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Imaging and Radiologic Intervention in the Biliary Tract

This chapter includes a review of both imaging and percutaneous intervention of the biliary system. A thorough evaluation of a patient with obstructive jaundice includes detailed medical and surgical history, physical examination, laboratory data, and evaluation of pertinent imaging. A multidisciplinary approach including the primary care physician, surgeon, gastroenterologist, and interventional radiologist provides comprehensive management options. Noninvasive imaging studies provide the foundation for treatment planning, including…

Anatomy, Embryology, Anomalies, and Physiology of the Biliary Tract

Cholelithiasis represents a significant problem for the health system in both developed and developing societies, affecting 10% to 15% of the adult population, corresponding to 20 to 25 million Americans who have or will have cholelithiasis. Laparoscopic cholecystectomy is the most common surgery performed in the United States, with a considerably low complication rate. Knowledge of the anatomy, embryology, and anomalies of the biliary tract is…

Prevention and Management of Complications of Pancreatic Surgery

Mortality after pancreatic resection has greatly decreased in comparison with historical series, from 33% following Whipple's initial reports to currently less than 2% in most high-volume centers, resulting in the recognition that assessment of surgical quality for these high-acuity patients warrants further refinement. Birkmeyer et al. have demonstrated the impact of hospital volume on actual operative mortality for pancreatic cancer resections, among other high-acuity operations, but these…

Pancreas and Islet Allotransplantation

In 1993 the Diabetes Control and Complications Trial Research Group reported that patients with insulin-dependent diabetes mellitus (IDDM) treated with intensive insulin therapy showed a reduced risk of developing retinopathy, albuminuria or microalbuminuria, and clinical neuropathy, when compared with patients who received conventional insulin therapy. In this trial the intensive therapy group was shown to have achieved sustained lowered blood glucose concentrations over time, as reflected…

Pancreatic Problems in Infants and Children

There is much about the pediatric pancreas that can be informative to the adult surgical specialist. Problems that are commonly seen in infants and children, such as annular pancreas, may remain occult until adulthood. Pediatric management strategies, such as the nonoperative management of pancreatic trauma, have been found to be effective in this patient population, and the adult clinician must make an informed decision whether to…

Pancreatic Trauma

Pancreatic injuries, despite their relative infrequency, are regarded with great respect among experienced trauma surgeons because of their significant associated mortality and morbidity. Pancreatic injuries occur in up to 3% of patients with significant blunt abdominal trauma and a slightly higher percentage of those sustaining abdominal gunshot and stab wounds. Penetrating trauma accounts for more than 70% of pancreatic injuries, and, given its anatomic location, associated…

Minimally Invasive Pancreas Surgery

The introduction of laparoscopy in the 1980s has revolutionized the field of complex abdominal surgery. Once highly morbid procedures requiring open exposure and prolonged recovery are now accomplished through minimally invasive techniques with comparable outcomes. In 1994 Gagner and Pomp described the first laparoscopic pylorus-sparing pancreaticoduodenectomy (PD) in a 30-year-old female with chronic pancreatitis (CP). The operative time was 10 hours, and her postoperative course was…

Techniques of Pancreatic Resection for Cancer

Pancreatic resection and reconstruction remain a therapeutic challenge to surgeons treating neoplastic disease of the pancreas, distal common bile duct, ampulla of Vater, and proximal duodenum. Despite appreciable improvements in perioperative, postoperative, and intraoperative techniques, morbidity for these procedures remains high. The majority of this morbidity is attributed to pancreatic reconstruction and subsequent anastomotic and pancreatic leaks. Historical Background The first reported resection of a pancreatic…

Unusual Pancreatic Tumors

Although pancreatic ductal adenocarcinomas account for approximately 85% of all pancreatic tumors, epithelial tumors of the pancreas are increasingly being identified due to the frequent and improved quality of abdominal imaging modalities, such as computed tomography (CT). Solid pancreatic masses with atypical clinical presentations or unusual imaging characteristics may be diagnostically challenging, and familiarity with less common pancreatic conditions is necessary to develop a comprehensive differential…

Primary Pancreatic Cystic Neoplasms

Over the past century, clinicians have been challenged by the more frequent identification of primary pancreatic cystic neoplasms (PCNs). Increased use of cross-sectional imaging studies, such as computed tomography and magnetic resonance imaging (MRI), have led to a sustained increased “incidence” of these lesions. Management decisions are extremely difficult due to the uncertain biologic behavior of these lesions and the lack of prognostic biomarkers to assist…

