The arterial supply of the major duodenal papilla and its relevance to endoscopic sphincterotomy

Background and study aims: Arterial bleeding from the major duodenal papilla is an uncommon but potentially life-threatening complication of endoscopic sphincterotomy. We investigated the arterial blood supply of the papilla to determine whether there might be a safer region for sphincterotomy.

Methods: Arteries supplying the major duodenal papilla were studied in 19 cadaver pancreaticoduodenal specimens (nine male, mean age 81 years, range 64 – 97 years) using a combination of microdissection and histology. The number, origin, caliber, and distribution of arteries within 5 mm of the major duodenal papilla were recorded.

Results: A total of 98 papillary arteries were identified by microdissection giving a mean of 5.2 arteries (range 3 – 9) per specimen. Papillary arteries originated from three sources: communicating arteries and the posterior and anterior pancreaticoduodenal arcade arteries. The majority of arteries were related to the antero-superior and postero-inferior quadrants of the major duodenal papilla, both at their point of entry into the duodenal wall or bile/pancreatic ducts (microdissection) and in their distribution 5 mm from the tip of the papilla (histology). The combined 10 and 11 o'clock segments of the papilla (as viewed endoscopically) contained only 10 % and 11 % of all papillary arteries on microdissection and histology, respectively, with seven of 19 specimens having no arteries in this region.

Conclusions: This study documents for the first time the distribution of papillary arteries around the circumference of the major duodenal papilla. Arterial bleeding complicating endoscopic sphincterotomy might be reduced by incising the papilla in the 10 – 11 o'clock region rather than the currently recommended 11 – 1 o'clock position.

References

• 1 Classen M, Demling L. Endoskopische sphinkterotomie der papilla Vateri und steinextraktion aus dem ductus choledochus.  Deutsche Med Wochenschrift. 1974;  99 496-497
• 2 Kawai K, Akasaka Y, Murakami K et al. Endoscopic sphincterotomy of the ampulla of Vater.  Gastrointest Endosc. 1974;  20 148-151
• 3 Williams E J, Taylor S, Fairclough P et al. Risk factors for complication following ERCP: results of a large-scale, prospective multicenter study.  Endoscopy. 2007;  39 793-801
• 4 Colton J B, Curran C C. Quality indicators, including complications, of ERCP in a community setting: a prospective study.  Gastrointest Endosc. 2009;  70 457-467
• 5 Cotton P B, Garrow D A, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years.  Gastrointest Endosc. 2009;  70 80-88
• 6 Kim K O, Kim T N, Kim S B, Lee J Y. Characteristics of delayed hemorrhage after endoscopic sphincterotomy.  J Gastroenterol Hepatol. 2010;  25 532-538
• 7 Katsinelos P, Kountouras J, Chatzimavroudis G et al. Endoscopic hemostasis using monopolar coagulation for postendoscopic sphincterotomy bleeding refractory to injection treatment.  Surg Laparosc Endosc Percutan Tech. 2010;  20 84-88
• 8 Ferreira L E, Baron T H. Post-sphincterotomy bleeding: who, what, when, and how.  Am J Gastroenterol. 2007;  102 2850-2858
• 9 Nelson D B, Freeman M L. Major hemorrhage from endoscopic sphincterotomy: Risk factor analysis.  J Clin Gastroenterol. 1994;  19 283-287
• 10 Wilcox C M, Canakis J, Monkemuller K E et al. Patterns of bleeding after endoscopic sphincterotomy, the subsequent risk of bleeding, and the role of epinephrine injection.  Am J Gastroenterol. 2004;  99 244-248
• 11 Bertelli E, Di Gregorio F, Bertelli L, Mosca S. The arterial blood supply of the pancreas: a review. I. The superior pancreaticoduodenal and the anterior superior pancreaticoduodenal arteries. An anatomical and radiological study.  Surg Radiol Anat. 1995;  17 97-106
• 12 Bertelli E, Di Gregorio F, Bertelli L et al. The arterial blood supply of the pancreas: a review. II. The posterior superior pancreaticoduodenal artery. An anatomical and radiological study.  Surg Radiol Anat. 1996;  18 1-9
• 13 Bertelli E, Di Gregorio F, Bertelli L et al. The arterial blood supply of the pancreas: a review. III. The inferior pancreaticoduodenal artery. An anatomical review and a radiological study.  Surg Radiol Anat. 1996;  18 67-74
• 14 Bertelli E, Di Gregorio F, Bertelli L et al. The arterial blood supply of the pancreas: a review. IV. The anterior inferior and posterior pancreaticoduodenal aa., and minor sources of blood supply for the head of the pancreas. An anatomical review and radiologic study.  Surg Radiol Anat. 1997;  19 203-212
• 15 Murakami G, Hirata K, Takamuro T et al. Vascular anatomy of the pancreaticoduodenal region: A review.  J Hepatobiliary Pancreat Surg. 1999;  6 55-68
• 16 Farisse J, Cannoni M, Gau M et al. Sur les artères de la papille duodenale.  C R Ass Anat. 1966;  134 384-395
• 17 Yamaguchi H, Wakiguchi S, Murakami G et al. Blood supply to the duodenal papilla and the communicating artery between the anterior and posterior pancreaticoduodenal arterial arcades.  J Hepatobiliary Pancreat Surg. 2001;  8 238-244
• 18 Young B, Heath J W. Wheater's functional histology.. 4th edn. Edinburgh: Churchill Livingstone; 2000: 149
• 19 Leung J. Fundamentals of ERCP.. In: Leung J, Cotton P, eds. Advanced digestive endoscopy.. ERCP; 2004. http://www.gastrohep.com/ebooks Accessed: 28 July 2010
• 20 Morino M, Arezzo A. Cholecystocholedocholithiasis: two-stage treatment.. In: Borzellino G, Cordiano C, eds. Biliary lithiasis. Basic science, current diagnosis and management.. Milan: Springer Italia; 2008: 325-339
• 21 Manes G. Biliary sphincterotomy techniques.. In: Mönkemüller K, Wilcox C M, Muñoz-Navas M, eds. Interventional and therapeutic gastrointestinal endoscopy.. Basel: Karger; 2010: 319-327