THE PANCREAS

Pancreas- Brief History

Herophilus, Greek surgeon first described pancreas. Wirsung discovered the pancreatic duct in 1642. Pancreas as a secretory gland was investigated by Graaf in 1671. R. Fitz established pancreatitis as a disease in 1889. Whipple performed the first pancreaticoduodenectomy in 1935 and refined it in 1940.

Pancreas

Gland with both exocrine and endocrine functions 6-10 inch in length 60-100 gram in weight Location: retro-peritoneum*, 2nd lumbar vertebral level Extends in an oblique, transverse position, Parts of pancreas: head, neck, body and tail

The Pancreas in situ

Right lobe of liver Falciform ligament Gallbladder Pancreas Duodenum L-3

Embryology of pancreas

Endodermal origin Develops from ventral and dorsal pancreatic buds Ventral bud becomes the uncinate process and inferior head of pancreas Dorsal bud becomes superior head, neck, body and tail Ventral bud duct fuses with dorsal bud duct to become mail pancreatic duct (Wirsung)

Pancreas, Introduction, continued

D. E. F.

Head fills concavity of duodenum Body crosses left kidney Tail reaches hilus of the spleen

G. Related anteriorly to transverse colon

Pancreas in situ

Duodenum Head of Pancreas

Pancreas, Introduction, continued

H. Aorta, IVC lie posterior I. Uncinate process: a. Lies posterior to SMA and SMV b. Lies anterior to aorta

J.

Neck lies anterior to SMV, with pylorus just above

Venous Drainage of the Pancreas

Introduction, continued

L. Body related
posteriorly to left crus, left adrenal, left renal vein, and splenic vein K. Celiac Axis lies superior to body

II. Detailed Anatomy

A. Landmark structures 1. Splenic Artery: a. Branch of celiac trunk b. passes right to left c. Course is along upper margin of body and tail

Detailed Anatomy, cont

2. Hepatic Artery:
a. Branch of celiac trunk b. courses left to right c. along upper margin of neck and head

3. Superior Mesenteric Artery: at its origin from aorta, points at body of pancreas

Proper Hepatic Artery Common Hepatic Artery Superior Mesenteric Artery

Landmark structures, continued

4. Splenic Vein:
a. runs parallel to artery b. on posterior surface of pancreas c. Terminates in portal vein

Landmark structures, continued

5. Superior & Inferior Mesenteric Veins:

a. pass (inferior to superior) deep to pancreas b. merge with splenic vein c. Terminate in portal vein

Landmark structures, continued

6. Common Bile Duct:

a. passes behind first portion of duodenum b. then through head of pancreas c. Terminates at ampulla of vater

Detailed Anatomy continued

B. Head of Pancreas
1. Important clinically because:
a. Numerous ducts and vessels traverse it b. Carcinoma usually located here

Head of Pancreas, Detailed Anatomy, continued

2. Tumor will compress surrounding structures a. First indication may be jaundice b. Tumor may compress duodenum c. May involve local vessels *Metastases may spread through these vessels*

Head of Pancreas, Detailed Anatomy, continued

3. Lymphatics from head of pancreas a. Drain to celiac nodes

b. metastases may follow lymph

c. Metastases may spread via lesser omentum to liver d. Some terminate in lumbar nodes

Head of Pancreas, Detailed Anatomy, continued

4. Vessels supplying head of pancreas a. Superior & inferior pancreaticoduodenal arteries b. Both divide into two parallel vessels c. one anterior and one posterior to head

Head of Pancreas, Detailed Anatomy, continued

1. Anterior branch of pancreaticoduodenal artery a. superior branch:

anterior superior pancreaticoduodenal artery

b. inferior branch:
anterior inferior pancreaticoduodenal artery

Head of Pancreas, Detailed Anatomy, continued

2. Posterior branch of pancreaticoduodenal artery

a. superior branch:
posterior superior pancreaticoduodenal artery

b. inferior branch:
posterior inferior pancreaticoduodenal artery

**extensive blood supply**

Detailed Anatomy, continued

C. Body & Tail of Pancreas: 1. Supplied by splenic artery 2. Have three surfaces: a. Anterior surface
1. Concave 2. Deep to stomach 3. Separated from stomach by lesser sac

