Unusual duplication and vulnerable intrapancreatic course of the left gastroepiploic artery: a rare anatomical variation.

The left gastroepiploic artery (LGEA) is the least described artery in the medical literature. Unusual variations of this artery might lead to vascular injuries, causing intraoperative bleeding after surgery. We observed rare vascular variations in an adult male cadaver. The left gastroepiploic artery after its origin from splenic artery pierced the pancreatic parenchyma at its posterior surface. After a short intrapancreatic course, the LGEA emerged out from the superior border of the body of the pancreas. LGEA then trifurcated into an omental branch, duplicated LGEA and another branch that continued as the main trunk of LGEA. Main LGEA and duplicated LGEA coursed towards the greater curvature of the stomach. The main LGEA ended by anastomosing with the right gastroepiploic artery, while the duplicated LGEA ended at the greater curvature of the stomach by ramifying into minute branches on the walls of the stomach and gave few gastric branches to supply the stomach and also supplied the greater omentum. This variation was associated with the presence of an accessory splenic artery. Anatomists, surgeons, and radiologists should be aware of such anomalous vascular variations as it could help to minimize complications related to pancreatectomy, omentoplasty, and resection of pancreatic tumors.

Anatomical Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomographic Angiography.

BACKGROUND: The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer. The anatomy of the gastroepiploic vessels, omentum, and lymph nodes has not been investigated. The purpose of this article is to describe the right gastroepiploic artery and related structures by using computed tomographic angiography. METHODS: A retrospective analysis was conducted on 34 patients who underwent computed tomographic angiography. Statistical models were applied to identify right gastroepiploic artery and lymph node anatomical characteristics. RESULTS: The right gastroepiploic artery was identified in 33 of 34 patients. It was found to have a diameter of 2.49 ± 0.66 mm at its origin. The gastroduodenal artery length before right gastroepiploic artery takeoff was 3.09 ± 1.31 cm. Twenty-five patients had lymph nodes in the right gastroepiploic artery lymphosome. There were 2.7 ± 2.12 lymph nodes identified per patient. The distance from the right gastroepiploic artery origin to the most proximal lymph node was 3.99 ± 2.21 cm. The distance from the gastroepiploic artery origin to the third lymph node was 9.12 ± 5.06 cm. Each lymph node was within 7.00 ± 6.2 mm of the right gastroepiploic artery. CONCLUSIONS: When using the right gastroepiploic artery donor site for vascularized lymph node transfer, the plastic surgeon should anticipate using a pedicle length of 4 cm, a total flap length of 9 cm, and 3 cm of surrounding tissue to obtain at least three lymph nodes for transfer. Computed tomographic angiography is an effective imaging modality that can be used for patient-specific surgical navigation before vascularized lymph node transfer.

Surgical anatomy of the right gastro-omental artery: a study on 100 cadaver dissections.

PURPOSE: The gastro-omental artery (GOA) with the greater omentum (GO) is known for its high quality as a vascular graft, its resistance to infections as an omental flap and for its multiple applications in surgery. A better knowledge of anatomical variations of GO and its vascularization can improve the application in surgery and decrease complications. The purpose of this study was to measure diameters and lengths of the right GOA (RGOA) and study the interindividual variability of these anatomical structures. METHODS: In 100 cadaveric dissections, we carried out dissection of the RGOA and of the GO. In 70 unfixed cadavers, the transillumination technique was used to identify all RGOA branches. In the remaining 30 cadavers, prepared with Winckler's solution, barium sulfate with colored latex was injected. Digital X-ray was used to measure RGOA lengths, internal diameters and the distribution of the omental branches. The gastro-omental vein was also dissected. RESULTS: The mean proximal and distal diameters of RGOA were 2.68 (± 0.39) mm and 0.94 (± 0.24) mm, respectively. The mean length was 244.3 (± 34.4) mm. The thickness of the omentum ranged from 5 to 15.5 mm. The arteria omentalis magna, defined in this study for the fist time as the longest and widest omental branch, was present in 73.3% cases. The trans-omental arch was present in 6% cases. CONCLUSIONS: This morphometric study allowed us to define the vascularization and the anatomical variations of RGOA and GO. This may lead to improvement of applications in surgery and decrease complications.

