SURGICAL ANATOMY OF PANCREAS

Dr

ganesh

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

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 main pancreatic duct (Wirsung)

Ventral Bud

Pancreas

Head of Pancreas

Includes uncinate process Flattened structure, 2 3 cm thick Attached to the 2nd and 3rd portions of duodenum on the right Emerges into neck on the left Border b/w head & neck is determined by GDA insertion SPDA and IPDA anastamose b/w the duodenum and the rt. lateral border

Neck of Pancreas

2.5 cm in length Straddles SMV and PV Antero-superior surface supports the pylorus Superior mesenteric vessels emerge from the inferior border Posteriorly, SMV and splenic vein confluence to form portal vein Posteriorly, mostly no branches to pancreas

Pancreas

Body of Pancreas

Elongated, long structure Anterior surface, separated from stomach by lesser sac Posterior surface, related to aorta, lt. adrenal gland, lt. renal vessels and upper 1/3rd of lt. kidney Splenic vein runs embedded in the post. Surface Inferior surface is covered by tran. mesocolon

Tail of Pancreas

Narrow, short segment Lies at the level of the 12th thoracic vertebra Ends within the splenic hilum Lies in the splenophrenic ligament Anteriorly, related to splenic flexure of colon May be injured during splenectomy (fistula)

Pancreatic Duct

Main duct (Wirsung) runs the entire length of pancreas Joins CBD at the ampulla of Vater 2 4 mm in diameter, 20 secondary branches Ductal pressure is 15 30 mm Hg (vs. 7 17 in CBD) thus preventing damage to panc. duct Lesser duct (Santorini) drains superior portion of head and empties separately into 2nd portion of duodenum

Arterial Supply of Pancreas

Variety of major arterial sources (celiac, SMA and splenic) Celiac Common Hepatic Artery Gastroduodenal Artery Superior pancreaticoduodenal artery which divides into anterior and posterior branches SMA Inferior pancreaticoduodenal artery which divides into anterior and posterior branches

Arterial Supply of Pancreas

Anterior collateral arcade b/w anterosuperior and anteroinferior PDA Posterior collateral arcade b/w posterosuperior and posteroinferior PDA Body and tail supplied by splenic artery by about 10 branches Three biggest branches are
Dorsal

pancreatic artery Pancreatica Magna (midportion of body) Caudal pancreatic artery (tail)

Arterial Supply of Pancreas

Venous Drainage of Pancreas

Follows arterial supply Anterior and posterior arcades drain head and the body Splenic vein drains the body and tail Major drainage areas are
Suprapancreatic

PV Retropancreatic PV Splenic vein Infrapancreatic SMV

Ultimately, into portal vein

Venous Drainage of Pancreas

Lymphatic Drainage

Rich periacinar network that drain into 5 nodal groups

Superior

nodes Anterior nodes Inferior nodes Posterior PD nodes Splenic nodes

Innervation of Pancreas

Sympathetic fibers from the splanchnic nerves Parasympathetic fibers from the vagus Both give rise to intrapancreatic periacinar plexuses Parasympathetic fibers stimulate both exocrine and endocrine secretion Sympathetic fibers have a predominantly inhibitory effect

Innervation of Pancreas

Peptidergic neurons that secrete amines and peptides (somatostatin, vasoactive intestinal peptide, calcitonin gene-related peptide, and galanin Rich afferent sensory fiber network Ganglionectomy or celiac ganglion blockade interrupt these somatic fibers (pancreatic pain*)

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 acinus) is responsible for fluid and electrolyte secretion by the pancreas

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

makes HCO3

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

Physiology Exocrine Pancreas

Secretion of water and electrolytes originates in the centroacinar and intercalated duct cells Pancreatic enzymes originate in the acinar cells Final product is a colorless, odorless, and isosmotic alkaline fluid that contains digestive enzymes (amylase, lipase, and trypsinogen)

Physiology Exocrine Pancreas

500 to 800 ml pancreatic fluid secreted per day Alkaline pH results from secreted bicarbonate which serves to neutralize gastric acid and regulate the pH of the intestine Enzymes digest carbohydrates, proteins, and fats

Bicarbonate Secretion

Centroacinar cells and ductular epithelium secrete 20 mmol of bicarbonate per liter in the basal state Fluid (pH from 7.6 to 9.0) acts as a vehicle to carry inactive proteolytic enzymes to the duodenal lumen Sodium and potassium concentrations are constant and equal those of plasma Chloride secretion varies inversely with bicarbonate secretion

Bicarbonate Secretion

Bicarbonate is formed from carbonic acid by the enzyme carbonic anhydrase Major stimulants
Secretin, Cholecystokinin, Gastrin, Acetylcholine

Major inhibitors
Atropine, Somatostatin, Pancreatic polypeptide and Glucagon

Secretin - released from the duodenal mucosa in response to a duodenal luminal pH < 3

Enzyme Secretion

Acinar cells secrete isozymes

amylases, lipases, and proteases

Cholecystokinin, Acetylcholine, Secretin, VIP

Major stimulants

Synthesized in the endoplasmic reticulum of the acinar cells and are packaged in the zymogen granules Released from the acinar cells into the lumen of the acinus and then transported into the duodenal lumen, where the enzymes are activated.

Enzymes

Amylase
only

digestive enzyme secreted by the pancreas in an active form functions optimally at a pH of 7 hydrolyzes starch and glycogen to glucose, maltose, maltotriose, and dextrins

Lipase
function

optimally at a pH of 7 to 9 emulsify and hydrolyze fat in the presence of bile salts

Enzymes of Pancreas

Proteases
essential

for protein digestion secreted as proenzymes and require activation for proteolytic activity duodenal enzyme, enterokinase, converts trypsinogen to trypsin Trypsin, in turn, activates chymotrypsin, elastase, carboxypeptidase, and phospholipase

Within the pancreas, enzyme activation is prevented by an antiproteolytic enzyme secreted by the acinar cells

Insulin

Synthesized in the B cells of the islets of Langerhans 80% of the islet cell mass must be surgically removed before diabetes becomes clinically apparent Proinsulin, is transported from the endoplasmic reticulum to the Golgi complex where it is packaged into granules and cleaved into insulin and a residual connecting peptide, or C peptide

Insulin

Major stimulants
Glucose,

amino acids, glucagon, GIP, CCK, sulfonylurea compounds, -Sympathetic fibers amylin, pancreastatin, sympathetic fibers

Major inhibitors
somatostatin,

Glucagon

Secreted by the A cells of the islet Glucagon elevates blood glucose levels through the stimulation of glycogenolysis and gluconeogenesis Major stimulants
Aminoacids,

Cholinergic fibers, -Sympathetic

fibers

Major inhibitors
Glucose,

insulin, somatostatin, -sympathetic

fibers

Somatostatin

Secreted by the D cells of the islet Inhibits the release of growth hormone Inhibits the release of almost all peptide hormones Inhibits gastric, pancreatic, and biliary secretion Used to treat both endocrine and exocrine disorders