Arterial supply of gastric fundus in human – final results

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ABSTRACT

Arterial supply of gaster

gaster anatomy, gastric artery, surgical anatomy

2 027

no conflicts of interest

Background: General scheme of stomach arterial supply is well known and was repeatedly described but the-re are only few reports about gastric fundus arterial supply. The aim of the study is to describe the anatomy of the gastric arterial fundic branches with special reference to their selected morphometric and morphologic features, determination of the relationship between certain gastric arterial fundic branches and the selected gastric ligaments and indication of the exact site of the arterial fundic branches perforation in relation to its quadrants (defined vascular areas). Material and methods: The study was performed on 50 samples taken during post-mortem autopsy. In the whole material, a total 304 gastric arterial fundic branches were identified and measured. Statistical analysis was performed. Conclusions: The splenic artery almost always participa-tes in gastric fundus arterial supply and other arteries inconstantly participate in the process . There are three morphological types of arterial fundic branches. The branches occurring in the superior part of gastro-splenic ligament usually supply posteromedial quadrant. Sequence of quadrants in terms of number of arterial bran-ches supplying them is as follows: the postero-lateral, postero-medial, antero-medial and antero-lateral. There were no differences in gastric fundus arterial supply between males and females

Knowledge of the gastric fundus arteries anatomy is very important in the diagnosis and treatment of patients with gastrointestinal tract or vascular system disease. This knowledge makes it easier to per-form many surgical procedures and minimizes the risk of complications.

Mariusz Gregorczyk1, Jóźwik Agnieszka2

1. Clinical Department of General Gastrointestinal and Oncological Surgery, Prof. Orlowsky Hospital, The Medical Center of Postgraduate Education, ul. Czerniakowska 231, 00-416 Warsaw, Poland.

2. Department of General and Transplantation Surgery, Warsaw Medical University, Nowogrodzka 59th Street, 02-006 Warsaw, Poland

#Corresponding author: Agnieszka Jóźwik, Department of General and Transplantation Surgery, Medical University of Warsaw,Ul. Nowogrodz-ka 59 , 02-006 Warsaw, Poland. Phone:+48 225021482, Fax:+48 225022155, e-mail: agniechaaj@gmail.com

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BACKGROUND

Knowledge of the gastric fundus arteries ana-tomy is very important in the diagnosis and treatment of patients with gastrointestinal tract

or vascular system disease. This knowledge makes it easier to perform many surgical procedures and minimizes the risk of complications. Only few au-thors dealt with the topic of the gastric fundus arterial supply. Most publications relate to the posterior gastric and the splenic artery fundic branches. There is no work that would treat the topic as a whole. Most authors are focused on one or only few source arteries involved in supplying gastric fundus. They hardly ever mentioned specific details concerning the incidence, number, length and the diameter of gastric arterial fundic branches and their place of perforations in the different quadrants of the gastric fundus. Their analysis did not relate to lengths and diameters of arterial fundic branches either.

Arterial supply of stomach derives mainly from celiac trunk, both from its direct branches (left gastric arte-ry, splenic artery, common hepatic artery) and from vessels, it derives indirectly from celiac trunk (right gastric artery, right gastro-epiploic artery, left gastro--epiploic artery, additional left hepatic artery, poste-rior gastric artery, gastro – splenic artery, superior polar artery) [5].

Only few of the above mentioned vessels are a po-tential source of blood supply of gastric fundus. Arte-rial supply of gastric fundus derives mainly from two arteries branching from celiac trunk: the left gastric artery and splenic artery [6]. The left superior supra-renal artery and left inferior phrenic artery may also function as additional arterial supply. . A group of arteries deriving from splenic artery: posterior gastric artery, gastro-splenic artery, superior polar artery, left gastro-epiploic artery and short gastric arteries sho-uld also be mentioned. Some of these vessels are not always present. All the above mentioned vessels (so-urce arteries) can branch off arterial fundic branches to gastric fundus and directly perforate its individual quadrants. Despite their importance in planning and certain surgical procedures, their anatomy and topo-graphic relations are not sufficiently described.

Nowadays, there are a lot of possible non-invasive radiological methods of imaging blood supply of eve-ry human organ but sound knowledge of anatomy is necessary for the correct interpretation.

