International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 02, January 2015, Pages 23-33
Original article: Arterial arcades of Pancreas and their variations Chavan NN*, Wabale RN**
[*Assistant Professor, ** Professor and Head] Department of Anatomy, Rural Medical College, PIMS, Loni , Tal. Rahata, Dist. Ahmednagar, Maharashtra, Pin - 413736. Corresponding author: Dr Chavan NM
Abstract: Introduction : Pancreas is a highly vascular organ supplied by number of arteries and arterial arcades which provide blood supply to the organ. Arteries contributing to the arterial arcades are celiac and superior mesenteric arteries forming anterior and posterior arcades. These vascular arcades lie upon the surface of the pancreas but also supply the duodenal wall and are the chief obstacles to complete pancreatectomy without duodenectomy. Knowledge of variations of upper abdominal arteries is important while dealing with gastric and duodenal ulcers, biliary tract surgeries and mobilization of the head of the pancreas, as bleeding is one of the complications of these surgeries. During pancreaticoduodenectomies or lymph node resection procedures, these arcades are liable to injuries. Material and methods : Study was conducted on 50 specimens of pancreas removed enbloc from cadavers to study variations in the arcade. Observation and result : Anterior arterial arcade was present in 98% specimens and absent in 2%. It was formed by anterior superior pancreaticoduodenal artery(ASPDA) and anterior inferior pancreaticoduodenal artery(AIPDA) in 92%, Anterior superior pancreaticoduodenal artery (ASPDA), Anterior inferior pancreaticoduodenal artery (AIPDA) and Right dorsal pancreatic artery (Rt.DPA) in 2%, Anterior superior pancreaticoduodenal artery (ASPDA) only in 2%, Anterior superior pancreaticoduodenal artery (ASPDA) and Posterior inferior pancreaticoduodenal artery (PIPDA) in 2%, Arcade was absent and Anterior superior pancreaticoduodenal artery (ASPDA) gave branches in 2%. Similarly posterior arcade also showed variations with presence in only 98% specimens. Conclusion : Wide range of statistical records of arterial supply of pancreas, show that it is an organ that lies in three peripancreatic interlocking arterial circles with varying degree of variations making it difficult to differentiate and classify normal, variant and anomalous. It shows that developmental probabilities and possibilities associated with two pancreatic buds approaching each other, enlarging and invading into a meshwork of blood vessels are many. Key words: Arcades, variations, surgical importance
Introduction digestion of ingested food and the other is an Pancreas is second largest of digestive glands of the endocrine part for glucose homeostasis and human body having glandular tissue of two different gastrointestinal motility. types for accomplishing two different functions. The Pancreas is an organ that develops at the boundary major part is an exocrine gland secreting enzymes for between foregut and midgut. The area of foregut is
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 02, January 2015, Pages 23-33
supplied by the celiac trunk and the midgut by findings with available literature to establish a data superior mesenteric artery. This explains the for this region. description of classical anatomy of the area that the Material and methods blood supply of second part of duodenum and the The study was carried out on 50 specimens removed head of pancreas originates from several arteries that enbloc from the cadavers, available in the department spring from the celiac axis and the superior of Anatomy of Rural Medical College, Loni, mesenteric artery. 1 The pancreaticoduodenal arcades Maharashtra. The approval of the Institutional Ethical which are located anterior and posterior to the and Research Committee was sought before pancreatic head, are major source of blood supply of beginning the study. pancreatic head and the second part of the duodenum. Inclusion criteria : Formalin embalmed adult Extensive interference with the pancreaticoduodenal cadavers with normal anatomy of pancreas arcades in the course of a 95% pancreatectomy may irrespective of sex were used in this study. These compromise the blood supply of the duodenum were the cadavers meant for utilization by first year because of the shared blood supply of the duodenum medical students for routine dissection. and pancreatic head. 2 In addition, because the Exclusion criteria : The cadaveric specimens with duodenojejunal flexure and the first part of the obvious abdominal pathology or operative procedures jejunum may derive their blood supply from branches were excluded from the study. of the inferior pancreaticoduodenal artery or the The enbloc removal, along with pancreas included pancreaticoduodenal arcades, ligation of these vessels the duodenum, the spleen, the related part of the in the course of a resection may render the proximal abdominal aorta and portal vein. The dissection jejunum ischemic. 