulla through the epicholedochal plexus.

Injury may occur to the ASPD artery during the Puestow side-to-side pancreaticojejunostomy.

The superior and inferior pancreaticoduodenal arteries should not be ligated until the neck of the pancreas can be elevated from the underlying vessels. Premature ligation could cause necrosis of the head of the pancreas and duodenum.

Angiography should be considered before surgery. Lo et al.109 reported localization rates prior to surgery for pancreatic insulinomas using ultrasonography (33%), computed tomography (44%) and angiography (52%). Intraoperative ultrasonography (IOUS) had the highest rate of accurate detection. Huai et al.110 found that IOUS also delineated spatial relationships of neighboring anatomic entities such as the splenic and superior mesenteric vessels, portal vein, CBD, and pancreatic duct, aiding successful resection and avoiding blind pancreatectomy.

Noncommunication between the splenic and transverse pancreatic arteries is possible. It can result in possible infarction at the area of the tail.

Ligation of the splenic artery does not require splenectomy; ligation of the splenic vein does.

Collateral circulation can develop as a result of stenosis of the superior mesenteric artery or celiac artery. Koshi et al.111 found abnormal blood flow through the pancreaticoduodenal arcade during angiographic examination (Figs. 21-37 and 21-38).

Ligation of both pancreaticoduodenal arterial arcades results in duodenal ischemia and necrosis.

Two cadavers used in our first-year dissection lab had huge pancreatic carcinomas. We noticed that mesenteric arteries and veins were not obstructed and collateral circulation was not present. This may have been because these unfortunate individuals died at an age before obstruction of the vessels would normally occur.

The veins of the pancreatic parenchyma are located between the ducts above and the arteries below.

Pancreatic veins enter the lateral side of the portal vein or superior mesenteric vein from the pancreas to the right side of the portal vein. Be careful.

The surgeon must avoid traction upon the head of the pancreas and carefully ligate veins in the area.

There are usually no branches on the anterior surface of the portal vein.

The four possible vascular anomalies of the portal vein are as follows.

 

– The portal vein may lie anterior to the pancreas and duodenum (Fig. 21-39A).

– The portal vein may empty into the superior vena cava.

– A pulmonary vein may join the portal vein (Fig. 21-39B).

– The portal vein may have congenital strictures (Fig. 21-39C).

As part of a resident’s training, it is advisable to arteriographically visualize the branches of the celiac axis and superior mesenteric artery which are related to the pancreas. We recommend this in addition to the other diagnostic tools often replacing selective arteriography. Justification for this expensive modality is the typical resident’s woeful lack of knowledge of anatomy due to the extremely poor teaching of this discipline of basic science in the United States, and perhaps all over the world.

Fig. 21-37.

Selective celiac angiogram showing segments of vascular tree. Note opacification of hepatic artery and proximal duodenal artery. A, Narrowing of celiac artery; B, Gastroduodenal artery; C, Hepatic artery. (From Koshi T, Govil S, Koshi R. Problem in diagnostic imaging: pancreaticoduodenal arcade in splanchnic arterial stenosis. Clin Anat 1998; 11:206-208; with permission.)

Fig. 21-38.

Selective superior mesenteric angiogram showing segments of vascular tree. Note retrograde opacification of hepatic artery via pancreaticoduodenal arcade and gastroduodenal artery. A, Superior mesenteric artery; B, Gastroduodenal artery; C, Pancreaticoduodenal arcade; D, Hepatic artery. (From Koshi T, Govil S, Koshi R. Problem in diagnostic imaging: pancreaticoduodenal arcade in splanchnic arterial stenosis. Clin Anat 1998;11:206-208; with permission.)

Fig. 21-39.

Anomalies of portal vein. A, Vein and its tributaries lie anterior to pancreas and duodenum. B, Pulmonary vein joins portal vein. C, Congenital stricture of portal vein. (Modified from Mc Gregor AL, Du Plessis DJ. A Synopsis of Surgical Anatomy (10th ed). Baltimore: Williams & Wilkins, 1969; with permission.)

Arterial Blood Supply (by Bertelli and Colleagues)

The arterial blood supply of the pancreas is provided mainly by the celiac and superior mesenteric arteries. From these arteries and/or from their major branches, eight main arteries arise with various patterns of origin and supply the pancreas:

 

PSPD: posterior superior pancreaticoduodenal artery

ASPD: anterior superior pancreaticoduodenal artery

AIPD: anterior inferior pancreaticoduodenal artery

PIPD: posterior inferior pancreaticoduodenal artery

DP: dorsal pancreatic artery

PM: pancreatica magna artery

TP: transverse pancreatic artery

CP: caudal pancreatic artery

The most common arrangements of these arteries are illustrated in Fig. 21-40. Many other arrangements are possible due to the variations in number, incidence, sites of origin and, sometimes, even course of pancreatic arteries. This marked irregularity, particularly in the distal segment of the pancreas (body/tail), leads to difficulty in interpreting the patterns of arterial vascularization and to strikingly divergent statistical analyses.

Fig. 21-40.

Most common patterns of pancreatic arterial blood supply. h, common hepatic artery; g, gastroduodenal artery; s, splenic artery; as, anterior superior pancreaticoduodenal (ASPD) artery; ps, posterior superior pancreaticoduodenal (PSPD) artery; pi, posterior inferior pancreaticoduodenal (PIPD) artery; ai, anterior inferior pancreaticoduodenal (AIPD) artery; d, dorsal pancreatic (DP) artery; p, prepancreatic arcade; t, transverse pancreatic (TP) artery (“short type” in A, “long-type” in B); m, pancreatica magna (PM) artery; k, caudal pancreatic (CP) artery; c, choledochus; i, inferior pancreaticoduodenal artery. (Courtesy Dr. Eugenio Bertelli.)

In this overview, we cite almost all the statistical surveys available in the anatomic literature (except that from “in vivo” angiographic studies) since, at the moment, it is impossible to ascertain which, among them, has been compiled most correctly. Our purpose is not to generate fruitless doubts in the reader’s mind. On the contrary, we wish to strongly emphasize how tricky it is to delineate the pancreatic arterial network. It is doubtful that any definite anatomic conclusion can be drawn yet.

We present a detailed portrait of each artery involved in the blood supply of the pancreas. We will follow topographic criteria in our exposition, dividing the description into three parts corresponding to the head, the neck/ body, and the tail of the pancreas.

Head of the Pancreas

(Figs. 21-40, 21-41) The head of the pancreas receives blood mainly from the hepatic artery, via the gastroduodenal artery, and from the superior mesenteric artery via the inferior pancreaticoduodenal (IPD) artery. The gastroduodenal artery supplies the PSPD and the ASPD arteries to the head of the pancreas, sometimes through a common superior pancreaticoduodenal (SPD) artery. The IPD artery divides into the PIPD and the AIPD arteries which, anastomosing with the two SPD arteries, form two pancreaticoduodenal (PD) arcades, namely the anterior and the posterior PD arcades.

Fig 21-41.

Arterial blood supply of pancreatic head. A, Selective angiography of celiac trunk (g) (anteroposterior projection). Frequent pattern of arterial vascularization: two SPD arteries arise from gastroduodenal artery (h). Two IPD arteries originate from division of common IPD artery (a). PSPD artery (b); ASPD artery (c); AIPD artery (d); PIPD artery (e); right gastroepiploic artery (f). B, Selective angiography of common hepatic artery (f) (anteroposterior projection). Rare variation of origin of SPD arteries which stem separately from the right hepatic artery. PSPD artery (a); ASPD artery (b); AIPD artery (c); PIPD artery (d); IPD artery (e); right gastroepiploic artery (g); right gastric artery (h). C, Selective angiography of accessory right hepatic artery arising from superior mesenteric artery (a) (anteroposterior projection). Variation of origin of two IPD arteries. The AIPD (d) and PIPD (c) arteries originate separately from common trunk (b) with jejunal artery (e). SPD, superior pancreaticoduodenal; IPD, inferior pancreaticoduodenal; PSPD, posterior superior pancreaticoduodenal; ASPD, anterior superior pancreaticoduodenal; AIPD, anterior inferior pancreaticoduodenal; PIPD, posterior inferior pancreaticoduodenal; IPD, inferior pancreaticoduodenal. (Courtesy Dr. Eugenio Bertelli.)

A detailed description of this complex of PD arteries and their frequent variations can be found in a series of recent articles.93,94,95,96,112 Here, we will summarize some notions of major interest to the surgeon.

Posterior Superior Pancreaticoduodenal (PSPD) Artery

The PSPD artery has been previously referred to as the retroduodenal artery.113-116 This name can cause confusion, since “retroduodenal” has also been used for a distinct group of small arteries that arise a little above the terminal division of the gastroduodenal artery to supply the first and second portions of the duodenum.117-120

The PSPD artery is considered a constant.98,121,122,123 In some cases, its calibre is so small as to be hardly detectable by routine angiography. The PSPD artery can also be as large as 3 mm.115,121,123

In about 70-80% of cases the PSPD artery arises within the first 2 cm of the gastroduodenal artery,121,124,125 usually from its posterior aspect, as the first collateral branch. In general, the PSPD artery has a spiral, descending course that surrounds the choledochus: it runs transversely from left to right in front of the CBD, turns around its right lateral side, then again crosses the choledochus, from right to left (this time posteriorly), to anastomose with the PIPD artery. Several variations can occur, especially when the artery arises from other sources.

The PSPD artery can arise, in more than 20% of cases, from “non-conventional” sources, mainly the hepatic artery or its branches, regardless of their origin. These sites and the frequency of their occurrence have been noted by various investigators:

 

common hepatic artery (3%)115,125,126

right hepatic artery (2-3%)114,121,122,125

an accessory right hepatic artery stemming from the superior mesenteric artery (3-8%)94,113,114,125,126,127

common hepatic artery arising from the superior mesenteric artery (3%)125

proper hepatic artery (2-8%)94,121,124

superior mesenteric artery (3-5%)94,125

SPD artery (5-7%)93,124,125

DP artery (1%)114

left hepatic artery (infrequent)94,128

Among the many possible collateral branches of the PSPD artery, we recall those of surgical interest:

 

cystic artery (1%)115

superficial cystic artery (3%)115

right gastric artery (1%)114

retroduodenal artery117,120

accessory right hepatic artery115,128

Anterior Superior Pancreaticoduodenal (ASPD) Artery

The ASPD artery is an almost constant artery,119,129 usually larger than the PSPD artery. In more than 90% of cases it arises from the gastroduodenal artery122,124 as one of its terminal branches, behind the inferior edge of the first duodenal portion. In almost all other cases (5-7%) the ASPD artery originates from the SPD artery,93,124,125 or exceptionally from other sources.93,116,121,122

Running downward, the ASPD artery can lie either in front of the duodenum or on the surface of the pancreatic head.130 Sometimes it is buried in the parenchyma of the gland.118 At the level of the duodenal papilla, the artery occasionally can be separated from the choledochus by only 1 mm of pancreatic parenchyma.130 Upon reaching the lower flexure of the duodenum, the ASPD artery usually turns backward and courses over the posterior surface of the uncinate process,115,118,122,125,127,131 where it anastomoses with the AIPD artery. In a minority of cases, the artery may remain on the anterior aspect of Winslow’s process.117,118,122

Some collateral branches of surgical interest have been sporadically reported:

 

TP artery (8-10%)93,126,127

retroduodenal artery93,120

cystic artery121

right root of the prepancreatic arcade (see below)

Inferior Pancreaticoduodenal (IPD) Artery

The AIPD and the PIPD arteries originate from the bifurcation of the IPD artery in 60-70% of cases.115,119

The IPD artery arises directly from the superior mesenteric artery95 as its first right collateral branch. When an accessory right hepatic artery is present, the IPD artery is the second right collateral branch.123 The incidence of such a pattern of origin has not been clearly determined; it has been reported as ranging from 4% to 47% of cases, depending on the authors.121,124,125,126,132,133

The level at which the IPD artery arises from the superior mesenteric artery is variable, corresponding more frequently to the inferior edge of the neck of the pancreas.118,121 An origin behind the pancreas is not uncommon.95,118,119

In other cases, the IPD artery arises through a common trunk with the first jejunal artery.95 This trunk is referred to as the pancreaticoduodenojejunal (PDJ) trunk. Its occurrence has been reported in about 20% to 64% of cases.121,124,125,126,132,133,134 Any statistical analysis could be affected by the interpretation that each investigator gave to the name “PDJ trunk.” According to these authors, in fact, the term “PDJ trunk” could also refer to the common trunks composed of the first jejunal artery and just one of the IPD arteries, or by the first jejunal artery and both IPD arteries stemming without forming a common IPD artery.

Less frequent sites of origin for the IPD artery:

 

accessory right hepatic artery arising from the superior mesenteric artery (1%)95,98,115,123

through a common trunk with the DP artery (6-8%)98,121,125

through a common trunk with the 2nd jejunal artery (2%)125

through a common trunk with the first 2 or 3 jejunal arteries95,117

middle colic artery115,119

The course of the first portion of the IPD artery varies according to the site of origin. It runs downward when arising behind the pancreas. When arising through common trunks with the jejunal arteries, it goes transversely from left to right, crossing the superior mesenteric artery posteriorly.98,117,126,133 Regardless of its origination, the IPD artery crosses behind the superior mesenteric vein and is in contact with the posterior face of the uncinate process,121 where it divides into the AIPD and the PIPD arteries.