Neuroendocrine Tumors of the Pancreas

The overall prevalence and incidence of pancreatic neuroendocrine tumors (PNETs) is low, approximately 1 to 6 per million population, but it is increasing. Gastrinoma and insulinoma are the two most common functional NETs. Most PNETs are malignant, except insulinomas, which are generally benign. The diagnosis of malignancy may be based on Ki67, which is a marker of cellular proliferation. Malignancy is difficult to diagnose based on…

Pancreatic and Periampullary Cancer

Pancreatic and periampullary tumors include a diverse group of malignant neoplasms that arise in the pancreas or at or near the ampulla of Vater. These neoplasms commonly include adenocarcinomas of the pancreas (pancreatic ductal adenocarcinomas [PDACs]), duodenum, distant common bile duct, or ampulla of Vater in addition to pancreatic neuroendocrine tumors (PNETs). Other neoplasms located in this region include intraductal papillary mucinous neoplasms (IPMNs), acinar cell…

Imaging and Radiologic Intervention in the Pancreas

Cross-sectional imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography are commonly used for diagnosis of pancreatic diseases. CT has been the most commonly used technique because it can provide high-resolution images of the pancreas and depict even small lesions and calcifications. With the advent of multidetector computed tomography (MDCT) technology, acquisition speed and image quality have significantly improved. The development of…

Endoscopic and Minimally Invasive Therapy for Complications of Pancreatitis

Acute pancreatitis (AP) and chronic pancreatitis (CP) are dynamic inflammatory conditions that can result in local complications necessitating invasive treatment. Although AP and CP were previously considered and managed as distinct clinical entities, advances in experimental pancreatitis models, improved clinical characterization, and discovery of genetic mutations have resulted in a better understanding of the natural history and pathophysiology of what is now recognized as a clinical…

Pseudocysts and Other Complications of Pancreatitis

Pancreatic and Peripancreatic Fluid Collections Pancreatitis often results in sequelae of pseudocyst formation or other complications. The consensus guidelines of the revised Atlanta classification of pancreatitis describe various features of acute pancreatitis, distinguishing between interstitial edematous pancreatitis and the more aggressive necrotizing pancreatitis ( Table 93.1 ). Acute peripancreatic fluid collections are defined specifically as fluid lacking the presence of tissue necrosis. A pancreatic pseudocyst is…

Chronic Pancreatitis

Chronic pancreatitis is a progressive inflammatory disorder that leads to irreversible destruction of the exocrine and endocrine tissue of the pancreas. Fibrotic replacement of the normal pancreas may be associated with persistent abdominal pain, the development of exocrine insufficiency, and ultimately, diabetes mellitus. Inflammation may lead to local complications, including biliary and gastrointestinal obstruction, ascites, mesoportal-splenic thrombosis, pseudocyst formation, hemorrhage, and sepsis. In its advanced stages,…

Acute Pancreatitis

Acute pancreatitis is the most common gastrointestinal disease for which patients are acutely hospitalized and its incidence is rising. Around 80% of patients with acute pancreatitis have a mild disease course where symptoms usually resolve within 1 week. Approximately 20% of patients develop severe acute pancreatitis with organ failure and/or necrotizing pancreatitis. Necrotizing pancreatitis is defined by pancreatic parenchymal necrosis and/or peripancreatic fat necrosis. Those patients…

Anatomy, Physiology, and Embryology of the Pancreas

The term pancreas is derived from Greek meaning “all flesh” and developmental biologists have been intrigued for years with the fascinating embryologic development of the pancreas. It is an endodermally derived organ, consisting of two morphologically distinct tissues, the exocrine and endocrine pancreas ( Fig. 90.1 ). Some have even described it as two organs in one due to the disparate function and organization of these…

Mesenteric Arterial Trauma

The superior mesenteric artery (SMA) and inferior mesenteric artery are susceptible to injury from both blunt and penetrating trauma. Injuries to the mesenteric arteries compose a small subset of intraabdominal vascular trauma. A multiinstitutional study involving 34 trauma centers reported only 250 patients with SMA injuries over 10 years. Due to its smaller size, the incidence of injury to the inferior mesenteric artery is even rarer.…

Aortoenteric Fistula and Visceral Artery Aneurysms

Aortoenteric Fistulas Aortoenteric fistulas (AEFs) are rare entities that can quickly lead to sepsis, hemorrhage, and lethal exsanguination if they are not quickly diagnosed and treated. Sir Astley Cooper, an English comparative anatomist and surgeon, was the first to describe AEFs in 1829. An AEF is an abnormal communication between the aorta or branches of the aorta and the gastrointestinal (GI) system. The mortality rate of…