Superior Pancreaticoduodenal Vein Research Articles

Investigation of the variation of vessels around the pancreatic head based on the first jejunal vein anatomy at pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) for pancreatic cancer carries a high risk of massive intraoperative blood loss. The artery first approach (AFA) prevents blood loss during PD, but the optimal approach is unclear. The first jejunal vein (FJV) often comprises multiple veins and broadly supports venous drainage of the proximal jejunum. Its ligation carries a risk of proximal jejunum congestion. Here we investigated the anatomical characteristics of PD-associated vessels and AFA approach selection based on FJV anatomy. This study included 148 Japanese living donors for liver transplantation. We reviewed their computed tomography images and assessed the anatomical pattern of PD-associated vessels in terms of FJV anatomy. The FJV traveled posterior to the superior mesenteric artery in 128 patients (86.5%, dorsal group) and anterior in 20 (13.5%, ventral group). The predominant draining vein of the inferior pancreaticoduodenal vein was the superior mesenteric vein in the ventral group (87.5%) and the FJV in the dorsal group (97.9%). Compared with the dorsal group, the ventral group had a significantly greater percentage with the superior mesenteric vein ventral to the superior mesenteric artery (30.0% versus 10.9%) and a significantly larger posterior superior pancreaticoduodenal vein diameter (3.2 ± 0.9 versus 2.7 ± 0.6mm, p = 0.0029). These results were validated in patients with pancreatic head cancer. The anatomical characteristics of PD-associated vessels differed significantly between groups defined by FJV anatomy. Understanding the venous anatomy, especially the FJV, could support selection of the best approach in AFA for PD.

A case in which the ileocolic vein draining into the gastrocolic trunk of Henle could be diagnosed preoperatively: a rare anatomical case report

BackgroundNumerous variations in vascular anatomy have been reported in the right colon. The ileocolic vein (ICV) generally drains directly into the superior mesenteric vein (SMV), and is an important landmark for laparoscopic surgery in right colon cancer. We present here a patient with a vascular anomaly of the ICV that was diagnosed on preoperative imaging.Case presentationA 65-year-old woman was diagnosed with transverse colon cancer by colonoscopy. Preoperative computed tomography scan showed that the ICV drained into the gastrocolic trunk of Henle (GCT) rather than the SMV. Single-incision laparoscopic transverse colectomy with D3 lymph node dissection was performed, dividing the middle colic vein (MCV) and preserving the right gastroepiploic vein (RGEV), anterior superior pancreaticoduodenal vein (ASPDV), GCT and ICV. The intraoperatively identified venous anatomy was consistent with the preoperative evaluation, and the RGEV, ASPDV and ICV were found to form the GCT.ConclusionWe report a rare vascular anatomical anomaly that was diagnosed preoperatively, facilitating safe and successful single-incision laparoscopic surgery with D3 lymph node dissection.

Vascular variants in laparoscopic extended right hemicolectomy with central vascular ligation for right colon cancer.

To evaluate the right colic vascularity, focusing on the confluences of veins. The subjects of this retrospective study were 100 patients who underwent laparoscopic extended right hemicolectomy (Lap-ERHC) between April 2015 and September 2020, at our hospitals. Veins draining into the superior mesenteric vein (SMV) included the ileocecal vein (ICV), the right colic vein (RCV), the middle colic vein (MCV), and the gastrocolic trunk of Henle (GCT). Veins draining into vessels other than the SMV were defined as accessory colic veins (aICV, aRCV or aMCV). The GCT, aRCV, and aMCV were found in 86, 89, and 15 patients, respectively. In 66 patients with one aRCV, drainage was split as the anterior superior pancreaticoduodenal vein (ASPDV) in 12, the right gastroepiploic vein (RGEV) in 7, and the GCT in 47. In 23 patients with two aRCVs, drainage was split as the ASPDV in 4, the RGEV in 1, the GCT in 11, and the ASPDV and GCT in 7. In 14 patients with one aMCV, drainage was split as the GCT in 8, the splenic vein in 5, and the first jejunal vein (FJV) in 1. One patient had two aMCVs, draining into the GCT and the FJV. The findings of our evaluation of vascular anatomy, focusing on confluences of the colic veins, provides useful information for colorectal surgeons.