Some important collateral branches of the IPD artery can be:

 

jejunal arteries121,123,133

right gastroepiploic artery115

an anastomotic branch with the first jejunal artery116

Anterior Inferior Pancreaticoduodenal (AIPD) Artery

The AIPD artery is usually the smallest of the PD arteries.133,135 It is almost always constant.124

In the majority of cases, the AIPD artery arises from the division of the IPD artery. Alternate sources are common:

 

a common trunk with the first jejunal and the PIPD arteries (do not confuse with the PDJ trunk) (17-30%)96,122,132,134

first jejunal artery (5-30%)96,121,122,124,126,132,133

superior mesenteric artery (5-16%)96,122,124,126,127,133

second jejunal artery (2-6%)121,133

DP artery (infrequent)126

an accessory right hepatic artery (infrequent)121,126

middle colic artery (infrequent)121

When arising from a site situated on the left of the superior mesenteric artery, the AIPD artery crosses the superior mesenteric vessels posteriorly. The AIPD artery usually runs behind the uncinate process,122 but it may be prepancreatic,122,133 subpancreatic,133 or even intrapancreatic.133 In 90% of cases, it ends by anastomosing with the ASPD artery.124

Posterior Inferior Pancreaticoduodenal (PIPD) Artery

The PIPD artery is an almost constant artery which originates mainly from the IPD artery. Less frequently, it arises from:

 

a common trunk with the first jejunal artery and the AIPD artery (do not confuse with the PDJ trunk) (17-30%)96,122,132,133

superior mesenteric artery (8-25%)121,122,124,126,127,132,133

first jejunal artery (3-16%)121,122,124,126,132

an accessory right hepatic artery (2-7%)121,124,126,132,133

DP artery (2-8%)124,126,132

a common trunk with the TP artery (rare)132,133

second jejunal artery (rare)124

The course of the PIPD artery is generally short. When the PIPD artery arises from the first jejunal artery or from the PDJ trunk, it may be longer, since it has to cross behind the superior mesenteric vessels.126 On the whole, the PIPD artery has a course parallel to the AIPD artery, which is situated 2-3 cm below.96

Prepancreatic (Kirk’s) Arcade

The head of the pancreas is supplied also by the right branch of the DP artery. This branch crosses the anterior surface of the head in an intermediate position. It forms the prepancreatic (Kirk’s) arcade,93,115,126 joining with a small artery coming from the gastroduodenal, right gastroepiploic or, less frequently, ASPD arteries. This arcade has been reported in 75% to 93% of cases.125,126,135,136

Variations

In relation to the head of the pancreas, two major variations of the pattern of arterial vascularization should be remembered:

 

DP artery

 

– In about 20% of cases, the DP artery may arise from the common hepatic artery. Therefore, its first portion can be found behind the head of the pancreas.

TP artery

 

– The TP artery, usually the left branch of the DP artery, may cross the anterior surface of the pancreatic head in about 30% of cases. It arises from the gastroduodenal,115,116,126,137 ASPD,115,118,126,127,137,138 or right gastroepiploic arteries.114,115,127,138

– The TP artery may also arise from an accessory right94 or proper (Fig. 21-42) hepatic artery coming from the superior mesenteric artery, or from the IPD artery.137

Fig. 21-42.

Arterial blood supply of pancreatic body shows patient with dominant “short-type” TP artery. A, Selective angiography of (c) celiac trunk (anteroposterior projection). Note very limited blood supply to pancreas coming from (g) gastroduodenal and (s) splenic arteries. B, Selective angiography of (m) superior mesenteric artery (anteroposterior projection). The (h) proper hepatic artery stems from superior mesenteric artery and gives off a large dominant TP artery (arrowheads). TP, transverse pancreatic. (Courtesy Dr. Eugenio Bertelli.)

Remember

In all these variations, the TP artery, crossing the usual line of Whipple resection, may represent a vascular hazard, especially when it acquires dominance (see below).

Neck and Body of the Pancreas

(Figs. 21-40, 21-42, 21-43) The neck and body of the pancreas are supplied by 3 to 7 minor branches of the splenic artery,134 and by the DP, PM, and TP arteries.

Fig. 21-43.

Arterial blood supply of pancreatic body. Selective angiography of celiac trunk (anteroposterior projection). Frequent pattern of arterial vascularization: (d), DP artery takes origin from (s) splenic artery soon after arising from celiac artery. DP artery divides into a right branch (p) prepancreatic arcade, and left branch (t) TP artery. TP artery anastomoses distally with (m) PM artery. DP, dorsal pancreatic; TP, transverse pancreatic; PM, pancreatica magna. (Courtesy Dr. Eugenio Bertelli.)

Dorsal Pancreatic (DP) Artery

The DP artery was first described by Haller128 who referred to it as “arteria pancreatica suprema.” Subsequently, it has been called by many different names, thus creating confusion. We recall those frequently used:

 

“superior pancreatic artery”118,121,127

“middle pancreatic artery”123,139

“isthmic pancreatic artery”123,134

“arteria pancreatica magna”117,123,124,134,139

“arteria colli pancreatis”125,140

In the absence of pathological collateral circulations, the DP artery is certainly the largest vessel of the pancreas; its calibre can be as large as 1 cm.118 The DP artery is present in 80-98% of cases.98,126,127,139,141,142

The DP artery may arise from four main sources. Various investigators have found quite different incidences for each pattern of origin:

 

first portion of the splenic artery (22-80%)98,117,123,125,126,127,134,137,139,143

celiac trunk (3-33%)98,117,121,123,125,126,127,134,137,139,143

first portion of the common hepatic artery (12-25%)98,117,123,125,126,127,134,137,139

superior mesenteric artery (6-25%)117,123,125,126,127,137,139,143

Less frequently reported patterns of origin of the DP artery are from:

 

an accessory right hepatic artery arising from the superior mesenteric artery125,134,137

a common trunk with the IPD artery98,115,121,125

gastroduodenal artery121,125,127,137,144

aorta128,138

left inferior phrenic artery138

right gastric artery134

left gastric artery117,128

PSPD artery127

middle colic artery115,137,138

proper hepatic artery97

The course of the DP artery is rather constant since the origin is almost always situated close to the division of the celiac trunk.117,137 When the DP artery has a high origin (hepatic, celiac, or splenic arteries), it goes downward with a course that slightly bends to the left when arising from the common hepatic artery, or to the right when arising from the splenic artery.117

In general, the DP artery, situated on the left of the portal vein, crosses the terminal segment of the splenic vein posteriorly.101,115,117,118,138 When arising from the superior mesenteric artery, however, the DP artery divides into its terminal branches after a very short course directed upward.115

The site of division is rather constant. It is situated close to the lower border of the pancreas, at the junction between the neck and the body, near the corner formed by the splenic and superior mesenteric veins.117,139

The DP artery divides as an inverted T into two terminal branches which run transversely in opposite directions.118,125,126,131,143 The right terminal branch runs behind the superior mesenteric vein131,139 and forms the prepancreatic arcade93 (see above); less frequently, it may resolve into minute branches for the ventral surface of the pancreatic head.131 The left terminal branch of the DP artery is the TP artery (see below).

Some collateral branches of the DP artery have been reported occasionally. We mention those of surgical interest:

 

middle colic artery115,117,118,125,126,137,138

accessory right hepatic artery138,145

right colic artery138

left colic artery98,138,146

IPD artery115

PSPD artery114,115,125,126

AIPD artery124,125,126

PIPD artery96,124,125,126,131,132

jejunal arteries98

Pancreatic Magna (PM) Artery

The PM artery126,147 is also known as “arteria corporis pancreatis”125,140 or “great pancreatic artery.”144 Its incidence ranges between 64 and 98%.126,140,141,142 Its calibre averages 2 mm.140

The PM artery is a branch of the splenic artery. Typically the PM artery arises from the middle third of the splenic artery, or at the junction between the middle and distal thirds.116,126 Less frequently, the PM artery has been reported as originating from the proximal142 or distal142 third of the splenic artery, or from the left gastroepiploic artery.140 Exceptionally, it arises from the superior mesenteric artery144 or from the hepatic artery.144

The PM artery can be double (33-54%)140,142 or triple (3%).140

As soon as it arises, the PM artery enters the substance of the pancreas126 and passes behind the pancreatic duct.116 The PM artery anastomoses with the TP artery in 90% of cases, with the DP artery in 20% of cases, and with the CP artery in 20% of cases. Multiple anastomoses are possible.142

Transverse Pancreatic (TP) Artery

The TP artery is also called the “inferior pancreatic artery.”126,127,135 It is an almost constant artery, present in about 90% of cases.127,141,142 It can be very thin, but in many cases its calibre can be as large as 3 to 4 mm.98 Usually, the TP artery is detectable angiographically as a single vessel.97,116 Numerical variations have been reported in a minority of cases.97,129,134,142

According to the site of origin, we can distinguish between “long-type” and “short-type” TP arteries. The TP artery is “long-type” in about 30% of cases. The distinction is important because the “short-type” supplies only the body/tail of the pancreas, whereas the “long-type” supplies the head as well.

The “long-type” TP artery may originate from the:

 

gastroduodenal artery (2-5%)98,126,129

ASPD artery (10-14%)126,127

right gastroepiploic artery (3-14%)114,127

common hepatic artery97,144

The “short-type” TP artery may arise from the:

 

DP artery (37-84%)98,126,127

superior mesenteric artery (1-33%)98,126,127,129

IPD artery (6%)129,134

aorta (3%)134

PM artery (1%)126

The “short-type” may also arise from a proper hepatic artery coming from the superior mesenteric artery (Fig. 21-42B).

The “short-type” TP artery runs along the inferior edge of the pancreas toward the tail.115,123,134,138 It is frequently embedded a few millimeters under the surface of its dorsal aspect.101,118,126,143 In other individuals, the “short-type” TP artery runs superficially for a variable tract before sinking into the substance of the pancreas.117,127

The “long-type” TP artery crosses the anterior surface of the pancreatic head, runs superficial to the superior mesenteric vein,127 and then follows the same course of the “short-type.”

The TP artery may join with:

 

a branch of the PM artery115,126,137,138 (70% of cases)142

CP arteries115,117,126,137,138 (90% of cases)142

left gastroepiploic artery131

In some cases the TP artery can bifurcate at the level of the neck of the pancreas; the superior branch can go to the left and upward.101,148

The TP artery represents the only connection between two arterial systems that are otherwise independent: the one supplying the head of the pancreas, and the other supplying the body. In other cases, when the TP artery is “short-type,” this connection is guaranteed by the prepancreatic arcade.

Arterial Dominance

The DP, PM, and TP arteries, along with other minor branches of the splenic artery, supply the neck, body, and sometimes even the tail of the pancreas. It is important to emphasize that each of these arteries may acquire dominance in supplying its segment of pancreas. In other words, in some cases, just one artery can supply the entire distal part of the pancreas.

The concept of a dominant TP artery (Fig. 21-42) has been previously noted.98 More recently, a dominant DP artery149 as well as a dominant PM artery149 have been demonstrated. However, a single artery supplying the distal segment of the pancreas has often been reported,150,151 and should not be considered extraordinary.

Tail of the Pancreas

(Fig. 21-40) The tail of the pancreas is supplied by one or more CP arteries and/or by the distal extremities of the arteries of the body.152 CP arteries have been reported to occur in 66% to 95% of cases,117,126,134,141,152 but are considered constant by many investigators.140,142 In many cases (32-36%) the CP artery is single.140,142 Two CP arteries are detectable in 46% of cases,140,142 3 CP arteries in 8-20% of cases,140,142 and 4 CP arteries in 2% of cases.142

The CP arteries arise from:

 

a common trunk formed by the left gastroepiploic artery and the inferior splenic branch (50%)125

splenic artery (21%)125

left gastroepiploic artery (20%)125

inferior or superior splenic branches (9%)125

The CP arteries run downward or transversely to the right depending on the site of origin. In most cases, they enter the gland from the anterior face of the tail.117 Anastomosis is usually with the TP artery, less frequently with the PM or DP artery.142 In 33% of cases, the CP arteries are the sole source of blood for the tail of the pancreas with no apparent anastomosis with the arteries of the pancreatic body.152

Some Considerations

If we imagine the pancreas as a stage where the play “Arterial Blood Supply of the Pancreas” is performed, we should consider the arteries as the actors of the play. The plot twist of this play is that the actors play extemporaneously. The spectator (the surgeon) can never be sure about a number of facts: the importance of the role played by each actor (dominance of an artery), the number of actors in the cast (at times all the arteries are present, other times just a few of them supply the pancreas), and the entrances and exits on the set (big variation of the source of each artery). Actors playing roles in other scenarios (i.e. liver, colon) may cross the pancreatic stage as well. There is only one plot device that keeps our play from turning into a tragedy: preoperative angiography.

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Venous Drainage (by Bertelli and Colleagues)

The venous drainage of the head of the pancreas is arranged mainly in two venous arcades. The venous arcades follow, on a more superficial plane, the course of the homonymous arterial arcades.136

The anterior PD venous arcade is formed by the ASPD and AIPD veins. The ASPD vein empties into the right gastroepiploic vein118,127,136,153 that, in its turn, drains into the superior mesenteric vein through the gastrocolic trunk.127,136 The AIPD vein follows the artery behind the uncinate process and the superior mesenteric vessels, and joins the uppermost jejunal vein,127 usually via a common trunk with the PIPD vein. Less frequently, the AIPD vein drains directly into the superior mesenteric vein.127,153

The posterior PD venous arcade is formed by the PSPD and the PIPD veins. The PSPD vein is considered the largest venous trunk of the pancreatic head.129 The PSPD vein follows the same course as the artery but, in 40% of cases, when it reaches the superior edge of the pancreas,127,136 it leaves the PSPD artery and crosses behind the choledochus123,147 before joining the right side of the portal vein.118,127,153,154 The PIPD vein may join the AIPD vein, or may end directly into the superior mesenteric vein.154

In addition to the anterior and posterior PD arcades, two further vessels take part in the venous drainage of the pancreatic head: an inferior venous arcade joining the IPD veins154 and the anteromedial PD vein.122

According to Olsen and Woodburne,153 the anteromedial PD vein occurs only occasionally. It originates from the confluence of two or more branches coming from the second portion of the duodenum.147 The anteromedial PD vein crosses the head of the pancreas transversely in an intermediate position.122,147 It empties into the superior mesenteric vein or, less frequently, into the right gastroepiploic vein.147

To summarize: the neck, the body, and the tail of the pancreas are drained by a number of veins that usually follow the same course as the homonymous arteries:

 

A system of small superior pancreatic veins (from 3 to 13) empties into the splenic vein.147,149,153

In 34-50% of cases,149,154 the TP vein originates from the splenic vein,147 and joins the inferior mesenteric vein,136,149,153,154 the superior mesenteric vein,136,153 or the splenic vein itself.136,149,153 The TP vein, also known as the inferior pancreatic vein,149,153,154 may be as large as 10 mm.

A DP vein,147 a PM vein, and one or more CP veins are usually detectable close to the corresponding arteries.

Lymphatic Drainage

As the position of the pancreas might predict, lymphatic drainage is centrifugal to the surrounding nodes. No standard terminology for those nodes exists, although Evans and Ochsner155 propose one. None of the efforts to demarcate specific drainage areas of the pancreas have gained wide acceptance. Studies of Cubilla et al.156 provide the basis for most recent works.

The lymphatic vessels of the pancreas arise in a rich, perilobular, interanastomosing network (Fig. 21-44A). Channels course along the surface of the gland and in the interlobular spaces with the blood vessels. These lymphatics drain into five main collecting trunks and five lymph node groups: superior nodes, inferior nodes, anterior nodes, posterior nodes, and splenic nodes (Fig. 21-44B). The following paragraphs discuss these nodes.

Fig. 21-44.

