The Pancreas

By Dr. Zuba Ashraf

Post Graduate Resident
Paediatric Surgery unit 1
Clinical scenario
• A 8 year old boy presented in OPD with complains of epigastric pain
and vomiting for 6 weeks. Patient has history of being hit by bike
handle while falling off a bicycle 6 weeks back. On abdominal
examination a 6*6 cm non-tender mass is palpable in upper
abdomen.
• A. what CT scan findings will you expect in this patient?
• B. Indications for surgery?
• C. Options for surgery?
Embryology
• dorsal pancreatic primordium, derived from the duodenum and gives rise to the body and
tail of the pancreas
• ventral pancreatic primordium, derived from the hepatic diverticulum and gives rise to the
head and uncinate process of the pancreas
• fuse by the seventh week of gestation.
• The main pancreatic duct of Wirsung, which is formed by the fusion of the ventral duct and
distal dorsal duct, drains into the duodenum at the ampulla of Vater.
• The proximal duct may persist as the duct of Santorini, draining through an accessory
papilla cephalad and posterior to the ampulla of Vater.
• The islets of Langerhans are recognizable by the end of the third month.

(reference: Langmann’s medical embryology)

.
Errors in Pancreatic Development

• Aplasia and hypoplasia

• Hyperplasia and hypertrophy
• Dysplasia
• Ductal anomalies
• Pancreas divisum
• Annular pancreas
• Rotational anomalies
• Heterotopic pancreas
• Cysts
• Arterial, vascular, and lymphatic anomalies
• Neoplasm
• Cystic fibrosis
Anatomy
• head: sits to the right on L2, the body covers L1, and the tail rises to
T12 on the left.
• The pancreas is retroperitoneal. Peritoneal reflections from the
transverse mesocolon, small intestinal mesentery, and the
splenorenal and phrenocolic ligaments are present.
• The head is intimately associated with the duodenal C loop, whereas
the tail lies in the hilum of the spleen
• To assess the integrity of the pancreatic head, an extensive Kocher
maneuver is required. The body and tail of pancreas are examined
through the lesser sac.
Blood supply
• The splenic artery provides most of the blood supply to the pancreas
and lies along its superior border with the splenic vein.
• The head of the pancreas shares its blood supply with the duodenum
through the gastroduodenal artery and superior and inferior
pancreaticoduodenal arteries, which may complicate surgery on the
head of the pancreas.
• Blood from the pancreas drains in a posterior direction into the
superior mesenteric vein and splenic vein via small, delicate branches.
Annular pancreas
The ventral pancreatic bud consists of two
components that normally fuse and rotate
around the duodenum so that they come to
lie below the dorsal pancreatic bud.
Occasionally, however, the right portion of
the ventral bud migrates along its normal
route, but the left migrates in the opposite
direction.
The duodenum is surrounded by pancreatic
tissue, and an annular pancreas is formed
that constricts the duodenum and causes
complete obstruction

(reference: Langmann’s medical

embryology)
Pancreas Divisum

• separate drainage of the dorsal and ventral pancreatic ducts into the
duodenum. Mostly asymptomatic, However, stenosis of the minor or accessory
papilla may lead to recurrent acute pancreatitis.
• MRCP or ERCP: duct of Wirsung fails to be visualized after injection of the
major papilla and the duct of Santorini is the dominant duct and that it
extends the entire length of the body and tail of the pancreas.
• Imaging of the duct of Santorini occasionally demonstrates dilatation,
irregularity, or stricture suggestive of chronic pancreatitis.
• adequate drainage of the duct of Santorini is achieved by accessory papilla
sphincteroplasty or Longitudinal pancreaticojejunostomy
Acute pancreatitis

• Clinically, acute pancreatitis is defined as a single episode or recurrent

episodes of abdominal pain associated with elevated serum
pancreatic enzyme levels.