There are a lot of diseases that affect the area supplied by the gastric fundus arteries, which often require surgical treatment. The most important are the conditions requiring gastrectomy e.g gastric cancer, gastric ulcer or obesity. Hiatus hernia is also very important because surgical treatment of this disorder is sometimes recommended. The most po-pular and most frequently used technique is called Nissen fundoplication can sometimes cause very

serious complications. Other important diseases are visceral artery aneurysms which are more frequ-ent than abdominal aortic aneurysm [1]. Splanchnic artery aneurysms could be single or multiple and may be complicated by rupture associated with high mortality [2]. There is a large group of conditions the only effective treatment of which is splenectomy e.g. ruptured spleen, a lot of hematological diseases, cysts and tumors of the spleen. For the treatment of hematological disorders laparoscopic splenectomy is becoming the gold standard method [3]. In that pro-cedure proper hemostasis and adequate exposure of the splenic hilum are crucial. The next very impor-tant condition is median arcuate ligament syndrome, also known as Dunbar syndrome. This rare disorder is caused by extrinsic compression and narrowing celiac trunk [4]. Patients with this syndrome, in most cases need surgery to achieve celiac trunk decom-pression. In treatment of all these conditions, know-ledge of anatomy is of utmost importance.

The aim of the study is to describe the anatomy of the gastric arterial fundic branches with special reference to their selected morphometric and mor-phologic features, determination of the relationship between certain gastric arterial fundic branches, the selected gastric ligaments and indication of the exact site of the arterial fundic branches perforation in rela-tion to its quadrants ( specific vascular areas).

MATERIAL AND METHODS

The study was performed on 50 samples taken during post-mortem autopsy. The content of the specimens were as follows: a fragment of the abdo-minal aorta with the departure of the inferior phrenic arteries, coeliac trunk, the proximal segment of supe-rior mesenteric artery and splenic artery; part of the pleura; the abdominal part of esophagus; stomach; duodenum; pancreas; spleen and left suprarenal gland.

All cut vessels were selectively tied. The next step was to flush the arterial system of the test prepara-tion with 1000ml 0,9% NaCl solution at a temperatu-re of 40ºC. Thus prepared arteries were injected at a pressure of 120 mmHg with a mixture of 15% gelatin solution with universal Mixol 10 red pigment concen-trate. In some specimens Foley catheter was placed in a portal vein. Through the catheter, the venous system was flushed with 1000ml 0,9% NaCl solution at a temperature of 40ºC and next it was injected at a pressure of 120 mm Hg with a mixture of 15% gelatin solution with universal Mixol 10 blue pigment concentrate.Such prepared research material was solidified in 10% formaldehyde for about three weeks. Then the landmarks described the boundaries of each quadrant of gastric fundus and parts of the selec-ted gastric ligaments. Then began the preparation of source arteries and its fundic branches using an OPM1 operating microscope and a set of microsur-

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length of arterial fundic branches perforating the posterior-lateral quadrant. Comparison of average lengths of arterial fundic branches originating from different source arteries revealed that average dia-meter of the fundic branches departing from the left inferior phrenic artery, left gastric artery, accessory left hepatic artery, splenic artery and the left gastro--epiploic artery is statistically significantly longer than the average diameter fundic branches deriving from the posterior gastric and the superior polar arteries.

Evaluation of gastric arterial fundic branches diame-ters showed the widest diameter in the left gastric artery fundic branches and the narrowest in the ac-cessory left hepatic artery fundic branches. Examina-tion of a number of distributions of all arterial fundic branches diameters revealed that the diameter of two thirds of them ranges between 0,5 and 1,5 mm. There are three morphological types of posterior gastric artery and superior polar artery: single vessel, bifurcate and with perforators. Detailed examination of the morphology of the arterial branches of the stomach fundus showed that 47,68% reflect perfo-rates, the 36,09% are a single vessels and 16,23% just before the perforation of the stomach bifurcate. Furthermore, statistically significant correlation be-tween the length and the diameter of fundic branches originated from the left inferior phrenic artery, left gastric artery, accessory left hepatic artery and the left gastro-epiploic artery was found.

DISCUSSION

Recently The anatomy of the gastric arteries was described for the first time in 1847 by Arnold [7] and updated by many further authors. The stomach is ar-terial supplied by four well-anastomosed arteries [8]. Only a few authors dealt with the topic of the gastric fundus arterial supply.