Evaluating quality and completeness of gastrectomy for gastric cancer: review of surgical videos from the public domain.

YouTube® has provided a forum to share surgical videos in the public domain which may be used for education. The quality of surgery and accompanying educational material is unknown. YouTube® videos of gastrectomy with D2 lymphadenectomy (D2-LND) for gastric cancer were evaluated for quality and completeness. YouTube® was searched using the terms "D2 lymphadenectomy" and "Gastric Cancer" for open and laparoscopic videos. The Korean Laparoscopic Gastrointestinal Surgical Society (KLASS) outlined 22 steps that define quality and completeness of D2-LND. These guidelines were used to score D2-LND for each video. Four physician reviewers independently scored each surgical video. Scores were compared using Student's t-test. Ten laparoscopic and 10 open surgery videos were assessed. Each video was scored for quality and completeness and assigned a score out of 22. Mean score for open D2-LND was 15 (95% CI: 12.54-17.46). Mean score for laparoscopic D2-LND was 15.4 (95% CI: 14.34-16.46; P=0.77). The most consistently performed steps were the dissection of lymph node stations 1, 3, 4 and 5. The most commonly omitted steps were the dissection of lymph node station 6: exposure and identification of the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the level of the bifurcation of the anterior superior pancreaticoduodenal vein and right gastroepiploic vein. There is a wide range of quality and completeness of D2-LND videos. On average, D2-LND videos are only two-thirds complete.

Preoperative evaluation using multi-slice spiral CT angiography of right-side colon vascular in laparoscopic radical operation for right colon cancer

Objectives: To examine the value of multi-slice spiral CT angiography (MSCTA) in the analysis of anatomical variation and structural classification of right colon vessels. Methods: From August 2015 to August 2017, 198 patients (96 of whom underwent laparoscopic radical resection of right colon cancer) at Department of General surgery of Peking University First Hospital were retrospectively collected, and the results of abdominal enhanced CT scan were collected and three-dimensional reconstruction of blood vessels was performed. There were 104 males and 94 females. The age was 64(27) years (M(Q(R)), range: 19 to 87 years). Right gastroepiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein (RCV), superior right colonic vein, ileocolon artery or vein (ICA or ICV), middle colon artery or vein (MCA or MCV) and Henle trunk were observed and recorded respectively. The anatomical relationship between the positions of blood vessels, the length of Henle trunk and surgical trunk were measured. Results: ICV and ICA were the most constant anatomic structures. The ICV/ICA of all patients came directly from SMV/SMA, 36.9% (73/198) ICV going in front of SMV and 63.1% (125/198) behind SMV. 72.2% (143/198) of the patients had RCV imported into Henle trunk and the rest into SMV. Middle colonic vein (MCV) could be observed in 81.3% (161/198) of the cases. 81.4% (131/161) of MCV were imported into SMV, 16.8% (27/161) into Henle trunk, 1.2% (2/161) into the first jejunal vein and 0.6% (1/161) into the splenic vein. Henle trunk was divided into 4 types, among which the occurrence probability of gastric node and pancreatic trunk was the highest. The dry length of Henle trunk was (0.82±0.39) cm (range: 0.37 to 1.68 cm). The length of surgical trunk was (2.54±0.83) cm (range: 1.57 to 3.95 cm). Accuracy of MSCTA results was 96.9%(93/96). Conclusions: Anatomical variation of blood vessels in the right colon is common. Abdominal CT angiography can accurately determine the anatomical structure of the blood vessels in the right colon.

Gastrocolic trunk of Henle and its variants: review of the literature and clinical relevance in colectomy for right-sided colon cancer.

