Integrative Pancreatic Intervention Therapy

A Holistic Approach

Ligong Lu, Yueyong Xiao, Deliang Fu, Haijun Zhang

• Publisher: Elsevier
• Year: 2020
• Print ISBN:
  9780128194027
• eBook ISBN:
  9780128194034
• Topic: Scienze biologiche
• Subtopic: Biologia

Integrative Pancreatic Intervention Therapy: A Holistic Approach summarizes, in a systematic manner, the diagnosis and treatment of late, critical pancreatic diseases. The book gives insights into each interventional technique, with an ultimate goal of improving survival rates for late stage pancreatic cancer patients. Six sections cover basic and transformation research on pancreatic diseases, interventional therapy for benign pancreatic disease, interventional therapy for malignant pancreatic diseases, interventional therapy for pancreative cancer-related lesions, stem cell and targeted molecular therapy for pancreative carcinoma, and combined interventional therapy for pancreative carcinoma. This book will be useful for those looking to understand how best to apply interventional therapy for the improvement of late state pancreatic cancer treatment. - Gives a step-by-step account of interventional therapy in late stage pancreatic cancer - Presents research on interventional techniques for plotting a management plan for late stage pancreatic cancer patients - Provides fundamental research in pancreatic cancer on the genes and signaling pathways relating to tumorigenesis and metastasis of advanced pancreatic cancer - Considers the combination of different interventional techniques to achieve better survival rates and increase quality of life for patients - Assesses the usefulness of combining interventional therapies into a holistic treatment approach

Part I

Basics and transformation research of pancreatic diseases

Outline

• Chapter 1 Anatomy and physiology of the pancreas
• Chapter 2 Epidemiology, pathology, and physiology of pancreatic diseases
• Chapter 3 Clinical laboratory and imaging diagnosis of pancreatic diseases
• Chapter 4 Internal medicine treatment of pancreatic lesions
• Chapter 5 Surgical treatment of pancreatic diseases
• Chapter 6 Emergency and critical care medicine of pancreatic diseases
• Chapter 7 Progress in transformation and application of pancreatic lesions

Chapter 1

Anatomy and physiology of the pancreas

Qionglan Yuan¹, Aihua Pan², Yuanshan Fu³ and Yalei Dai⁴, ¹1Department of Neurology, Shanghai Tongji hospital, Tongji University School of Medicine, Shanghai, P.R. China, ²2Xiangya School of Medicine, Central South University, Changsha, P.R. China, ³3Dalian Medical University, Dalian, P.R. China, ⁴4Department of Immunology, Tongji University School of Medicine, Shanghai, P.R. China

Abstract

This chapter introduces the location and morphology of the pancreas and the relationship of the pancreas with adjacent structures and duct system. In addition, arterial supply, venous and lymph drainage, and innervations of pancreas are discussed.

Keywords

Pancreas; pancreatic duct system; vessels and nerves of pancreas

Section 1 Anatomy of the pancreas

The pancreas is elongated and the second-largest accessory digestive gland in the body. It is composed of exocrine and endocrine portions (pancreatic islet). The exocrine portion (mainly composed of acinar cells) produces pancreatic juice, which contains digestive enzymes (such as protease, lipase, and amylase) that help digest fats, proteins, and carbohydrates. The endocrine portion or pancreatic islet is distributed throughout parenchyma of the gland and is numerous in the tail of the pancreas. The islet produces glucagon and insulin, which help the body to use glucose for energy, and regulate glucose levels in the blood.