A, Highly diagrammatic theoretical presentation of possible lymphatic drainage of pancreas. Drainage to nearest margin of pancreas. B, Distribution of lymph nodes in 21 pancreatectomy resection specimens. Fraction numerators indicate number of patients with metastasis in that lymph node group. Denominators indicate number of patients in which lymph nodes in this group were examined. Stippled line, Whipple resection; SH, superior head; SB, superior body; IH, inferior head; IB, inferior body; APD, anterior pancreatoduodenal; PPD, posterior pancreatoduodenal; CBD, common bile duct; Py, pylorus; LC, lesser curvature; GC, greater curvature; S, splenic; J, jejunum; Col, colon. (A, Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15(6):17-50; with permission. B, From Cubilla AL, Fitzgerald PJ. Cancer of the exocrine pancreas: the pathologic aspects. CA Cancer J Clin 1985;35:2-18; with permission.)

Superior Nodes

The collecting trunks of this group of nodes arise from the anterior and posterior superior half of the pancreas. Most end in the suprapancreatic lymph nodes located along the superior border of the pancreas. The names of the nodes typically reflect the areas drained, such as the superior head and the superior body. Some lymphatics occasionally terminate in the nodes of the gastropancreatic fold or in the lymph nodes of the hepatic chain.

Inferior Nodes

These collecting trunks drain the anterior and posterior lower half of the head and body of the pancreas. They lead into the inferior pancreatic group of lymph nodes, most of which are located along the inferior border of the head and body of the pancreas. Further, they may extend into the superior mesenteric and left lateroaortic lymph nodes. Although infrequent, a collecting trunk may terminate directly in a lumbar trunk.

Anterior Nodes

Two collecting trunks run along the anterior surface of the superior and inferior portions of the head of the pancreas. They extend to the infrapyloric and anterior pancreatoduodenal lymph nodes. They may extend also to some of the mesenteric lymph nodes at the root of the mesentery of the transverse colon.

Posterior Nodes

The posterior nodes follow the posterior surface of the superior and inferior portions of the head of the pancreas. They drain into the posterior pancreaticoduodenal lymph nodes, common bile duct lymph nodes, right lateroaortic lymph nodes, and some nodes at the origin of the superior mesenteric artery. Most lymphatics of the common bile duct and ampulla of Vater also end in the posterior pancreaticoduodenal group of lymph nodes.

Splenic Nodes

These lymphatics originate from the tail of the pancreas. They drain into those at the hilum of the spleen, splenophrenic ligament, and inferior and superior lymph nodes of the tail of the pancreas. A few lymphatic channels, however, end in the lymph nodes superior and inferior to the body of the pancreas.

Surgical Applications

We continue to learn more about pancreatic lymphatics. The following paragraphs describe some of this new information.

 

Deki and Sato157 state that the lymphatics of the anterior surface of the head and neck of the pancreas are associated with the common hepatic group and with the superior mesenteric nodal group. All terminate at a lymph node situated to the right of the origins of the celiac trunk and the superior mesenteric artery. Lymphatics of the posterior surface of the head terminate in a node located behind the previously described node. The lymphatics of the left half of the pancreas terminate in a node to the left of the celiac trunk and superior mesenteric artery. Both the right and left nodes drain into the abdominal aortic nodes.

The lymphatics of the head and body of the pancreas do not drain toward the tail of the pancreas or the splenic nodes. Rarely, however, the lymph vessels from the tail of the pancreas can terminate in the superior body and inferior body subgroups of nodes.

Donatini and Hidden158 studied the routes of lymphatic drainage from the pancreas using injection into several pancreatic segments, followed by dissection. They concluded that dye injected into the body and tail followed the splenic and inferior pancreatic pathways, terminating first to the left interceliacomesenteric node and then to the suprarenal and infrarenal lymph nodes. From the head of the pancreas, dye followed one of three routes.

 

– The lymphatics of the anterior and posterior aspects of the head followed the superior mesenteric route and reached the right interceliacomesenteric node and then terminated bilaterally in the suprarenal and infrarenal nodes.

– The anterosuperior segment of the head followed two routes. The gastroduodenal joined the right interceliacomesenteric node. An inferior route terminated by flowing backward in direction to the isthmus.

– The drainage of the posterosuperior segment of the head followed the CBD and hepatic artery, reaching the pericholedochal nodes and hepatic pedicular nodes and occasionally the right interceliacomesenteric node.

Donatini and Hidden158 consider the right interoceliacomesenteric node the principal relay station for the head of the pancreas.

No lymphatic communications exist between the pancreas and the lymph nodes of the greater and lesser curvatures of the stomach.

Lymph moves from the pancreas to the duodenum, not from the duodenum to the pancreas.

Based on studies of the lymphatic network of the guinea pig, Bertelli et al.159 concluded the following: “All lymph vessels in the pancreas are absorbing lymph vessels, characterized by a very thin endothelial wall, anchoring filaments and the absence of a definitive basal membrane.”

According to Cubilla et al.,156 a total pancreatectomy may involve removing 70 nodes. The Whipple partial pancreatectomy may involve removing 33 nodes. It is the opinion of the authors of this chapter that 15-20 is a good harvest.

Examination of surgical specimens removed during regional pancreatectomy in patients with pancreatic and peripancreatic cancers revealed both the number of lymph nodes present in each of the nodal drainage areas and the presence of metastatic disease in them.156 The average number of lymph nodes present in each lymph node group is shown in Table 21-8.

Pissas160 wrote that the value of radical surgery is diminished by the very rapid passage of lymph into the thoracic duct.

Delcore et al.161 reported that 56 percent of patients undergoing curative resection for pancreatic carcinoma were found to have lymph node metastases.

It is well known that pancreatic cancer disseminates rapidly because of the retroperitoneal position of the pancreas and its rich lymphatic and venous drainage.

Table 21-8. Anatomic Distribution of Peripancreatic Lymph Nodes in Resected Specimens

Lymph Node Av. No. of Lymph Nodes Present
Group Subgroup Regional Total Whipple
  Gastric 7 6 7
Superior Superior head 17 9 10
  Superior body 13 10 2
  Inferior head 1
Inferior Inferior body 1
  Mid colic 1
  Pyloric 1 2
Anterior Pancreaticoduodenal 3 2 4
  Mesenteric (jejunal) 3
Posterior Pancreaticoduodenal 4 4 3
  Common bile duct 2 2 1
Splenic Tail of pancreas-spleen 10 3

Source: Cubilla AL, Fortner J, Fitzgerald PJ. Lymph node involvement in carcinoma of the head of the pancreas area. Cancer 41:880-887, 1978; with permission.

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Mukaiya et al.162 stated that excessive lymph node dissection in advanced cases of ductal adenocarcinoma of the head of the pancreas does not necessarily lead to a favorable prognosis. They found that patients who undergo a radical operation with adequate lymph node dissection have longer survival periods.

Nakao et al.163 presented a histopathologic examination of lymph nodes with metastasis from 139 specimens with cancer of the head of the pancreas (Fig. 21-45 and Tables 21-9, 21-10). Nakao et al. advised that wide dissection of lymph nodes, including paraaortic nodes, is necessary in patients with carcinoma of the pancreatic head.

Vossen et al.164 reported that pancreatic tumors in children are rare, the tumor pattern and biologic behavior is not the same as in adults, and complete surgical excision is the treatment of choice.

Sho et al.165 reported that intraductal papillary mucinous pancreatic tumors (IPMT) have high recurrence at the pancreatic remnant even after curative resection. The results of their study suggest that IPMT is a multicentric phenomenon and advise avoiding incomplete resection.

Nakagohri et al.166 found that intraductal papillary mucinous tumors, a localized malignancy, had a favorable prognosis after surgical treatment. They recommend curative pancreatectomy.

We quote from Kobari et al.:167

Intraductal papillary mucinous tumors may be comprised of 2 clinically distinct subtypes: MDTs [main duct tumors] and BDTs [branch duct tumors]. Initially, although distal pancreatectomy can be recommended for most MDTs, the need for cancer-free margins in this more aggressive type may necessitate total pancreatectomy. Pylorus-preserving pancreatoduodenectomies are recommended for most BDTs, but, because these tumors are more often adenomas, a good prognosis can be expected.

 

The enigmatic malignancy of the pancreatic head still produces problems for the patient and the surgeon.

We appreciate the emphatic statement of Warshaw168 on the diagnosis of pancreatic cancer, “If I think there is a mass, I want to be sure I have a high-quality contrast CT scan in hand as my principal imaging modality.”

Table 21-9. Operative Procedures for Carcinoma of the Head of the Pancreas Region

  No. of Total Pancreatectomies No. of Pancreatoduodenectomies
Carcinoma of the head of the pancreas (n = 90) 48 (48) 42 (41)
Carcinoma of the distal bile duct (n = 22) 1 (1) 21 (2)
Carcinoma of the papilla of Vater (n = 27) 1 (1) 26 (2)

Values in parentheses indicate the number of portal vein resections.

Source: Nakao A, Harada A, Nonami T, Kaneko T, Murakami H, Inoue S, Takeuchi Y, Takagi H. Lymph node metastases in carcinoma of the head of the pancreas region. Br J Surg 82:399-402, 1995; with permission.

Table 21-10. Lymph Node Involvement in Patients with Carcinoma of the Head of the Pancreas Region

Lymph Nodes Carcinoma of the Head of the Pancreas(n=90) Carcinoma of the Distal Bile Duct (n=22) Carcinoma of the Papilla of Vater (n=27)
1 0 0 0
2 0 0 0
3 0 0 0
4 0 0 1 (4)
5 0 0 0
6 13 (14) 0 0
7 0 0 0
8 12 (13) 1 (4) 0
9 2 (2) 1 (4) 0
10 1 (1) 0 0
11 16 (18) 0 0
12 17 (19) 5 (23) 1 (4)
13 46 (51) 3 (14) 11 (41)
14 21 (23) 2 (9) 3 (11)
15 0 0 0
16 23 (26) 2 (9) 0
17 35 (39) 1 (4) 6 (22)
18 3 (3) 1 (4) 0

Values in parentheses represent percentages.

Source: Nakao A, Harada A, Nonami T, Kaneko T, Murakami H, Inoue S, Takeuchi Y, Takagi H. Lymph node metastases in carcinoma of the head of the pancreas region. Br J Surg 82:399-402, 1995; with permission.

Fig 21-45.

Nomenclature of (A) perigastric lymph nodes in patients with carcinoma of the head of the pancreas and (B) lymph nodes in carcinoma of the head of the pancreas region. 1, right cardiac lymph nodes; 2, left cardiac lymph nodes; 3, lesser curvature lymph nodes; 4, greater curvature lymph nodes; 5, suprapyloric lymph nodes; 6, infrapyloric lymph nodes; 7, lymph nodes around the left gastric artery; 8, lymph nodes around the common hepatic artery; 9, lymph nodes around the celiac trunk; 10, lymph nodes at the hilum of the spleen; 11, lymph nodes along the splenic artery; 12, lymph nodes of the hepatoduodenal ligament; 13, posterior pancreaticoduodenal lymph nodes; 14, lymph nodes around the superior mesenteric artery; 15, lymph nodes along the middle colic artery; 16, para-aortic lymph nodes; 17, anterior pancreticoduodenal lymph nodes; 18, inferior pancreatic body lymph nodes. (Modified from Nakao A, Harada A, Nonami T, Kaneko T, Murakami H, Inoue S, Takeuchi Y, Takagi H. Lymph node metastases in carcinoma of the head of the pancreas region. Br J Surg 1995;82:399-402; with permission.)

Nerve Supply

Innervation of the pancreas occurs by the sympathetic division of the autonomic nervous system (Fig. 21-46) through the splanchnic nerves and by the parasympathetic division through the vagus nerve. The nerves generally follow blood vessels to their destinations. Perhaps together they constitute the “pancreatic nerve” of Holst.169

Fig. 21-46.

Autonomic nerve supply to pancreas. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979;15:17-50; with permission.)

Efferent and Afferent Fibers

Both the sympathetic and parasympathetic divisions provide efferent (motor) fibers to the wall of the blood vessels, the pancreatic duct, and pancreatic acini. Further, both contain visceral afferent (pain) fibers. The distribution of these in the pancreas, however, is not well understood.

Sympathetic Nerve Path

Preganglionic sympathetic innervation is from the greater and lesser thoracic splanchnic nerves. The former is composed of preganglionic efferent fibers from the 5th to the 9th or 10th thoracic segments. The latter is composed of fibers from the 9th and 10th or the 10th and 11th segments. Some fibers may be contributed by the least splanchnic nerve.

The sympathetic nerves pierce the diaphragmatic crura to reach the celiac and superior mesenteric ganglia. Postganglionic fibers arising from neurons in these ganglia accompany branches of the celiac and superior mesenteric arteries to reach the pancreas.

Some afferent fibers cross over the midline in the celiac plexus. The celiac ganglion contains cell bodies of efferent fibers for the pancreas. Cell bodies of afferent fibers are in the dorsal root ganglia at the same spinal nerve levels as those that contribute the preganglionic sympathetic fibers.

Interconnections of the afferent fibers from the pancreas with other sensory fibers from the body wall are presumably responsible for referral of pancreatic pain to the surface of the abdominal wall. Pain fibers from the pancreas pass cranially within the greater thoracic splanchnic nerve. They leave it by way of white communicating rami and enter the midthoracic spinal nerves. These neurons have their cell bodies within the dorsal root ganglia of those nerves.

Parasympathetic Nerve Path

Parasympathetic innervation is by way of the celiac division of the posterior vagal trunk. The efferent fibers are preganglionic axons from cell bodies in the dorsal motor nucleus of the vagus nerve in the brain.

The preganglionic vagal fibers synapse with terminal ganglion cells within the pancreas. The postganglionic fibers terminate at pancreatic islet cells. Almost 90 percent of the fibers carried by the vagus nerve are sensory in function, having to do with stretch, chemoreceptors, osmoreceptors, and thermoreceptors.170,171

Grundy172 states that fewer than 10 percent of the fibers carried by the vagus are autonomic efferents. The remaining fibers are sensory. These afferent fibers are processes of sensory neurons located in the sensory ganglia of the right vagus nerve at the jugular foramen of the skull. Vagal fibers pass through the esophageal hiatus of the diaphragm, usually as anterior and posterior trunks.

The posterior trunk divides into a posterior gastric and celiac division near the lesser curvature of the stomach.107 The neuronal processes of the celiac division of the posterior vagus traverse the nerve plexuses at the origins of the celiac and superior mesenteric arteries and accompany the branches of these arteries to reach the organs supplied by them. None of the fibers carried by the vagus synapse within the celiac ganglia.

Pain

Anatomically, it is not easy to explain the severe, excruciating pain of pancreatic disease. The etiology of pain secondary to pancreatic cancer is enigmatic and not easily understood. Drapiewski173 believes the nerves are invaded by the tumor in 84 percent of cases. Bockman and colleagues174 believe that the perineurium is damaged. Frey65 and Bockman et al.174 contend that inflammatory cells frequently concentrate around the nerves and the ganglia in patients with chronic pancreatitis.