Morphometric and morphologic features of celiac trunk were repeatedly described. Generally the trunk gave rise to left gastric, common hepatic and sple-nic arteries but there is a lot of their possible origin [9]. The most common type is truncus hepatospe-nogastricus (84% in our study, comparable in other studies [10-16]). Other types are truncus hepatosple-nicus, truncus hepatosplenomesentericus, truncus hepatogastricus, truncus splenogastricus, truncus celiacomesentericus. The average diameter of the most common type of celiac trunk was 7,22mm and the average length was 26,35mm there were no diffe-rences between male and female gender.

In our study left gastric artery originates from celiac trunk in 83,33%, directly from aorta in 8,33%, from truncus splenogastricus in 6,25% and from truncus hepatogastricus in 2,08%. Theset results are compa-rable to the most of the results of the other autors. In our material there was accessory left hepatic artery in 16% cases (in literature from 5,95% to 43%). [17]

gical instruments. The particular stages of prepa-ration, tested morphological features and relations were photographically documented by EOS 350D DIGITAL Canon camera and G600 Konica Minolta Dimage . The photos were processed using GIMP 2.6.8. All measurements were made using electronic Topex calipers and the data obtained was reported in the pre-prepared forms of research. The base was created using Excel on which the data from 50 preparations was summarized. The program was also used in some cases to prepare graphs showing dependency tests. Statistical analysis was performed using STATISTICA 6.0.

RESULTS

After the measurements, 272 correlation tests were performed.

The percentage of individual source arteries involved in arterial vascularization of gastric fundus is as fol-lows: splenic artery – 96%, the superior polar artery – 69,2%, an accessory left hepatic artery – 55,6%, the posterior gastric artery – 44%, the left gastric ar-tery – 36%, the left inferior phrenic artery – 30%, the left gastro-epiploic artery – 8% and the left superior suprarenal artery – 2%. Left gastric artery and splenic can originate in several different ways but there is no correlation between that and diameters of arteries. There are two morphological types of splenic artery: single vessel and bifurcate. There is no statistically significant correlation between size of splenic artery and morphological type.

There is statistically a significant correlation between average diameter of splenic artery and average dia-meters of splenic artery fundic branches but there is no correlation between average diameter of splenic artery and the number of artery fundic branches.

In whole material total 304 gastric arterial fundic branches was identified, of which 154 perforated postero-lateral quadrant, 108 - postero-medial qu-adrant, 28 – antero-medial quadrant and 13 – antero--lateral quadrant.

The longest gastric arterial fundic branches aban-doned the left gastro-epiploic artery. The shortest ones originated from the posterior gastric artery. The average length of branches was 36 mm. As many as 41,31% of arterial fundic branches ranged in the length between 10 and 25 mm. Compared to the test done on the the least significant differences ,between the average length of the arterial fundic branches in relation to the place of their perforation the findings showed that the average length of gastric arterial fundic branches perforating the antero-lateral qu-adrant issignificantly longer than average length of gastric arterial fundic branches supplying postero-medial quadrant. Secondly: the average length of arterial fundic branches perforating postero-medial quadrant is significantly shorter than the average

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[18].

CONCLUSION

The studies led to the following conclusions. The splenic artery almost always participates in gastric fundus supply (in 48 of 50 examined cases). The left inferior phrenic, left gastric, accessory left hepatic, posterior gastric, superior polar and the left gastro-e-piploic artery inconstantly take part in gastric fundus arterial supply. There are three morphological types of arterial fundic branches. Arterial fundic branches occurring in the superior part of gastro-splenic liga-ment usually supply postero-medial quadrant. Sequ-ence of quadrants in terms of numbers of arterial branches supplying them is as follows: the postero--lateral, postero-medial, antero-medial and antero--lateral. There were no differences in gastric fundus arterial supply between male and female gender.

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LIST OF THE FIGURES

Fig. 1. Scheme of stomach arterial supply

Fig. 2. The specimen

Fig. 3. Splenic artery – single vessel

Fig. 4. Splenic artery – bifurcate

Fig. 5. Arterial fundic branches

Fig. 6. Celiac trunk by Michaelis classification

FIG. 1. SCHEME OF STOMACH ARTERIAL SUPPLY

1 - aorta 2 - left inferior phrenic artery 3 - left superior suprarenal artery4 - posterior gastric artery5 - gastro-splenic artery 6 - superior polar artery 7 - accessory left hepatic artery 8 - celiac trunk 9 - left gastric artery10 - splenic artery

11 - short gastric arteries12 - gastroduodenal artery13 - right gastric artery14 - common hepatic artery15 - right gastro-epiploic artery16 - left gastro-epiploic arteryA - fundusB - spleenC – pyloric part of stomachD – corpus of stomach