Venous vascular anatomy of the right colon presents a high degree of variability. Henle's Gastrocolic Trunk is considered an important anatomical landmark by colorectal surgeons. The classical description concerns a bipod vascular structure or tripod, but several variants are associated to it. The aim of this study is to merge the most updated literature on the anatomy knowledge of the Gastrocolic Trunk by evaluating all possible variants, as well as to underline its surgical importance due to its topographical relationships. Twelve studies describing the anatomy of the gastrocolic trunk were selected, each of them dealing with a more or less extensive series of cases. A distinction was drawn between the gastropancreatic trunk, devoid of the colonic component, and the gastrocolic trunk; and then the frequency of the different resulting variants was reported. The data obtained from cadavers and radiological studies were analyzed separately. The Gastrocolic Trunk is found in 74% of cadaver studies, and in 86% of radiological studies. Its most frequent configuration is represented by the union of right gastroepiploic vein + anterior superior pancreaticoduodenal vein + superior right colic vein, respectively, 32.5% and 42.5%, followed by the right colic vein which replaces (26.9%, 12.3%) or is added (10%, 20.1%) to the superior right colic vein. The superior right colic vein joins the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein thus forming, in most cases, the gastrocolic trunk. The anatomical knowledge of vascular structures forms the basis for both the interpretation of preoperative radiological images and the surgical procedure itself, despite the considerable anatomical variability of tributaries.

A case of pancreatic ductal adenocarcinoma with portal vein tumor thrombus continuously invading through the posterior superior pancreatico-duodenal vein

A case of pancreatic ductal adenocarcinoma with portal vein tumor thrombus continuously invading through the posterior superior pancreatico-duodenal vein

The venous trunk of henle (gastrocolic trunk): A systematic review and meta-analysis of its prevalence, dimensions, and tributary variations.

Surgeons have recognized the clinical significance of the venous trunk of Henle during multiple pancreatic, colorectal, and hepatobiliary procedures. To date, no study has followed the principles of evidence-based anatomy to characterize it. Our aim was to find, gather, and systematize available anatomical data concerning this structure. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science databases were searched. The following data were extracted: prevalence of the trunk of Henle, its mean diameter and length, the organization of its tributaries, method of anatomical assessment (cadaveric, radiological, or intraoperative), geographical origin, study sample, and known health status. Our search identified 38 records that included data from 2,686 subjects. Overall, the prevalence of the trunk of Henle was 86.9% (95% CI, 0.81-0.92) and the mean diameter was 4.2 mm. Only one study reported the length of the trunk (10.7 mm). The most common type of venous trunk (56.1%) was a vessel comprising three tributaries: gastric (right gastro-epiploic vein), pancreatic (most commonly the anterior superior pancreaticoduodenal vein), and colic (most commonly the superior right colic vein). The trunk of Henle is a common variant in the anatomy of the portal circulation. It is a highly variable vessel, but the most common type is a gastro-pancreato-colic trunk. In surgical practice, the presence of this venous trunk poses a high risk for bleeding, but it can also be a useful landmark during various abdominal procedures. Clin. Anat. 31:1109-1121, 2018. © 2018 Wiley Periodicals, Inc.

Value of the multi-slice spiral CT angiography, CT colonography and image fusion technology in preoperative evaluation of laparoscopic right colon cancer