3 Typically, the posterosuperior necessary to study the arterial supply of different pancreaticoduodenal artery arises from the parts of the pancreas was carried out. A hand lens gastroduodenal artery and passes to the right, anterior was used wherever necessary. Each and every to the common bile duct, forming a major source of specimen thus dissected was documented with the blood supply to common bile duct. This relation is of help of line drawing and photograph. surgical importance in case of operation involving After removal and cleaning the dissected specimen mobilization of the lower end of the common bile all parameters such as origin of arteries forming duct. 3 arcade, distance of arcade from duodenum, number There are variations in this arcades like; it may be of arcades and number of branches were noted. The doubled or tripled. The posterior arcade may also data collected was analyzed and expressed as anastomose with an aberrant right hepatic artery from percentage. Wherever required the data was subjected the superior mesenteric artery and also there are to statistical analysis. Other incidental observations in variations in the origins of arteries forming arcade. the course of study were recorded and discussed in So the study was conducted to study the pattern of the light of existing literature. arterial arcades supplying pancreas and the variations Abbreviations - (AA- Abdominal Aorta , CT- Celiac in arterial arcades of pancreas and to compare the trunk , CHA - Common Hepatic Artery, HA - Hepatic Artery Proper, GDA - Gastroduodenal Artery ,
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ASPDA - Anterior Superior Pancreaticoduodenal 1. Anterior Pancreaticoduodenal Arcade (APAr): Artery PSPDA -Posterior Superior Two major arterial arcades were identified i.e. Pancreaticoduodenal Artery, RGEA - Right anterior and posterior. Anterior arcade is formed by Gastroepiploic Artery , IPDA- Inferior anterior superior pancreaticoduodenal and anterior Pancreaticoduodenal Artery , AIPDA - Anterior inferior pancreaticoduodenal arteries and posterior Inferior Pancreaticoduodenal Artery, PIPDA - arcade is formed by posterior superior Posterior Inferior Pancreaticoduodenal Artery, pancreaticoduodenal and posterior inferior APAr - Anterior Pancreaticoduodenal pancreaticoduodenal arteries, mostly. Arcade/Anterior arcade, PPAr - Posterior Anterior arcade was present in 98% (49/50) Pancreaticoduodenal Arcade /Posterior arcade) specimens and absent in 2%. Observation Arteries of origin are shown in table 1 (figure 1 and Photograph 1,2,3,4).
Table 1: Showing origin of Anterior Pancreaticoduodenal Arcade Origin No. %
Anterior superior pancreaticoduodenal artery (ASPDA) and Anterior inferior 46/50 92% pancreaticoduodenal artery (AIPDA) Anterior superior pancreaticoduodenal artery (ASPDA), Anterior inferior 1/50 2% pancreaticoduodenal artery (AIPDA) and Right dorsal pancreatic artery (Rt.DPA) Anterior superior pancreaticoduodenal artery (ASPDA) only 1/50 2% Anterior superior pancreaticoduodenal artery (ASPDA) and Posterior inferior 1/50 2% pancreaticoduodenal artery (PIPDA) Arcade absent and Anterior superior pancreaticoduodenal artery (ASPDA) gives 1/50 2% branches Total 50/50 100%
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Figure 1: Showing arteries of origin for Anterior Pancreaticoduodenal Arcade
ASPDA RT. DPA
AIPDA
ASPDA, AIPDA and Rt.DPA 1/50 (2%) ASPDA only1/50 (2%) (Photograph 1) (Photograph 2)
ASPDA
PIPDA
ASPDA & PIPDA 1/50 (2%) Arcade absent &ASPDA gives branches 1/50 (2%). (Photograph 3) (Photograph 4)
Distance of arcade from duodenum: The distance of arcade from duodenum ranged from 0(at pancreaticoduodenal junction) to 3 cm with mean 0.54 and standard deviation of 0.68. In 20 specimens the arcade was hidden by pancreatic tissue (40%). Number of Arcade: In all specimens only single arcades were found. Number of branches by arcade: Average number =8; Range =6 - 10 2. Posterior pancreaticoduodenal arcade (PPAr): This arcade was present in 98% and absent in 2% specimens. Arteries of origin are shown in table 2 (Figure 2 and Photograph 5,6,7,8,9,10)
