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PANCREAS
ANATOMY
Dr Harsh Shah
MS, DNB(GI), MCh(GI), FMAS, FALS
Kaizen Hospital, Ahmedabad
Anatomy
■ Pan Kreas (Greek)– all flesh
Pancreas anatomy for experts by Dr Harsh Shah(www.gastroclinix.com)
Uncinate Process
Variation in extent of uncinate process
Pancreatic ducts
Celiac Trunk
Arterial supply
Arterial Anatomy - Variations
Venous Drainage
First Jejunal vein
Kobayashi 2017, J Surg Onco
Should you preserve FJV ?
■ Large FJV (>7mm)
– Usually drains >4 JVs
– Can result in venous congestion
Kobayashi 2017, J Surg Oncol
Specimen
MESOPANCREAS
The Reality..
■ Overall 5 year survival 5%
■ 20% are resectable at presentation
■ 5 year survival after resection - 20%
■ Siegel R, Ma J, Zou Z, et al. Cancer statistics, 2014. CA
Cancer J Clin 2014; 64: 9–29.
■ Gillen et al. Preoperative/neoadjuvant therapy in pancreatic
cancer: a systematic review and meta-analysis of response
and resection percentages. PLoS Med 2010; 7: e1000267.
Poor prognostic factors in pancreatic
cancer
■ Poor differentiation
■ Node positivity
■ R1 resection
R1 Resection
■ Positive medial & posterior margin
■ Lymph nodes
■ Perineural spread
Mesorectum
Concept
■ Has embryological basis
■ Not a well defined anatomical structure
■ Rather a surgical entity
■ Fibrofatty tissue with lymphatics & nerves located
behind head of pancreas responsible for positive
resection margin in resected specimen of
Carcinoma head of pancreas
Xu et al, JOC, 2017
What’s in a name ?
- William Shakespeare
■ Mesopancreas – Gockel, 2007
■ Pancreatic head plexus II – JCS, 7th Ed.
■ Retroportal lamina – Bouassida, 2013
■ Pseudomesopancreas – Sharma, 2016
Accepted Definition
– firm, well-vascularized structure
– that extends from the posterior face of the pancreatic head
behind the mesenteric artery and vein
– in which the areolar tissue, adipose tissue, and peripheral
nerves are identified histologically
Perineural lymphatic layer located dorsally to
the pancreas
- Gockel et al, WJSO 2007
Ramia et al, 2018
Pancreas anatomy for experts by Dr Harsh Shah(www.gastroclinix.com)
Possible benefits of TMpE
■ R0 resection
■ Improved lymph node yield
■ Early identification of arterial involvement
■ Early identification of aberrant arterial anatomy
■ Reduced blood loss
However…
■ Lack of anatomic boundary
– Enbloc resection difficuly
– Difficult to standardize
– Questionable survival advantage
– Morbidity
SEGMENTATION
Concept
■ 1957 – Couinaud – Liver segmentation
■ Made liver surgery safe
■ Pancreatic segmental resection may
– Reduce leak rate
– Reduce blood loss
– Improve lymph node yield
Parts of Pancreas
■ Head (Includes uncinate)
■ Neck
■ Body
■ Tail
■ No well defined borders
■ Does not have anatomical basis
Pancreas anatomy for experts by Dr Harsh Shah(www.gastroclinix.com)
Vascular segmentation
Renard, WJS 2017
Vascular segmentation
■ Head – Gastroduodenal artery
■ Body/tail – Splenic artery
■ Neck – Hypovascular area
■ Evidence
– CT angiography
– Cadaver studies
– Disconnected duct syndrome after acute pancreatitis
Embryological Segmentation
Theory
Renard, WJS 2017
Embryological Segmentation
Theory
Suda et al Takada et al
LYMPHATIC
SEGMENTATION
THEORY
Cubilla et al.
Pissas et al.
Donatini et al.
Pancreas anatomy for experts by Dr Harsh Shah(www.gastroclinix.com)

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Pancreas anatomy for experts by Dr Harsh Shah(www.gastroclinix.com)

