Pancreaticoduodenal

Regional node(s) cannot be assessed No regional lymph node metastasis Metastasis in the cystic ducts, pericholedochal lymph nodes, and/or hilar lymph nodes (i.e., in the hepatoduodenal ligament) Metastasis in the peripancreatic (head only), periduodenal, periportal, celiac, superior mesenteric, and/or posterior pancreaticoduodenal lymph nodes... 

Exposure of rats to carbon tetrachloride (up to 160 mg/kg/day for 10 days) by gavage did not alter the primary antibody response to sheep red blood cells, lymphoproliferative responses to mitogen or mixed leukocytes, natural killer cell activity, or cytotoxic T lymphocyte responses also, spleen and thymus weights were comparable to controls (Smialowicz et al. 1991). In rats exposed twice weekly for 4-12 weeks to 3,688 mg/kg/day, there was histologic evidence of hemorrhage, hemosiderin deposition, and lymphocyte depletion in the pancreaticoduodenal lymph node (Doi et al. 1991), an effect which may be secondary to induced hepatic damage. 

Immunological Effects. The effects of carbon tetrachloride on the immune system have not been evaluated in humans. Immune responses were not affected in rats orally exposed to carbon tetrachloride (Smialowicz et al. 1991). Parenteral exposure of animals to carbon tetrachloride has been reported to impair the immune system (Kaminski et al. 1989 Muro et al. 1990 Tajima et al. 1985), and oral exposure caused depletion of lymphocytes, hemorrhage, and hemosiderin deposition in the pancreaticoduodenal lymph node (Doi et al. 1991). These findings are supported by in vitro studies in which the IgM antibody formation response of isolated mouse splenocytes to sheep erythrocytes was inhibited in a dose-dependent manner when the splenocytes were exposed to carbon tetrachloride for 1-3 hours in the presence of cocultured hepatocytes (Kaminski and Stevens 1992). No effects were observed in the absence of cocultured hepatocytes. Mice appear to be more sensitive than rats to carbon tetrachloride-induced immunosuppression, but the biological significance to humans of these reported effects are yet ascertainable from the available data. 

Perkins, J. D., Munn, S. R., Barr, D., Ferguson, D. C., and Carpenter, H. A. Evidence that the soluble interleukin-2 receptor level may determine the optimal time for cystoscopically-di-rected biopsy in pancreaticoduodenal allograft recipients. Transplantation 49,363-366 (1990). Pessara, U., and Koch, N. Tumor necrosis factor alpha regulates expression of the major histocompatibility complex class 11-associated invariant chain by binding of an NF-kappa B-like factor to a promoter element. Mol. Cell Biol. 10, 4146-4154 (1990). 

Bertelli E, Di Gregorio F, Bertelli L, Civeli L, Mosca S (1996b) The arterial blood supply of the pancreas a review. III. The inferior pancreaticoduodenal artery. An anatomical review and a radiological study. Surg Radiol Anat 18 67-74... 

Supraduodenal artery - This vessel provides blood supply to the upper portion of the duodenum and pylorus [2]. The origin of this vessel is also variable, and it communicates with the pancreaticoduodenal arcade as well as right gastric branches [7]. If identified, this vessel should be prophylactically embolized. 

Antegrade obliteration of the superior duodenal branches via the gastroduodenal artery is often insufficient alone, as the bleeding points can be quickly pressurized via the rich anastomotic connections from the inferior pancreaticoduodenal arcade. In such cases, a coil-sandwich technique or alternatively direct obliteration of the bleeding segment or pseudoaneurysm by nested coils or a casting agent may be needed to prevent recurrence. 

The duodenum is supplied by the pancreaticoduodenal arteries, consisting of two, sometimes three or more trunks bridging the gastroduodenal and superior mesenteric artery. One pancreaticoduodenal arcade is located anteriorly (mostly as a continuation of the gastroduodenal artery) and one posteriorly, with multiple anastomoses between them and other pancreatic arteries, building a rich collateral plexus (Fig. 5.4). 

Fig. 5.4. DSA of the gastroduodenal artery with a 5-F Cobra catheter (white arrows). Anterior (black arrowheads) and posterior (white arrowheads) pancreaticoduodenal arcades originating with superior and inferior common trunks. Multiple interconnected mural arteries (small black arrowheads) build loops (small white arrowheads) between the upper and the lower arcade, completing the dual duodenal supply. Superior mesenteric artery (black arrows)...

Gastroduodenal, pancreaticoduodenal arcade. Also called muscular branches. 

Fig. 7.8. Gastroduodenal arteriogram in a patient who had undergone two previous coil embolizations for a slow filling pseudoaneurysm that filled from small GDA and pancreaticoduodenal branches. In this late phase the pseudoaneurysm has recurred from numerous small duodenal collaterals. Further embolization was not possible...

Yamaguchi H, Wakiguchi S, Murakami G (2001) Blood supply to the duodenal papilla and the communicating artery between the anterior and posterior pancreaticoduodenal arterial arcades. J Hepato Biliary Pancreatic Surg... 

Fig.8.3a-c. Balloon-occluded retrograde transvenous obliteration for duodenal varices, a A varicogram obtained by-injection of sclerosant through a microcatheter advanced into the pancreaticoduodenal vein shows duodenal varices (arrowheads). A balloon catheter is inserted into the right ovarian vein (flrrow).b A contrast-enhanced CT obtained before BRTO shows duodenal varices (arrow), c A contrast-enhanced CT obtained 7 days after B-RTO shows thrombosis of the duodenal varices... 

Similarly, adjacent inflammatory changes such as pancreatitis can cause compromise of vessel wall integrity. Proteolytic degradation can occur if pancreatic enzymes come in contact with arteries. Gastroduodenal and pancreaticoduodenal pseudoaneurysms are especially prone to rupture in the presence of duodenal ulceration, pancreatitis, or pseudocyst formation [6,7]. These should be treated regardless of size. 

The gastroduodenal artery arises from the common hepatic artery and supplies branches to the pancreatic head via the superior pancreaticoduodenal arcade (SPDA) and greater curvature of the stomach via the gastroepiploic It is an excellent collateral vessel connecting the celiac to the SMA if either one becomes occluded. 

The SMA arises at the LI level and supplies the small bowel via jejunal and ileal branches, the right and middle colon via the ileocolic, right and middle colic arteries, as well as the pancreatic head via the inferior pancreaticoduodenal arcade (I PDA). 

Generally, SMA aneurysms are mycotic, celiac aneurysms develop from cystic medial degeneration, GDA pseudoaneurysms occur in the presence of duodenal ulceration, and gastroepiploic and pancreaticoduodenal aneurysms arise secondary to inflammatory changes from pancreatitis. Other causes include polyarteritis nodosa, amphetamine abuse, and connective tissue disorders. 

Often, pseudoaneurysm formation in the pancreaticoduodenal, SMA, and IMA distributions is due to adjacent inflammatory processes such as pancreatitis or diverticulitis. (Fig. 8.7) Hematomas in the mesentery can become abscesses. Even though microcoils are used in these instances, it is unwise to implant a stent graft into a potentially infected bed. 

Mean initial values + S.E. Blood pressure 161 + 4.01 mmHg Pancreaticoduodenal blood flow 16.6 + 2.18 ml/min Femoral blood flow 65 + 5.88 ml/min. 

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