Objective To observe the distribution and variation of right colonic vessels, and investigate the clinical value of computed tomography angiography (CTA), computed tomography colonography (CTC) and image fusion technology in preoperative evaluation of laparoscopic right colonic cancer (RCC). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 38 patients who underwent laparoscopic extended radical resection of RCC + D3 lymphadenectomy in the Affiliated Wuxi Second People′s Hospital of Nanjing Medical University between January 2015 and July 2017 were collected. Patients received preoperative plain and enhanced scans of abdominal and pelvic CT. The original images were reconstructed and fused by CTA and CTC, and then coming out with three-dimensional images of blood vessels and gut. Observation indicators: (1) branches of superior mesenteric artery (SMA); (2) positional relationship between SMA and superior mesenteric vein (SMV); (3) composition of gastrocolic venous trunk. Results Scan images of 38 patients had fused with scan images of vessels and primary tumors and reached the diagnostic standard, with a good imaging performance. Distribution of blood vessels of virtual reality (VR) images and were compared with that of naked blood vessels under intraoperative laparoscopy, showing a coincidence rate of 100.0%(38/38). (1) Branches of SMA: results of CTA and intraoperative anatomy showed that the occurrence rate of the right colonic artery, middle colonic artery and ileocolic artery were respectively 94.7%(36/38), 92.1%(35/38) and 100.0%(38/38). A right colonic artery was found in 28 patients. Ten patients had structure variation of right colonic artery, including 3 with 2 right colonic arteries and 2 without right colonic artery. The right colonic artery and middle colonic artery merged into the same trunk and then flowed into SMA were detected in 2 patients; the right colonic artery and ileocolic artery merged into the same trunk and then flowed into SMA were detected in 3 patients. (2) Positional relationship between SMA and SMV: results of CTA and intraoperative anatomy showed that the occurrence rate of both SMA and SMV was 100.0%(38/38). The SMA in 20 patients was located in the ventral side of SMV; SMA in 18 patients was located in the dorsal side of SMV. (3) Composition of gastrocolic venous trunk: results of CTA and intraoperative anatomy showed that 29 of 38 patients had gastrocolic venous trunks, which belonged to four sources, including right colonic vein, middle colonic vein, right gastric epiploic vein and anterior superior pancreaticoduodenal vein. Among 29 patients, 18 had 2- or 3-branch type of gastrocolic trunk that consisted of the right gastric epiploic vein, middle colonic vein and right colonic vein; 3 had 2-branch type of gastric pancreatic trunk that consisted of the right gastric epiploic vein and anterior superior pancreaticoduodenal vein; 8 had 3- or 4-branch type of stomach-pancreas-colon trunk that consisted of right gastric epiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein and middle colonic vein. Conclusion CTA, CTC and image fusion technology can intuitively show the anatomy and variation of right colonic vessels, with a high clinical value. Key words: Colonic neoplasms; Preoperative evaluation; Vascular reconstruction; Computed tomography angiography; Computed tomography colonography; Extend right hemicolectomy; Laparoscopy

Key vessels assessment and operation highlights in laparoscopic extended right hemicolectomy

Laparoscopic radical colectomies have been more widely used gradually, among which laparoscopic extended right hemicolectomy is considered as the most difficult procedure. The difficulty of extended right hemicolectomy lies in the need to dissect lymph nodes along the superior mesenteric vein (SMV) and disconnect numerous and possible aberrant vessels. To address this problem, we emphasize two points in key vessel assessment: getting familiar with the anatomy along the medial-to-lateral approach and having a good understanding about the preoperative imaging presentations. An accurately preoperative imaging assessment by abdominal enhanced CT can help the surgeon understand the relative position of the key vessels to be dealt with during operation and the situation of the possible aberrant vessels so as to guide the procedure more effectively and facilitate the prevention and management of the intraoperative complications. During operation, the operator should pay special attention to the management of the vessels in the ileocolic vessel region, Henle's trunk and middle colon vessels. The operation highlights of the key vessels are as follows: (1) The ileocolic vessels: identifying the Toldt's gap correctly and opening the vascular sheath of the SMV securely; making sure that the duodenum is well protected. (2) Henle's trunk: dissecting along the surface of the Henle's trunk; preserving the anterior superior pancreaticoduodenal vein (ASPDV) and main trunk of the Henle's trunk; disconnecting the roots of the right colic vein (RCV) and right gastroepiploic vein (RGEV), and then dissecting lymph nodes along the surface of the pancreas. (3) The middle colon vessels: identifying the root of the middle colon vessel along the lower edge of the pancreas; avoiding entering behind the pancreas; mobilizing the transverse mesocolon sufficiently along the surface of the pancreas. Finally, we discuss and analyze the disputes currently existing in laparoscopic extended right hemicolectomy, including dissection of No.6 lymph nodes, naking the SMA and dissecting lymph nodes around the roots of the branches of SMA. This article shares our experience about laparoscopic extended right hemicolectomy, hoping that it could help beginners master the technique more safely and skillfully.

Three-Dimensional Reconstruction of the Peripancreatic Vascular System Based on Computed Tomographic Angiography Images and Its Clinical Application in the Surgical Management of Pancreatic Tumors

