Blood supply of the duodenum

1. Origin

• Foregut part (above the major papilla) → coeliac trunk via the gastroduodenal artery (GDA)
• Midgut part (below the major papilla) → superior mesenteric artery (SMA)
• Supply of the first part → most variable segment

2. Course and relations

Gastroduodenal artery

• Origin → common hepatic artery at the upper border of the first part
• Descends behind the first part of the duodenum
• Divides → right gastroepiploic artery and anterior superior pancreaticoduodenal artery

Supraduodenal artery (of Wilkie)

• Origin → proper hepatic artery, GDA or right gastric artery (13%)
• Supplies the upper first part

Posterior superior pancreaticoduodenal artery (PSPDA)

• Also called the retroduodenal artery (of Edwards and Michels)
• Origin → GDA
• Crosses in front of the common bile duct (CBD), then spirals right and behind it
• Descends behind the pancreatic head

Anterior superior pancreaticoduodenal artery (ASPDA)

• Origin → GDA, on the front of the pancreatic head
• Commonly 2 in number

Inferior pancreaticoduodenal arteries

• Anterior (AIPDA) and posterior (PIPDA) branches
• Origin → SMA or its first jejunal branch, separately or as a common stem

3. Branches / Parts

• Anterior arcade → ASPDA ↔ AIPDA
• Posterior arcade → PSPDA ↔ PIPDA
• Arteriae rectae → from the arcades to the duodenal wall; may run inside the pancreas
• First part → supraduodenal and retroduodenal arteries only
• Third and fourth parts → also direct branches of the SMA and first jejunal artery; no collateral supply

4. Blood supply, venous and lymphatic drainage

Veins

• Venous arcades → follow the arterial arcades, superficial to them
• Drain → superior mesenteric vein (SMV) and portal vein
• Lower first part and pylorus → right gastroepiploic vein
• Communicating vein between the right gastroepiploic and middle colic veins → bleeds when mobilising the greater curvature or hepatic flexure

Lymphatics

• Anterior and posterior pancreaticoduodenal nodes

5. Clinical significance

• Ligate only one arcade, superior or inferior
• Both arcades ligated → duodenal ischaemia
• Shared supply with the pancreatic head → duodenum resected with it (pancreaticoduodenectomy)
• First part skeletonised > 2 cm → ischaemia, duodenal stump blow-out
• Antimesenteric border (midline of the anterior wall) → least efficient blood supply
• Extended Kocher manoeuvre along the third part → middle colic vessels cross here

Bleeding posterior duodenal ulcer

1. Kocher manoeuvre → laxity for closure
2. Longitudinal duodenotomy 2–3 cm across the pylorus onto the antrum 2–3 cm
3. Cephalad stitch → around the GDA above the ulcer
4. Caudal stitch → around the GDA below the ulcer
5. Medial stitch → transverse pancreatic artery (retrograde bleeding)
6. No lateral stitch → CBD lies lateral and posterior to the GDA