The unrecognized posterior gastric artery: a potential cause of surgical complications in pancreas transplantation

BACKGROUND

Our report describes, for the first time, a pre-transplant vascular complication in a pancreas graft related to the posterior gastric artery - a major, but relatively unknown side branch of the splenic artery. The posterior gastric artery that was overlooked by a surgical procurement team during donor pancreatectomy led to distortion of the peripancreatic vascular anatomy and set the stage for a splenic artery injury.

METHODS

We identified the transected, partially resected graft splenic artery during backtable preparation of the pancreas, and repaired it using standard vascular surgical techniques.

RESULTS

The recipient's post-operative course was uncomplicated. At 9-yr post-transplant, the recipient is alive with good pancreas graft function.

CONCLUSIONS

The relevance of the posterior gastric artery with regard to general surgical procedures was only recently recognized. Our case demonstrates that the posterior gastric artery is also important in transplant surgery. Awareness of this anatomical structure during organ procurement would help minimize pre-transplant vascular complications.

Branches of the splenic artery and splenic arterial segments

In 200 adult autopsy specimens, the arterial supply to the pancreas and spleen was studied radiologically and by manual dissection. The splenic artery divided into two or three lobar arteries, which supplied its corresponding lobe; each lobar artery subsequently divided into two to four lobular branches. Six to twelve lobular branches were observed entering the splenic substance at the hilum. Lobar arteries did not anastomose with each other, hence, the lobes of the spleen are also termed segments. The lobules, however, were not found to be independent segments and the arteries of one lobule anastomosed with those of other lobules. The branching pattern of the splenic artery varied from one specimen to another, so much so that a prevailing pattern could not be identified. Polar arteries, particularly to the superior pole, arose quite proximal to the hilum in 51% of cases and were occasionally missed. In 45% of males and 40% of females, the posterior gastric artery arose from about the middle of the splenic artery. The splenic artery was not found to be tortuous in fetuses, newborns, and young children. Tortuosity was seen in only 10% of adults; thus, the characteristic tortuosity of the splenic artery appears to develop with age.

Anatomical study of the pancreas in the house musk shrew (Suncus murinus), with special reference to the blood supply and innervation

To examine the macroscopic structure, blood supply, and innervation of the pancreas in the house musk shrew (Suncus murinus), we performed gross anatomical dissection and whole-mount immunostaining of the autonomic nerve of Suncus pancreases based on neurofilament protein (NFP) immunoreactivity. The adult Suncus pancreas is clearly separated into right and left lobes that are not fused. The right lobe of the Suncus pancreas is located in the dorsum of the duodenum and to the right of the common bile duct independently. The right lobe is supplied by branches of the superior mesenteric artery, and is innervated by branches that originate from the superior mesenteric plexus and run along the arterial branches of the superior mesenteric artery. The left lobe occupies 9/10 of the entire pancreas and is located to the left of the common bile duct. It is supplied mainly by branches of the splenic and common hepatic arteries, and is innervated by branches that originate from the celiac plexus and run along the splenic and common hepatic arteries. According to previous studies on the blood supply and innervation of the human pancreas, the right and left lobes of the Suncus pancreas correspond to the pancreatic parts derived from the ventral and dorsal pancreatic buds. The current results suggest that the Suncus pancreas is a suitable experimental model for studying the development of the human pancreas.

Three Cases of the Gastrosplenic and the Hepatomesenteric Trunks

Three common branches of the celiac trunk are the left gastric artery, the splenic artery and the common hepatic artery. The variation of the three branches of the celiac trunk has an importance for the arterial supply to the digestive organs of the upper abdomen. In this study, we present three cases of the gastrosplenic and the hepatomesenteric trunks in Japanese cadavers. Especially, in Case 1, the left inferior phrenic artery arose from the gastrosplenic trunk and the left hepatic artery arose from the left gastric artery. In Cases 2 and 3, the common hepatic artery penetrated the pancreatic parenchyma before reaching liver. In Case 3, the right hepatic artery arose from the hepatomesenteric trunk.