Editor's Notes

  1. (A) Vascular anatomy of the proximal jejunal mesentery. The vascular anatomy of the superior mesenteric artery (SMA), superior mesenteric vein (SMV), and branches off the SMA and SMV. The jejunal veins were numbered J1v, J2v, J3v, and so on based on the accompanying jejunal arteries (J1a, J2a, J3a, and so on). The common trunk of several JVs derived from the SMV was defined as the jejunal venous trunk (JVT). The mesojejunum drained by the JVT was described as the mesenteric tributary area. (B) Categorization of the 1st JVT in reference to the SMA
  2. Embryology: The pancreas originates from the endoderm of the foregut at the 5th week of embryonic development and contains the ventral and dorsal anlagen. Like the other intraperitoneal organs, the pancreas is covered with two layers of peritoneum. The fusion of the ventral and dorsal pancreas occurs in the 6th week when the vessels primarily come from the coeliac artery. After the 6th week, the pancreas is carried along with the mesogastrium and lies in a transverse plane, with its head to the right embedded in the bend of the duodenum and its tail reaching the spleen on the left. At this time, the IPDA from the SMA grows along the groove between the duodenum and the pancreatic head and connects with the branches from the GDA. Therefore, coeliac artery and SMA are considered the intra-mesopancreatic and core structure like the superior rectal artery for the rectum, along which the nerves, fascia and lymphatic tissues are distributed. The mesentery of the pancreas then fuses with the adjacent peritoneum, and the pancreas is firmly fixed. Then, the pancreas becomes an “extra-peritoneal organ”, and the mesopancreas become vague duo to the fusion.
  3. The anatomy and concept of a total mesopancreas excision (Level I). a. b & c. Retropancreatic view via extended Kocher manoeuvre to dissect the posterior lateral mesopancreas. The red dotted line indicated the range of the TMpE. A small red or yellow circle indicated the mesopancreatic root. d, e & f. Anterior view of the range of the TMpE. The mesopancreas presented as a quadrilateral structure
  4. Not a true mesopanncreas – as does not have a sheath, well defined boundaries & posterior attachment. However, it does contain blood vessels, nerves & lymphatics.
  5. NP – Neural plexus, PH- Pancreatic head
  6. Anatomical scheme of the pancreatic head plexus in Japanese classification of pancreatic cancer, 7th edition It distinctly illustrates the nerve plexuses behind the pancreatic head; and differentiates between pancreatic head plexus I (PLphI; the region which mainly includes nerve tissue distributed to dorsal surface of pancreatic head from the celiac plexus) and II (PLphII; the region which mainly includes nerve tissue distributed to the uncinate process from the SMA plexus, including inferior pancreaticoduodenal artery) (Fig). Areolar tissue surrounding pancreatic head plexus II is considered to be anatomically consistent with ‘ mesopancreas’ and it should be designated as such.
  7. TMpE – Total mesopancreas excision
  8. right and left pancreas segment separated by the hypovascular area
  9. Embryological development of the pancreas between the fifth and ninth weeks. a Embryological disposition at the fifth week; b the ventral pancreatic bud (which contains the future biliopancreatic junction), translates behind the duodenum and arises forward and under the dorsal pancreatic bud; c both pancreatic buds merge after a total or partial agenesis of the proximal part of the dorsal pancreatic bud
  10. Embryological segmentation theory. Left (according to Suda et al.): A posterior head segment; B anterior head segment; C body segment; D tail segment. Right (according to Takada et al.): A posterior; B proximal; C medial; D distal (corresponding to 3 and 4 of Suda et al.). Middle: sagittal section of the head of the pancreas. A Posterior (Takada et al.) or posterior head (Suda et al.) segment; B proximal (Takada et al.) or anterior head (Suda et al.) segment
  11. a Segmentation according to Cubilla et al. with anterior view (left) and sagittal section of the head (right). A Superior portion of the head and body; B inferior portion of the head and body; C anterior surface of the head;D posterior surface of the head; E tail. b Segmentation according to Pissas with anterior view (left) and sagittal section of the head (right). A Anterior surface of the head; B posterior surface of the head; C uncinate process; D superior portion of the corporeocaudal segment; E inferior portion of the corporeocaudal segment. c Segmentation according to Donatini and Hidden with anterior view (left) and sagittal section of the head (right). A Body and tail; B inferior segment of the head; C anterosuperior segment of the head; D posterosuperior segment of the head