Ductal hypertension, also, is responsible for the production of pain. Widdison et al.175 speculate on a compartment syndrome due to increased tissue and ductal pressure.

Bockman176 assumes that there are multiple paths for the genesis of pancreatic pain. He states that pain does not always occur with invasion of nerves by cancer or with distention of the pancreatic ducts.

Surgical Applications

Both sympathetic and parasympathetic pancreatic networks of patients with pancreatitis or pancreatic carcinoma can be treated by sympathectomy and vagotomy. The hope is always that division of the pathways of pain will relieve the terrible suffering of these unfortunate individuals.

According to Howard,177 sympathectomy has not proven a good procedure for palliation. However, Mallet-Guy,178,179 the father of left splanchnicectomy, reported good or perfect results in 83 percent of his patients. Stone and Chauvin180 found that pancreatic denervation (left transthoracic splanchnicectomy and bilateral vagotomy) gives reasonable control of incapacitating pain of chronic alcoholic pancreatitis. Cuschieri et al.181 advise bilateral endoscopic splanchnicectomy through a posterior thorascopic approach for the relief of intractable pain in patients with advanced pancreatic cancer. Thorascopic splanchnicectomy for palliation of inoperable pancreatic carcinoma is also reported by various workers.182,183

We quote from Skandalakis et al.184 about the use of vagotomy for treatment of severe pain secondary to pancreatic cancer or pancreatitis.

It is not clear whether afferent fibers of the vagus are involved in pancreatic pain. Vagotomy alone does not relieve the pain of pancreatitis,185 but Merendino186 believes that bilateral truncal vagotomy may provide relief from the pain of an inoperable carcinoma. This view has not won complete acceptance.

Flanigan and Kraft187 advised injection of 40 ml of 5% phenol in almond oil or 75% alcohol into the celiac plexus and splanchnic nerves. This chemical splanchnicectomy relieves pancreatic pain. Gardner and Solomon188 also recommended chemical splanchnicectomy to control pain secondary to unresectable carcinoma of the pancreas.

Hegedus189 reported that radiography-guided celiac ganglion block together with enzymatic substitution is useful for the relief of pancreatic pain.

Histology and Physiology

For all practical purposes, the pancreas consists of the islets of Langerhans and the acinar cells, the former fulfilling the endocrine function and the latter the exocrine function. The pancreas is poorly “encapsulated” by a very thin connective tissue (if the word “encapsulated” is permissible), since in the posterior wall of the pancreas there is no peritoneum.

Endocrine Function

The islets of Langerhans form small networks of cells that secrete hormones that control and regulate glucose. The islets of Langerhans constitute only 2 percent of the pancreatic mass. They consist of several types of cells: A (alpha), B (beta), D (delta), and F or PP (pancreatic polypeptide). Each type has a different physiological destiny: A secretes glucagon; B secretes insulin; D secretes somatostatin (inhibitor of insulin and glucagon); F secretes pancreatic polypeptide (inhibitor of pancreatic exocrine secretion).

It is well known that some bodybuilders use insulin to improve athletic performance. These athletes unfortunately ignore the health risks of insulin use.190

The distribution of the types of cells throughout the pancreas varies. For example, B and D cells are evenly distributed, while islets in the uncinate process are rich in F cells and poor in A cells. Islets in the body and tail are rich in A cells and poor in F cells.191

From the portion of the ventral diverticulum of the duodenum —which gives rise to the terminal portion of the main pancreatic duct (of Wirsung), the uncinate process, and part of the head of the pancreas— no islets (of Langerhans) are present in the pancreatic parenchyma.

Exocrine Function

The exocrine pancreas is formed by acinar cells, ducts, and ductules. Together they constitute 80 percent to 90 percent of the pancreatic mass. An acinus is a collection of acinar cells responsible for the secretion of enzymes of digestion, pancreatic fluids, and electrolytes. All secretions of the acini drain through the ductal network into the duodenum through the major and minor duodenal papillae.

It is well known that vagal stimulation augments the exocrine secretion of the pancreas. Perhaps the sympathetic nervous system inhibits the exocrine secretion.

The pancreas secretes 500 to 800 mL/d of an alkaline fluid that contains bicarbonate and digestive enzymes such as amylase, lipase, and trypsinogen.192

Surgical Applications

 

Resection of the head of the pancreas for cancer by pancreaticoduodenectomy theoretically removes the cancer, but according to Seymour et al.,193 also removes 95 percent of the PP cells because most of these cells are located in the uncinate process. Because of the even distribution of B and D cells throughout the pancreas, subtotal pancreaticoduodenectomy will not disturb the secretion of insulin and somatostatin. Since B cells are responsible for the synthesis of insulin, 80 percent of the islet mass194 must be destroyed, surgically or otherwise, before diabetes will be obvious.

Repeated episodes of chronic and acute pancreatitis will partially or totally destroy the ductular draining network. This produces not only pancreatic exocrine insufficiency but also pancreatic cysts and pain.

Yamaguchi et al.195 recommend the use of red litmus paper to detect pancreatoenterostomy leakage of alkaline pancreatic juice.

Sato et al.196 reported that there is a correlation between preoperative exocrine function and pancreatic juice secretion and leakage after pancreaticojejunostomy. Greater pancreatic juice production occurred in patients who had exhibited normal preoperative exocrine pancreatic function than in those with low pancreatic juice production. Greater pancreatic juice production also correlated with risk of pancreatic juice leakage.

Sho et al.197 demonstrated that evaluation of the function of the pancreatic remnant after pancreaticoduodenectomy is feasible with secretin-stimulated magnetic resonance cholangiopancreatography.

Pancreatitis

Laboratory findings and etiological factors of acute pancreatitis presented by Ranson198 are shown in Table 21-11 and Table 21-12 respectively.

Table 21-11. Routine Laboratory Findings in 100 Patients with Acute Pancreatitis versus Those in 100 Patients with Other Acute Abdominal Emergencies

Laboratory Test Acute Pancreatitis (%) Other (%)
Serum amylase (Somogyi units/dl)    
  >500 59 1
  200-500 36 4
  <200 5 95
Hematocrit (%)    
  >45 31 23
  <45 69 77
White blood cell count (cells/mm3) 
 
   
  >12,000 41 53
  <12,000 59 47
Blood glucose (mg/dl)     
  >300 7 0
  200-300 9 7
  Diabetics excluded: <200 84 93
Serum calcium (mg/dl)    
  >9 76 67
  8-9 15 31
  <8 9 2
Serum LDH (IU/L)    
  >225 48 24
  <225 52 76
Serum GOT (Sigma-Frankel units/dl)    
  >100 37 8
  <100 63 92

Source: Ranson JHC. Diagnostic standards for acute pancreatitis. World J Surg 21:136-142, 1997; with permission.

Table 21-12. Etiologic Factors of Acute Pancreatitis

Metabolic
  Alcohol abuse
  Hyperlipoproteinemia
  Hypercalcemia
  Drugs
  Genetic
  Scorpion venom
Mechanical
  Cholelithiasis
  Postoperative (gastric, biliary)
  Pancreas divisum
  Posttraumatic
  Retrograde pancreatography
  Pancreatic duct obstruction: pancreatic tumor, Ascaris
  infestation
  Pancreatic ductal bleeding
  Duodenal obstruction
Vascular
  Postoperative (cardiopulmonary bypass)
  Periarteritis nodosa
  Atheroembolism
Infection
  Mumps
  Coxsackie B
  Cytomegalovirus
  Cryptococcus 

Source: Ranson JHC. Diagnostic standards for acute pancreatitis. World J Surg 21:136-142, 1997; with permission.

The etiologic factors of pancreatitis are multiple:

 

Alcohol-induced (most common)

Postoperative

Endoscopic retrograde cholangiopancreatography- and endoscopic sphincterotomy-induced

Infectious disease

Lad et al.199 reported recurrent pancreatitis secondary to a duodenal duplication cyst.

We recommend the excellent text by Berger and colleagues200 to the interested student.

Extravasations of Pancreatic Fluid

The track of pathological peripancreatic fluid collections (Figs. 21-47, 21-48, 21-49, and 21-50), as in pancreatitis, depends on the involved part of the organ. However, the chest and peritoneal cavity are not immune. Occasionally the scrotum is involved. Primarily, the spaces around the kidneys are the first to be occupied by pancreatic fluid. To understand the pathways of the fluid, the extraperitoneal spaces should be studied. These are described below.

Fig 21-47.

Fluid collection in right anterior pararenal compartment with viscus displacement. P, pancreas; C, colon; K, kidney; D, duodenum. (Modified from Meyers MA. The extraperitoneal spaces: normal and pathologic anatomy. In: Meyers MA. Dynamic Radiology of the Abdomen (4th ed). New York: Springer-Verlag, 1994. Original drawing appeared in Meyers MA, Whalen JP, Peelle K. Radiologic features of extraperitoneal effusions: an anatomic approach. Radiology 1972; 104:249-257; with permission.)

Fig. 21-48.

Anterior pararenal hemorrhage from ruptured calcified splenic artery aneurysm (arrows). Extension from ruptured splenic artery into anterior pararenal space and into phrenicocolic ligament. C, colon; P, pancreas; K, kidney. (Modified from Meyers MA. The extraperitoneal spaces: normal and pathologic anatomy. In: Meyers MA. Dynamic Radiology of the Abdomen (4th ed). New York: Springer-Verlag, 1994. Original drawing appeared in Meyers MA, Whalen JP, Peelle K. Radiologic features of extraperitoneal effusions: an anatomic approach. Radiology 1972;104:249-257; with permission.)

Fig. 21-49.

Pancreatic extravasation with extension down anterior pararenal space, then upward into posterior pararenal compartment. Sagittal diagram illustrates fluid collection in left anterior pararenal space from pancreas, and continuity under and around cone of renal fascia into posterior pararenal compartment. P, pancreas; K, kidney. (Modified from Meyers MA. Acute extraperitoneal infection. Semin Roentgenol 1973;8:445-464; with permission.)

Fig. 21-50.

Pathways of pancreatic extravasations to neck, mediastinum, lesser sac, root of small bowel mesentery, mesentery of transverse colon, pouch of Douglas, and scrotum through a patent tunica vaginalis. Lv, liver; ST, stomach; P, pancreas, D, duodenum; C, colon; SI, small intestine; BL, bladder; R, rectum. (Modified from Skandalakis LJ, Skandalakis JE, Gray SW. Anatomy of the pancreas. In: Glazer G, Ranson JHC (eds). Acute Pancreatitis. London: Baillière Tindall, 1988, pp. 51-99; with permission.)

Extraperitoneal Spaces and the Pancreas

The posterior parietal peritoneum and the transversalis fascia are the anterior and posterior boundaries, respectively, of the retroperitoneal space. This space extends from the pelvic brim inferiorly to the diaphragm superiorly. Among the major structures it encompasses are the adrenal glands, kidneys, ureters, portions of the duodenum, pancreas, inferior vena cava, aorta, portal vein, and ascending and descending colon. In a horizontal cross section, the space is somewhat C-shaped due to the curvature of the lumbar spine. As a result, some retroperitoneal structures (pancreas and duodenal loop) lie anterior to others (spleen, kidneys, and posterior aspect of the liver).

Meyers201 divides the extraperitoneal region into three compartments according to their demarcation by well-defined fascial planes (Figs. 21-51, 21-52, and 21-53). The anterior and posterior layers of Gerota’s fascia are central to the division of the extraperitoneal region. The kidney and the perirenal fat are enveloped by this dense sheath. The fusion of its two layers behind the ascending or descending colon forms a single lateroconal fascia. This continues around the flank to blend with the peritoneal reflection and to form the paracolic gutter.

Fig. 21-51.

Three extraperitoneal compartments. Stripes, anterior pararenal space; stipples, perirenal space; cross-hatches, posterior pararenal space. (Modified from Meyers MA. Radiologic features of the spread and localization of extraperitoneal gas and their relationship to its source: An anatomical approach. Radiology 1974;111: 17-26; with permission.)

Fig. 21-52.

Three extraperitoneal spaces. 1, anterior pararenal space; 2, perirenal space; 3; posterior pararenal space; QL, quadratus lumborum muscle; C, colon; K, kidney; PM, psoas major muscle. (Modified from Meyers MA. The extraperitoneal spaces: normal and pathologic anatomy. In Meyers MA. Dynamic Radiology of the Abdomen (4th ed). New York: Springer-Verlag, 1994; with permission.)

Fig. 21-53.

Relationships and structures of three extraperitoneal spaces on left. Sigmoid colon in continuity with posterior and anterior pararenal compartments. L, liver; P, pancreas; K, kidney; C, colon. (Modified from Meyers MA. Acute extraperitoneal infection. Semin Roentgenol 1973;8:445-464; with permission.)

Meyers named these three compartments, listed here and discussed in the paragraphs below.

 

Anterior pararenal space. This space extends from the posterior parietal peritoneum to the anterior renal fascia. It is confined laterally by the lateroconal fascia.

Perirenal space. Within this space, the kidney and perirenal fat reside within the confines of Gerota’s fascia.

Posterior pararenal space. This area extends from the posterior renal fascia to the transversalis fascia. It is a thin layer of fat lateral to the lateroconal fascia, also known as the preperitoneal fat.

Anterior Pararenal Space

The anterior pararenal space includes the ascending and descending colon, the duodenal loop, and the pancreas, which are the extraperitoneal portions of the alimentary tract. This space is continuous across the midline. It is important to understand this anatomy when considering the pathways that pancreatic extravasations can take.

Perirenal Space

Although debate continues on the issue, it is often said that the perirenal space has no continuity across the midline. This is due to fusion at two locations. The posterior fascial layers fuse with the psoas or quadratus lumborum fascia medially. The renal fascia fuse with the dense mass of connective tissue surrounding the great vessels in the root of the mesentery and behind the pancreas and duodenum anteriorly. If continuity of the perirenal spaces is present, as seen in the passage of extravasating fluids or blood across the midline, it usually appears at the level of the hila and inferior poles of the kidneys.

Posterior Pararenal Space

The fusion of the transversalis fascia medially with the muscle fascia demarcates the posterior pararenal space. Thus, the margin of the psoas muscle limits and parallels the space. No organs are contained within this space. Potential communication with the preperitoneal fat of the anterior lateral abdominal wall, however, is possible.

Anatomy of Pancreatitis

Having reviewed the anatomy of the retroperitoneum, one can begin to understand the pathways that pancreatic extravasations can take. Eventually these extravasations arrest and form a pseudocyst, or subsequently an abscess. Knowledge of the extraperitoneal structures and planes can help us understand how adjacent structures contribute to the wall of the pseudocyst or abscess.