FIG. 2. THE SPECIMEN

1 - diaphragm2 - fundus 3 – gastrosplenic ligament 4 - spleen 5 - pyloric part of stomach6 – greater curvature 7 - greater omentum FIG. 3. SPLENIC ARTERY – SINGLE VESSEL

1 - celiac trunk2 - splenic artery3 - pancreas4 - spleen

FIG. 4. SPLENIC ARTERY – BIFURCATE

1 - splenic artery2 - posteriori gastric artery3 - stomach4 -superior branch of splenic artery5 - inferior branch of splenic artery

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6. Kurylcio L, Metera A, Modrzewski Z, Wilgoszynski A. Ar-teries of the gastric fundus in man. Folia Morphol (Warsz). 1970;29(2):173-9.

7. Arnold F. Handb. d. Anat. d. Menschen. vol.2/I Freiburg 1847.8. Vandamme JP, Bonte J: The blood supply of the stomach.

Acta Anat. 1988; 131:89-96. 9. Yi SQ, Terayama H, Naito M, Hayashi S, Moriyama H, Tsuchi-

da A, Itoh M.A common celiacomesenteric trunk, and a brief review of the literature.Ann Anat. 2007;189(5):482-8.

10. Eaton PB The coeliac axis. Anat Rec 1917 13(6):369-74. 11. Adachi B. Das Arteriensystem der Japaner. Bd. 2. Kyoto:

Maruzen, 1928. 12. Lipschutz B. A composite study of the coeliac axis artery. Ann

Surg. 1917 65:159-169. 13. Michels NA.The variational anatomy of the spleen and splenic

artery. Am J Anat 1942 70:21-72. 14. Hollinshead WH.Some variations and anomalies of the

vascular system in the abdomen.Surg Clin North Am. 1955 Aug;Mayo Clinic .:1123-31.

15. Vandamme JP, Bonte J: The branches of the celiac trunk. Acta Anat.Basel. 1985; 122: 110-114.

16. Matsuki M, Kani H, Tatsugami F, Yoshikawa S, Narabayashi I, Lee SW, Shinohara H, Nomura E, Tanigawa N. Preoperative assessment of vascular anatomy around the stomach by 3D imaging using MDCT before laparoscopy-assisted gastrecto-my. AJR Am J Roentgenol. 2004 Jul;183(1):145-51.

17. Hollinshead WH.Some variations and anomalies of the vascular system in the abdomen.Surg Clin North Am. 1955 Aug;Mayo Clinic .:1123-31.

18. Ishigami K, Yoshimitsu K, Irie H, Tajima T, Asayama Y, Hira-kawa M, Honda H.Accessory left gastric artery from left he-patic artery shown on MDCT and conventional angiography: correlation with CT hepatic.

FIG. 5. ARTERIAL FUNDIC BRANCHES

1 - posterior gastric artery fundic branches2 - splenic artery fundic branches, 3 - left gastro-epiploic artery fundic branches4 - left inferior phrenic artery fundic branches5 - left gastric artery fundic branches

A - postero-medial quadrantB - postero-lateral quadrant,C - antero-medial quadrantD - antero-lateral quadrant

FIG. 6. CELIAC TRUNK BY MICHAELIS CLASSIFICATION

1 - aorta2 - left gastric artery3 - common hepatic artery4 - splenic artery5 - superior mesenteric artery

BIBLIOGRAPHY

1. Pasha SF, Gloviczki P, Stanson AW, Kamath PS.Splanchnic artery aneurysms.Mayo Clin Proc. 2007 Apr;82(4):472-9.

2. Raad E, Demaria R, Rouvière P, Prudhomme M, Frapier JM, Dauzat M, Albat B.Visceral artery aneurysms. Multiple aneu-rysmal localization: a case report and literature reviewJ Mal Vasc. 2007 Dec;32(4-5):216-20.

3. Machado MA, Makdissi FF, Herman P, Montagnini AL, Sallum RA, Machado MC. Exposure of splenic hilum increases safety of laparoscopic splenectomy. Surg Laparosc Endosc Per-cutan Tech. 2004 Feb;14(1):23-5.

4. Delis KT, Gloviczki P, Altuwaijri M, McKusick MA.Median arcuate ligament syndrome: open celiac artery reconstruction and ligament division after endovascular failure.J Vasc Surg. 2007 Oct;46(4):799-802.

5. Bochenek A, Reicher M. Anatomia człowieka. PZWL 2006.

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