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Dorsal Pancreatic Artery—A Study of Its Detailed Anatomy for Safe Pancreaticoduodenectomy

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Dorsal Pancreatic Artery—A Study of Its Detailed Anatomy for Safe Pancreaticoduodenectomy Indian Journal of Surgery (February 2021) 83(1):144–149 https://doi.org/10.1007/s12262-020-02255-2 ORIGINAL ARTICLE Dorsal Pancreatic Artery—a Study of Its Detailed Anatomy for Safe Pancreaticoduodenectomy T Tatsuoka1 & TNoie2 & TNoro1 & M Nakata3 & HYamada4 & Y Harihara2 Received: 29 October 2019 /Accepted: 24 April 2020 /Published online: 155 May 2020 # The Author(s) 2020 Abstract Early division of the dorsal pancreatic artery (DPA) or its branches to the uncinate process during pancreaticoduodenectomy (PD) in addition to early division of the gastroduodenal artery and inferior pancreaticoduodenal artery should be performed to reduce blood loss by completely avoiding venous congestion. However, the significance of early division of DPA or its branches to the uncinate process has not been reported. The aim of this study was to investigate the anatomy of DPA and its branches to the uncinate process using the currently available high-resolution dynamic computed tomography (CT) as the first step to investigate the significance of DPA in the artery-first approach during PD. Preoperative dynamic thin-slice CT data of 160 consecutive patients who underwent hepato–pancreato–biliary surgery were examined focusing on the anatomy of DPA and its branches to the uncinate process. DPAwas recognized in 103 patients (64%); it originated from the celiac axis or its branches in 70 patients and from the superior mesenteric artery or its branches in 34 patients. The branches to the uncinate process were visualized in 82 patients (80% of those with DPA), with diameters of 0.5–1.5 mm in approximately 80% of the 82 patients irrespective of DPA origin. DPA branches to the uncinate process were recognized using high-resolution CT in approximately half of the patients. Keywords Dorsal pancreatic artery . Pancreaticoduodenectomy . Uncinate process Introduction many individual differences in DPA anatomy. DPA branches that feed the uncinate process of the pancreas exist in many Blood loss reduction by avoiding venous congestion in the cases [1, 15, 16, 24, 27]. In such cases, to completely avoid resected specimen during pancreaticoduodenectomy (PD) is venous congestion, DPA or its branches distributed to the one of the main indications of the artery-first approach [3, 6, 8, uncinate process should be divided before dissecting from 9, 11, 18, 19, 23]. Early division of the inferior the portal vein (PV) and superior mesenteric vein (SMV) in pancreaticoduodenal artery (IPDA) along with the gastroduode- the artery-first approach during PD. However, no study has nal artery is considered important for avoiding venous congestion investigated the significance of DPA in the artery-first ap- using the artery-first approach [3, 6, 8, 9, 11, 18, 19, 23]. proach during PD. The dorsal pancreatic artery (DPA) exists in many cases [1, Preoperatively, in each case, the surgeon compre- 15, 16, 24, 27]. DPA ramification is complex, and there are hends the pancreatic vascular anatomy necessary for PD from preoperative computed tomography (CT) data. Thus, many studies have reported the CT depiction of * TNoie the peripancreatic vascular system, including DPA [4, 7, [email protected] 10, 14, 20, 22]. However, CT data of DPA branch dis- tributed to the uncinate process have not been previous- ly reported, although classical dissection studies have 1 Department of Surgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan reported the anatomy of the uncinate process branch of DPA [16, 27]. Thus, the aim of the present study was to 2 Department of Surgery, NTT Medical Center Tokyo, Tokyo, Japan 3 investigate the anatomy of DPA and its branches to the Department of Radiology, Dokkyo Medical University Saitama uncinate process on current high-resolution dynamic CT, Medical Center, Saitama, Japan 4 as the first step to investigate the significance of DPA Department of Radiology, NTT Medical Center Tokyo, in the artery-first approach during PD. Tokyo, Japan Indian J Surg (February 2021) 83(1):144 ative dynamic thin-slice CT inAmong 103 the patients 160 (64%) patients, (Table DPA was recognized using preoper- Results study, and the requirement for informed consentMedical was Center waived. Tokyo, Japan,University approved Saitama this Medical retrospective C Tokyo, Japan) with consensus on readings. workstation (Synapse EX versionevaluated 1.9; by FUJIFILM two Medical, authorscolic artery (TT (AMCA) and were TN) examined. Allcreatic using head imaging and data a existence were and diagnostic origincess, of the along accessory with middle the caliberDPA, especially of the existence the of arteries branches to that the feed uncinate pro- the pan- and 40 s, respectively, afterimaging. starting Early the and infusion. late arterial phase imagesLtd., were