Pancreatic ductal anatomy: more than meets the eye.

PURPOSE: Anatomical variations of the pancreas are relatively frequent and often understudied. The ductal system of the pancreas has multiple variations, which are not frequently reported in the literature. MATERIALS AND METHODS: The anatomy of the pancreas was studied through macroscopic anatomical dissection on 50 organ complexes (the pancreas, spleen, and duodenum) donated to the department of human anatomy, from patients, who died of causes not related to pancreatic diseases. RESULTS: In type I, the main pancreatic duct (Wirsung's duct, MPD) and the accessory pancreatic duct (Santorini's duct, APD) were merged but most of the head was drained by the MPD (10% of cases). In type II, the MPD and APD were merged but most of the head was drained by the APD (4% of cases). In type III, the APD was absent and the head was drained by the MPD (14% of cases). In type IV, there was an inverted pancreas divisum where the ducts did not merge but each drained a part of the head (6% of cases). Classical pancreas divisum where the ducts did not merge but each drained a part of the head was considered as type V (4% of cases). In type VI, the MPD and APD merged and each drained a part of the head (48% of cases). In type VII, the MPD and APD merged but the upper part of the head was drained by the main pancreatic duct (4% of cases). In type VIII, the MPD and APD merged but the lower part of the head was drained by the main pancreatic duct (4% of cases). In the IX type, the MPD and APD merged but the head was drained by the branches of the MPD (6% of cases). CONCLUSIONS: There are several drainage patterns of the pancreas. In some cases, one of the ducts provides more drainage of the gland than the other. This is clinically relevant since blockage of the main source of drainage leads to pancreatic juice stasis. It also explains cases when partial or total blockage of the duct results in the pancreatitis of an isolated zone.

Deconstructing the principles of ductal network formation in the pancreas.

The mammalian pancreas is a branched organ that does not exhibit stereotypic branching patterns, similarly to most other glands. Inside branches, it contains a network of ducts that undergo a transition from unconnected microlumen to a mesh of interconnected ducts and finally to a treelike structure. This ductal remodeling is poorly understood, both on a microscopic and macroscopic level. In this article, we quantify the network properties at different developmental stages. We find that the pancreatic network exhibits stereotypic traits at each stage and that the network properties change with time toward the most economical and optimized delivery of exocrine products into the duodenum. Using in silico modeling, we show how steps of pancreatic network development can be deconstructed into two simple rules likely to be conserved for many other glands. The early stage of the network is explained by noisy, redundant duct connection as new microlumens form. The later transition is attributed to pruning of the network based on the flux of fluid running through the pancreatic network into the duodenum.

Pasireotide administration after pancreaticoduodenectomy may decrease clinically relevant postoperative pancreatic fistula in high-risk patients with small pancreatic ducts, soft pancreatic parenchyma and cystic or neuroendocrine neoplasia.

OBJECTIVES: Post-operative pancreatic fistula (POPF) is a feared complication after a pancreaticoduodenectomy. Previously in a randomized trial found fewer clinically relevant fistulas (CR-POPF) accompanying administration of perioperative pasireotide. Our hospital previously found that the risk for CR-POPF reached 7% in pancreaticoduodenectomy patients. Here, we aimed to determine the CR-POPF rate accompanying prophylactic pasireotide in patients with a normal pancreas at resection level. METHODS: In this clinical study, perioperative pasireotide was administered to pancreaticoduodenectomy patients treated between 1 July 2014 and 30 April 2016. High-risk individuals were defined preoperatively by the surgeon based on the following: no dilatation of the pancreatic duct, suspected soft pancreas and a cystic or neuroendocrine tumor at the head of the pancreas. If the pancreas was considered hard at surgery, thereby carrying a lower risk for fistula, pasireotide was discontinued following one preoperative 900-µg dose. Among high-risk patients, pasireotide was continued for one week or until discharge from the hospital. RESULTS: During the study period, 153/215 pancreatic operations were pancreaticoduodenectomies, 58 (38%) of which were considered high risk for developing clinically significant pancreatic fistula. Among these, 4 (2.6%) developed a grade B or C fistula: 2 in the pasireotide group [3.5%, 95% confidence interval (CI) 0.4-11.9%], 1 in the low-risk group (1.2%, 95% CI 0.0-6.4%; difference: 2.3%, 95% CI -6.4-17.3%) and 1 in the discontinued group (10%). CONCLUSION: We found similar rates of CR-POPF among high- and low-risk patients undergoing pancreaticoduodenectomy when using prophylactic perioperative pasireotide in high-risk patients.