This study aimed to investigate the clinical significance of 3-dimensional (3D) reconstruction of peripancreatic vessels for patients with suspected pancreatic cancer (PC). A total of 89 patients with PC were included; 60 patients randomly underwent computed tomographic angiography. Based on the findings of 3D reconstruction of peripancreatic vessels, the appropriate method for individualized tumor resection was determined. These patients were compared with 29 conventionally treated patients with PC. The rate of visualization was 100% for great vessels around the pancreas. The detection rates for anterior superior pancreaticoduodenal artery, posterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, posterior inferior pancreaticoduodenal artery, dorsal pancreatic artery, superior marginal arterial branch of the pancreatic head, anterior superior pancreaticoduodenal vein, posterior superior pancreaticoduodenal vein, anterior inferior pancreaticoduodenal vein, and posterior inferior pancreaticoduodenal vein were 86.6%, 85.0%, 76.6%, 71.6%, 91.6%, 53.3%, 61.6%, 55.0%, 43.3%, and 51.6%, respectively. Forty-three patients who had undergone 3D reconstruction underwent surgery. Of the 29 conventionally treated patients, 19 underwent surgery. The operative time, blood loss, length of hospital stay, and complication incidence of the 43 patients were superior to that of the 19 patients. A peripancreatic vascular reconstruction can reveal the vascular anatomy, variations of peripancreatic vascular, and tumor-induced vascular changes; the application of the simulation surgery platform could reduce surgical trauma and decrease operative time.

Ectopic varices.

Ectopic varices.

Living Donor Liver Transplantation for the Patients With Portal Vein Thrombosis: Use of an Interpositional Venous Graft Passed Posteriorly to the Pancreatic Parenchyma Without Using Jump Graft

BackgroundIt is difficult to reconstruct the portal vein (PV) using a long interpositional venous graft in living donor liver transplant (LDLT) patients with portal vein thrombosis (PVT), which involves the confluence of the superior mesenteric vein (SMV) and splenic vein (SV). We successfully performed LDLT for three patients with PVT using an interpositional vascular conduit passing posterior to the pancreas without a jump graft. MethodsThree of 130 patients who underwent LDLT in our hospital between March 2002 and June 2011 required this technique. After indentifying the location of the SMV, SV and gastrocolic trunk, we ligated and cut the posterior superior pancreaticoduodenal vein and other short branches from the PV. The PV was drawn inferiorly to the pancreas and transected at the confluence of SMV and SV. The external iliac vein or internal jugular vein was sacrificed as a graft for anastomosis to the cut end of the SMV using 6-0 polypropylene running sutures. Then the venous graft was drawn superiorly to the pancreas by passing it posterior to the pancreas parenchyma for anastomosis to the liver graft PV. The interpositional vein was placed posterior to the pancreas where the PV used to be. ResultsAll three patients displayed favorable postoperative courses with the Doppler ultrasound demonstrating good portal flow perioperatively. The postoperative portogram demonstrated patency of the vascular graft. ConclusionThis method is easy and helpful to treat portal vein thrombosis, by providing the shortest route between the PV of the donor and the SMV of the recipient.

Ruptured duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration : report of a case

A 66-year-old man with alcoholic cirrhosis was admitted to our hospital with fatigue and weakness for the last few days. He had recent on set of melena with severe anemia. Emergent upper gastrointestinal endoscopy revealed dark-red colored tense varices in the descending portion of duodenum. Multidimensional computed tomography (MDCT) demonstrated the duodenal varices (DV) supplied by the posterior superior pancreaticoduodenal vein (PSPDV) and drained into right testicular vein. We performed balloon-occluded retrograde transvenous obliteration (BRTO) because the ruptured DV were the cause of melena. A balloon catheter was inserted via the right femoral vein and wedged into the rt. testicular vein. Digital subtraction angiography showed DV supplied by the PSPDV and DV collaterals. The collateral veins were embolized with microcoils. The sclerosing agent, 5% solution of ethanolamine oleate with iopamidol (EOI), was continuously infused into DV under the ballon infration until DV were filled with screlosant completely. No major procedure-related complications occurred. Post-BRTO endoscopy and abdominal CT showed successful obliteration of DV. In conclusion, we report a case of DV successfully treated with BRTO. There is no established treatment of DV. Further studies are needed to clarify appropriate treatment for the eradication of DV.