1 Location and surface anatomy of the pancreas

The pancreas, an elongated gland, weighs about 82–117 g. It is soft and grayish pink during life, and usually 17–20 cm long, 3–5 cm wide and 1.5–2.5 cm thick. It lies retroperitoneally, mainly in the floor of the lesser sac in the epigastric and left hypochondriac regions, overlying and transversely crossing the bodies of the L1 and L2 vertebra (at the level of the transpyloric plane) on the posterior abdominal wall. From the anterior, the surface marking of the inferior and superior margin of pancreas lies approximately 5.0 and 10 cm superior to the umbilical plane, respectively. The pancreas is anteriorly separated from the stomach by the omental bursa. Peritoneum covers its anterior aspect, but it is bare of peritoneum posteriorly, except for the tail of the pancreas. The position of the pancreas may change as a result of diaphragmatic movements during respiration, the contents of abdominal fat, and the position of the person. The head of the pancreas is lower and curved by the duodenum, while the tail of the pancreas is higher and runs to the splenic hilum. Because the pancreas is closely related to the posterior abdominal wall and posterior to the stomach, transversal colon and omental bursa, the early physical sign in anterior abdominal wall is not evident when pancreatitis. Consequently, it is difficult to early diagnose it.

2 Division and relationship of the pancreas

The pancreas is divided into four parts: head, neck, body, and tail, which have no clear demarcation (see Fig. 1.1). The head and neck lie to the right of the anterior median line; while the body and tail lie to the left of the anterior median line.

Figure 1.1 Appearance and relationship of pancreas.

The head of the pancreas, the expanded part of the gland, is embraced by the C-shaped curve of the duodenum. It lies anterior and to the right of the body of the L1 vertebra. Because it firmly attaches to the medial aspect of the descending and horizontal parts of the duodenum, cancer of the head often compresses the duodenum, resulting in the obstruction of duodenum. The uncinate process, a projection from the inferior part of the pancreatic head, extends medially to the left, posterior to the superior mesenteric artery (SMA) and vein (SMV). At the junction of the head of the pancreas and SMV, two to five small veins from the head and uncinate process of the pancreas pierce the right part of posterior wall of the SMV. Therefore, these small veins have to be treated carefully in pancreaticoduodenectomy, otherwise, damaged veins cause a lethal hemorrhea.

Anteriorly, the pancreatic head is crossed by the root of the transverse mesocolon and related to the jejunum; posteriorly, the pancreatic head is associated with the inferior vena cava, right renal artery and vein, right testicular or ovarian artery and vein, and common bile duct (Fig. 1.2). Superior mesenteric vessels and the initial part of hepatic portal vein are situated in the junction between the uncinate process and the head or neck of the pancreas. Enlargement of the pancreatic head may compress the heportic portal vein, resulting in ascites and splenic enlargement. On its way to opening into the descending part of the duodenum, the common bile duct lies in a groove on the posterosuperior surface of the head or is embedded in its substance. Consequently, cancer of the head often compresses and obstructs the common bile duct and/or the hepatopancreatic ampulla. This causes obstruction, resulting in the retention of bile pigments, enlargement of the gallbladder, and jaundice.

Figure 1.2 Posterior view of the pancreas.

The neck of the pancreas is a narrower part between the head and body of the pancreas. It is usually 1.5–2.0 cm in length, 2–2.5 cm in width, lying at the level of the L1 vertebrae. It overlies the superior mesenteric vessels, which form a groove in its posterior aspect. The anterior surface of the neck, covered with peritoneum, is adjacent to the pylorus of the stomach. The SMV joins the splenic vein posterior to the neck to form the hepatic portal vein (Fig. 1.2), which is joined on the right side by the left gastric vein but on the left side by the pancreaticoduodenal veins. Middle colic artery enters the transverse mesocolon inferior to the pancreatic neck, occasionally penetrating throughout substance of the pancreas.