Intraperitoneal and extraperitoneal anastomoses of spleen arteries

The importance of supporting the spleen with blood is enormous especially from the surgical point of view. The main vessel of spleen is the splenic artery. In this study we would like to extend current knowledge of anastomoses between the splenic artery and surrounding arteries. Seven donor bodies of both sexes were used for detailed dissection. We were concerned with both the intraperitoneal and extraperitoneal anastomoses. In another 100 donor bodies, the relationship between the spleen and the anterior surface of the posterior body wall was studied. The superficial anastomoses were found mainly in the peritoneal duplications. They were the short gastric arteries; the epiploic branches of the left gastroepiploic artery; branches of the middle and left colic arteries and arteries from the region of the pancreatic tail. Deep anastomoses were found between the spleen and the parietal branches of the aorta, i.e. the superior and inferior phrenic arteries and the arteries of the anterior surface of the posterior body wall: the posterior intercostal artery and lumbar arteries. Authors also expect small anastomoses in 40-50% of spleens that lie directly on the anterior surface of the posterior body wall. Our findings correspond with the clinical observations that after ligation of the splenic artery necroses in the spleen do not occur.

The importance of the anatomy of the splenic artery and its branches in splenic artery embolisation

Splenic artery embolisation can be performed preoperatively in an attempt to decrease thrombocyte destruction, or as an alternative to surgery, to obtain partial or total organ ablation. During this procedure, it is very important to deliver embolising agents distal to the origin to pancreatic branches to avoid the risk of pancreatitis. Therefore, a detailed knowledge of the anatomy of the splenic artery and its branches is required to achieve safe embolisation. The purpose of our study is to measure the average distance between the origin of the last pancreatic branch and the splenic hilum in digital angiograms and cadaver specimens.

[Anatomy of the splenic artery]

Due to the importance and permanent improvements as regards the treatment of different diseases involving abdominal organs such as the abdomen, pancreas and spleen. I was indined to investigate, both from the anatomic and surgical point of view, one of the collateral arterial branches of the celiac trunk, which is possibly considered to be one the least studied and, historically one of the most forgotten by the vessels irrigating the liver and stomach. Considering the fact that anatomic understanding is the starting point of medical knowledge, and that its conquests give it permanently new fundaments, I was determined to do research, intensely and thoroughly on splenic artery. This research work relates in detail, on the corresponding chapters, the material and methods used, which consist on human bodies and foetus fixed with formol and in a fresh condition. These human bodies and foetus were submitted to dissection techniques of inter-arterial injection with resin, and then they were corroded with acid and angiographic studies. Finally selective arteriographic tests were performed on living beings by means of digitalis removal of the splenic artery. The following chapter deals with the results obtained from saied research work, showing that the splenic artery originates, in all cases, from the celiac trunk, and this artery is the most important with an average length of 10.6 centimeters and of 2.3 flexuosities in all. This chapter also enumerates the relationships existing between the splenic artery and neighboring organs, the homonymous vein, its collateral and terminal branches which in the hundred percent of cases showed one superior and one inferior, to immediately subdivide in different ones at the level of the splenic pedide. The collateral branches found were the following: arterial pancreatic branches found in the 73% of the cases with an average of 1.8 arteries in all. posterior esophaguscardiotuberosity artery appearing in a 33% of the cases. superior polar artery appearing in a 53% of the cases. inferior polar artery appearing in a 33% of the cases. the short vessels appeared in the 100% of the cases, from which in a 73% were superior short vessels and in the remaining 27% inferior short vessels. the left gastroepiploon artery appeared in all the cases considered. I have discussed the anatomic importance of the splenic artery and gland with their multiple variations and relationships. I have also considered the splenic pedicle, depending on the rear fixation which has the extremity of the pancreas and the splenic hillum of 2.2 centimeters, with final figures ranging from 0 to 4 centimeters. I have also mentioned the appearance of a 10% of super numerary spleens. Finally in our experience with splenic segmentation and with corrosion pharmaceutical preparation and arteriographic studies as the basic ingredients, we have found that in a 62.5% they have two segments, in a 17% they have three segments, in a 12.5% they have four segments, in a 12.5% they have four segments and in an 8% they have five segments in all, in these cases generally due to the high importance of the polar arteries. Likewise, it is a truth universally accepted that splenic circulation is terminal and that spleen division into segments is separated by non-vascular levels.