Anatomical variations of peripancreatic veins and their intrapancreatic tributaries: multidetector-row CT scanning

To date the anatomy of the intrapancreatic and peripancreatic veins using multidetector-row CT (MDCT) was not assessed. The object of this study is to establish 3D CT anatomy of these veins. A total of 100 consecutive patients who underwent abdominal triple-phase CT using 16-detector MDCT were retrospectively reviewed. The anatomical variations of the peripancreatic and intrapancreatic veins were assessed. Among the 100 cases, 42 cases (42%) had a single posterior superior pancreaticoduodenal vein crossing the ventral side of the common bile duct, while 30 cases (30%) had an uncinate vein running upward behind the medial side of the pancreatic. In the pancreatic head and body/tail area, there were many small veins that directly entered the superior mesenteric or splenic vein. In 59 cases (59%), the centro-inferior pancreatic vein ran transversely along the inferior surface of the pancreatic body and drained the anterior or inferior parts of the pancreatic body, mainly into the splenic vein. Many variations exist in the running patterns of intrapancreatic veins as well as peripancreatic veins. Recognition of abnormalities of intrapancreatic veins on CT in the light of normal CT anatomy may contribute to the interpretation of pathological conditions of the pancreas.

Anatomic study of the superior right colic vein: its relevance to pancreatic and colonic surgery

Background This study was designed to describe the precise anatomic venous tributaries of the superior mesenteric vein with special emphasis on the superior right colic vein (SRCV), which is seldom mentioned in the literature. Methods Nine adult cadavers were dissected to define the venous tributaries of the superior mesenteric vein. The SRCV, middle colic vein, and right colic vein (RCV) were defined as those that drained from the marginal vein of the right flexure of the colon, the transverse colon, and the ascending colon, respectively. Results The SRCV was observed to drain from the right flexure of the colon to the confluence of the right gastroepiploic and superior pancreaticoduodenal veins and present the gastrocolic trunk of Henle (GTH) in 8 of 9 cases. The RCV terminated into the GTH in 4 cases. The SRCV, the RCV, and the middle colic vein formed a confluence and entered into the GTH in 1 case. Conclusions The SRCV exits and drains from the right colonic flexure to the GTH in 89% of cases.

Configuration of the straight veins and their intramural anastomoses in the human duodenum: an anatomical study using cast specimens.

There have, hitherto, been no anatomical investigations of the intramural venous system of the duodenum. Intramural longitudinal anastomoses of the straight veins in the human duodenum were investigated, using 15 latex resin cast specimens. The venous tree (with a straight vein as the trunk) was developed well, with numerous twigs (venules). We identified two types of longitudinal anastomoses between the straight veins; the direct and plexus-mediated types, with an equal incidence. The direct-type anastomosis was 0.1-0.5 mm in minimum diameter along the course and communicated in almost a straight line between the mother straight veins. In contrast, the plexus-mediated type was regarded as the thickest route (almost 0.1 mm) in the suggested submucosal venular network in the duodenal wall. These two types of anastomoses were distributed almost equally in most of the duodenum, although a relatively lower density was found in the superior portion. On the ventral side of the duodenum, the thicker straight veins had anastomotic branches significantly more frequently than the thinner ones (P = 0.0018). CONCLUSIONS; These results seemed to support the feasibility of Kocher mobilization, as well as the conventional poor preservation of the duodenal venous system during duodenum-preserving surgery. However, because the intramural longitudinal venous anastomoses were limited in number and location, we recommend preservation of the posterior superior pancreaticoduodenal vein and either of the inferior venous arcades, in combination with their concomitant arteries, in exchange for the unavoidable sacrifice of Henle's trunk and the dorsal pancreatic vein.

Novel gastroinsular axis involving a gastric transmural glucose flux and vagal mediation.

To determine whether the appearance of nutrients into the gastric lumen per se provokes insulin secretion, glucose solution was instilled into the pylorus-cannulated stomach via an orogastric tube in anesthetized dogs. When 200 ml of 0, 5, 10, and 20% glucose solution were sequentially instilled, transgastric gradients (TGG) of plasma glucose concentration across the fundus [short gastric vein (SGV) - femoral artery, TGG(SGV)] and insulin levels in the superior pancreaticoduodenal vein (SPDV) increased stepwise. Upon instillation of 300 ml of 10% glucose, but not 1.8% saline, for 12 min followed by 48-min spontaneous drainage via the cannula (n = 5 each), TGG(SGV) and insulin levels in the SPDV increased concomitantly and significantly by 0.95 mM and 1,334 pM (mean), respectively, regardless of unaltered arterial glucose levels. The amount of secreted insulin (area under the curve) significantly correlated with the maximum TGG(SGV) (r = 0.693). In selectively gastric-vagotomized dogs (n = 5), insulin levels in the SPDV did not increase upon instillation despite a TGG(SGV) rise comparable to that in normal dogs. These results indicate that intragastric glucose appearance provokes vagus-mediated insulin secretion probably related to the transfundic glucose flux, suggesting the presence of a novel neurogenic gastroinsular axis.

