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  1. 1. Pancreas By Dr. Ihab Samy Lecturer of Surgical Oncology National Cancer Institute Cairo University 2014
  2. 2. • The pancreas was first mentioned in the writings of Eristratos (310-250 bc) and given its name by Rufus of Ephesus (circa 100 ad). • The name pancreas (Greek pan, all; kreas, flesh or meat) was used because the organ contains neither cartilage nor bone.
  3. 3. Location And Gross Description • The pancreas lies transversely in the retroperitonium across the posterior wall of the abdomen, at the back of the epigastric and left hypochondrial region , 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. • It is long and irregularly prismatic in shape. Its length varies from 12.5 to 15 cm., and its weight from 60 to 100 gm
  4. 4. Parts Of The Pancreas And Their Relations • Traditionally, the pancreas has 4 parts. • The right extremity, being broad, is called the head, and is connected to the main portion of the organ, or body, by a slight constriction, the neck; while its left extremity gradually tapers to form the tail.
  5. 5. • The posterior surface may be related to the third part of the common bile duct (CBD) in a variety of ways: • The bile duct is partially covered by a tongue of pancreatic tissue (44 %). • The bile duct is completely covered (30 %). • The duct is uncovered in (16.5 %) of cases . • The (CBD) is covered by two tongues of pancreatic tissue (9%) of cases.
  6. 6. Uncinate Process • Is a hook-like 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, with the left renal vein above and the 3rd part of duodenum below.
  7. 7. Pancreatic Ductal Anatomy • The main pancreatic and accessory ducts lie in an anterior plane to the major pancreatic vessels. • The main pancreatic duct (Wirsung) arises in the tail of the pancreas and lies between the superior and inferior borders, slightly closer to the superior border, and lies in a more posterior than an anterior plane.
  8. 8. • There are 15 - 20 short tributaries that enter the duct at right angles. • 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. • After entering the head of the pancreas, it turns inferiorly and posteriorly. In the lower part of the head of pancreas, it joins the distal end of (CBD) forming the hepatopancreatic ampulla (Vater), which enters the descending part of the duodenum at the major duodenal papilla.
  9. 9. • Its length varies from 175 to 275 mm.The diameter is greatest in the pancreatic head at 3 to 4 mm and decreases to 1 to 2 mm in the tail. • The accessory pancreatic duct (Santorini) (absent in 15%-30% of individuals) empties into the duodenum just above the major duodenal papilla at the minor duodenal papilla. • In 11% of cases the main duct is suppressed and loses its connection to the accessory duct (pancreas divisum). • The pancreatic duct and (CBD) may open separately in the duodenum.
  10. 10. Pancreatic Ductal System
  11. 11. Ampulla of Vater The ampulla is a dilatation of the common pancreatico-biliary channel adjacent to the major duodenal papilla and below the junction of the two ducts.
  12. 12. According to Michels’ Classification there are 3 types: • Type 1: 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 %). • Type 2: The pancreatic and bile ducts open near one another, but separately, on the major duodenal papilla (5%). • Type 3: The pancreatic and bile ducts open into the duodenum at separate points (9%)
  13. 13. Duodenal Papillae • The major duodenal papilla: is a nipple-like projection of the duodenal mucosa through which the distal end of the ampulla of Vater passes into the duodenum. It lies on the posteromedial wall of the second portion of the duodenum, 7 to 10 cm from the pylorus. • The minor duodenal papilla: lies about 2 cm cranial and slightly anterior to the major papilla. It is smaller and its site lacks the characteristic mucosal folds that mark the site of the major papilla. Its opening is guarded by muscular and elastic fibers (sphincter of Helly), which is not a typical anatomical sphinter
  14. 14. Sphincter of Oddi It is the sphincter of the pancreatico-biliary channel which is a circular smooth muscle complex largely within the duodenal wall. It is made up of four different sphincters: 1. The sphincter pancreaticus encircling the pancreatic duct 2.3.The superior and inferior choledochal sphincters around the bile duct 4. the sphincter ampullae around the ampulla.
  15. 15. Anatomy of upper abdominal viscera
  16. 16. Pancreatic Vascular Anatomy • the body and tail are supplied by branches of the splenic artery. • Whereas the head and uncinate process receive their supply through arcades originating from the gastro-duodenal artery (GDA) of hepatic artery of the celiac trunk and from the inferior pancreatico –duodenal artery , the first branch of the superior mesenteric artery (SMA).
  17. 17. The Anterior Pancreatic Arcade • On the anterior surface of the head ,supplying it together with the concave surface of the duodenum. • It is formed by the anastomosing branches of two main arteries: The (GDA) and the anterior inferior pancreatico-duodenal (AIPD) artery.
  18. 18. Gastro-duodenal artery (GDA) • One of the two terminal branches of the common hepatic artery branch of the celiac trunk . • It may give off supra-duodenal and retro-duodenal arteries before descending posterior to the superior part of the duodenum. • Reaching the lower border of the superior part of the duodenum, the (GDA) divides into its terminal branches, the right gastro-omental artery and the superior pancreatico-duodenal artery which further divides into anterior superior pancreatico-duodenal (ASPD) artery and posterior superior pancreatico-duodenal (PSPD) artery.