Effects of hindlimb unloading on rat cerebral, splenic, and mesenteric resistance artery morphology

Hindlimb unloading (HU) of rats induces a cephalic shift in body fluids. We hypothesized that the putative increase in cranial fluid pressure and decrease in peripheral fluid pressure would alter the morphology of resistance arteries from 2-wk HU male Sprague-Dawley rats. To test this hypothesis, the cerebral basilar, mesenteric, and splenic arteries were removed from control (C) and HU animals. The vessels were cannulated, and luminal pressure was set to 60 cmH(2)O. The resistance arteries were then relaxed with 10(-4) M nitroprusside, fixed, and cut into transverse cross sections (5 microm thick). Media cross-sectional area (CSA), intraluminal CSA, media layer thickness, vessel outer perimeter, and media nuclei number were determined. In the basilar artery, both media CSA (HU 17, 893 +/- 2,539 microm(2); C 12,904 +/- 1,433 microm(2)) and thickness (HU 33.9 +/- 4.1 microm; C 22.3 +/- 3.2 microm) were increased with hindlimb unloading (P < 0.05), intraluminal CSA decreased (HU 7,816 +/- 3,045 microm(2); C 13,469 +/- 5,500 microm(2)) (P < 0.05), and vessel outer perimeter and media nuclei number were unaltered. There were no differences in mesenteric or splenic resistance artery morphology between HU and C rats. These findings suggest that hindlimb unloading-induced increases in cephalic arterial pressure and, correspondingly, increases in circumferential wall stress result in the hypertrophy of basilar artery smooth muscle cells.

The arterial blood supply of the pancreas: a review. V. The dorsal pancreatic artery. An anatomic review and a radiologic study

The present article is the fifth part of a comprehensive review on the arterial blood supply of the pancreas and deals with the dorsal pancreatic artery. The aim of this review is to summarise the anatomic studies, starting from Haller's reports, and to supply, as far as possible with original material, angiographic evidence for the classic anatomic notions. For this purpose, the overall research was carried out by studying 1015 selective angiographies (celiac trunk and its branches, superior mesenteric artery) taken from the angiographic archives of the Institutes of Radiology of Siena, Rome (Catholic University), and Perugia. Angiographically, the authors could demonstrate the dorsal pancreatic artery, present in most instances, as arising from the splenic artery, common hepatic artery, superior mesenteric artery or celiac trunk and accessory right hepatic artery as coming from the superior mesenteric artery. Variations in the course and length of the dorsal pancreatic artery were demonstrated as well as some collateral branches. The authors underline the discordant opinions still existing regarding the incidence of the different ways the dorsal pancreatic artery arises, and discuss its uncertain embryologic development and surgical relevance.

Laparoscopic surgery combined with preservation of the spleen for distal pancreatic tumors

BACKGROUND

Laparoscopic distal pancreatectomy combined with spleen salvage by preservation of the splenic vessels has been described in selected patients with islet cell tumors.

METHODS

Laparoscopic resection of the left side of the pancreas with spleen preservation on the vasa brevia was attempted in six consecutive patients.

RESULTS

Four distal pancreatectomies with spleen preservation were completed laparoscopically. There were two conversions to laparotomy. The median operating time was 300 min (range, 240-360). There was no mortality, but two patients developed a pancreatic fistula. The median postoperative hospital stay was 34.5 days (range, 5-60). All the patients remain well at a median follow-up of 30 months (range, 22-41).

CONCLUSIONS

Minimally invasive surgery for distal pancreatic tumors is feasible and appropriate for most benign tumors. The spleen can be safely preserved laparoscopically on its blood supply from the short gastric vessels. The operative technique and especially the closure of the pancreatic stump need further study.

Contrast-enhanced three-dimensional magnetic resonance angiography of the splanchnic vasculature before and after caloric stimulation. Original investigation

RATIONALE AND OBJECTIVES

To develop a comprehensive noninvasive magnetic resonance angiography (MRA) strategy for the morphologic and functional assessment of the splanchnic arteries, based on a combination of breath-held contrast-enhanced 3D MRA and segmented k-space 2D phase-contrast acquisitions acquired before and after caloric stimulation.

METHODS

Ten healthy volunteers were examined twice: once in the fasting state (6 hours with no food intake) and a second time following caloric stimulation with a standard 475-kcal meal. Flow in the superior mesenteric artery (SMA) and vein (SMV) was quantitated using a 2D breath-held, segmented k-space phase-contrast (PC) acquisition in a plane perpendicular to the axis of the vessels, while vascular morphology was displayed with a contrast-enhanced 3D MRA acquisition consisting of 44 contiguous 2-mm sections, acquired in apnea (28 seconds). For comparative analysis, the splanchnic vasculature was divided into 11 segments and evaluated on a 2-point scale (cannot exclude pathology, can exclude pathology).