Different portions of the pancreas drain and localize to different areas. Drainage from the head of the pancreas is downward and to the right. The fluid can then come into contact with the ascending colon when traveling in the anterior pararenal space. Extravasations from the tail of the pancreas travel to the left in the anterior pararenal space, encountering the left colon, spleen, and left kidney.

Pancreatic extravasations can travel from any portion of the pancreas craniad to the neck, mediastinum, or lesser sac, into the root of the small bowel mesentery, and transperitoneally to settle into the most dependent portion of the peritoneal cavity. If a patent tunica vaginalis exists, this extravasation can present as a hydrocele in the male. This fluid can then extend below the level of the lateroconal fascia, gain access to the preperitoneal flank fat, and continue externally to the peritoneum.

With severe pancreatitis, the extravasations can travel through fascial planes to the posterior pararenal space from the anterior pararenal space without contaminating the perirenal compartment. Pancreatic extravasations can travel down the anterior pararenal space, rise posterior to the cone of the renal fascia, and thus reside within the posterior pararenal space. This displaces the kidney and colon anteriorly. This pathway provides an explanation for the classical signs of extensive pancreatitis, such as the subcutaneous discoloration known as Grey Turner’s sign or Cullen’s sign.

After the pancreatic extravasation enters the posterior pararenal space, it can violate the transversalis fascia. It can travel up to the chest or mediastinum. Though the transversalis fascia is known as “the girdle of the abdomen,” there are some areas where it is attenuated and therefore weak. As the transversalis fascia ascends toward the diaphragm, it becomes thinner, especially where it blends with the diaphragm. Fibers of transversalis fascia can actually become lost in the area of fat external to Gerota’s fascia covering the posterior surface of the kidneys. The transversalis fascia can become attenuated in this area posterior to the kidney. It is here, also, that fluid in the posterior pararenal space can gain access to the plane outside the transversalis fascia.

A study by Nakamura et al.202 found that pancreaticobiliary maljunction (PBM), an anomaly commonly associated with congenital dilatation of the bile duct (CDBD), may be a possible cause of recurrent pancreatitis. Reflux of pancreatic juice into the bile duct is possible through the PBM. This study suggested involvement of activated phospholipase A2 in the pathogenesis of choledochal cyst-associated pancreatitis. Sugiyama et al.203 reported that magnetic resonance cholangiopancreatography is an accurate method for the diagnosis of anomalous pancreaticobiliary junction.

Retroperitoneal Dissection Secondary to Pancreatic Inflammatory Disease

Pancreatic inflammation at the height of the attack does not respect fascial planes, although residual exudate may be confined to definite spaces. If pancreatic fluid violates the retroperitoneal spaces, it may rupture into a hollow viscus such as the duodenum or transverse colon or it may rupture into the peritoneal cavity.

The continuity of the retroperitoneal spaces allows extension of pancreatic fluid into the thorax above and the scrotum below, as well as into the left retroperitoneal space, perihepatic and peripancreatic spaces, transverse mesocolon, and gastrocolic omentum204,205 (Fig. 21-54). Jaffe and colleagues206 reported 12 cases with dissection into the mediastinum, six through the aortic hiatus, and six through the esophageal hiatus.

Fig. 21-54.

Spaces and peritoneal reflections of abdomen. Spaces: A, right subphrenic; B, left subphrenic; C, right subhepatic; D, lesser sac; E, perisplenic; F, right paracolic; G, left paracolic; H, pelvic; J, left infracolic; K, right infracolic. Reflections: 1, coronary ligaments and bare area; 2, duodenum; 3, small intestine; 4, colon; 5, stomach; 6, phrenicocolic ligament; 7, scrotum; 8, gastrosplenic ligament; 9, hepatogastric ligament; 10, falciform ligament. Possible pathways of pancreatic drainage: W, left paracolic space to scrotum; X, perforation into duodenum or colon; Y, perforation into perisplenic or left paracolic spaces; Z, perforation through diaphragm to pleura and lung. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Schoenberg et al.207 defined “pancreatic abscess” as a localized collection of pus surrounded by a capsule or a pseudocapsule. “Septic (infected) necrosis” is a diffuse bacterial inflammatory process of necrotic pancreatic and peripancreatic tissues. Surgery is the treatment of choice for both conditions. However, for culture-positive peripancreatic fluid collections or abscesses Baril and colleagues208 recommended percutaneous catheter drainage as the initial treatment, with surgical intervention reserved for patients in whom treatment fails.

We quote from Seifert et al.209:

Standard management of infected peripancreatic necrosis consists of open surgical debridement and lavage – a traumatic intervention with substantial morbidity and mortality. [A]n alternative and novel approach with minimum invasiveness…[is] fenestration of the gastric wall and debridement of infected necrosis by direct retroperitoneal endoscopy…this strategy led to rapid clinical improvement and no serious complications. Transgastric endoscopic therapy may be a less traumatic alternative to surgery and should be further assessed in prospective studies.

Beger et al.210 reported the determinants of the natural course of acute pancreatitis.

 

Pancreatic parenchymal necrosis

Extrapancreatic retroperitoneal fatty tissue necrosis

Biologically-active compounds in pancreatic ascites

Infection or necrosis

Two subgroups of patients with necrotizing pancreatitis have been identified by Sakorafas et al.211 The group with totally necrotic pancreatic parenchyma and peripancreatic tissues had a poor prognosis. The second group, with peripancreatic necrosis only and with viable pancreatic parenchyma, had a better prognosis.

A standard treatment protocol for managing biliary pancreatitis used by Liu et al.212 is shown in Figure 21-55. Uomo et al.213 concluded that severe biliary pancreatitis in patients with sterile necrosis frequently produces loss of integrity of the main pancreatic duct, and this should not be considered an absolute indication for surgical intervention.

Fig. 21-55.

Treatment protocol for biliary pancreatitis. ERCP, endoscopic retrograde cholangiopancreatography; ES, endoscopic sphincterotomy; CT, computed tomography; IOC, intraoperative cholangiogram; CBDE, common bile duct exploration. (From Liu CL, Lo CM, Fan ST. Acute biliary pancreatitis: diagnosis and management. World J Surg 1997;21:149-154; with permission.)

Stolte and Waltschew214 studied the relation of chronic pancreatitis and the papilla of Vater. They reported the following:

 

1. Chronic pancreatitis is often associated with inflammatory changes of the papilla of Vater.

2. Benign stenosis of the papilla may be caused by heterotopic pancreas or by peripapillary duodenal wall cysts.

3. Benign stenosis is located at the pre-papillary part of the pancreatic duct.

4. The function of the papilla is enigmatic.

Do Stolte and Waltschew mean ampulla of Vater or papilla?

Bosscha et al.215 advised open management of the abdomen and planned reoperation for the treatment of patients with fulminant acute pancreatitis.

Chronic pancreatitis in childhood is a rare but potentially debilitating disorder. Weber and Keller216 advocate distal pancreatectomy and pancreaticojejunostomy to treat this condition. DuBay and colleagues217 favor the modified Puestow procedure (longitudinal pancreaticojejunostomy), and state that direct pancreatic duct localization during the procedure carries a lower morbidity rate than localization via distal pancreatectomy.

Apoptotic cell death of renal tubules takes place in severe acute pancreatitis and thus might be one of the mechanisms of renal failure, according to Takase et al.218

Surgery

Exploration of the Pancreas

The entire pancreas must be methodically evaluated. It can be approached by dividing the hepatogastric omentum or the gastrocolic omentum. Under usual circumstances, the gastrocolic omentum is incised widely and provides good exposure of the entire pancreas. If this exposure proves to be inadequate, the hepatogastric omenta can be divided also, and upward traction can be applied to the stomach.

Kocherization of the duodenum is necessary for palpation of the head of the pancreas. The hepatic flexure of the colon is mobilized, then the peritoneum is incised lateral to the second part of the duodenum. After completing this step, the left index and middle fingers are placed posterior to the duodenum and the head of the pancreas, with the left thumb anterior. The surgeon can now palpate the head of the pancreas as well as the pancreatic portion of the common bile duct. Lymph nodes can sometimes be felt at the distal portion of the CBD, near the upper part of the posterior surface of the head of the pancreas.

The left index finger can continue the exploration posterior to the neck of the pancreas. Occasionally, both index fingers can be used (Fig. 21-56). The surgeon’s left hand approaches the neck from above, the left index finger posterior to the neck. The right hand proceeds from below, the right index finger posterior to the neck.

Fig. 21-56.

Exploration of pancreas. Surgeon’s fingers shown passing behind neck of pancreas, which should separate easily from underlying blood vessels. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 1979; 15:17-50; with permission.)

One criterion for resection for cancer is the ability to separate the neck of the pancreas from the underlying superior mesenteric and portal veins. Silen66 rejects this maneuver because of possible avulsion of a posterosuperior pancreatoduodenal vein that may enter the superior mesenteric vein on its anterior surface.

Papadimitriou et al.219 presented a modificaton of pancreaticoduodenectomy for the treatment of carcinoma of the pancreas and stated the following:

Careful detachment of the posterior surface of the pancreas from the anterior surface of the portal vein and performance of pancreaticojejunal anastomosis to a defunctionalized jejunal loop results in lower mortality and morbidity rates, thus making pancreatoduodenectomy a safe procedure.

The uncinate process is the most difficult part of the pancreas to explore and evaluate because of its close relation to the superior mesenteric artery and vein.

The following paragraphs report research findings regarding surgical methods and prognosis. Preliminary abdominal exploratory maneuvers are discussed in the chapter on the peritoneum and omenta. Here we are concerned with specific approaches to the pancreas after the abdomen has been opened. Pancreatic carcinoma is discussed following this section.

There are at least six possible routes for abdominal exploration. Each route has particular advantages and disadvantages:220

 

Through the gastrocolic ligament: route used by most surgeons.

Through the hepatogastric omentum: useful in patients with exceptionally ptotic stomachs.

By detaching the greater omentum from the transverse colon: time consuming, but better visualization of the entire lesser sac.

Through the mesocolon: limited exposure of the pancreas, and risks injury to the middle colic blood vessels.

Kocher maneuver: good exposure of the posterior surface of the head of the pancreas.

Mobilization of the splenic flexure inferiorly and the spleen and tail of the pancreas: appropriate when partial pancreatectomy and splenectomy are seriously contemplated.

Evaluating Resectability

We believe the most appropriate way to evaluate the resectability of a cancerous pancreas is to evaluate the area least likely to be invaded by the neoplasm and proceed to areas most likely to be invaded. Our criteria for resectability are as follows:

 

The surgeon must perform good general exploration of the abdomen with special attention to the pancreas.

Attention must be given to specific areas of lymph node drainage that are accessible without further incision, i.e., the pyloric and pancreatoduodenal nodes and the nodes at the root of the mesentery (Fig. 21-44A).

Further investigation of lymph nodes is necessary. This requires some incision of the hepatogastric omenta and a Kocher maneuver. Pancreatoduodenal, celiac, and left gastric nodes, together with nodes of the superior and inferior pancreatic borders, should be inspected.

Once the diagnosis of cancer has been determined and the previously outlined exploration has indicated a resectable lesion, the following final steps should be undertaken before the start of the actual resection.

 

– Further exploration of the area of the ligament of Treitz to ensure mobility of the fourth part of the duodenum and the first portion of the jejunum.

– Evaluation of the posterior surface of the head of the pancreas and the distal common bile duct. Ensure there is no fixation to underlying structures, including the inferior vena cava.

– Gentle examination of the uncinate process and elevation of the neck of the pancreas with one or two fingers. Ensure they are not fixed to the superior mesenteric vessels or to the portal vein (see Fig. 21-56). Cattell and Warren221 recommend incision of the hepatogastric ligament with division of the right gastric and gastroduodenal arteries to ensure adequate evaluation of possible fixation in this region.

– Final review of the local anatomy to identify any previously undetected vascular anomalies. Any available angiograms should be studied.

Recently, Merchant et al.222 found that positive peritoneal cytology is very specific in predicting when a pancreatic carcinoma is not resectable.

In their classic paper published in 1979, Hermann and Cooperman223 wrote that localized masses in the head of the pancreas should be resected, even in the absence of histologic proof of malignancy. They suggested that “the smallest tumors, and perhaps those with the most favorable outcome, may never be resected for lack of histologic proof of the diagnosis.”

Commenting on a more radical operation, Roder et al.224 reported that portal vein resection did not prolong survival in patients with carcinoma of the head of the pancreas or of the distal common bile duct. The authors considered the prognosis “dismal” for such patients. Nakao and Kaneko225 recommend intravascular ultrasonography to rule out invasion of the portal vein by pancreatic carcinoma.

Farouk et al.226 reported excision of the papilla of Vater for benign and malignant processes. In all cases, pathology had been suggested by endoscopic biopsy.

Sauvanet et al.227 stated that a combination of endoscopic sphincterotomy and endoscopic ultrasonography prior to surgery are not accurate to distinguish benignancy from malignancy. Therefore, local excision of the tumor is not safe.

Howard et al.228 found that helical CT scanning prior to surgery is the best diagnostic test to determine tumor resectability. According to these authors, endoscopic ultrasonography underestimates resectability, and selective angiography is no longer helpful for evaluation of periampullary tumors.

Sohn et al.229 reported that in 33% of patients with periampullary adenocarcinoma at The Johns Hopkins Medical Institutions, the tumors were not resectable. Surgical palliation, with operative mortality of 3.1% and morbidity of 22%, produced excellent long-term results.

Kasahara et al.230 suggested careful papillo-choledochectomy as an alternative to pancreaticoduodenectomy to treat periampullary cancer.

Ryu et al.231 advised that segmental duodenal resection, including what the authors call the papilla of Vater, for focal cancer in adenoma and anastomosis of the jejunum to the duodenum, common bile duct, and pancreatic duct, is a safe and effective procedure. (There is confusion in the literature regarding the terms ampulla and papilla. A papilla is a nipplelike process. The duodenal papilla, for all practical purposes, is the mucosal exit of the ampulla, permitting excretions from the pancreaticobiliary system to enter the duodenum. An ampulla is a dilation of a canal or a duct. Near its exit at the duodenal papilla the common pancreaticobiliary channel is dilated, forming the ampulla of Vater.)

Martignoni et al.232 reported that preoperative biliary instrumentation and biliary drainage do not affect early or late surgical outcome in patients undergoing pancreaticoduodenectomy.

Pancreatic Carcinoma

Despite all the modern diagnostic procedures, an early diagnosis of pancreatic cancer is still a rare phenomenon. The senior author of this chapter (JES) has performed a very small number of duodenopancreatectomies, but a great number of palliative procedures. However, one of the other authors of this chapter (LJS), the product of the current era of surgery, has performed more Whipple duodenopancreatectomies than palliative procedures such as choledochoduodenostomies.