  19. 19. The posterior Pancreatic Arcade • It lies on the posterior surface of the head supplying it together with the anterior and posterior surface of the 2nd part of the duodenum. It passes posterior to the intra- pancreatic portion of the CBD. • It is formed by anastomosis of (PSPD) artery and the posterior inferior pancreatico-duodenal (PIPD) artery.
  20. 20. Splenic Artery • The largest branch of the celiac trunk. • Gives off numerous small branches to supply the neck, body, and tail of the pancreas. • The dorsal pancreatic (DP) artery : is the first major branch of splenic artery usually joins one of the postero-superior arcades after giving off the inferior (transverse) pancreatic artery to the left.
  21. 21. • The inferior (transverse) pancreatic artery: is a collateral vessel runs within the pancreas and usually is formed by the left branch of the artery for the neck and/or the (DP) artery. • The great pancreatic artery of Von Haller (pancreatica magna): arises from the splenic artery near the junction of the body and tail. It may anastomoses with the inferior pancreatic artery. • The caudal pancreatic artery : arises from the distal segment of the splenic artery. It anastomoses with branches of the great pancreatic and other pancreatic arteries
  22. 22. Major arterial supply to pancreas • The large artery for the neck • The medium-sized artery for the body • The smaller arteries for the tail  all other branches from splenic artery which anastmose with the transverse pancreatic artery.
  23. 23. Venous Anatomy • The venous drainage of the head of the pancreas and duodenum: is via an anterior and a posterior arcade termed the (ASPD) and (AIPD) veins and the (PSPD) and (PIPD) veins. • The (PSPD) vein commonly drains directly into the portal vein near the superior border of the pancreas after crossing anterior to the bile duct.
  24. 24. • The (ASPD) vein drains directly into the gastro-colic trunk which is formed by the confluence of the right gastro- epiploic vein and middle colic vein. • The gastro-colic trunk then joins the superior mesenteric vein (SMV) just below the neck of the pancreas. • The veins of the neck, body, and tail of the pancreas: form two large venous channels, the splenic vein above and the transverse (inferior) pancreatic vein below. • The splenic vein receives from 3 to 13 short pancreatic tributaries. The inferior pancreatic vein may enter the left side of the (SMV), the inferior mesenteric vein (IMV) , or occasionally the splenic or the gastro-colic veins.
  25. 25. Lymphatic Drainage The standard regional lymph nodes draining the head and neck of the pancreas include: • Along the (CBD) • Common hepatic artery • Portal vein • Posterior and anterior pancreatico-duodenal arcades • Along the superior mesenteric vein • Along right lateral wall of the superior mesenteric artery.
  26. 26. • Those draining the body and tail lie along the common hepatic artery, celiac axis, splenic artery, and splenic hilum. • According to their relation to the pancreas , regional lymph nodes are described in five main groups: 1. Superior nodes 2. Inferior nodes 3. Anterior nodes 4. Posterior nodes 5. Splenic nodes
  27. 27. Congenital Anomalies • Pancreatic Divisum • Annular pancreas • Ectopic and Accessory Pancreas • Intraperitoneal Pancreas • Developmental Pancreatic Cysts
  28. 28. Types of Pancreatic Resection
  29. 29. Classic Pancreaticoduodenectomy (PD) • In 1898 ,Halsted performed the first local excision of carcinoma of ampulla of Vater. • In 1909, the first successful regional resection of a periampullary tumor was performed by Kausch. • He performed the operation as a 2-stage procedure in which a cholecystojejunostomy was performed 6 weeks before the second operation.
  30. 30. • Resection of periampullary tumor was popularized in a 1935 article by Whipple and colleagues. • Their 2-stage pancreatoduodenectomy consisted of posterior gastroenterostomy, ligation and division of the common bile duct and cholecystogastrostomy in the first stage, followed by resection of the duodenum and pancreatic head in the second stage. • The pancreatic stump was closed with sutures, without a pancreaticoenteric anastomosis.
  31. 31. • Whipple later completed the whole procedure in a single stage in 1940, and the reconstruction was modified in 1942 to include pancreaticojejunostomy, as he found a high rate of pancreatic fistula after closure of pancreatic stumps.
  32. 32. Indications: (A) Resectable neoplasms of the head and uncinate process as well as peri ampullary cancers have the following CT characteristics: 1-Normal fat plane between the low-density tumor and the superior mesenteric artery and superior mesenteric vein (SMV). 2-Absence of extrapancreatic disease. 3-Patent Superior mesenteric-Portal vein (SMPV) confluence (assumes ability of the surgeon to resect and reconstruct isolated segments of the SMV or SMPV) 4-No direct tumor extension to the celiac axis or SMA. (B) “Borderline” resectable neoplasms include: • 1-Short segment occlusion of the SMPV confluence with an adequate vessel for grafting above and below the site of occlusion (assumes the technical ability to resect and reconstruct the SMV or SMPV). • 2- Neoplasms which demonstrate short-segment (usually <1cm) abutment of the common or proper hepatic artery or the SMA on high-quality CT.
