Vater's Papilla

Vater's papilla (papilla Vateri, or papilla major) is a small protrusion located at the end of the longitudinal fold of the duodenum (plica longitudinalis duodeni); it is found in the descending part of the duodenum, at its midpoint or slightly lower (see Duodenum), at a distance from the pylorus of 6–8 cm according to Bobrov, 10 cm according to Rauber, and 14–15 cm according to Sappey. In the center of Vater's papilla, there is an opening through which the common bile duct and, in most cases, the pancreatic duct open into the intestine, although there are rare cases where both ducts open through separate, adjacent orifices. Embryologically, Vater's papilla develops later than the ducts (Kölliker, Kelly) and, according to Ruge, belongs to the common bile duct, as they are lined by a similar epithelium, which differs from the epithelium of the pancreatic duct mucosa. Immediately behind the opening of Vater's papilla, there is a small ampulla-like dilation (diverticulum Vateri), the volume of which is 2.5x3.5 mm according to Opie, and from 4x6 to 5x12 mm according to Ruge. On the posterior wall of Vater's papilla, at the border with the diverticulum Vateri, muscle bundles are attached that constitute the sphincter papillae Vateri, or sphincter of Oddi. Sometimes, slightly above Vater's papilla, there is a barely noticeable mucosal protrusion (papilla duodeni Santorini or papilla minor), through which the accessory pancreatic duct (ductus accessorius), which anastomoses with the main Wirsung's duct, opens into the duodenum. In the presence of a clinical picture of a non-functioning Vater's papilla, differential diagnosis between obstruction of Vater's papilla due to sphincter spasm, duct blockage (see Gallbladder), or a tumor of Vater's papilla itself is of great importance. In cases of severe spasms, gradual dilation of the papilla with bougies through an opening in the common bile duct or transduodenally is recommended. According to these authors (especially Bakes, who has about 400 cases), a lasting effect of dilation of Vater's papilla is obtained without any noticeable negative consequences. Among tumors here, carcinomas are the most common. Of all cancerous tumors of the bile ducts, Vater's papilla is affected in an average of 30% of cases, and in advanced cases, it is difficult to establish the site of origin of the tumor. The prognosis for tumors of Vater's papilla is poor due to late diagnosis and the proximity of the liver, pancreas, and large vessels, to which the tumor metastasizes rapidly. Treatment is possible only surgically, and the results of these operations, both immediate and long-term, are still not very encouraging, although recent statistics (Fulde) are somewhat more favorable. Some of the operations used for diseases of Vater's papilla are described among operations on the gallbladder (see). The operation of cutting Vater's papilla (papillotomy) can be performed both through the common bile duct and through the duodenum, sometimes as an independent intervention, and sometimes as part of an operation to create an anastomosis with the duodenum. In cases of cancer of the duodenum that has not spread to Vater's papilla, the latter can be isolated from the intestinal wall and sutured into the normal intestine. In these cases, Vater's papilla continues to periodically contract and relax, passing small portions of bile and pancreatic juice into the intestine each time (Odinov). In cases where Vater's papilla itself is affected by cancer, a transduodenal or retroduodenal papillectomy or a circular resection of the duodenum must be performed, depending on the spread of the tumor. In all of the latter operations, the ducts must be connected to the gastrointestinal tract. Lit.—see lit. to the articles Gallbladder, Duodenum, Pancreas. D. Odinov.