Three Surfaces, continued

2. Posterior surface: a. b. c. d. e. f.

separated from vertebrae by

Aorta Splenic vein Left kidney and renal vessels Left adrenal gland Left Crus of diaphragm SMA and SMV

Three surfaces, continued

3. Inferior surface of Pancreatic body: a. Rests on duodeno-jejunal flexure b. Left extremity (tail)
1. Rests on splenic flexure 2. Abuts hilus of spleen

Detailed Anatomy, continued

D. Pancreatic Duct System 1. Pancreatic Duct (of Wirsung) a. Course is left to right b. Receives numerous small ducts c. @ neck of pancreas, duct turns inferior, posterior & to the right

Duct of Wirsung (Main pancreatic duct)

Pancreatic Duct System, continued

d. joins CBD at Ampulla of Vater 3 - 4 below pylorus e. results from fusion of ducts during fetal development
1. One from ventral pancreas 2. One from dorsal pancreas

Duct of Wirsung

Duct of Wirsung

Pancreatic Duct System, continued

2. Duct of Santorini:

a. accessory pancreatic duct

b. Not universally identified

c. joins duodenum @ minor papilla

d. part of duct from dorsal pancreas

Duct of Santorini

Pancreatic Duct System, continued

3. In 10% of population
a. ducts fail to fuse b. result is drainage of tail, body, & most of head through minor papilla c. Not pathological

III. Scanning Anatomy A. Depends on recognition of pancreatic margins B. Sonography best used as screening procedure 1. May be interference from bowel gas (especially in tail region)

Scanning Anatomy, continued

2. Extremely accurate in detection of pseudocysts 3. U/S can show texture of organ 4. By ID-ing vessels, can delineate head, portions of body

Scanning Anatomy, continued

5. U/S can frequently detect dilation of pancreatic duct 6. Splenic Vein: landmark vessel a. usually seen along posterior margin of body, tail b. May be anterior (~30%)

Scanning Anatomy, continued

C. Head: 1. SMV outlines medial head to neck region 2. Duodenum & GB outline lateral head 3. Superiorly, delineated by gastroduodenal artery (GDA) 4. Inferiorly, bounded by CBD

Scanning Anatomy, continued

D. Further delineation by vascular landmarks:

IV. Pancreatic Disorders

A. Pancreatitis: diagnosis depends on clinical evidence

1. Usually secondary to biliary tract disease 2. Surgery of biliary tract or stomach, alcoholism are other causes

Pancreatitis, Pancreatic Disorders, continued

3. Infrequent causes: a. Infectious diseases b. Trauma d. Drugs e. Hyperparathyroidism

Pancreatic Disorders, continued

B. Pseudocysts:

1. False cysts that may arise

a. due to tissue necrosis

b. From enzymatic destruction

2. May persist after inflammation subsides

3. Usually near or in pancreas

Pancreatic Disorders, continued

C. Pancreatic Tumors 1. Malignant tumors usually arise as adenocarcinomas

2. In head of Pancreas: Sx a. Painless jaundice b. Anorexia

Histology-Exocrine Pancreas

2 major components acinar cells and ducts Constitute 80% to 90% of the pancreatic mass Acinar cells secrete the digestive enzymes 20 to 40 acinar cells coalesce into a unit called the acinus Centroacinar cell (2nd cell type in the

Histology-Exocrine Pancreas

Ductular system - network of conduits that carry the exocrine secretions into the duodenum Acinus small intercalated ducts interlobular duct pancreatic duct Interlobular ducts contribute to fluid and electrolyte secretion along with the centroacinar cells

Histology-Endocrine Pancreas

Accounts for only 2% of the pancreatic mass Nests of cells - islets of Langerhans Four major cell types

Alpha (A) cells secrete glucagon Beta (B) cells secrete insulin Delta (D) cells secrete somatostatin F cells secrete pancreatic polypeptide

Histology-Endocrine Pancreas

B cells are centrally located within the islet and constitute 70% of the islet mass PP, A, and D cells are located at the periphery of the islet