Surgical anatomy of the pancreas for limited resection.

The fusion fascia of the head of the pancreas is called the "fusion fascia of Treitz" and that of the body and tail of the pancreas is termed the "fusion fascia of Toldt". The fusion fascia is histologically composed of a loose connective tissue membrane. All of the important pancreaticoduodenal arcades of arteries and veins are situated on this membrane, i.e., between this membrane and the pancreatic parenchyma. The topography of the head of the pancreas shows that, after departing from the gastroducodenal artery, the anterior superior pancreaticoduodenal artery runs toward a point 1.5 cm below the papilla of Vater, then turns to the posterior aspect of the pancreas to join the anterior inferior pancreaticoduodenal artery. For preserving the duodenum, the artery toward the papilla is very important. The artery toward the papilla of Vater runs along the right side of the common bile duct after departing from the posterior superior pancreaticoduodenal artery. The gastrocolic trunk of Henle has been reported to be found in about 60% of individuals. It is possible that the gastroepiploic vein and anterior superior pancreaticoduodenal vein (ASPDV) can be divided at pancreaticoduodenectomy, with preservation of the superior right colic vein, if this area is free of carcinoma. The ASPDV and anterior inferior pancreaticoduodenal vein form an arcade on the anterior surface of the pancreas. However, arcade formation was not found between the posterior superior pancreaticoduodenal vein and posterior inferior pancreaticoduodenal vein in many of the individuals examined. The vein joined by the inferior mesenteric vein was also investigated.

CT assessment of the inferior peripancreatic veins: clinical significance.

The purpose of this study was to evaluate and clarify the clinical significance of CT scans of the inferior peripancreatic veins. Forty-three patients with suspected pancreatic disease underwent three-phase helical CT (collimation, 5 mm; reconstruction, 2.5 mm; scan delay, 30, 60, and 150 sec). The frequency of visualization on CT of the anterior and posterior inferior pancreaticoduodenal veins, inferior pancreaticoduodenal vein, and first jejunal trunk was assessed and correlated with angiographic and pathologic findings. The frequency of visualization of normal inferior peripancreatic veins in patients (n = 22) with a normal portomesenteric vein was 36% for the anteroinferior pancreaticoduodenal vein, 36% for the posteroinferior pancreaticoduodenal vein, 59% for the inferior pancreaticoduodenal vein, and 100% for the first jejunal trunk. The smaller inferior peripancreatic veins were frequently not visualized when normal. In patients (n = 13) with pancreatic carcinoma involving the portosuperior mesenteric vein, all of the inferior peripancreatic veins were dilated and easily recognizable. When the tumor did not involve the portosuperior mesenteric vein but did involve the anteroinferior pancreaticoduodenal, posteroinferior pancreaticoduodenal, and inferior pancreaticoduodenal veins (n = 8), some of the other peripancreatic veins (first jejunal trunk, anterior and posterior superior pancreaticoduodenal veins, and gastrocolic trunk) were dilated. Dilatation indicated tumor extension to the third portion of the duodenum. In patients (n = 7) with involvement of the inferior pancreaticoduodenal vein, the first jejunal trunk, or both without the involvement of the portosuperior mesenteric vein, dilatation of the other peripancreatic veins (anteroinferior pancreaticoduodenal vein, posteroinferior pancreaticoduodenal vein, anterosuperior pancreaticoduodenal vein, posterosuperior pancreaticoduodenal vein, and gastrocolic trunk) indicated tumor invasion of only the second portion of the extrapancreatic nerve plexus (n = 4) and tumor invasion of both the second portion of the extrapancreatic nerve and the mesenteric root (n = 3). Dilatation of peripancreatic veins with nonvisualization of inferior peripancreatic veins suggests tumor invasion of peripancreatic tissue.