Vascular anatomy of the stomach related to resection procedures strategy.

This study is focused on the vascular anatomy of the stomach in relation to the gastric pull-up construction. The vascular anatomy was studied on forty-one human specimens. We find out the differences in blood supplement between anterior and posterior wall. It was maked an review of the main trunk arteries of the stomach. To display the vessels of the stomach we used diaphanoscopy, digital shooting in special mode and micro preparation of the vessels. We find out that left gastric artery gives more branches to the posterior wall and right gastroepiploic artery (RGEA) gives more branches to the anterior wall. But brunches of RGEA are longer on the posterior wall than on the anterior. Also we are offering the new classification of the RGEA related to gastric pull-up construction. This classification based not only on the anatomical shapes of RGEA but on the properties of the flow dynamics through the artery.

Anatomical and surgical evaluation of gastroepiploic artery.

OBJECTIVE: Knowledge of the anatomy of the stomach and its surrounding structures is essential for lymph node dissection. This is the first gross anatomical investigation of anastomosis variations in the gastroepiploic arteries (GEA). The aim of this study is to examine the anastomosis pattern of the right and left GEA (RGEA and LGEA, respectively). METHODS: Seventeen cadavers were dissected, and the anastomotic patterns of RGEA and LGEA were observed macroscopically. RESULTS: The anastomotic patterns were classified into two groups. Type 1 had direct anastomosis (n = 16; 94.1%), whereas Type 2 had no anastomosis (n = 1; 5.9%). Formation of an arterial arch along the greater curvature was observed in twelve cases (70.6%), whereas four cases (23.5%) exhibited mesh-like anastomosis or narrow anastomotic branches. CONCLUSIONS: Direct anastomoses were observed in almost all the cases. These results are significant, and may be useful in the classification of lymph nodes or speculation of cancer metastases.

Arterial Vascularization of the Gastrointestinal Tract of the Pampas Deer (Ozotoceros bezoarticus, Linnaeus, 1758).

Based on gross dissection of fifteen adult animals (11 females, 4 males), we described the arterial supply of the stomach and intestines of the pampas deer (Ozotoceros bezoarticus), a South American endangered species. The coeliac artery emitted the splenic, left gastric and hepatic arteries. The splenic artery directed towards the spleen, and the right ruminal artery, which is its only collateral directed towards the stomach, being the main artery of the rumen. The left gastric artery gave origin to the left ruminal, the reticular and the left gastroepiploic arteries. The left gastroepiploic artery originated the reticular accessory artery. Both arteries, gastric and left gastroepiploic, anastomosed their right counterparts derived from the hepatic artery on the curvatures of the abomasum. The cranial mesenteric artery irrigated the second half of the duodenum until the beginning of the descending colon. The thickest branch emitted by the cranial mesenteric artery was the ileocolic artery, which was destined to the ascending colon, caecum and ileum. The colic branches and the right colic arteries were irradiated on the right surface of the spiral loop of the ascending colon and distributed to both centripetal and centrifugal coils of the ascending colon; the colic branches were also anastomosed with the last jejunals and ileals and with the right colic arteries. There were no variations in the origin of any of the main branches derived from the coeliac and cranial mesenteric arteries. This species had a basic pattern of arterial distribution similar to small domestic ruminants.

Morphometric and quantitative evaluation of the gastroepiploic artery.