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Table 2: Showing origin of Posterior Pancreaticoduodenal Arcade Origin No. % Posterior superior pancreaticoduodenal artery (PSPDA) and Posterior inferior 43/50 86% pancreaticoduodenal artery (PIPDA) Posterior superior pancreaticoduodenal artery (PSPDA), Posterior inferior pancreaticoduodenal 2/50 4% artery (PIPDA) and extra branch from superior mesenteric artery (SMA) Posterior superior pancreaticoduodenal artery (PSPDA),Posterior inferior pancreaticoduodenal 1/50 2% artery (PIPDA) and extra branch from abdominal aorta (AA) Posterior superior pancreaticoduodenal artery (PSPDA ) only 1/50 2% Anterior inferior pancreaticoduodenal artery (AIPDA) and Posterior superior pancreaticoduodenal 1/50 2% artery (PSPDA) Arcade absent and Right hepatic artery (RHA) gives branches 1/50 2% Posterior superior pancreaticoduodenal artery (PSPDA), Posterior inferior pancreaticoduodenal 1/50 2% artery (PIPDA) and Anterior inferior pancreaticoduodenal artery (AIPDA) Total 50/50 100%
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Figure 2: Showing arteries of origin for Posterior Pancreaticoduodenal Arcade
PSPDA PSPDA EXTRA BRANCH EXTRA BRANCH FROM SMA FROM AA PIPDA PIPDA
PSPDA, PIPDA and Extra branch PSPDA, PIPDA and extra branch from from SMA 2/50 (4%). AA 1/50 (2%). (Photograph 5) (Photograph 6)
PSPDA
AIPDA
PSPDA only forms arcade 1/50 (2%). PSPDA and AIPDA 1/50 (2%). (Photograph 7) (Photograph 8)
RHA
PIPDA PSPDA
AIPDA
PPAr is absent and RHA gives PSPDA, PIPDA and AIPDA 1/50 (2%). branches 1/50 (2%) (Photograph 9) (Photograph 10)
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Distance from duodenum-The distance of arcade Photograph 11: Anterior arcade embedded within from duodenum ranged from 0 (at pancreat- pancreatic tissue. icoduodenal junction) to 2.9 cm, with a mean 1.36 Posterior Pancreaticoduodenal Arcade (PPAr): and standard deviation of 0.52. There was a Another arcade artery supplying posterior surface of statistically significant difference (p value< 0.05) duodenum and pancreas is present in 98% of cases in between the mean distance of anterior arcade and this study, in all the cases studied by Michel NA et mean distance of posterior arcade from al 9, and 88% of cases studied by Kimura W et pancreaticoduodenal junction. al. 16 Variable origin of the two source arteries for Number of arcades - arcade was single in all cases. arcade was noted in this study; arcade formation by Number of branches by arcade: Average number posterior superior pancreaticoduodenal artery and =7; Range = 6 - 10. posterior inferior pancreaticoduodenal artery was Discussion seen in 86% cases. Similar combination is seen in Anterior Pancreaticoduodenal Arcade (APAr): An 78% by Van Damme et al 8, and in 88% cases studied arcade of an artery supplying branches to anterior by Kimura W et al. 16 surface of both duodenum and head of pancreas is Location of this arcade was farther away from present in 98% cases in this study; same was present duodenum as compared to anterior arcade. On an in all cases studied by Kimura W et al. 16 In 92% average we found seven branches arising from cases this arcade is formed by anterior superior posterior arcade supplying duodenum (2 nd part) along pancreaticoduodenal artery and anterior inferior with common bile duct. Smaller delicate branches pancreaticoduodenal artery; whereas same is noted in arising from the arcade sunk into posterior surface of all cases studied by Kimura W et al. 16 In 40% cases head of pancreas the lower 2/3 rd arcade was found to be partly There are anastomoses at all levels of pancreas. This embedded within pancreatic tissue; this occurrence extensive arterial network of the pancreas is an finds no mention anywhere in the available literature. important source of collateral blood supply in cases On an average we found eight branches arising from of occlusion of celiac axis, superior mesenteric or anterior arcade supplying only the duodenum. splenic arteries. The existence of individual Smaller delicate branches arising from the arcade differences, development of arterial–arterial sunk directly into substance of pancreas (Photograph anastomosis asks for obligatory preoperative No.11). supraselective angiography which enables insight into distribution of blood vessels. 17 It is into this meshwork of vessels the pancreatic buds sprout from two opposite sides i.e. dorsal and ventral of the second part of duodenum (Picture No.1).