RESULTS

Flow volume in the SMA increased from 2.3 ml/min/kg (+/- 0.9 ml/min kg) to 7.3 ml/min kg (+/- 4.7 ml/min kg) following caloric stimulation (P < 0.05). Flow in the SMV exceeded flow in the SMA and increased from 3.4 ml/min/kg (+/- 0.3 ml/min kg) to 9.1 ml/min/kg (+/- 4.8 ml/min/kg) following stimulation. Flow volume of SMV correlated better with SMA flow after stimulation. Caloric stimulation significantly improved visualization of the splanchnic arterial vasculature (P < 0.05). Only 5 of 110 evaluated arterial segments (4.5%) remained inadequately seen to exclude vascular pathology.

CONCLUSION

Magnetic resonance imaging offers a comprehensive assessment of the splanchnic arterial vasculature based on 3D display of vessel morphology and analysis of flow function. While the most relevant proximal vessel segments are visible even under fasting conditions, caloric stimulation enhances visualization of small vessels.

A contribution to the types of branching and anastomoses of the splenic artery in human spleen

The authors observed in 60 human spleens the course of the splenic artery in the splenic hilus and branching of segmental branches in the spleen. Specimens of blood vessels and casts showed two extreme types of segmental branches entering the splenic parenchyma: 1. Vertical type and 2. subcapsular type. The authors also studied the occurrence of anastomoses between the individual branches of the splenic artery and recognized three types of them: 1. hilar--extraparenchymatous, 2. intraparenchymatous and 3. subcapsular.

The size of the splenic hilus, diameter of the splenic artery and its branches in the human spleen

Sixty spleens were observed according to the size of the splenic hilus depending on the size of the human spleen. The diameter and area of the lumina of the arterial branches were measured in 30 casts of the vascular bed of the spleen. Results were statistically evaluated, tabelated and graphed.

Independent origin of the hepatic and splenic arteries from the abdominal aorta: CT demonstration

PURPOSE

The purpose of this work was to illustrate the CT appearance of the independent origin of the hepatic and splenic arteries from the abdominal aorta.

METHOD

A retrospective review of available scans from 159 consecutive contrast-enhanced abdominal CT examinations was undertaken to document the frequency with which this vascular variant is seen at helical CT.

RESULTS

Independent origin of the hepatic and splenic arteries was seen in 2 of 159 examinations (1.3%). This correlates well with the 1% incidence reported in the angiographic and surgical literature.

CONCLUSION

Independent origin of the hepatic and splenic arteries from the aorta should be seen in approximately 1% of abdominal CT examinations. Knowledge of this vascular variant and its CT appearance may prevent confusion or mislabeling.

The true splenic blood supply and its surgical applications

BACKGROUND/AIMS

In 1981 we described a simple porta-azygous disconnection procedure to stop the bleeding in esophago-gastric varices. This surgical technique included ligature of the splenic artery and the short gastric vessels. In spite of the arterial ligatures, no alteration was seen in splenic circulation.

METHODOLOGY

In 1988, Warshaw presented a study of twenty-two cases of distal pancreatectomy without splenectomy. Since then, we have studied our porta-azygous disconnected patients using radioactive substances and found, surprisingly, that there is a normal splenic blood supply. Simultaneously, we started an experimental study with dogs and human cadavers by placing acrylic fluid into the splenic arterial vessels. Solidification and corrosion of soft tissue showed the true arterial architecture of the vessels.

RESULTS

Both the animal experiments and the results of injecting acrylic into the arterial splenic arteries of human cadavers demonstrated that in addition to the splenic artery and the short arteries there is another important artery which reaches the splenic hilum. Injecting acrylic into this artery showed that this was the left gastroepiploic artery.

CONCLUSIONS

The spleen is irrigated by the splenic artery and the short vessels, but also by the left gastroepiploic artery. These findings suggest surgical applications such as distal pancreatectomy without splenectomy, and, more importantly, that in the portal-azygous disconnection previously described it may not be necessary to ligate the splenic artery.

Morphometry of the human splenic artery: muscular columns, morphofunctional aspects and developmental implications

There is a paucity of studies in the literature concerning the structural characteristics of the arterial wall in the abdominal region using human material and specialized morphometric techniques. In the present study we carry out the morphometric study, describing a series of structural peculiarities in 12 segments of the human splenic artery. Among these the presence of length-wise or spiral-shaped muscular columns in the medial layer which mark and reduce the diameter of the arterial lumen is of major importance. In its underlying intima small localized thickenings appear which, with age may become generalized. We also analyze the different intimal thickenings and such indices as the Intimal Thickening Index, Lumen Reduction Index and Pathologic Thickening Index, with differences among the groups we have considered. The study of elastin in the various parietal structures help us to understand the possible pathogenesis of the thickenings, and to clarify the important morphological-functional correlation for the regulation of blood flow which exists in this arterial region.