The body of the pancreas is the largest part between the body and tail of the pancreas. It is a somewhat triangular- and cylindrical-shaped appearance and approximately 7.8 cm in length. It runs transversely to the left at the level of the L1 vertebral body, and is slightly convex. The anterior surface of the body of the pancreas is covered with peritoneum and lies in the floor of the omental bursa and forms part of the stomach bed. Thus cancer of the posterior wall of the stomach or a posterior gastric ulcer may erode through the stomach wall into the pancreas, resulting in the adhesion of the pancreas. The posterior surface of the pancreatic body is devoid of peritoneum and is in contact with the extraperitoneal fatty containing aorta, SMA, left suprarenal gland, left kidney, renal vessels, and splenic vein. Superior margin of the pancreatic body is associated with the celiac trunk and its branches splenic artery and common hepatic artery, and celiac plexus. The splenic artery follows a tortuous course posterior to the omental bursa and runs along the superior border of the pancreas to the splenic hilum, passing over the left kidney. The common hepatic artery runs to the right along the superior border of the pancreas to enter the hepatoduodenal ligament. Splenic vein runs posterior to the body and tail of the pancreas throughout most of its course and is joined by the inferior mesenteric vein. The splenic vein unites with the SMV posterior to the neck of the pancreas to form the hepatic portal vein.

The tail of the pancreas is the left-narrowed end of the pancreas and has no demarcation with the body of the pancreas. It lies in the left hypochondriac region, and passes anterior to the left kidney, where it runs to the splenic hilum and the left colic flexure. In some cases, the tail of the pancreas is closely in contact with the splenic hilum. Most commonly, it is not closely related to the splenic hilum. The tail is covered by the peritoneum, and this can serve as a landmark to distinguish the body and tail of the pancreas. Because the tail of the pancreas passes between the layers of the splenorenal ligament with the splenic vessels, it is relatively mobile and should be paid attention not to injury it when ligating the splenic vessels in splenectomy.

3 Pancreatic duct

The excretory duct system of the pancreas includes the main pancreatic duct, usually called the pancreatic duct, and accessory pancreatic duct (see Fig. 1.3). The pancreatic duct starts in the tail of the pancreas and runs through the parenchyma of the gland to the pancreatic head. It lies in the dorsal portion of the pancreatic parenchyma, and receives the interlobular ducts throughout its course. The pancreatic duct is about 13.8 cm long and becomes bigger in diameter from the tail to the head of the pancreas, 2–3 mm on average. The pancreatic duct normally appears relative constrictions in two places: (1) at the junction of the head and the body of the pancreas, (2) at the middle third of the pancreatic body. The pancreatic duct lying in the pancreatic head runs posteriorly and inferiorly to enter the posteromedial wall of the descending part of the duodenum, where it lies to the left, medial, and inferior of and parallels to the common bile duct. The pancreatic duct runs obliquely through the wall of this part of the duodenum, opening on eminence, called the major duodenal papilla. On the right of pancreatic head, the pancreatic duct usually unites to the common bile duct to form the hepatopancreatic ampulla, which opens at the major duodenal papilla. Most commonly, these two ducts are merged usually at a 45-degree angle. Sometimes the two ducts are separate. In addition, 82% of this confluence lies outside the duodenal wall and 18% on this wall. The relationship of the common bile duct and the pancreatic duct has five types: (1) the pancreatic duct unites to the common bile duct to form a dilation, the hepatopancreatic ampulla; (2) the pancreatic duct unites to the common bile duct to form a no dilated common passage; (3) the pancreatic duct unites to the common bile duct to form a common channel, which is mainly composed of the common bile duct; (4) the common bile duct unites to the pancreatic duct to form a common channel, which is mainly composed of the pancreatic duct; and (5) the pancreatic duct and the common bile duct open into the descending part of the duodenum separately.

The accessory pancreatic duct is located in the upper part of the pancreatic head and is formed...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• List of contributors
• Part I: Basics and transformation research of pancreatic diseases
• Part II: Interventional therapy for benign pancreatic disease
• Part III: Interventional therapy for malignant pancreatic diseases
• Part IV: Interventional therapy for pancreatic cancer-related lesions
• Part V: Stem cell and targeted molecular therapy for pancreatic carcinoma
• Part VI: Combined interventional therapy for pancreatic carcinomas
• Index