In a study of 7,145 patients,233 cancer of the pancreas was located in the head in 73.2 percent, in the body in 19.9 percent, and in the tail in 6.8 percent. Pancreatic carcinoma is a terrible disease whose cause is not known. We know something from demographic and epidemiological studies, but not enough to explain the etiology of primary pancreatic cancer.

Gudjonsson,234 using data collected 1972-1982, found that fewer than 1% of patients survive for more than five years. Sperti et al.235 and Ihse236 characterized long-term survival after surgical removal of pancreatic carcinoma as “poor” and “dismal.”

However, Tan et al.237 wrote that there is no reason for a nihilistic approach to pancreatic carcinoma. The median 5-year survival rate for resection alone is achievable in 15-25 percent of patients. A combined modality treatment approach may improve on that rate.

We quote from Tsiotos et al., who separate actual from actuarial survival (Table 21-13):238

Although pancreatectomy is still performed in fewer than 20% of all patients with pancreatic cancer, and 99% of all patients who develop pancreatic cancer eventually die of their disease, significant improvements have been made. Pancreatectomy is now safer, with major morbidity occurring in about 20% and operative deaths in less than 5%. After curative resection, the five year actual survival is realistically about 10%, with median survivals of 12 to 18 months. In smaller subgroups with favorable pathologic characteristics (neoplasms <2 cm without nodal or perineural invasion), the prognossis appears to be significantly better, with the 5-year survival about 20%. Further improvements in survival should be sought at the areas of earlier diagnosis and novel treatments designed to prevent locoregional recurrences; the actual role of extended resections will be determined by current, ongoing prospective, randomized trials.

Table 21-13. Survival Data after Pancreatectomy for Pancreatic Cancer in Recent Publications (since 1990)

Study Time Period Year of Publication No. of Patients 5-Year Actuarial Survival (%) 5-Year Actual Survival (%) Median Survival (Months)
Nitecki (4) 1981-1991 1995 174a 
 
7   18
Trede (5) 1972-1984 1990 44   25  
Yeo (6) 1970-1994 1995 201 26 13 18
Mosca (14) 1980-1994 1997 105 10   15
Connoly (26) 1946-1983 1987 89   3  
Wade (29) 1987-1991 1995 252 9   15
Janes (31) 1983-1985 1996 758a 
 
17    
Conlon (32) 1983-1989 1996 118a 
 
  10 14.3
Tsao (33) 1979-1992 1994 27 7    
Bramhall (34) 1977-1986 1995 145a 
 
10    
Sperti (38) 1970-1992 1997 113   6  
Griffin (39) 1977-1987 1990 36a 
 
17   11.5
Fortner (40) 1979-1991 1996 56   14  
Niederhuber (41) 1985-1986, 1991 1995 2160a 
 
12    
Enayati (42) 1987-1995 1997 37a 
 
35 “Few”  
Klempnauer (43) 1971-1993 1995 170a 
 
  7  
Roder (44) 1982-1990 1992 53 6   12

aStudies including tumors of the body/tail requiring distal pancreatectomy.

Source: Tsiotos GG, Farnell MB, Sarr MG. Are the results of pancreatectomy for pancreatic cancer improving? World J Surg 23:913-919, 1999; with permission.

Hirata et al.239 presented 1001 cases of pancreatic resection for invasive ductal carcinoma. They report that extensive lymph node dissection does not necessarily produce a favorable prognosis. In commenting on these findings, Traverso248 emphasized the difference between Japanese anatomic staging and Western clinical staging. Gouma et al.241 reported that there are no results which confirm that palliative resection should be performed routinely for pancreatic cancer.

Harrison et al.242 recommended pancreaticoduodenectomy to treat isolated metastatic or locally advanced nonperiampullary tumors. Edwards et al.243 described pancreaticoduodenectomy with en bloc colectomy as curative procedures for primary malignancies of the duodenum.

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Crawford244 reported cytologic diagnosis of solid and papillary epithelial pancreatic neoplasm. This tumor, which typically is found in young women, does not metastasize, and is amenable to cure.

John et al.245 found laparoscopic ultrasonography indispensible for detecting occult intraperitoneal metastases and pancreatic malignancies.

DiFronzo et al.246 stated that the procedure of choice for unresectable carcinoma of the pancreas is choledochoduodenostomy, which provides relief of jaundice and causes little morbidity.

Clavien and Selzner247 advised partial resection of the duodenum and pancreatic head for selected patients with duodenal and pancreatic pathological entities that do not require complete pancreatic head resection. Di Carlo et al.248 stated that the treatment of choice for cancer of the pancreatic head is the pylorus-preserving pancreaticoduodenectomy.

Hiraoka and Kanemitsu249 recommended intraoperative radiotherapy and extended pancreatic resection for local pancreatic carcinoma. They advocated hepatic resection with metastasis to the liver. Yeo and Cameron250 supported adjuvant chemoradiation therapy for resected patients with pancreatic carcinoma.

Remember

 

Cancer of the pancreas is a disease of acquired and inherited mutations in cancer-causing genes.254

There is no “correct” staging approach for the patient with pancreatic cancer. Nonetheless, Conlon’s study255 at Memorial Sloan Kettering Cancer Center found that pancreatic resections were performed in 77% of cases between 1993 and 1997 in comparison to 35% for the years 1983 to 1992. In most cases laparoscopic staging is used in combination with CT imaging, resulting in a decrease in unnecessary laparotomy but increased resection in cases where surgery is beneficial.

Yeo256 reported the following topographic locations of pancreatic pathology:

 

Pancreatic cancer: 43%

Ampullary cancer: 11%

Duodenal cancer: 4%

Chronic pancreatitis: 11%

Neuroendocrine tumors: 5%

The same author also reported the following from the Johns Hopkins experience:

The tumor-specific 10-year actuarial survival rates were: pancreatic, 5%; ampullary, 25%; distal bile duct, 21%; and duodenal, 59%. Particularly for patients with pancreatic adenocarcinoma, 5-year survival is not equated with cure because patients succumb to recurrent disease more than 5 years following resection.

 

Sarr wrote (personal communication, 1999, between M.G. Sarr and J.E. Skandalakis) that ductal adenocarcinoma of the body and tail of the pancreas accounts for 15-20% of all pancreatic cancers. He stated also that because a pancreatic tumor could be other than adenocarcinoma, a nihilistic approach would not be appropriate; the approach should be aggressive and realistic. The five-year survival was less than 10% at the Mayo Clinic, where Sarr practices.

Böttger and Junginger257 stated that pancreaticoduodenectomy should be performed for any pancreatic tumor even without histologic confirmation.

Balcom and colleagues258 noted a trend of older patients undergoing pancreatic resection for malignant and benign conditions, with an increasing frequency of operations being performed for cystic tumors and fewer for chronic pancreatitis.

Beger et al.259 concluded the following:

In patients with villous adenoma of the ampulla, ampullectomy was an adequate surgical treatment. In patients with a low-risk cancer in stages pTis and PT1 N0 M0, G1 or G2, a local resection with ampullectomy including local lymph node dissection is justified. An oncological resection of cancer of the ampulla by means of a pylorus-preserving partial pancreatoduodenectomy or the Kausch-Whipple resection is the surgical procedure of choice; the 3- and 5-year survival rates were 72% and 52%, respectively, in patients with R0 resections.

 

We quote Treitschke et al.260:

Villous adenoma is the most common tumor of the papilla of Vater, and transition from adenoma to carcinoma is now generally accepted as proven. It is thus essential for an adenoma to be removed… Ampullectomy provides an adequate surgical treatment of benign adenoma of the ampulla of Vater…If the histological findings as to benignity are unclear, resection of the head of the pancreas with preservation of the pylorus by an experienced surgeon is indicated.

 

Schwarz et al.261 advised that in patients with pancreatic carcinoma, splenectomy should be avoided unless required due to tumor proximity or invasion to the spleen.

Horvath and Chabot262 advocated that all patients able to tolerate surgery who have been diagnosed with a cystic pancreatic neoplasm undergo an aggressive surgical approach.

Pancreatic Resection

Total Pancreatectomy (Pancreatoduodenectomy)

Total pancreatectomy involves resection of the entire pancreas, as well as the distal stomach, duodenum, proximal jejunum, distal CBD, and spleen. It preserves the portal vein, the superior mesenteric artery and vein, the middle colic artery, and anomalous hepatic arteries. There are several modifications of the procedure.

Karpoff et al.263 offer this concise summary:

Total pancreatectomy can be performed safely with low mortality; survival is predicted by the underlying pathologic findings: patients undergoing total pancreatectomy for adenocarcinoma have a uniformly poor outcome. Those undergoing total pancreatectomy for benign disease or nonadenocarcinoma variants can have long-term survival. In patients who require total pancreatectomy for ductal carcinoma, the survival is so poor as to bring into question the value of the operation.

In editorial remarks about the National Cancer Data Base, Brennan264 reemphasized the lethality of pancreatic adenocarcinoma.

Trede265 stated, “Whipple’s duodenopancreatectomies remain the gold standard of surgical treatments for adenocarcinoma of the head of the pancreas.” Sung et al.266 found that “Whipple’s pancreatoduodenectomy offers not only a superior palliation but also the hope of cure.” Böttger et al.267 agreed with Sung and colleagues. They advised that even with elderly patients, the procedure of choice for ampullary carcinoma is radical resection.

But Madura et al.268 suggested that in patients with adenosquamous carcinoma of the pancreas, aggressive therapy should be tempered by the recognition that few patients with this disease live more than one year.

We quote from Moosa269:

Although the Whipple resection remains the first and best option for cancer of the head of the gland and periampullary region, total pancreatectomy should still be considered in rare specific instances for patients with long-standing diabetes who require insulin, such as (1) when there is obvious tumor growth along the main pancreatic duct or when multicentricity is suspected clinically; (2) when the pancreatic remnant is atrophic, soft, and friable and does not hold sutures; and (3) when a post operative pancreatojejunal leak cannot be controlled and reexploration necessitates a complete pancreatectomy.

Whipple Procedure (Partial Pancreatoduodenectomy)

Partial pancreatoduodenectomy differs from a total procedure in that the body and tail of the pancreas are preserved (Fig. 21-57). The Whipple procedure has been called proximal resection, but that term is ambiguous. The head of the pancreas is proximal in the developmental sense, but it is distal in terms of secretory flow in the pancreatic ducts.

Fig. 21-57.

Partial pancreatectomy: 95 percent pancreatectomy; 85 percent pancreatectomy; Whipple procedure; distal pancreatectomy. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Traverso and Longmire270 describe a pancreatoduodenectomy in which the pylorus and the first part of the duodenum, together with their blood supply, are preserved. The tail of the pancreas is preserved by a pancreaticojejunostomy, biliary function by a choledochojejunostomy, and continuity of the gut by a duodenojejunostomy. Van Berge Henegouwen et al.271 reported that pylorus-preserving pancreaticoduodenectomy (PPPD) is as safe a procedure as classic pancreaticoduodenectomy. Mosca et al.272 found that PPPD was as successful as the Whipple procedure, with nearly identical long term survival.

Takao et al.273 reported that pylorus-preserving pancreaticoduodectomy is an acceptable procedure in comparison to Whipple procedure for the treatment of periampullary cancer, having practically the same long-term survival and recurrence. PPPD has been advised by other authors as well.274-276

Tamura et al.277 reported that in cancer patients with pylorus-preserving pancreaticoduodenectomy and extensive resection of the portal vein, a splenic-inferior mesenteric venous anastomosis prevents gastric congestion.

Beger et al.278 also emphasized the preservation of the endocrine pancreatic function after doing a duodenum-preserving surgery for pancreatitis. Another study by Beger et al.279 reported that ampullectomy (removal of papilla and ampulla of Vater) has a mortality of 0.4% and morbidity less than 10%.

Pancreas-sparing duodenectomy or duodenum-sparing pancreatectomy for benign diseases are new procedures that are not in use by the majority of surgeons. Nagakawa et al.280 presented two cases with total resection of the pancreatic head and preservation of the duodenum, bile duct, and papilla. After careful study of the vasculature of the pancreatic head (anterior and posterior pancreaticoduodenal arcades), the following were ligated: right gastroepiploic artery and vein, anterior superior pancreaticoduodenal artery, several vessels running into the portal vein from the proximal portion of the pancreas, and the posterior inferior pancreaticoduodenal artery. Eddes et al.281 stated that neither endocrine nor exocrine function of the pancreas are negatively influenced by duodenum-preserving pancreatic head resection.

Sugiyama et al.282 recommended ultrasonography for detection of pancreatobiliary carcinomas as well as for detection of invasion of the portal vein.

Takahashi et al.283 advised that the branches of the uncinate process to the accessory pancreatic duct should be studied carefully for an accurate diagnosis of the pancreatic head region.

Furukawa et al.,284 using CT arteriography, found that the pancreatic head can be separated into two segments, each of which can be removed due to separate blood supplies (Fig. 21-58). The blood supply for the right cephalic side springs from the celiac artery. The blood supply for the left caudal side (uncinate process) is derived from the superior mesenteric artery.

Fig. 21-58.

Schema of blood supply to the peripancreatic region. SMV, Superior mesenteric vein; PSPD, Posterior superior pancreaticoduodenal artery; CEA, Celiac axis; MPD, Main pancreatic duct; CBD, Common bile duct; SMA, Superior mesenteric artery; SMV, Superior mesenteric vein. (Modified from Furukawa H, Iwata R, Moriyama N, Kosuge T. Blood supply to the pancreatic head, bile duct, and duodenum. Arch Surg 1999;134: 1086-1090; with permission.)

Takano et al.285 reported that pancreaticogastrostomy after pancreaticoduodenectomy is safer than pancreaticojejunostomy, especially with regard to the incidence of pancreatic fistula.

Ninety-Five Percent Pancreatectomy

Partial pancreatectomy and 95% pancreatectomy (which was first described by Barrett and Bowers286 and popularized by Fry and Child287 for chronic pancreatitis) are used instead of total pancreatectomy whenever possible because of the high mortality associated with total pancreatectomy.

In 1979, in a monograph about the surgical anatomy of the pancreas that was published in Contemporary Surgery, Skandalakis et al.136 wrote:

Embryologically, anatomically and surgically these three anatomical entities [pancreas, duodenum, common bile duct] form an inseparable unit. Their relations and blood supplies make it impossible for the surgeon to remove completely the head of the pancreas without removing the duodenum and the distal part of the common bile duct. Here embryology and anatomy conspire to produce some of the most difficult surgery of the abdominal cavity. The only alternative procedure, the so-called 95% pancreatectomy, leaves a rim of pancreas along the medial border of the duodenum to preserve the duodenal blood supply.