Laparoscopic distal resection of the pancreas with the preservation of the spleen

Management of the pancreatic diseases is still a challenge to the laparoscopic technique. Some experience has been gained in the laparoscopic exploration of the pancreas and staging in cancer. Anatomically the accessibility of the distal pancreas provides the laparoscopic approach technically feasible.

PATIENT AND METHOD

A case of insuloma in the tail of the pancreas is presented, where distal pancreatic resection was performed laparoscopically with the preservation of the spleen. In a 55 years old female patient with typical clinical symptoms of hyperinsulinism CT identified a 3 cm large solid tumor in the tail of the pancreas. Complete mobilization of the distal pancreas was enhanced by the use of an ultrasonic dissector (UltraCision). The pancreas is detached from the splenic hilum after dividing the spleen vessels. The pancreas is transected proximally by laparoscopic linear stapler. Preservation of the short gastric vessels provides the necessary blood supply of the spleen following division of the splenic artery and vein. Thus removal of the spleen is not a necessary step in this procedure. The operation was carried out within 4.5 hours. Postoperative course was uneventful, the patient left the hospital on the 5th postoperative day. Advantages of the procedure were the earlier mobilization and shorter recovery time, less postoperative pain. The procedure can be safely performed with a good experience in both pancreatic and laparoscopic surgery.

[Significance of greater omentum anatomic structure]

The examination of the greater omentum was performed in 102 cadavers. Most frequently the quadrangular shape of omentum was found, less frequently--triangular and appendicular shape. The anterior duplicature of the omentum receives blood supply from the right gastro-omental artery, that often has 5 omental branches. The posterior duplicature is blood supplied by spleno-omental artery, that creates the inferior arterial arch. The methods of lengthening of omentum are worked out. Satisfactory filling of the created omental flaps was proved by arteriography.

Anatomical and surgical aspects of splenic segmentectomies

Based upon the anatomicosurgical segments of the spleen, suggested by DiDio and demonstrated in cadavers, classified and named by Neder (1958) and Zappalá (1958, 1959, 1963), the normal segmental organization was anatomically and radiologically confirmed in 51 human spleens, after studying corrosion casts and radiograms of intraparenchymal vessels (Christo, 1959 a, b, 1960, 1962, 1963, 1993). From 1958 to 1965, pioneer segmental resections were performed successfully in 34 dogs and in 9 patients to safely remove traumatic injured splenic segments. At the same time, the overwhelming postsplenectomy infection (OPSI) became well identified. Consequently, to save normally functioning splenic parenchyma became the most important issue in the management of splenic injuries. The anatomical basis for partial splenectomy and splenic segmentectomy is discussed. The term "splenorrhaphy" was employed to designate all conservative or parenchyma saving operations of spleen based upon its vascular supply: from topical packings to splenic sutures including "cappings" and partial splenectomies. From analysis of 38 consecutive reports in 20 years, covering 4,076 patients, it was concluded that "splenorrhaphies" had been electively employed in 46% of the injuries and partial splenectomies were identified in 8.6% of these surgical interventions. However, the critical minimal mass of splenic tissue to be preserved after partial splenectomies is still to be defined. Postoperative complications directly related to "splenorrhaphies" are rare. Uncommonly performed after splenectomies, the heterotopical splenic autotransplantation has presented dubious results. Trials with nonoperative management of splenic blunt trauma injuries have been safer among children, whose spleens are predominantly transversally disrupted and have a higher relationship "capsular resistance/parenchymal bulk". Splenectomies have been most frequently the ultimate result of delayed laparotomy and underlying risks of growing blood requirements may surpass the advantages of preventing OPSI.

Balloon dissection in extended retroperitoneoscopy

The anatomy of the retroperitoneum, including the high retroperitoneum, was studied as it appears with balloon dissecting techniques. We used fresh cadavers in this study. A relatively unknown fascia that is located between the lateral aspect of the perirenal fascia and the posterior parietal peritoneum, called the paraconal fascia, was a constant finding. This structure is important because it protects delicate retroperitoneal organs: the duodenum, pancreas, celiac axis, and superior mesenteric artery. Locating this fascia is an important step in the dissection of the high retroperitoneum, which is of interest in advanced videoendoscopic procedures involving retroperitoneal organs.