• The morphologic correlate is acute focal or diffuse swelling and

inflammation of the pancreas.
.
Diagnostic criteria
• The parameters are age (<7 years),
• Weight (<23 kg),
• admission white blood cell count (>18,500),
• Admission lactate dehydrogenase level (>2000),
• 48-hour trough Calcium level (<8.3 mg/dL),
• 48-hour trough albumin level (<2.6 g/dL),
• 48-hour fluid sequestration (>75 mL/kg/48 hr),
• and 48-hour rise in blood urea nitrogen (>5 mg/dL).
Investigations
• Plain radiographs: excludes intestinal perforation, radiopaque
gallstones, a gas-filled right colon, Left basal pleural effusion
• Radiographic studies enhanced by water-soluble contrast of the
upper gastrointestinal tract are occasionally useful, particularly in
cases of trauma when injury to the duodenum or small intestine is
suspected.
• Ultrasonography (US) and computed tomography (CT) are useful for
detecting pancreatic abnormalities.
Investigations
• ERCP; not an option during the acute phase of pancreatitis.
• Magnetic resonance cholangiopancreatography (MRCP) is a
noninvasive method of obtaining images of the pancreaticobiliary
tract.
• MRCP images the common bile duct in more than 96% of patients and
detects common bile duct stones with a sensitivity of 71% to 100%,
thus exceeding the sensitivity of US (20% to 65%) and CT (45% to
85%).
• Visualization of the smaller pancreatic duct is successful in more than
80% of patients
Treatment
• two primary goals by medical management:
(1) to minimize any causative factors and
(2) to provide meticulous supportive care including liberal use of analgesics, administration of parenteral fluids,
maintenance of nutrition, prevention of infection, and inhibition of endocrine and exocrine activity.
• nasogastric suction to reduce vomiting and abdominal distention
• Aspiration of gastric acid to reduce pancreatic exocrine secretion by limiting the release of secretin.
• Oral feeding must be withheld to reduce pancreatic stimulation.
• Total parenteral nutrition should be initiated early to avoid malnutrition.
• In addition, early placement of a central venous catheter in patients with severe disease will provide access
for aggressive intravascular volume support and nutrition.
• prophylactic antibiotics in patients with necrotizing pancreatitis
• The hematocrit and serum levels of glucose and calcium should be measured, and hourly urine output should
be monitored carefully.
• Surgical intervention: Complications such as pseudocyst or abscess
Chronic relapsing pancreatitis
• Chronic relapsing pancreatitis is characterized by recurrent episodes
of upper abdominal pain associated with varying degrees of
pancreatic exocrine and endocrine dysfunction.
• The disease produces a wide variation of progressive and irreversible
structural changes in the pancreas
.
Investigations
• The degree of permanent damage to the pancreas may be assessed
by blood tests (pancreatic enzymes), stool tests (pancreatic enzymes,
fecal fat), and noninvasive tests of pancreatic function such as the
pancreatic stimulation (secretin) test.
• In 30% to 50% of adolescents and adults with chronic pancreatitis,
plain radiographs of the abdomen reveal pancreatic calcification,
which is diagnostic.
Investigations
• US is ideal for examining the pancreas in children. Dilatation of the
pancreatic or biliary tracts may be noted, and calcification and
complications such as pseudocysts, abscesses, calculi, and ascites can
be seen.
• CT; size of the pancreas, its ducts and small calculi
• ERCP; detects Pancreaticobiliary malunion with or without dilatation
of the bile duct
• MRCP, equivalent to ERCP for the diagnosis of many pancreatic and
biliary conditions and is preferable because it is noninvasive and safer
surgical treatment