Is the remnant pancreas still working over a year after surgery in patients undergoing pancreaticoduodenectomy with reconstruction by pancreaticogastrostomy?

BACKGROUND: Pancreaticogastrostomy (PG) has been widely used as an alternative to pancreatojejunostomy (PJ) in patients undergoing pancreaticoduodenectomy (PD), but its long-term exocrine function remains unclear. The present study aimed to measure the secretion of pancreatic α-amylase (p-AMY) into the gastric cavity in patients who underwent PG reconstruction after PD over 1 year after surgery and to evaluate the relationship between gastric p-AMY level and clinically available indirect tests. METHODS: Clinical records of 39 patients who underwent PG reconstruction after PD were reviewed. Pancreatic exocrine function was evaluated over 1 year after surgery using the following methods: 1) Measurement of p-AMY level in gastric fluids (gastric p-AMY level) during routine gastrointestinal endoscopy, 2) Qualitative faecal fat determination by Sudan III staining on faeces and 3) Pancreatic function diagnostic (PFD) test using oral administration of N-benzoyl-l-tyrosyl-p-aminobenzoic acid. RESULTS: Gastric p-AMY level was detectable in 31 of 39 patients (79%), and 12 patients (30.8%) had steatorrhea over a year after surgery. Patients with steatorrhea had significantly lower gastric p-AMY level, larger diameter of remnant main pancreatic duct (MPD) and larger pancreatic duct to parenchymal thickness ratio than those without steatorrhea (84 IU/L vs 7979 IU/L, respectively; P < 0.001, 5.3 mm vs 3.2 mm, respectively; P = 0.001, and 0.38 vs 0.23, respectively; P = 0.007). Receiver operating characteristic analysis showed that the cut-off value of the diameter of the remnant MPD to predict steatorrhea was 3.5 mm (sensitivity, 92.3%; specificity, 70.4%). PFD test was not associated with any clinical data. CONCLUSIONS: Pancreatic enzyme was detected in 79% of patients having PG reconstruction. Diameter of remnant MPD >3.5 mm and pancreatic parenchymal atrophy may be surrogate markers of postoperative exocrine insufficiency following PD.

Role of magnetic resonance cholangiopancreatography (MRCP) in learning anatomical variations in pancreatic duct.

OBJECTIVE: To assess the frequency of anatomical variations of pancreatic duct through magnetic resonance cholangiography pancreatography. . METHODS: The cross-sectional prospective study was conducted from May 2011 to December 2012 at the Department of Anatomy, Institute of Basic Medical Sciences (IBMS), Dow University of Health Sciences, Karachi, in collaboration with the Department of Radiology, Aga Khan University Hospital, Karachi. The study comprised diagnosed cases of pancreato-biliary disease booked for magnetic resonance cholangiography pancreatography. Images were obtained using 1.5 Tesla magnetic resonance imaging scanner, and information of anatomical variations visualised on the imaging film was assessed and documented. RESULTS: Of the 377 subjects, 196(52%) were females and 181(48%) were males. Pancreas divisum was found in 21(5.6%) subjects; 13(62%) females and 8(38%) males. . Duct of Santorini was detected in 3(0.8%) subjects; 2(66.6%) females and 1(33.3%) male. CONCLUSIONS: Variations in pancreatic duct could be identified by using the simple, non-invasive method of magnetic resonance cholangiography pancreatography.