Tokyo, obtained Japan) at was 25 infusedionic at 600 contrast mgI/kg agent for (350 30Otawara, s mgI/ml, Japan prior at Iomeron; to NTT Bracco MedicalCenter, Eisai Center Japan, Co., Tokyo, and Japan). Aquilion ATokyo, non- ONE; Japan Toshiba at Medical Dokkyoscanner Systems, Medical (320-MDCT; Aquilion University ONE; Saitama Toshiba Medical Medical Systems, with a median ageour of institutions. There 70 were years 100 male (36 ary and surgery 60 female between patients Januaryconsecutive patients 2016 who and underwent DecemberWe hepato assessed 2017 preoperative, dynamic, at thin-slice CT data of 160 Materials and Methods intraductal papillary mucinous neoplasm in 22,pancreatic and so cancer on. in 47 patients, bile duct cancer in 23, the frequency of the representative branches(Fig. are presented in rior side of SMA;scends at and the left enters posterior into sideto of the the SMV and uncinate inferior at pancreatic the process body artery); right entering ante- in from the many caudal side cases, ofSV; finally SV most (usually de- connecting often subsequently hasbranch to branches the to pancreatic body the entering from pancreatic thebranch cranial to side of the pancreatic head; sometimesproximal subsequently part has of a the splenicruns vein caudally (SV); behind rarely initially theDPA has originating pancreatic from a CA neck or or its branches body is and as follows: the DPA originating from both CA and SMAbranches series) (Table in 34 patientspatients (68%) (33%) and the (one superior mesenteric artery patient (SMA) orDPA originated its had from the two celiac axis DPAs (CA) or its branches in 70 The institutional review boards of the Dokkyo Medical The existence, origin, and ramification and anatomy of The most representative ramification and the anatomy of CT scans were performed usin 1 a). The origin of DPA from CA or its branches and g a 320-row multidetector CT – enter, Japan, and the NTT 149 – 87). The diagnoses are – pancreato 1 ). – bili- 1 ). Table 1 Existence, origin, ramification, and caliber of the dorsal pancreatic artery (DPA) DPA Origin of DPA Early head branch (n) Body branch Body branch entering Branch to the uncinate Caliber (mm) entering from the cranial from the caudal side of SV (n) process (n) side of SV (n) DPA Uncinate process branch (+) (n = 103, 64%) CA CHA (n =28b) 0 (0%) 12 (43%) 23 (82%) 23 (82%) 1.8 ± 0.5 1.1 ± 0.5 n a ( =70,68%) SA (n = 27) 3 (11%) 8 (30%) 20 (74%) 22 (81%) 2.0 ± 0.6 0.9 ± 0.4 CA (n =15c) 0 (0%) 0 (0%) 12 (80%) 14 (93%) 1.6 ± 0.4 1.0 ± 0.3 SMA SMA (n = 27) 3 (11%) 3 (11%) 23 (85%) 18 (67%) 1.8 ± 0.7 1.1 ± 0.5 (n =34a, d, 33%) r-RHA (n =8e) 0 (0%) 4 (50%) 6 (75%) 4 (50%) (37 branches) AIPDA (n =1) 0 0 1 0 MCA (n =1) 0 0 1 1 (−)(n = 57, 36%) DPA dorsal pancreatic artery, SV splenic vein, CA celiac axis, CHA common hepatic artery, SA splenic artery, SMA superior mesenteric artery, r-RHA replaced right hepatic artery, AIPDA anterior inferior pancreaticoduodenal artery, MCA middle colic artery a One case had two DPAs from both CA and SMA series b Including three cases with DPA from the right hepatic artery that originates early near CA and passes behind the portal vein c Including two cases with DPA from the left gastric artery (one from the aorta and one with no CHA) 145 d Including three cases with two DPAs from the SMA series (two with both arteries from SMA and one with arteries from SMA and r-RHA) e Including one case with DPA from the replaced common hepatic artery 146 Indian J Surg (February 2021) 83(1):144–149 ab Fig. 1 3D reconstruction of the course of the dorsal pancreatic artery. a superior mesenteric artery. 3D reconstruction of the CT scans of a 70- Dorsal pancreatic artery from the splenic artery. 3D reconstruction of the year-old woman with gallbladder cancer. The dorsal pancreatic artery and CT scans of an 81-year-old man with hepatocellular carcinoma. The dor- its branches are depicted as red vessels. The splenic vein and portal vein sal pancreatic artery and its branches are depicted as red vessels. The are depicted as purple vessels, and the pancreatic parenchyma is depicted splenic vein (SV) and portal vein are indicated as purple vessels, and in weak blue color. The dorsal pancreatic artery (large arrowhead) origi- the pancreatic parenchyma is indicated in weak blue color. The dorsal nates from the superior mesenteric artery (SMA), ascends in front of pancreatic artery (arrowhead) originates from the splenic artery, runs cau- SMA, initially produces the accessory middle colic artery (small arrow- dally behind the proximal part of SV, produces branches to the pancreatic head) in this case, and divides into branches to the pancreatic body (thin body (thin arrow), descends at the right anterior side of the superior arrow) and uncinate process (bold arrow). The branch to the uncinate mesenteric artery as a branch to the uncinate process (bold arrow), and process descends at the right side of SMA and enters into the uncinate enters into the uncinate process.
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