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Picture 1: Development of Blood supply of Gastrointestinal tract and Pancreas 18
Dorsal bud sprouts and enlarges on the left side of variations often making it difficult to differentiate network of vessels in the dorsal mesentery of and classify normal, variant and anomalous. duodenum. Hence after rotation and fixation of the • All the arteries supplying arcades of duodenal loop the blood vessels for body and tail of pancreas were found to have a variable pancreas are seen to be located on posterior surface origin, length and termination. only. Ventral bud along with bile duct and network of • Different studies on the arterial supply of vessels on its both side rotates and fuses with dorsal pancreas came up with a wide range of bud, hence the presence of blood vessels in the form statistical records. No one particular reason of arcade is seen on both surfaces of head of can satisfactorily explain occurrence of such pancreas. In a general way, this explains the variations in arteries supplying pancreas. existence of three peripancreatic, interlocking arterial • These studies are from different region of circles; the variations among the pancreatic vessels in the world. Food type, bodily habitus, and the different individuals; and the varying calibers of habitat vary from region to region leading to 14 vessels. Thus pancreatic arteries may have variable variation in morphology of organs origins as well as variable caliber. Arteriography can associated with alimentary system and outline most of the arteries of the pancreas, so it is consequent rearrangement of vessels. advisable to obtain preoperative angiograms to • The reason for variations being found in the provide more orderly intraoperative identification and same geographical region may lie in the control of the arterial blood. many developmental probabilities and Summary and conclusion possibilities associated with two pancreatic All the arteries supplying different parts of pancreas buds approaching each other, enlarging and were studied with respect to their origin, termination, invading into a meshwork of blood vessels. length, and parts of pancreas supplied. We found that • One Should have precise knowledge pancreas is an organ that lies in three peripancreatic regarding the anatomy of the pancr- interlocking arterial circles with varying degree of eaticoduodenal region ( pancreaticoduodenal
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arteries) which provide blood to the One thing that became apparent in this study was duodenum. need to include a larger sample size in view of the • There is a need to preserve the quantum and spectrum of variations that we came pancreaticoduodenal arteries to avoid across in a relatively small sample size. Study in a duodenal necrosis larger sample size was not possible due to constraints • Preservation of the pancreaticoduodenal with respect to time and availability of specimens for arteries would provide a better supply of study. blood to the duodenal wall. A thorough search of literature did not yield any • Distance of posterior arcade from publication related to study of arteries of pancreas duodenojejunal junction was found to be from our region. This was probabaly the first attempt significantly more than the distance of in our region to study and document arteries of anterior arcade which is most probably due pancreas in detail. The knowledge of the vascular to presence of common bile duct between anatomy of pancreatic region is an important posterior arcade and duodenum. prerequisite for planned surgical intervention. The • In 40% specimens the arcade was hidden by awareness of the existing vascular anomalies pancreatic tissue. enhances the insight of any region and thus the chances of successful outcome.
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