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Abdomen
Published in David Heylings, Stephen Carmichael, Samuel Leinster, Janak Saada, Bari M. Logan, Ralph T. Hutchings, McMinn’s Concise Human Anatomy, 2017
David Heylings, Stephen Carmichael, Samuel Leinster, Janak Saada, Bari M. Logan, Ralph T. Hutchings
Duodenum - 25 cm (or 12 finger breadths in length, as its name implies) long, is C-shaped, with four parts (usually called first to fourth) that run respectively posteriorly on the right of midline from the pylorus, down on the right of vertebrae L1 and L2, across the midline to the left at L3 and finally up on the left of vertebra L2 (posterior to the stomach), embracing the head of the pancreas and lying at the levels of L1-L3 vertebrae (Figs.6.3, 6.10, 6.11, 6.13). The first part and the end of the fourth part, the duodenojejunal flexure, are intraperitoneal whereas the second, third and part of the fourth part are plastered onto the posterior abdominal wall by peritoneum (i.e. are retroperitoneal). It receives the bile and main pancreatic ducts that join at the hepatopancreatic ampulla (of Vater) embedded in the posteromedial wall of the second part and opening at the major duodenal papilla (Fig.6.17). Occasionally, there may be an adjacent minor duodenal papilla receiving the opening of the accessory pancreatic duct (of Santorini).
The pancreas, the neuroendocrine system, neoplasia, traditional open pancreatectomy
Published in Demetrius Pertsemlidis, William B. Inabnet III, Michel Gagner, Endocrine Surgery, 2017
Demetrius Pertsemlidis, David S. Pertsemlidis
Pancreas divisum is the result of nonfusion of the dorsal and ventral pancreatic ducts (Figure 41.3). This anomaly has been recognized in about 10% of patients undergoing endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography (MRCP) for presumed pancreatic disease. In this anomaly, the major portion of the pancreas (superior head, neck, body, and tail) is drained by the duct of Santorini through the minor duodenal papilla. The major duodenal papilla usually communicates with a small duct of Wirsung, which drains the inferior head and uncinate process. The significance of the pancreas divisum remains controversial. In some series, endoscopic pancreatography for idiopathic pancreatitis revealed a high incidence of pancreas divisum approaching 25%, but it was not clear whether the ductal anomaly had any causal relationship to the pancreatitis. Speculation that functional stenosis of the minor duodenal papilla can cause pancreatitis has led to transduodenal sphincterplasty of the minor papilla, without success.
Establishment of a Canine Training Model for Digestive Tract Reconstruction after Pancreaticoduodenectomy
Published in Journal of Investigative Surgery, 2021
Jing-Rui Yang, Rui Xiao, Jiang Zhou, Lu Wang, Jia-Xing Wang, Qian Zhang, Jian-Xiang Niu, Ze-Feng Wang, Rui-Feng Yang, Jian-Jun Ren
In addition, we need to pay close attention to the canine’s minor duodenal papilla and the major duodenal papilla, which have pancreatic duct openings. In the partial resection of the pancreas, only they were ligated, making the animal model more similar to the PJ in human PD. The dog’s pancreas is divided into two left and right lobes, which is slightly different from the human pancreas. However, the size and texture of the dog pancreas do not affect the simulated human PJ. The PJ method we applied was a modified end-to-side dunking PJ. The advantage is that the jejunum tube is pushed to the pancreas and the suture is straightened when the posterior wall is sutured, which makes it hard to tear the pancreas, and can realize a seamless connection between the jejunum and the pancreas under direct observation. In healthy Europeans with a normally functioning gallbladder, the CBD diameter was 4–8 mm [11], and the diameter of the common bile duct in a canine is about 2 mm, which brings greater challenges to the canine’s BEA. Only a skilled technique and a suitable method can complete a high-quality BEA on a canine. This uses a modified technique of a BEA with a two-point interrupted eversion suture on the posterior wall. Its advantage is that the surgical field is clear, the suture is hard to entangle, and the knots are left outside the anastomosis. The anastomosis is elastically expanded during the procedure. No anastomotic stenosis and bile leakage occurred in the general specimen examination of the 6 experimental canines 30 days postoperatively.
Current status of endoscopic diagnosis and treatment for superficial non-ampullary duodenal epithelial tumors
Published in Scandinavian Journal of Gastroenterology, 2021
Cold snare polypectomy (CSP) is a snare polypectomy procedure without electrocautery, thus reduce the incidence of complications caused by thermal injury. It is traditionally recognized for treating diminutive polyps, especially <5mm, and has been widely reported in colorectal polyp resection. Because CSP scarcely damages the deep submucosal layer and the large blood vessels in it, the risk of complications is relatively low. The safety and effectiveness of CSP were documented in patients with familial adenomatous polyposis (FAP) [40–42]. A total of 332 polyps among 10 patients of FAP were resected by CSP with no perforation or postoperative hemorrhage [40]. A small prospective clinical study also performed CSP for duodenal adenomas [43], and none of the patients were discovered with delayed bleeding, intraprocedural or delayed perforation and local recurrence. However, as is reported, severe acute pancreatitis occurred after cold polypectomy of the minor duodenal papilla in a patient with incomplete pancreas divisum [44], which entails precise diagnosis prior to the procedure. Although CSP has been validated to be safe in a number of studies, it is associated with a moderate incidence of incomplete resection as reported in previous studies (1.8–3.9%) [45,46]. Another issue was raised that 57% of the mucosal layer was not removed completely by CSP, indicating that CSP should only be applied to intra-epithelial lesions, which requires evaluating the lesions before the operation correctly [47]. Though the outcomes of the studies were acceptable, as a new implement, the indication and practicality of CSP in duodenum still remain to be verified due to the lack of sufficient data.
Clinical importance of main pancreatic duct variants and possible correlation with pancreatic diseases
Published in Scandinavian Journal of Gastroenterology, 2020
Ana Dugic, Sara Nikolic, Steffen Mühldorfer, Milutin Bulajic, Raffaella Pozzi Mucelli, Apostolos V. Tsolakis, J.-Matthias Löhr, Miroslav Vujasinovic
Bud fusion is most commonly accompanied by the fusion of their axial ducts, with the point of junction located between the isthmus and the head of the pancreas. The fusion between the ventral duct and lateral two-thirds of the dorsal duct leads to formation of the duct of Wirsung, which grows to be MPD and sometimes the only excretory pancreatic duct, opening into major duodenal papilla [6]. The medial part of the dorsal duct partially regresses to become the accessory pancreatic duct (APD), known as a duct of Santorini, which commonly opens into minor duodenal papilla (MiP) [8,9]. The process of PDS formation is very complicated, resulting in many individual anatomical variants.