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.
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M. D. StringerMS
Department of Anatomy
Otago School of Medical Sciences
University of Otago
PO Box 913
Dunedin
New Zealand
Fax: +64-3-4797254
eMail: mark.stringer@anatomy.otago.ac.nz