Randomized clinical trial of the effect of a fibrin sealant patch on pancreatic fistula formation after pancreatoduodenectomy.

BACKGROUND: The potential for a fibrin sealant patch to reduce the risk of postoperative pancreatic fistula (POPF) remains uncertain. The aim of this study was to evaluate whether a fibrin sealant patch is able to reduce POPF in patients undergoing pancreatoduodenectomy with pancreatojejunostomy. METHODS: In this multicentre trial, patients undergoing pancreatoduodenectomy were randomized to receive either a fibrin patch (patch group) or no patch (control group), and stratified by gland texture, pancreatic duct size and neoadjuvant treatment. The primary endpoint was POPF. Secondary endpoints included complications, drain-related factors and duration of hospital stay. Risk factors for POPF were identified by logistic regression analysis. RESULTS: A total of 142 patients were enrolled. Forty-five of 71 patients (63 per cent) in the patch group and 40 of 71 (56 per cent) in the control group developed biochemical leakage or POPF (P = 0·392). Fistulas were classified as grade B or C in 16 (23 per cent) and ten (14 per cent) patients respectively (P = 0·277). There were no differences in postoperative complications (54 patients in patch group and 50 in control group; P = 0·839), drain amylase concentration (P = 0·494), time until drain removal (mean(s.d.) 11·6(1·0) versus 13·3(1·3) days; P = 0·613), fistula closure (17·6(2·2) versus 16·5(2·1) days; P = 0·740) and duration of hospital stay (22·1(2·2) versus 18·2(0·9) days; P = 0·810) between the two groups. Multivariable logistic regression analysis confirmed that obesity (odds ratio (OR) 5·28, 95 per cent c.i. 1·20 to 23·18; P = 0·027), soft gland texture (OR 9·86, 3·41 to 28·54; P < 0·001) and a small duct (OR 5·50, 1·84 to 16·44; P = 0·002) were significant risk factors for POPF. A patch did not reduce the incidence of POPF in patients at higher risk. CONCLUSION: The use of a fibrin sealant patch did not reduce the occurrence of POPF and complications after pancreatoduodenectomy with pancreatojejunostomy. Registration number: 2013-000639-29 (EudraCT register).

Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct.

PURPOSE: We performed three-dimensional (3D) surgical simulation of pancreatic surgery, including the size and location of the main pancreatic duct on the resected pancreatic surface. METHODS: The subjects of this retrospective analysis were 162 patients who underwent pancreatic surgery. This cohort was sequentially divided into a "without-3D" group (n = 81) and a "with-3D" group (n = 81). We compared the pancreatic duct diameter and its location, using nine sections in a grid pattern, with the intraoperative findings. The perioperative outcomes were also compared between patients who underwent pancreaticoduodenectomy (PD) and those who underwent distal pancreatectomy (DP). RESULTS: There were no significant differences in the main pancreatic duct diameter between the 3D-simulated values and the operative findings. The 3D-simulated main pancreatic duct location was consistent with its actual location in 80 % of patients (65/81). In comparing the PD and DP groups, the intraoperative blood loss was 1174 ± 867 and 817 ± 925 ml in the without-3D group, and 828 ± 739 and 307 ± 192 ml in the with-3D group, respectively (p = 0.024, 0.026). CONCLUSION: The 3D surgical simulation provided useful information to promote our understanding of the pancreatic anatomy, including details on the size and location of the main pancreatic duct.

Closed loop of main duct of pancreas: a rare variant configuration.

During routine dissection, duplication of main pancreatic duct extending from body to head region of pancreas was observed in a 78-year-old formalin fixed male cadaver. Main pancreatic duct gave a prominent branch which joined back the parent duct in head resulting in the formation of a closed loop. This gave the appearance of focal duplication in the form of a closed loop, an unusual variant. This was an incidental finding. Such cases usually remain asymptomatic; however, if undetected may be the cause of postoperative pancreatic fistula following pancreaticobiliary surgery. Knowledge of variable anatomy of pancreatic duct system became important to reduce the risk of postoperative complication and during various endoscopic guided procedures like drainage of pseudocyst or placement of stent into the duct.