BACKGROUND: The gastroepiploic artery (GEA) has been described in various ways by anatomical texts and surgical manuals. Currently, there are no studies that have investigated the thickness and length of GEA using gross anatomical methods. In the present study, we measured the length, circumference, area, and major axis of GEA, and quantitatively evaluated the differences between right and left GEA (RGEA and LGEA), using gross anatomical and morphometric methods for the first time. MATERIALS AND METHOD: Seventeen cadavers were selected. The median age of the cadavers was 82 years. We observed and evaluated GEA with naked eyes, as well as under a stereoscopic microscope. RESULTS: RGEA was significantly longer than LGEA (p < 0.0001). The mean length of RGEA and LGEA were 26.51 ± 5.15 cm and 14.05 ± 3.12 cm, respectively. The mean area of RGEA, LGEA, and the anastomotic point were 3.31 ± 1.71 mm(2), 1.33 ± 1.01 mm(2), and 0.51 ± 0.28 mm(2) respectively. CONCLUSION: RGEA was significantly longer and thicker than LGEA. The results also showed that in almost all of the cases RGEA and LGEA anastomosed with each other and grew thinner as they approached the middle of the greater curvature of the stomach.

Right gastroepiploic artery arising from the dorsal pancreatic artery: a very rare anatomic variation underlying interesting embryologic implications.

The exceptional case of the right gastroepiploic artery (RGE) arising from the dorsal pancreatic (DP) artery in an individual affected by hepatocellular carcinoma is presented. This anatomic variant was demonstrated with a selective angiography of the common hepatic artery that showed a distinct DP artery branching from the injected artery. The DP artery gave off regular pancreatic branches and continued as a long and winding vessel that was identified as the RGE by its general course, the anterior epiploic branches arising from it, and the injection of the distal splenic artery, possibly via the anastomosis with the left gastroepiploic artery. The anatomy of the RGE has few variations, mostly limited to its origin from the superior mesenteric artery. Arising of the gastroepiploic artery from the DP artery has never been previously reported and represents an unexpected possible anatomic variant of which general and heart surgeons should be aware. In particular, this case is of interest in surgical procedures involving resection of the head of the pancreas, gastrectomies or coronary artery bypass grafting using the RGE. The embryology underlying the development of this anatomic variation is reviewed.

[The left gastroepiploic artery: a splenic origin but a variable birthplace]. / L'artère gastro-omentale gauche : une origine splénique mais un niveau de naissance variable.

The left gastroepiploic artery (LGEA) is rarely described. The aim of this study is to report the fashion of its origin considering the greatly surgical interest of the short gastric vessels in the spleen-preserving distal pancreatectomy with excision of splenic pedicle. About 79 fresh cadaveric pieces we dissect and opacified the LGEA to specify its origin based on the Pinus's classification. We measured the distances between the origin of the LGEA and the terminal division of the splenic artery, the splenic hilus and the great gastric curvature. The LGEA arise from the splenic artery. Dissection underlines a troncular origin (type I) in 20.25% of cases, a distal origin from an inferior polar branch (type II) in 68.35% of cases and an origin from a common spleno-gastroepiploic trunk (type III) in 11.4% of cases. The three distances measured was respectively of 28.7, 25.3 and 31.4mm. The arteriography revealed respectively for the same types 21.21, 51.51 and 27.28%. The vascular disposition of the type III well illustrates the important role of the LGEA for the vascularization of the inferior pole of the spleen. Although the LGEA arise from a polar splenic lower branch in more half of the cases, it is important to know the frequency of the other modalities of its origin. These anatomical variations vascular are to be considered during spleen-preserving distal pancreatectomy with excision of splenic pedicle as well as for gastric esophagoplasty.

Vascular anatomy of the stomach related to gastric tube construction.