Fry and Child287 had presented their work on 95% distal pancreatectomy in Annals of Surgery in 1965. The senior author of this chapter, JES, had several conversations about 95% distal pancreatectomy with Dr. Child in Atlanta. He remembers him emphasizing the importance of carefully preserving the blood supply of the duodenum. This technique was popularized with several publications about duodenal perservation by Beger et al.288-292

A 95% pancreatectomy preserves a margin of pancreatic tissue along the concave border of the duodenum, together with the four pancreatoduodenal arteries and their arcades.293 The duodenum, the distal stomach, and the proximal jejunum are spared, together with about 5% of the pancreas. A more conservative variant is the 85% pancreatectomy (Fig. 21-57).

Distal Pancreatectomy

In a distal pancreatectomy, the pancreas is transected at the neck and the body. The tail and, usually, the spleen are removed (Fig. 21-57). The removal of the spleen is either to facilitate pancreatic resection294 or because of inflammatory fixation of the splenic vessels to the pancreas.295 In children, every effort should be made to preserve the spleen in pancreatic surgery.296

Sawyer and Frey297 indicated that for a select group of patients with chronic pancreatitis, namely, those with severe pain, ducts less than 5 mm in diameter, and whose disease is confined to the body or the tail of the pancreas, a 50% to 60% distal pancreatectomy may be the best operation.

According to White and colleagues,298 chronic pancreatitis may be treated with spleen-preserving pancreatectomy, with 80% of patients exhibiting complete pain relief. They caution that when the splenic artery and vein cannot be preserved, there is minimal risk of splenic complications needing further treatment, but splenectomy is avoided for the majority of patients.

Benoist et al.299 stated that for benign pancreatic disease, distal pancreatectomy with splenectomy has a lower morbidity rate than spleen-preserving distal pancreatectomy, and was considered the best procedure.

Kau et al.300 reported that the carbohydrate antigen 19-9 (CA 19-9) provides more diagnostic, resectability, and prognostic values than the carcinoembryonic antigen (CEA) in cases of periampullary carcinoma.

Mason301 reported that pancreatogastrostomy following pancreaticoduodenectomy for carcinoma of the pancreas is a good, safe procedure with anastomotic leakage rate of 4% in 733 cases.

Siech et al.302 reported that the treatment of choice for all pancreatic cysts and intraductal papillary mucinous pancreatic tumors is surgical resection.

Huguier and Mason303 reported that resection, if feasible, gives the best survival rates irrespective of tumor size or spread in groups of carefully selected patients with cancer of the exocrine pancreas.

Lo et al.304 advised distal subtotal pancreatectomy and enucleation of any tumor of the pancreatic head for insulinomas in multiple endocrine neoplasia type 1 (MEN-I) patients.

Doherty et al.305 advised aggressive screening programs for identification and initiation of treament of malignant MEN-I. Skogseid et al.306 recommended OctreoScan testing (Indium-111-penteoctreotide scan detection) for patients with multiple endocrine neoplasia type I, since conventional pancreatic imaging was not helpful. In cases other than limited disease, OctreoScan testing found true positives more often than any other method (75%).

Park et al.307 reported that most islet-cell tumors of the pancreatic head can be removed with enucleation and not with pancreaticoduodenectomy. However, if the lesion is located close to the pancreatic duct, pancreaticoduodenectomy is the procedure indicated.

Segmental Pancreatectomy

Is segmental pancreatectomy a useful procedure? Most likely, yes.

Warshaw et al.308 evaluated resection in the body of the pancreas. We strongly advise that the pancreatic surgeon read this beautiful paper. In commenting on this procedure, Lillemoe309 supported midpancreatic resection in selected patients for “making the operation fit the disease.” To summarize, the operation consists of:

 

Segmental resection of middle segment with tumor

Closure of the cephalic stump

Roux-en-Y jejunal loop mucosa-to-mucosa anastomosis of remaining body and tail of pancreas

In contrast, Borghi et al.310 advocated extended resections over segmental pancreatectomy in patients with pancreatic cancer. They cited close embryologic relations of both pancreatic buds with lymphatic and nerve networks and a possible relation to metastasis.

Espat et al.311 of Memorial Sloan-Kettering Cancer Center report the following in regard to patients with laparoscopically staged unresectable pancreatic adenocarcinoma:

 

1. Their study did not support the practice of routine prophylactic bypass procedures.

2. They advised biliary bypass only for patients with obstructive jaundice who fail endoscopic stent placement.

3. They advocated that gastroenterostomy be reserved for patients with confirmed gastric outlet obstruction.

Controversy

The controversy between total and partial pancreatectomy continues. One wonders why we should not always strive for total pancreatectomy, considering the anatomy of the pancreas. Perhaps it is because it does not increase survival!

Anatomic points to consider:

 

Absence of a capsule in which to place firm sutures

Intimate relations with the duodenum, CBD, and large blood vessels

Residual tumor left in about one-third of patients undergoing the Whipple partial pancreatectomy312

Drainage

Drainage for Chronic Pancreatitis: Pancreaticojejunostomy (Puestow Procedure)

A pancreaticojejunostomy (Fig. 21-59A) requires a longitudinal incision of the pancreas and the pancreatic ducts. This incision opens and drains all pockets of accumulated secretions. The spleen is removed and the tail and body of the pancreas are mobilized. The pancreas, thus prepared, is inserted into a defunctionalized limb of jejunum that has been brought through the transverse mesocolon. The jejunal stoma is sutured to the pancreas and the pancreatic duct. The blood supply is not impaired.313

Fig. 21-59.

Puestow procedures. A, Pancreas and its duct incised; entire pancreas is placed in a defunctionalized limb of jejunum; spleen is removed; end-to-side jejunojejunostomy completes operation. B, Pancreas may be too broad to fit into jejunum. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

An alternate method for a pancreas too broad to fit into the jejunum is to incise the pancreatic ducts without mobilizing the pancreas or removing the spleen. The defunctionalized limb of jejunum is anastomosed side-to-side to the incised pancreas (Fig. 21-59B). This gives adequate drainage if all obstructed pockets of the pancreatic duct are opened.

Internal Drainage of Pancreatic Pseudocysts

The treatment of pancreatic pseudocyst is controversial. Fusaro and Davis314 discuss the use of simple catheter drains, Roux-en-Y cystojejunostomy, and distal pancreatectomy.

The location of the pseudocyst determines the selection of the drainage site.315 The following paragraphs describe the treatment of pseudocysts.

Cystoduodenostomy

If the pseudocyst is in the head of the pancreas, it may be drained into the duodenum (Fig. 21-60). A probe is placed in the duodenal papilla to identify and protect the pancreatic duct. The pancreatic cyst is incised through the duodenal wall and the opening is sutured.

Fig. 21-60.

Cystoduodenostomy. (From Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: Mc Graw-Hill, 1983; with permission.)

Cystogastrostomy

If the pseudocyst is adherent to or displaces the posterior wall of the stomach, it may be drained into the stomach (Fig. 21-61). The anterior wall of the stomach is opened and the pancreatic cyst is incised through the posterior wall. The stomach wall and the cyst are sutured to provide drainage.

Fig. 21-61.

Cystogastrostomy. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Trías et al.316 performed laparoscopic cystogastrostomy for treatment of pancreatic pseudocyst.

Cystojejunostomy

If the pseudocyst is not close to the duodenum or the stomach, it may be drained into the jejunum (Fig. 21-62). The jejunal loop is raised and sutured to the pancreatic cyst to drain the cyst.

Fig. 21-62.

Cystojejunostomy. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Vitale et al.317 concluded that endoscopic drainage of pancreatic pseudocysts provides adequate treatment, and can be a valid option in selected patients before standard surgical treatment is utilized. Spivak et al.318 reported that operative management of pancreatic pseudocysts may be more successful than computed tomographic guided external drainage, currently very popular in many medical centers.

Stenting

Patients with a history of pancreatitis who exhibit signs of bile duct obstruction and pain, both of which resolve rapidly, should be examined for spontaneous pancreatic pseudocyst. According to Boulanger et al.,319 this rare complication of biliary fistula can be treated nonoperatively by endoscopic stenting of both the biliary tract and the fistula.

Pancreas and Laparoscopy

Laparoscopic procedures for pancreatic diseases began appearing in the literature in the mid-1990s. Hunter,320 one of the best laparoscopists, wrote the following in World Journal of Surgery:

It is perhaps surprising that I did not suggest in this “epilogue” that new procedures just over the horizon will again revolutionize minimally invasive surgery. It should be clear to the reader that every procedure that is usually performed through a laparotomy has been performed via laparoscopic access. This revolution will not be complete until we can objectively and reproducibly assess the value of each minimally invasive procedure and until we provide better uniform and reproducible training in endoscopic skills so these “herculean” procedures remain not in the domain of a few advanced laparoscopists but may be safely performed by most surgeons taking care of that organ system or disease group.

Park et al.321 reported the following:

 

1. For palliation in patients with pancreatic carcinoma, laparoscopic cholecystoenterostomy is technically straightforward, but has a higher rate of failure and complications than choledochoenterostomy (CDE). CDE requires advanced laparoscopic skills that preclude it from widespread adoption. Park et al. state their belief that a new CDE technique will be developed soon that will be technically feasible and practical.

2. Laparoscopic distal pancreatic resection, but not laparoscopic pancreaticoduodenectomy, benefits the patient with pancreatic cancer.

Laparoscopic pancreatic surgery for internal drainage of pancreatic pseudocysts and enucleation of benign insulinomas has had positive early reported outcomes, but experience is limited.322

Anatomic Complications

Complications of Exploration and Evaluation

Vascular Injury

The left gastric artery and vein may be injured by incision of the hepatogastric ligament. The middle colic artery may be injured by incision of the gastrocolic ligament. Bleeding from pancreatoduodenal arcades may result from an overenthusiastic Kocher maneuver.

Berney et al.323 stated that if the celiac axis is occluded due to atheromatous disease or arcuate ligament compression, temporary clamping of the gastroduodenal artery in some cases produces obvious ischemia. The above authors indicated that such occlusion in patients undergoing pancreatoduodenectomy rarely leads to significant problems. They also advised that trial clamping of the gastroduodenal artery is necessary to decide about the need for revascularization.

Organ Injury

The hepatic division of the anterior vagal trunk runs within the hepatogastric ligament and might be injured by incision of the ligament. The celiac ganglion should be identified and distinguished from lymph nodes removed for biopsy.

Inadequate Procedure

Failure to recognize metastatic lymph nodes can be a problem.

Complications of Diagnostic Procedures

Several diagnostic procedures that go beyond simple inspection may be necessary for diagnosis. These procedures and their possible complications are listed in Table 21-14.

Table 21-14. Complications of Some Diagnostic Procedures

Procedure Complications
1. Arteriography Hemorrhage
2. Percutaneous transhepatic cholangiography Hemorrhage
Bile peritonitis
Cholangitis
3. Transpancreatic or transduodenal pancreatography Pancreatitis
4. Endoscopic retrograde cholangiopancreatography (ERCP) Transient hyperamylasemia and hyperamylasuria (Classen et al., 1973)
Pancreatitis
Drug reactions
Pancreatic sepsis and pseudocyst abscess
Cholangitis (Bilbao et al., 1976)
Instrumental injury
5. Percutaneous core biopsy Sampling error
False negative results
Viscus perforation
Dissemination of cancer by seeding of the needle tract

Source: Modified from Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 15: 21-50, 1979; with permission.

Suits et al.324 reported that endoscopic ultrasound-guided fine needle aspiration is highly accurate in the diagnosis of pancreatic masses.

Is percutaneous core biopsy an attractive alternative to the diagnostic laparotomy, as stated by Karlson et al.325? Moossa,326 in an invited commentary on a paper by Tillou et al., was not convinced, and wrote “. . .one cannot escape the impression that routine preoperative biopsy of pancreatic masses is a triumph of technology over reason.” Moossa cited problems including sampling error, false negative findings, anatomic complications such as abscesses and fistulas resulting from colon perforation, dissemination of cancer by seeding of the needle tract, and interpretative errors by even the most accomplished pathologists.

Based on a study by Brandt et al.,327 Karlson et al.325 wrote, “Percutaneous passes through the stomach, spleen, colon, and small intestine previously have been accompanied by absence of complications in pancreatic biopsy.” This may be so, but we are in agreement with Moossa.326

Complications of Endoscopic Sphincterotomy

Lo et al.328 reported successful endoscopic sphincterotomy in 689 patients. Of these, complications (primarily associated with bleeding) occurred in 50 cases (7.1%), and 13 patients required emergency surgery.

We quote from Howard et al.329 on complications of endoscopic sphincterotomy (ES):

ES perforation has 3 distinct types: guidewire, periampullary, and duodenal. Guidewire perforations are recognized early and resolve with medical treatment. Periampullary perforations diagnosed early respond to aggressive endoscopic drainage and medical treatment. Postsphincterotomy perforations diagnosed late (particularly duodenal) require surgical drainage, which carries a high morbidity and mortality rate.

Stapfer et al.330 classified duodenal perforation injuries into four types by anatomic location:

 

I Lateral or medial wall (large injuries caused by endoscope requiring immediate surgery)

II Sphincter of Oddi (more discrete and less likely to require surgery)

III Distal bile duct near an obstructing entity (related to wire or basket instrumentation; manage with close surveillance)

IV Retroperitoneal air alone (no surgical intervention)

They stated that late recognition of duodenal perforation and nonsurgical treatment failures have a high complication and mortality rate.

Complications of Pancreatic Resection

Vascular Injury

Arteries

The surgeon should always determine whether an anomalous hepatic artery is present before proceeding with resection. If it is present, it should be preserved.

Aberrant Common Hepatic Artery

Accidental ligation of the aberrant common hepatic artery will not only result in hepatic ischemia and perhaps rare necrosis, but will jeopardize the duodenum as well.

Aberrant Right Hepatic Artery

The aberrant right hepatic artery occurs more frequently than the aberrant common hepatic artery. Since it is the only artery supplying the right lobe of the liver (or, to be more anatomically correct, the right half ot the liver), to avoid ischemia and necrosis, the aberrant right hepatic artery should not be ligated.

Aberrant Left Hepatic Artery

An aberrant left hepatic artery presents a problem in pancreatic surgery only when it arises from the right side of the superior mesenteric artery or from the gastroduodenal artery.

Middle Colic Artery

Accidental ligation of the middle colic artery may compromise the blood supply of the transverse colon.

Inferior Pancreatoduodenal Artery

While there is a common origin of the inferior pancreatoduodenal artery and the proximal jejunal arteries, ligation of the common trunk may compromise the viability of the proximal jejunum.220

Gastroduodenal Artery

Ligation of the gastroduodenal artery may result in ischemia. Section will result in hemorrhage.