Extraparenchymal Bile/Pancreatic Ducts and Duodenal Papillae: Pathologic Evaluation in Nonclinical Species--A Brief Review.

This review focuses on the anatomy, histologic preparation, and pathologic evaluation of extraparenchymal bile and pancreatic ducts (BPDs) and their openings at the duodenal papillae in the cynomolgus macaque (Macaca fascicularis), the Beagle dog (Canis familiaris), the Wistar Hanover rat (Rattus norvegicus), and the CD1 mouse (Mus musculus). In nonclinical safety assessment, intraparenchymal BPDs (with sections of liver and pancreas, respectively) are evaluated routinely. However, detailed evaluation of the extraparenchymal BPDs or the duodenal papillae is not included. In the context of nonclinical safety assessment studies, this review describes situations in which evaluation of extraparenchymal ductal structures and duodenal papillae may be useful in characterizing test article-related changes; elucidates anatomic similarities between human, macaque, and dog and notable differences in rats and mice; and consolidates the information required for the histopathologic evaluation of these tissues.

Reference values of MRI measurements of the common bile duct and pancreatic duct in children.

BACKGROUND: Magnetic resonance imaging/cholangiopancreatography (MRI/MRCP) is now an essential imaging modality for the evaluation of biliary and pancreatic pathology in children, but there are no data depicting the normal diameters of the common bile duct (CBD) and pancreatic duct. Recognition of abnormal duct size is important and the increasing use of MRCP necessitates normal MRI measurements. OBJECTIVE: To present normal MRI measurements for the common bile duct and pancreatic duct in children. MATERIALS AND METHODS: In this retrospective study we searched all children ages birth to 10 years in our MR urography (MRU) database from 2006 until 2013. We excluded children with a history of hepatobiliary or pancreatic surgery. We stratified 204 children into five age groups and retrospectively measured the CBD and the pancreatic duct on 2-D axial and 3-D coronal T2-weighted sequences. We performed statistical analysis, using logistic and linear regressions to detect the age association of the visibility and size of the duct measurements. We used non-parametric tests to detect gender and imaging plane differences. RESULTS: Our study included 204 children, 106 (52%) boys and 98 (48%) girls, with a median age of 33 months (range 0-119 months). The children were distributed into five age groups. The common bile duct was visible in all children in all age groups. The pancreatic duct was significantly less visible in the youngest children, group 1 (54/67, 80.5%; P = 0.003) than in the oldest children, group 5 (22/22, 100%). In group 2 the pancreatic duct was seen in 19/21 (90.4%), in group 3 52/55 (94.5%), and in group 4 39/39 (100%). All duct measurements increased with age (P < 0.001; r-value > 0.423), and the incremental differences between ages were significant. The measurement variations between the axial and coronal planes were statistically significant (P < 0.001); however these differences were fractions of millimeters. For example, in group 1 the mean coronal measurement of the CBD was 2.1 mm and the axial measurement was 2.0 mm; the mean coronal measurement of the pancreatic duct was 0.9 mm and the axial measurement was 0.8 mm. CONCLUSION: Our study provides normative measurements for the common bile duct and pancreatic duct for children up to age 10 years. The upper limits of the CBD and pancreatic duct increase with age, and the values range 1.1-4.0 mm for the CBD and 0.6-1.9 mm for the pancreatic duct.

The role of 64-slice CT following perfusion with iohexol via the hepatopancreatic ampulla in assessing pancreaticobiliary junctions.