In view of constructing a gastric tube after esophagus resection, the vascular anatomy of the greater curvature of the stomach, especially the connection between the left and right gastro-epiploic arteries, was investigated. The vascular anatomy was studied in 20 embalmed human specimens. After dissection a gastric tube of 4 cm wide was constructed, using the greater gastric curvature. Various lengths of the arterial arcades were measured. In 70% an anastomosis between the right and left gastro-epiploic arteries was present. With the construction of an isoperistaltic gastric tube, in which the left gastro-epiploic artery is left in situ (ligating it at the splenic hilus), there is an 18.7% increase of length of arterial arcade along the gastric tube. Leaving the left gastro-epiploic artery in situ increases the feeding arterial arcaded-length along the gastric tube with 5.0 cm (19%).

Distribuição da artéria gástrica esquerda e artérias gástricas curtas na superfície do estômago de eqüinos e relação com a área superficial do órgão / Distribution of left gastric artery and breve gastric arteries on the surfaceof equine stomach and the relation to the organ´s superficial area

Vasos responsáveis pelo suprimento sangüíneo do estômago originam-se da artéria celíaca, primeiro ramo da aorta abdominal, localizada na região do hiato aórtico. Assim, dirigem-se à superfície do estômago as artérias gástricas esquerda e direita, as artérias gastroepilóicas esquerda e direita e as artérias gástricas curtas. Apesar de bem conhecidas as origens destes vasos, informações a respeito do comportamento dos mesmos ao atingirem a superfície do estômago ainda são escassas. O fluxo sangüíneo na parede do estômago exerce importante papel nos mecanismos de defesa da mucosa gástrica. Eqüinos em treinamento intensivo apresentam alta freqüência de ocorrência de lesões ulcerativas na mucosa do estômago, tornando as pesquisas sobre vascularização sangüínea deste órgão com grande significado prático na compreensão dos mecanismos relacionados à proteção da mucosa gástrica. O objetivo deste trabalho foi avaliar alguns aspectos relacionados à distribuição arterial na superfície do estômago de eqüinos adultos, sem raça definida e destinados a abate. Utilizaram-se estômagos oriundos de 15 machos e 15 fêmeas. A área superficial do estômago foi mensurada com software de análise de imagens e os dados correlacionados ao número de ramos avaliados. Observou-se reduzida participação da artéria gástrica esquerda na irrigação da curvatura menor do estômago. Estes achados justificam estudos relacionados à particularidades anatômicas da região da curvatura menor do estômago de eqüinos, em trabalhos futuros.

Vessels responsible for stomach blood supply have their origin in the celyac artery, abdominal aorta first branch, in the aortic hiatus region. Thus, the stomach surface receives the left and right gastric arteries, the left and right gastroepiploic arteries and the breves gastric arteries. Origins of these vessels are well-known, but information about stomach surface arterial distribution are still unknown. Stomach surface blood supply has an important role on gastric mucosa defense mechanisms. Equines submitted to intensive training show high frequency of the ulcerative lesions in the gastric mucosa, with is a promising of applicability for researches on vascularization. The aim of this study was to analyze some aspects of the stomach surface arterial distribution, of the mixed breed adults equines destined to slaughter. Equine stomachs of 15 male and 15 female were analyzed. The stomach surface area was measured with images analysis software and the data correlation with number of vessels branch accounted. A low contribution of the left gastric artery to the stomach minor curvature irrigation was observed. These results justify studies related to anatomic particularities of the region of equine stomach minor curvature, in future researches.

Skeletonization of radial and gastroepiploic conduits in coronary artery bypass surgery.

The use of a skeletonized internal thoracic artery in coronary artery bypass graft surgery has been shown to confer certain advantages over a traditional pedicled technique, particularly in certain patient groups. Recent reports indicate that radial and gastroepiploic arteries can also be harvested using a skeletonized technique. The aim of this study is to systematically review the available evidence regarding the use of skeletonized radial and gastroepiploic arteries within coronary artery bypass surgery, focusing specifically on it's effect on conduit length and flow, levels of endothelial damage, graft patency and clinical outcome. Four electronic databases were systematically searched for studies reporting the utilisation of the skeletonization technique within coronary revascularisation surgery in humans. Reference lists of all identified studies were checked for any missing publications. There appears to be some evidence that skeletonization may improve angiographic patency, when compared with pedicled vessels in the short to mid-term. We have found no suggestion of increased complication rates or increased operating time. Skeletonization may increase the length of the conduit, and the number of sequential graft sites, but no clear clinical benefits are apparent. Our study suggests that there is not enough high quality or consistent evidence to currently advocate the application of this technique to radial or gastroepiploic conduits ahead of a traditional pedicled technique.