  33. 33. Contraindications: • Extrapancreatic metastatic disease • Neoplasms encasing the celiac axis or SMA (anything more than short-segment abutment).
  34. 34. Reconstruction after PD
  35. 35. Pylorus –Preserving Pancreaticoduodenectomy (PPPD) • Gastric dumping syndromes, gastritis, and ulcerations due to bile reflux, led to the introduction of the pylorus-preserving modification of the classical PD. • Introduced by Kenneth Watson in the 1940s, the pylorus-preserving pancreaticoduodenectomy (PPPD) was not frequently used until it was popularized in 1978 by Traverso and Longmire.
  36. 36. Indications: • Small periampullary neoplasms (it should not be performed in patients with bulky neoplasms of the pancreatic head).
  37. 37. Contraindications: • In cases where tumor involves the first or second part of duodenum or distal stomach. • Lesions associated with grossly positive pyloric or peripyloric lymph nodes. • Also in cases of peri ampullary lesions associated with hereditary syndromes like familial polyposis coli due to the high risk of malignant transformation within the duodenal remnant due to genetic field change throughout the duodenum.
  38. 38. PPPD
  39. 39. Advantages: • Some retrospective studies showed benefits with regard to digestive function (prevention of gastric dumping and reflux biliary gastritis) and quality of life for the PPPD. • No survival disadvantages or advantages were found by other trials, either retrospective or prospective randomized. • Eventually, many studies showed that there are no differences in postoperative rates of delayed gastric emptying (DGE) between PD and PPPD, although DGE had been cited as a disadvantage of PPPD before.
  40. 40. Distal Pancreatectomy • The technique for distal pancreas resection was first outlined by Mayo in 1913. • Indicated for tumors of the body and tail of the pancreas. • Tumors of the body and tail, have fewer clinical symptoms, tend to be diagnosed later.
  41. 41. Forms of Distal Pancreatectomy -Classic distal pancreatectomy with splenectomy -DP with splenic preservation. -DP with multi-organ Resection Main complications: • Diabetes mellitus (DM) occurs in 20% of patients following distal pancreatectomy. • Higher pancreatic fistula rates than pancreatico- duodenectomies (usually heal with external drainage)
  42. 42. Distal Pancreatic resection
  43. 43. Segmental Pancreatectomy • Centrally placed benign or low-malignant- potential lesions specially in the neck of the pancreas • Alternatively known as middle segmental pancreatic resection, median pancreatectomy, central pancreatectomy, or intermediate resection. • Involves removal of the lesion with adequate margins on either side, the procedure being guided by intraoperative frozen-section analysis.
  44. 44. Extended pancreatic resections • En bloc resection of the pancreas and surrounding organs, along with a retroperitoneal lymph node dissection. • Extended resections may include: 1. Total pancreatectomy (TP) 2. Extended lymph node dissection (ELND) 3. Arterial/venous resections with reconstruction
  45. 45. 1. Total pancreatectomy (TP) Advantages: • Allows for more extensive lymphadenectomy. • Obviates possible leak from the pancreatic anastomosis • Decreases the chances of a positive cut margin. Disadvantages: • Obligate diabetes mellitus. • Decreased immunity because of splenectomy. • Loss of pancreatic exocrine function. • worse survival.
  46. 46. 2. Extended lymph node dissection (ELND) • In addition to removal of the pancreaticoduodenal nodes, removal of lymph nodes along the hepatic artery, superior mesenteric artery, celiac axis, and between the aorta and the inferior pancreaticoduodenal artery. • Furthermore, the anterolateral aspect of the aorta and the inferior vena cava are also dissected. • The Japanese demonstrated improved survival rates with extended surgery. Further studies comparing SL with ELND showed no survival difference adding to increased morbidities following ELND.
  47. 47. 3. Arterial/venous resections with reconstruction Vascular resections can be performed based on two rationales: • Firstly, to achieve negative resection margins in case of vessel invasion by the tumor or adhesion of the vessel to the tumor, making separation impossible. • Secondly, it can be performed as part of an extended pancreactectomy with ELND.
  48. 48. • Vein resections include that of the portal vein (PV), superior mesenteric vein (SMV), or the SMV- PV confluence. • Venous resections followed by graft reconstruction can be performed without increased morbidity and mortality and may be performed to achieve negative resection margins. • In contrast, arterial resections of the mesenteric, celiac, and hepatic arteries are rarely performed and are considered by most as contraindicated in PD due to the greatly increased morbidity and mortality.
  49. 49. Laparoscopic pancreatic resections The morbidity of the Whipple's operation is not related to the length of the abdominal incision but to the extensive nature of the actual intra-abdominal surgery. At present there is no worthwhile evidence to suggest that laparoscopic Whipple's is better than open surgery. This procedure may be performed by highly trained surgeons, in high-volume dedicated centers, and that too within the context of good clinical trials.
  50. 50. • On the other hand, laparoscopic DP may well provide a distinct advantage over open surgery in the near future in highly selected small tumors of the body and tail.
  51. 51. Thank you