The aim of this study was to delineate the structure of the pancreatic and biliary ducts in premature infants using a novel imaging method. The duodenal papillae of 30 premature infant cadavers were dissected. The pancreatic and biliary ducts were visualized using 64-detector multislice spiral computed tomography (MSCT). Contrast agent was injected into the duodenal papilla via the hepatopancreatic ampulla of Vater. MSCT scanning revealed both the pancreatic and biliary ducts as well as the common channel in 18 cases. The bile duct was visualized in the remaining 12 cases. Four patterns of the pancreaticobiliary ductal junction were noted: Y-type (73.3%), U-type (13.3%), V-type (6.7%), and II-type (6.7%). The results showed that MSCT and three-dimensional reconstruction can be used to visualize the junction pattern and common channel of the pancreatic and biliary ducts, and the structure of the surrounding tissue, in premature infants.

Evaluation of date syrup as an oral negative contrast agent for MRCP.

OBJECTIVE: The purpose of this study was to compare the in vitro effects of date syrup with those of other contrast agents by qualitative and quantitative analysis and in vivo evaluation of the use of date syrup to improve the quality of MRCP images. MATERIALS AND METHODS: Phantoms containing date syrup, ferumoxsil, pineapple juice, and water were imaged by 1.5-T MRI with T2-weighted and MRCP sequences, and signal-to-noise ratios were calculated. Biochemical analysis of date syrup was performed to find the nature of iron in it, and the iron content was quantified by energy-dispersive x-ray spectroscopy. Sixty patients underwent MRCP before and 30 minutes after ingestion of 100 mL of date syrup. Unenhanced and contrast-enhanced images were scored for gastrointestinal tract signal suppression and visualization of various pancreaticobiliary structures. RESULTS: In vitro evaluation showed that images obtained with date syrup had a signal-to-noise ratio comparable to that of images obtained with ferumoxsil in T2-weighted and MRCP sequences. The iron concentration in date syrup was 2.6 mg/dL, and it was in ferric form. Images obtained after oral contrast administration had statistically significant improvement in gastrointestinal tract signal suppression (p < 0.001) and an increase in visibility of the common bile duct, cystic duct, and pancreatic duct (all p < 0.001). No adverse effects were noted in any of the patients. CONCLUSION: Date syrup can be used as a negative oral contrast agent for gastrointestinal tract signal suppression during MRCP and for improving visualization of various pancreaticobiliary structures.

Post-pancreaticoduodenectomy hemorrhage: risk factors, managements and outcomes.

BACKGROUND: Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH. METHODS: A total of 840 patients with PD between 2000 and 2010 were retrospectively analyzed. Among them, 73 patients had PPH: 19 patients had early PPH and 54 had late PPH. The assessment included the preoperative history of disease, pancreatic status and surgical techniques. Other postoperative complications were also evaluated. RESULTS: The incidence of PPH was 8.7% (73/840). There were no independent risk factors for early PPH. Male gender (OR=4.40, P=0.02), diameter of pancreatic duct (OR=0.64, P=0.01), end-to-side invagination pancreaticojejunostomy (OR=5.65, P=0.01), pancreatic fistula (OR=2.33, P=0.04) and intra-abdominal abscess (OR=12.19, P<0.01) were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8% (15/54). Initial endoscopy was operated in 12 patients (22.2%), initial angiography in 19 (35.2%), and relaparotomy in 15 (27.8%). Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure, hemorrhagic shock, sepsis and uncontrolled rebleeding. CONCLUSIONS: Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH, surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.

Pre-operative prediction of pancreatic fistula: is it possible?