Anatomic study of gastric vascularization and its relationship to cervical gastroplasty.

The aim of this study was to perform an anatomic study of the stomach and its vascularization, evaluating the frequency of communication between the right gastroepiploic artery (RGEA) and the left gastroepiploic artery (LGEA), as well as their relationship to the length of the stomach without extramural (direct) vascularization in cervical gastroplasty. Forty-two fresh human cadaveric specimens were studied, and the presence of communication between the RGEA and the LGEA was observed in 26 of the dissected stomachs (61.9%). When communication was present (group 1), to a total length of 49.60 cm of greater curvature length, it was verified that approximately 16.48 cm of this curvature lacked direct extramural vascularization (33.20%). When there was non-communication (group 2), to a greater curvature length of approximately 45.41 cm, it was found that 18.96 cm of this curvature (gastric fundus) lacked direct extramural vascular perfusion (41.76%). Results obtained in both groups were tested for statistically significant differences by the Pearson correlation test (P<0.05). A P value of 0.05 or less was considered statistically significant. It can be concluded that the presence of communication between the RGEA and the LGEA increases extramural vascularization in the great gastric curvature.

Configurational anatomy of the pancreas: its surgical relevance from ontogenetic and comparative-anatomical viewpoints.

The structure of the adult human pancreas retains develop-mental traits in ontogenesis and comparative anatomy, under-standing of which greatly contributes to pancreatic surgical anatomy. The pyramidal process called the "auricle" or "ear"at the inferior margin of the neck suggests the vestige of the ontogenetic twist at the neck, resulting from bursal bulging with rotation of the pancreatic body and tail. This anatomical consideration serves to avoid inadvertent bleeding or pancreatic fistula during dissection of the right gastroepiploic arteryand vein at their roots. Recognition of embryonic rotation of the gastrointestinal tract eases detachment of the pancreati-coduodenal and jejunal vessels at their origins, enabling "reversed Kocherization" and complete resection of the mesoduodenum and upper mesojejunum. Embryological knowledge of vascular arcades of the pancreatic head serves as a guide for limited resection of the pancreas. The anterior inferior pancreaticoduodenal artery often runs behind, not in front of, the lower portion ("mentum" or "chin") of the pancreatic head, but still on the anterior leaflet of the embryonic mesoduodenum. The attachment of the adult pancreatic head to the duodenum occurs only at the major papilla of Vater and at the region around the minor papilla, which seems to be rational from ontogenetical and comparative-anatomical aspects. Knowledge of the pancreatic attachment helps when performing duodenum-preserving pancreatectomy and pancreas-sparing duodenectomy. The "lingula" or "small tongue", a pancreatic portion overlapping the common bile duct on the posterior aspect of the pancreas, is a key structure in resection of the extrahepatic bile duct.

[Morphological characteristics of the right gastroepiploic artery and its use in myocardial revascularization]. / Morfologicheskaia kharakteristika pravoi zheludochno-sal'nikovoi arterii i ee ispol'zovanie pri revaskuliarizatsii miokarda.

The results of morphological and morphometrical investigation of the biopsy and autopsy material from 35 right gastroepiploic arteries were analyzed. Histological and histochemical methods were used. The anatomo-topographic and morphometrical characteristics of the right gastroepiploic artery allow it to be used for gastro-coronary shunting. It makes the possibilities of the aorto-arterial revascularization of the myocardium substantially wider.