(1) Sphincteroplasty (incision of ampullary, bile duct and pancreatic

duct sphincters)
(2) pancreatic drainage via
• longitudinal pancreaticojejunostomy (Puestow)
• end-to-end pancreaticojejunostomy (Duval)
• the Frey procedure
(3) partial or total pancreatectomy
Puestow procedure
Congenital and developmental cysts
• rare; Only 25 cases have been reported
• most common in the body and tail of the pancreas,
• mostly unilocular and lined with epithelium.
• The cysts are filled with a cloudy, yellow sterile fluid that has no enzyme activity, and
they are remarkably free of adhesions and infection.
• von Hippel-Lindau disease is characterized by hereditary cerebellar cysts, retinal
hemangiomas, and cysts of the pancreas and other organs
• Presents as asymptomatic mass or abdominal distention, as vomiting or jaundice
caused by extrinsic pressure on neighboring organs
• Surgical treatment consists of total excision of cysts located in the pancreatic body or
tail and either internal drainage or complete resection of those in the pancreatic head
Retention cysts
• result from chronic obstruction of the gland.
• They contain cloudy fluid composed of pancreatic exocrine secretions
and a high concentration of pancreatic enzymes.
• lined with ductal epithelium unless it has been destroyed by chronic
dilatation or inflammation from enzyme exposure.
Enteric duplications
• failure of regression of an enteric diverticulum formed from the
pancreatic duct
• lined with gastric-type epithelium, and contain ectopic pancreatic
tissue in their walls
• Pancreatitis is caused by obstruction of the pancreatic ducts by
viscous secretions from the cyst or by blood and debris from peptic
ulceration within the cyst.
• In patients without pancreatitis, pain may be caused by tension on
the wall of the cyst as a result of accumulation of secretions and
muscular contraction
• CT may help identify the location and size of duplication cysts, as well
as any edema of the pancreatic head.
• ERCP or MRCP is useful to outline ductal anatomy and demonstrate
any communication between the duplication cyst and the pancreatic
duct to aid in planning the surgical approach.
• To date, virtually all duplication cysts reported in the literature have
been treated by extirpation, and some have required
pancreaticoduodenectomy (whipple procedure)
Pseudocysts
• Pancreatic pseudocysts are localized collections of pancreatic secretions that
do not have an epithelial lining and develop after pancreatic injury,
inflammation, or duct obstruction.
• Causes: trauma and infection, Drug-induced acute pancreatitis
• These cysts typically lie in the lesser sac behind the stomach and are
composed of a fibrous capsule surrounded by inflamed connective tissue. The
capsule of the cyst may also be formed by neighboring tissue such as the
stomach, duodenum, colon, small intestine, or omentum.
• Pseudocyst fluid is clear or straw colored in most cases and may contain
toothpaste- like debris.
• The amylase level of cyst fluid is typically higher than 50,000 Somogyi U/mL.
• History of blunt abdominal trauma; an illness resembling pancreatitis, possibly
followed by a symptom-free interval of weeks to months;
• or palpation of a mass in the epigastrium or left upper quadrant. Abdominal pain is the
most common symptom, with jaundice, chest pain, signs of gastric obstruction,
vomiting, gastrointestinal hemorrhage, weight loss, fever, and ascites also being
features
• US, CT, and magnetic resonance imaging (MRI) are helpful and accurate in diagnosis.
These studies are also invaluable for evaluating the thickness of the cyst wall and for
observing changes in the cyst during the ensuing period of treatment
• ERCP is often useful because it can definitively determine the status of the pancreatic
duct and thus guide surgical interventions
 .
.
Management
• supportive therapy over a 6-week waiting period, during which time either the
cyst resolves spontaneously or the cyst wall undergoes fibrous maturation,
thereby permitting internal surgical drainage to the stomach or jejunum.
• Surgical drainage is usually performed in adults when necessary but is
controversial in children because some pancreatic pseudocysts in this group
resolve without surgical intervention and have a low risk for recurrence.
• Pseudocysts from nontraumatic etiologies are more likely to require surgical
intervention, whereas traumatic pseudocysts are more amenable to
nonoperative treatment.
• Octreotide acetate, a long-acting analogue of somatostatin, may facilitate
medical management of pancreatic pseudocysts
Surgical Management
• pseudocysts that are more than 6 weeks old and have a diameter larger than 5
cm
• internal drainage, especially transgastric cystogastrostomy or Roux-en-Y
cystojejunostomy
• Roux-en-Y cystojejunostomy is the most widely used and is associated with the
lowest rate of complications and recurrence.
• percutaneous drainage and endoscopic transmural drainage are safe and
efficient procedures but carries a higher risk for complications such as fistula
formation and a higher recurrence rate than internal drainage does.
• Pancreaticoduodenectomy: rarely done, when closely adherent to duodenum
• distal pancreatectomy: multiple cysts in body or tail
Laproscopic cyst gastrostomy
Hyperinsulinism
• Inappropriate oversecretion of insulin is the hallmark of HI
• HI is the most common cause of persistent hypoglycemia in neonates
and can lead to seizures and irreversible brain damage
• Genetically, abnormalities of the KATP channel, which are encoded by
the sulfonylurea receptor 1 (SUR1) and Kir6.2 genes, are responsible
for altered control of insulin secretion
• Types: diffuse involvement of the pancreatic beta-cells OR focal
adenomatous islet cell hyperplasia; both are clinically identical.
• Babies with HI present with severe and persistent hypoglycemia manifested by
seizures, lethargy, apnea, and other symptoms resulting from neuroglucopenia.
• The diagnosis of congenital HI is established if fasting hypoglycemia (glucose < 50
mg/dL) occurs simultaneously with an inappropriately elevated plasma insulin (>2
mU/mL), low plasma beta-hydroxybutyrate (<2 mmol/L) and free fatty acids (<1.5
mmol/L), and an inappropriate glycemic response to intravenous glucagon (>30
mg/dL rise in serum glucose level).
• PET-CT scan technique using 18-Fluoro-L-DOPA; differentiates between diffuse and
focal types.
• Medical treatment: high continuous intravenous infusions of glucose as measured by
the Glucose Infusion Rate (which is the amount of glucose infused in mg/kg/min),
frequent oral feedings, and administration of diazoxide, glucagon, and octreotide.
surgery
• suspected diffuse HI have intraoperative biopsies to confirm the diagnosis and
then undergo near-total pancreatectomy. Near-total pancreatectomy (95% to
98%) involves resection of the entire pancreas leaving only a tiny residual piece
of the pancreas between the common bile duct and the duodenum. The
intrapancreatic course of the common bile duct should be completely dissected
for an adequate near-total pancreatectomy to be performed. For children with
diffuse disease treated by near-total pancreatectomy, a gastrostomy tube is also
placed to make it easier to administer supplemental glucose or night-time
feedings if necessary

• For Suspected focal lesion, a partial pancreatectomy is performed using frozen

sections of margins to ensure a complete resection
Neoplasms
Cystic neoplasms of the pancreas are relatively rare, classified these
lesions into
(1) cystadenoma and cystadenocarcinoma,
• benign (microcystic) cystadenoma,
• benign and malignant mucinous (macrocystic) cystadenoma and
cystadenocarcinoma,
• papillary-cystic epithelial neoplasm
• acinar cell cystadenocarcinoma (not reported in children)
(2) teratomatous cysts.
Hormonally active tumors
Thank you