BACKGROUND/OBJECTIVES: Understanding a patient's risk of pancreatic fistula (PF) prior to pancreatoduodenectomy (PD) would permit an individualised approach to patient selection, consent and, potentially, treatment. Various intra and post operative factors including pancreatic duct width and steatosis are associated with PF. We sought to identify whether information available in the pre-operative phase can predict PF. METHODS: Associations between patient characteristics, pre-operative blood test results, data from pre-operative CT imaging and PF were explored. Pancreatic density (Hounsfield units, Hu), pancreatic duct size and gland thickness were measured using CT imaging. RESULTS: PF occurred in 42 of 155 cases (types A, B and C: 32, 8, 2 respectively). An inverse relationship between duct width and PF was observed. The odds ratio of PF, for each 1 mm increase in duct width, was 0.639 (95% CI = 0.531-0.769, p < 0.001). The gland thickness and density at the pancreatic resection margin were positively associated with PF (both p = 0.03). No patient variable was associated with PF. CONCLUSIONS: Pancreatic duct width has previously been assessed at the time of operation and simply regarded as normal or wide. Consideration of duct width as a continuous variable using pre-operative CT imaging can be used to simply predict risk of PF. The association between pancreatic density and PF is a novel finding. Whether pancreatic density in Hu relates to steatosis, as it does for hepatic steatosis, merits further review given the association between pancreatic steatosis and PF.

The mucosal folds at the pancreaticobiliary junction.

PURPOSE: The structure and function of the mucosal folds in the terminal bile and pancreatic ducts and hepatopancreatic ampulla are poorly characterised. The distribution, muscularity, and innervation of these folds were investigated. METHODS: The pancreaticobiliary junction was excised from ten cadavers (five male, 66-90 years) and examined histologically by serially sectioning (4-µm thickness) along the length of the terminal bile and pancreatic ducts from the tip of the major duodenal papilla. Three surgical specimens (two male, 63-72 years) were also evaluated. Sections were stained with haematoxylin and eosin, anti-actin (smooth muscle), anti-S100 (innervation), and anti-cholecystokinin (CCK)-A receptor antibodies. ImageJ software was used to compare relative radial fold projection and semi-quantitatively assess the smooth muscle and nerve content. In one additional cadaver specimen, folds were examined by scanning electron microscopy. RESULTS: Mucosal folds in the terminal bile duct were arranged circumferentially in a lattice-like arrangement and were distributed over an average distance of 7.3 mm along the terminal bile duct compared to 4.2 mm along the pancreatic duct (P = 0.001), projected further into the lumen, and were more densely innervated than those in the terminal pancreatic duct. Folds in both ducts contained smooth muscle which was more prominent in folds nearest to the major duodenal papilla. Mucosal folds in cadaver and surgical specimens showed no evidence of CCK-A receptor immunoreactivity. CONCLUSIONS: This study demonstrates that the mucosal folds of the terminal bile and pancreatic ducts contain muscle and nerve fibres, suggesting an active rather than purely passive function.

The length of main pancreatic duct in Bangladeshi cadaver at different age groups.

The anatomy of the pancreatic ductal system has received attention because of its importance in pancreaticobiliary diseases. Any blockage in pancreatic ductal system needs emergency maneuver. A full understanding of the variations in pancreatic ductal pattern is essential in the diagnosis and treatment of pancreatic diseases. In an attempt to gather data on the length of main pancreatic duct the present study was carried out on the pancreas of Bangladeshi male cadaver. The descriptive cross-sectional study was carried out in the department of anatomy Dhaka Medical College from October 2008 to September 2009. Total 50 human pancreatic duct were studied. The samples were divided into 7 different age groups ranged from 10-70 years and above 70 years. Length of the main pancreatic duct was measured in fresh samples by x-ray. Length of the main pancreatic duct of formol saline fixed pancreas was measured in situ and after removal from pancreatic tissue. The results of the present study show that the length of the main pancreatic duct increases with age. In all groups length of the main pancreatic duct was more after total removal from pancreas than in situ and x-ray. The mean±SD length of main pancreatic duct was 14.34±3.10 cm, 16.13±3.26 cm, 12.88±3.28 cm in situ, after total removal and in X-ray respectively. Further studies with large sample in both sexes are recommended. Measurement of bendings of ductal course, number of pancreatic ducts and corrosion casts of pancreatic ducts are recommended. The comparison between endoscopic retrograde cholangio pancreatography (ERCP) findings and the cadaveric dissected specimen findings should also be done.

Surgical morphology of the pancreatic isthmus.

