[Clinical and surgical anatomy of the lymphatic circulation of pancreas].

Data was collected from results of injection and dissection of 100 autopsy specimens; the examination of 34 case-reports of cancer patients; the injection of lymphatics in 14 live dogs; and the reconstruction of the mesodorsal region of the pancreas from a 30 mm embryo using Born's technique. Anatomy of the pancreas and lymph vessels shows that the "primary mesodorsal region" of the pancreas is two-fold; a right part for the right side of pancreas: the retroportal process (RPP); a left part for the left side of pancreas, a formation not previously described: the left lateroportal process (LLPP). Whereas lymphatic drainage visible on the anterior surface of the pancreas is apparently as described, posterior drainage, which collects lymph from posterior and anterior vessels, is quite atypical. The right portion drains into the RPP and the left into the LLPP. Terminal collecting vessels of pancreatic lymphatics have only a short distance to travel before emptying into the thoracic duct. The study of lymph node metastases from pancreatic cancer appears to confirm these cadaver anatomic results but the series is too small for valid exploitation. The very rapid passage into the thoracic duct probably greatly diminishes the value of widely extended surgery, justification for the latter being exclusively to remove lymph nodes insofar as adjuvant therapy has currently failed to demonstrate absolute efficacy. Precise knowledge of the anatomy of the pancreatic lymphatics should allow development of experimental models to study lymph circulation changes during acute pancreatitis. Pancreatic edema, an enzyme-rich fluid, is an essentially "lymphatic" edema. The interstitial and lymphatic shunt pathways due to increased duct pressure were evident during the dog study. The lymphatic system acts as a "buffer system" or "safety valve" against progression to necrosis. Ligature of very proximal pancreatic lymphatic efferents (included in the bands) was followed by a fatal necrotic pancreatitis on both occasions when this was performed. Development and study of a lymphagogue drug for the treatment of acute pancreatitis is a justifiable project. A protocol is proposed which combines lymphagogue treatment with anti-enzymes, the former assists use of the enzymes by the lymphatic system. The anti-proteases prevent the onset of fatal shock caused by the outpouring of enzymes into the lymphatic system and the general circulation.