Veins

Small veins from the neck of the pancreas occasionally drain into the anterior surfaces of the superior mesenteric or portal veins. These are a potential source of hemorrhage.220

Portal Vein

Hemorrhage from unsuspected tumor infiltration of the wall of the portal vein is a possible complication of pancreatoduodenectomy.331 The existence of this complication must be confirmed or excluded during the evaluation procedure before starting a pancreatoduodenectomy.

Other Vessels Subject to Injury

Other vessels subject to injury are the superior mesenteric artery or vein,332 splenic artery or vein,293 inferior vena cava, and renal artery or vein.

Organ Injury

In addition to the organs directly involved in total pancreatoduodenectomy, the cisterna chyli is vulnerable to injury, resulting in chylous ascites. The cisterna chyli lies beneath the pancreas and to the right of the superior mesenteric vessels at the level of the disk between the 12th thoracic and 2nd lumbar vertebrae. If sectioned accidentally, it must be ligated.333

Leakage of pancreatoenterostomy is a serious common complication of pancreatic resection. Yamaguchi et al.195 stated that red litmus paper can detect nondrained, transected pancreatic ductules on the cut surface of the pancreas. They can then be transfixed and closed with sutures.

To avoid dehiscence of pancreaticojejunostomy, Hamanaka and Suzuki334 cover the pancreatic stump with jejunal submucosa using a purse-string suture on the mucosal edge of the jejunum.

According to Büchler et al.,335 pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely necessitates surgical treatment.

Inadequate Procedure

Any partial pancreatectomy must be considered inadequate if portions of the tumor remain in the unresected pancreatic tissue. Other complications related to inadequate procedure are listed in Table 21-15.

Table 21-15. Anatomic Complications of Pancreatic Resection

Procedure Complications
1. Pancreatoenteric anastomosis (the least secure anastomosis) Leakage or disruption with:
  a. Abscess or peritonitis
  b. Ileus
  c. Pancreatic fistula
  d. Wound infection and dehiscence
  e. Bleeding from erosion of large vessels (Gadacz et al., 1978)
  f. Ductal fibrosis, obstruction, and pancreatitis
2. Biliary-enteric anastomosis (the most secure anastomosis) Leakage or disruption with:
  a. Abscess or bile peritonitis
  b. Biliary obstruction
  c. Biliary fistula
  d. Obstruction at the anastomotic site
  e. Ascending or descending cholangitis
3. Inadequate gastric resection Gastrojejunal ulceration (anastomotic ulcer)
4. General Operating room hemorrhage from major vessels:
  a. Portal vein
  b. Hepatic artery, normal or aberrant
  c. Superior mesenteric artery or vein
  d. Splenic artery or vein
  e. Inferior vena cava
  f. Renal arteries or veins
  g. Middle colic artery
Acute postoperative pancreatitis with:
  a. Ductal obstruction
  b. Direct injury to pancreas with leakage from pancreatic parenchyma
  c. Interference with blood supply or drainage

Source: Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 15:21-50, 1979; with permission.

Complications of Procedures Related to Pancreatitis

Pancreaticojejunostomy (Puestow Procedure)

Vascular Injury

Because the major vessels to the pancreas are not ligated, there should be few complications of major hemorrhage or ischemia. Sutures at the jejunal stoma must be placed so they avoid the main pancreatoduodenal arteries and veins. Injury may occur to the ASPD artery during the Puestow side-to-side pancreaticojejunostomy. Be careful with the middle colic artery.

Organ Injury

The spleen, if preserved, is subject to injury.

Inadequate Procedure

Failure to incise all dilated pockets of the pancreatic ducts may result in unrelieved pain after operation and require reoperation.313

Pancreatic Pseudocyst Drainage

We have generally considered the anatomy of pathologic processes to be beyond the scope of this book. Inflammatory pancreatic disease, however, so closely mimics iatrogenic complications that both conditions must be considered together. Some of these complications are shown in Table 21-16.

Table 21-16. Complications of Surgical Procedures

Procedure Complications
1. Internal drainage of pancreatic cyst  
  a. Cystogastrostomy Hemorrhage
Pancreatic necrosis
  b. Cystoduodenostomy Injury to common bile duct
Injury to pancreatic duct
Hemorrhage
  c. Cystojejunostomy (Roux-en-Y preferred) Hemorrhage
Reflux from too short defunctionalized limb or too small stoma
Comment: The site selected for internal drainage depends upon the location of the cyst. The lowest portion of the cyst must be able to drain by gravity into the anastomotic viscus chosen. Thus the operation must be planned to satisfy the need of the particular patient. 
2. External drainage of pancreatic cyst Complications minimal
Peritonitis
Comment: External drainage is outdated and is unpleasant for the patient. We have had to use it only twice. In a poor risk patient with multiple problems, external drainage of a pancreatic cyst should not be considered a sign of timidity but rather evidence of mature surgical judgment. 
3. Excision of cyst Duodenal fistula
Hemorrhage
Recurrence of cyst
Injury to common bile duct
Comment: Because the cyst is usually fixed firmly to surrounding organs, excision is not often recommended. It is the ideal operation where the cyst is in the body or tail and can be removed by itself. Only about 13 percent (Collins, 1950) are of this type. The mortality following excision is 8.7 percent (Warren et al., 1958). 
4. Sphincterotomy and sphincteroplasty Operating room complications: duodenal perforation, acute pancreatitis, postoperative hemorrhage, postoperative fibrosis and stenosis of ampulla, incomplete division of sphincter
Endoscopic complications: injury to the bile duct (Classen and Safrany, 1975), acute pancreatitis
5. Pancreaticoduodenostomy and pancreaticojejunostomy Anastomotic leak
Hemorrhage
Inadequate stoma
Injury to ducts with leakage and obstruction
Pancreatic necrosis from injury to vessel

Source: Skandalakis JE, Gray SW, Rowe JS Jr, Skandalakis LJ. Anatomical complications of pancreatic surgery. Contemp Surg 15:21-50, 1979; with permission.

For bleeding pseudocysts of the pancreas secondary to pancreatitis, Gambiez and colleagues326 advised arterial embolization of the affected artery (splenic, gastroduodenal, etc). In a separate study, Gambiez et al.327 advocate endoscopic retroperitoneal drainage of peripancreatic necrotic collections.

Retroperitoneal Dissection Secondary to Pancreatic Inflammatory Disease

Vascular Injury

Bleeding associated with pancreatitis may be from gastritis, duodenal ulcer, or esophageal varices. Erosion of major arteries and veins is the greatest danger. Gadacz and coworkers328 reviewed the literature (44 cases) and added 9 cases of their own.

The splenic artery is by far the most vulnerable vessel. The gastroduodenal artery is the second most frequently injured.293,339 Among 22 cases of preoperative hemorrhage reported by Gledhill,340 the splenic artery was the source of bleeding in nine, the gastroduodenal artery in three. Eckhauser and colleagues341 noted five cases of gastrointestinal bleeding secondary to aneurysmal degeneration of the gastroduodenal artery. There were three other cases in which the pancreatoduodenal artery was implicated. All were sequelae of acute or chronic pancreatitis.

Organ Injury

The organ most frequently affected by pancreatitis is the transverse colon, by reason of proximity (Fig. 21-63). Colonic complications include pseudo-obstruction owing to colonic spasm,342 ischemic obstruction,343 fistula formation,344 and gastrointestinal bleeding.

Fig. 21-63.

Relation of uncinate process of pancreas to transverse colon. Arrow indicates path pancreatic fluid may take to colon. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)

Other sites of injury, iatrogenic or from pancreatic juice, are the duodenum, CBD, and spleen. Splenic invasion by pancreatic pseudocysts leading to splenic rupture and hemorrhage is uncommon. However, it may be more common than findings indicate, because it may go unrecognized.339

Inadequate Procedure

Lack of knowledge of the best drainage route may result in failure to drain the pseudocyst. Lack of appreciation of the magnitude of peritoneal extension of the inflammatory process may result in failure to properly drain the fluid collection and perhaps to further the existing inflammation.

Pancreatic Transplantation

Anatomy of Pancreatic Transplantation

Most pancreas transplants are performed with kidney transplantation. Sudan et al.345 stated that simultaneous kidney-pancreas transplantation is a safe and effective treatment for advanced diabetic nephropathy associated with stable metabolic function, decreased cholesterol, improved hypertension control, and improved rehabilitation with low morbidity and mortality after the first year. We strongly advise consulting the chapter by Chauvin and Kittur in Cameron’s excellent book, Current Surgical Therapy, sixth edition346 for further information on simultaneous pancreas-kidney (SPK) transplantation.

Organ Procurement from Donor

 

1. Make a long midline incision from the sternal notch to the symphysis pubis (sternotomy and celiotomy).

2. Isolate the distal aorta and inferior vena cava. Control with vascular tape.

3. Enter the lesser sac through the gastrosplenic ligament by dividing and ligating the short gastric vessels.

4. Mobilize the spleen by incising the splenorenal ligament.

5. Rotate the pancreas and spleen medially.

6. Ligate and divide the inferior mesenteric vein.

7. Prepare and control the aortic segment just above the celiac axis by division of the diaphragmatic crura.

8. Isolate the origins of the celiac axis and superior mesenteric artery.

9. Identify and protect the left renal vessels.

10. Ligate the left adrenal and left gonadal veins.

11. Perform extensive duodenal kocherization.

12. Identify the distal common bile duct and ligate 1 cm to 2 cm from the pancreatic parenchyma.

13. Prepare and isolate the portal vein.

14. Mobilize the colon by dividing the gastrocolic and hepatocolic ligaments.

15. Ligate the mesentery of the small bowel with multiple nonabsorbable sutures.

16. Divide the gastropyloric junction using a TA-55 stapler.

17. Divide the small bowel distal to the ligament of Treitz using a GIA stapler.

18. Remove the small and large bowel from the peritoneal cavity.

19. The portal vein can be divided and the liver and pancreas can be removed en bloc.

20. Remove the donor iliac vessels (iliac Y graft) (Fig. 21-64) to be used for reconstruction of the splenic and superior mesenteric artery.

21. Perform duodenal resection leaving a 10 cm to 12 cm duodenal segment.

22. Perform splenectomy.

Fig. 21-64.

Donor pancreas prepared by splenectomy and ligation of splenic and superior mesenteric arteries (SMA) and veins (SMV). Duodenal stump secured with Lembert nonabsorbable suture. CBD, common bile duct; PV, portal vein. (Modified from Chauvin KD, Kittur DS. Pancreas transplantation. In Cameron JL. Current Surgical Therapy (6th ed). St. Louis: Mosby, 1998, pp. 539-543; with permission).

Organ Implantation to Recipient

 

1. Make a midline incision.

2. Graft the pancreas to the right iliac vessels.

3. Mobilize the right and left colon.

4. Expose the common, external, and internal iliac arteries.

5. Carefully prepare the right iliac vein by dividing and ligating all its posterior tributaries.

6. Anastomose the portal vein to the right iliac vein lateral to the iliac arteries.

7. Anastomose the reconstructed Y-graft and the common iliac artery.

8. Using your procedure of choice, anastomose the duodenum of the transplanted pancreas (exocrine secretion) to the urinary bladder (Fig. 21-65) or to a loop of small bowel, or perhaps ligate the pancreatic duct.

Fig. 21-65.

Simultaneous pancreas-kidney (SPK) transplantation utilizing ureteroneocystostomy. (Modified from Chauvin KD, Kittur DS. Pancreas transplantation. In Cameron JL. Current Surgical Therapy (6th ed). St. Louis: Mosby, 1998, pp. 539-543; with permission).

Stratta et al.347 reported that pancreas transplantation with portal venous delivery of insulin and enteric drainage of exocrine secretions can be performed with short-term results comparable to those of the more common procedures employing systemic venous delivery of insulin and bladder drainage of secretions.

Hricik et al.348 compared the prevalence and severity of hypertension in simultaneous pancreas-kidney transplantation patients and those receiving kidneys alone. They found that the beneficial effect of the pancreas transplant was limited to bladder-drained patients, and that blood pressure did not increase after conversion from bladder to enteric drainage.

The increased popularity of pancreas transplants has led to a growing number of potential candidates for retransplants after the initial graft has been lost to technical failure or rejection. Humar and colleagues349 stated that while retransplants can be performed with a minimal increase in surgical complications, graft survival is slightly inferior and patients require more aggressive monitoring for rejection.

Anatomic Complications of Simultaneous Pancreas-Kidney Transplantation and

Pancreas Transplantation

To illuminate urologic and nonurologic surgical complications of transplantation, we present two tables from the work of Chauvin and Kittur346 (Tables 21-17 & 21-18).

Table 21-17. Surgical Complications (Nonurologic) after Simultaneous Pancreas-Kidney Transplantation in 237 Recipients

Complications No. %
Non-transplant related    
  Small bowel obstruction 11 4.6
  Reoperation for intra-abdominal bleeding 11 4.6
  Wound infection 11 4.6
  Wound dehiscence 10 4.2
  Incisional hernia 5 2.1
  Negative laparotomy 4 1.7
  Intra-abdominal abscess drainage    
    Operative 5 2.1
    Percutaneous 3 1.3
  Enterocutaneous fistula repair 1 0.4
  Fasciitis 1 0.4
Transplant related    
  Lymphocele drainage 3 1.5
  Graft thrombosis    
    Pancreas only 3 1.3
    Pancreas-kidney 4 1.7
  Renal artery stenosis 1 0.4
  Iliac artery stenosis 1 0.4

Source: Chauvin KD, Kittur DS. Pancreas transplantation. In: Cameron JL. Current Surgical Therapy (6th ed). St. Louis: Mosby, 1998, pp. 539-543; with permission.

Table 21-18. Urologic Complications Related to Pancreas Transplant

Complications No. %
Hematuria 35 14.8
Bladder/duodenal segment leak 35 14.8
Reflux pancreatitis 24 10.1
Recurrent urinary tract infection 24 10.1
Urethritis 7 2.9
Urethral stricture/disruption 7 2.9

Source: Chauvin KD, Kittur DS. Pancreas transplantation. In: Cameron JL. Current Surgical Therapy (6th ed). St. Louis: Mosby, 1998, pp. 539-543; with permission.

Multiple nephrogenic adenomas of the bladder were reported in a patient three years after a simultaneous kidney-pancreas transplant. Pancreatic drainage was successfully converted from the bladder to the small bowel.350

Pancreatic Trauma

Pancreatic injury is an infrequent occurrence. Takashima and colleagues351 presented a classification of blunt pancreatic duct injuries discovered at pancreatography and their treatment:

 

Class 1. Radiographically normal ducts; no surgery required

Class 2a. Ductal branch damage without leakage; no surgery required

Class 2b. Ductal branch damage with minimal leakage; drainage laparotomy

Class 3. Main duct injuries; laparotomy

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