BACKGROUND: Pancreatic isthmus method anastomosis following pancreatic resection is an important factor of postoperative fistula formation. While the anatomy and vascular supply of the pancreatic head have been studied in detail, little is known about the morphology of the pancreatic isthmus. The authors determine the anatomy and morphology of the pancreatic isthmus. METHODS: 99 consecutive cadaveric pancreatic specimens were taken during standard autopsy. Organs were transected at the isthmus and pancreatograms and microscopic specimens of the transection plane were analyzed. RESULTS: The mean size of the Wirsung duct at the isthmus was 2.89 mm (+/-0.87 mm, from 1.4 to 6 mm). The main pancreatic duct was located approximately in the middle of the pancreatic cross-section plane in almost all specimens. The total number of second-degree pancreatic ducts visible on pancreatograms within the isthmus was 1.77 (+/-1.00, from 0 to 4) and 1.83 (+/-1.4, from 0 to 5) on microscopic analysis. CONCLUSIONS: The presence of second-degree pancreatic ducts at the transection site might favor the use of a pancreaticoenteric anastomosis with stump invagination to reduce the risk of anastomotic leakage. and IAP.

Major duodenal papilla and its normal anatomy.

The major duodenal papilla (papilla of Vater) is the point where the dilated junction of the bile and pancreatic ducts (ampulla of Vater) enter the duodenum. The ampulla is surrounded by the sphincter of Oddi, which not only controls the flow of bile and pancreatic juice into the duodenum, but also prevents the reflux of duodenal contents, bile and pancreatic juice into the bile and pancreatic ducts.

Pancreatic duct anatomy in the corpus area: implications for closure and anastomotic technique in pancreas surgery.

PURPOSE: Pancreatic anastomosis and stump closure after partial pancreatectomy is the most critical step in pancreas surgery due to a high percentage of postoperative fistulas. Whether transverse cut side branches or the main pancreatic duct presents the source of this leak is still unknown. Thus, better understanding of the anatomy of the pancreatic duct system in the resection area could significantly improve the surgical technique and reduce complications. METHODS: We investigated the anatomy of the pancreatic duct in 25 human cadaveric pancreata with focus on the corpus area. Contrast agent was instilled into the pancreatic duct, and computed tomography was used to visualize the duct system in detail. RESULTS: In addition to the main and accessory pancreatic duct in the head, an additional accessory duct was observed within the pancreas corpus in 16% of the cases. Within the plane of the portal vein, fewer transversely cut side branches were observed as compared to the resection planes 2-4 cm beneath. The number of side branches was independent of the presence of pancreatic fibrosis. CONCLUSIONS: From anatomical point of view, the resection level at the porto-mesenteric axis appears to be ideal. However, the presence of an accessory main duct has to be taken into account for sufficient surgical supply.

New anatomical data on the drainage patterns of the uncinate process of the pancreas.

PURPOSE: Recently, progress has been made in the surgical management of benign pancreatic tumors sparing as much of the pancreatic parenchyma and pancreatic function as possible. However, the main complication of partial pancreatectomy is the disruption of pancreatic ducts ensuing leak of pancreatic secretion leading to the formation of pancreatic fistulae. In this study, we attempt to precisely define the anatomy of the branch duct draining the uncinate process which is of interest to the surgeons. METHODS: Seventeen formalin-fixed pancreases were taken and ducts were injected with a colored gelatin solution. Within the uncinate process of the pancreases, the branch duct was localized, measured and its anatomical drainage defined. Statistics were performed using Spearman's correlation test. RESULTS: The uncinate process was drained exclusively by the main pancreatic duct in ten cases, by the accessory pancreatic duct in three cases, and by both the ducts in four cases. All of the branches drained into the main pancreatic duct downstream to the junction between the main and the accessory pancreatic duct, except for one. CONCLUSIONS: We have precised the possibility of double drainage of the uncinate process, but this could not be correlated with simple anatomical or radiological landmarks such as the length of the main pancreatic duct or the patency of the minor duodenal papilla.