Retroperitoneal fasciae as barriers for nerve and arterial passages connecting the retroperitoneal region to the peritoneal organs.

The fascia of the pancreatic head is referred to as the retropancreatic fascia of Treitz, and that of the body and tail of the pancreas is named the retropancreatic fascia of Toldt. However, the spatial relationship between the nerves, fascia, and the distribution of the fascia on the dorsal side of the pancreas remains unclear. Therefore, this study aimed to explore the distribution of these fasciae and elucidate the spatial relationship between the nerves and arteries connecting the retroperitoneal space and the peritoneal organs by studying eight cadavers using macroscopic anatomical examination, wide-range serial sectioning, and three-dimensional reconstruction. The fasciae of Treitz and Toldt converge caudally to the root of the superior mesenteric artery (SMA), forming a narrower gap around the roots of the celiac trunk and SMA than in the celiac plexus. The fasciae eventually get closer to each other, and the boundary between them becomes obscured, providing coverage to the anterior surface of the aorta between the SMA and the inferior mesenteric artery. The celiac plexus does not penetrate the fascia but converges before spreading into the pancreas. Similarly, the arteries pass through this gap in the fasciae. Our findings suggest that the retroperitoneal space and peritoneal organs are connected through a narrow no-fascia area, with the distribution of the fascia relating to nervous and vascular pathways. Our findings reveal that the distribution of the avascular plane may provide a crucial anatomical foundation for abdominal digestive organ surgery by reducing bleeding volume and determining the dissection region.

A comprehensive study of the abdominal ganglia part 1: Celiac, phrenic and superior mesenteric ganglia.

INTRODUCTION: Patients with pancreatic cancer, chronic pancreatitis and other abdominal pain syndromes may develop debilitating pain throughout the course of their illness with little to no relief by most conventional methods. While some form of relief is experienced by patients, not all benefit from these procedures and side effects, while transitory in most cases are severe and often not expected. Our aim was therefore to investigate the anatomy surrounding the abdominal sympathetic ganglia, the target for the invasive procedures in an attempt to understand the variations in results. MATERIALS AND METHODS: The abdominal cavities of nine individuals were dissected and the ganglia investigated, harvested and histologically and immunochemical stained. RESULTS: The phrenic ganglion was found inconsistently and more often in the left than the right. If present it was located in association with the inferior phrenic artery and often connected to the celiac ganglion. The celiac ganglion was located anterior to the diaphragmatic crus on both sides and specifically posteromedial to the suprarenal gland and superior to the renal artery on the left. On the right it was located posterior to the suprarenal gland and inferior vena cava also superior to the renal vessels. The superior mesenteric ganglion was only positively identified in one individual and was located on the left lateral aspect of the superior mesenteric artery. CONCLUSION: The blockade procedures for treatment of pain are developed to target the area around the celiac artery where the ganglion is commonly described to be located. However, based on our results of its location and interconnections the ganglion is not located in the targeted area.

The macro and micro-structure of the celiac and cranial mesenteric ganglia in a long-lived rodent - paca (Cuniculus paca, Linnaeus 1766) / La macro y micro estructura de los ganglios mesentéricos celíacos y craneales en un roedor longevo - paca (Cuniculus paca, Linnaeus 1766)

SUMMARY: The celiac, cranial mesenteric and celiacomesenteric ganglia of the paca (Cuniculus paca) were found between the celiac and cranial mesenteric arteries. Two predominant patterns were found: isolated celiac and cranial mesenteric ganglion and the celiacomesenteric ganglion. At the microscopic level, the ganglia are constituted by an agglomeration of neurons surrounded by capsule of connective tissue. Most of these neurons had a single eccentric nucleus. Satellite cells and mast cells were found around the soma. The mast cells were also found ar ound blood vessels and in the capsule of the ganglia.

RESUMEN: Los ganglios celíacos, mesentérico-craneales y celíaco mesentéricos de la paca (Cuniculus paca) se encontraron entre las arterias celíaca y mesentérica craneal. Se visalizaron dos patrones predominantes: celiaca aislada y ganglio mesentérico craneal y ganglio celiaco mesentérico. A nivel microscópico, los ganglios están constituidos por una aglomeración de neuronas rodeadas por una cápsula de tejido conectivo. La mayoría de estas neuronas tenían un solo núcleo excéntrico. Se encontraron células satélites y mastocitos alrededor del soma. Los mastocitos también se encontraron alrededor de los vasos sanguíneos y en la cápsula de los ganglios.

The mesopancreas and pancreatic head plexus: morphological, developmental, and clinical perspectives.

PURPOSE: Total mesopancreas excision has been found to be helpful for increasing no residual tumor resection rate and improving the prognosis of pancreatic cancer. This study analyzed the relationships among the mesopancreas and pancreatic head plexus from the morphological, developmental, and clinical perspectives. METHODS: Twenty-four cadavers were employed. The upper abdominal viscera were resected en-bloc with the hepatoduodenal ligament, abdominal aorta, and nerve plexuses, and the innervation of the pancreas was dissected. Ten additional cadavers were used for histological examination of the pancreatic head and neck, part of the duodenum, the superior mesenteric artery (SMA) and its surrounding tissues, and the related arteries and veins. RESULTS: As results, cross-sections of the SMA revealed 6-9 layers of membranous structures resembling the layers of an onion, and the nerve fibers of the superior mesenteric plexus ran between the layers. Loose areolar tissue, adipose tissue, and lymphatics existed between the SMA and the pancreatic head/uncinate process, along with abundant thin blood vessels and capillaries, but very few nerves were found approaching the pancreas. Several parallel layers of collagen fibers (so-called Treitz's fusion fascia) existed between the dorsal aspect of the pancreatic head and the aortocaval plane. CONCLUSION: The mesopancreas was continuous and connected with the para-aortic area. It may be better termed the mesopancreatoduodenum than the mesopancreas, as the duodenum-pancreas-SMA forms a complex morphological, developmental, functional, and pathological structure.

Celiac Plexus Block and Neurolysis: A Review.

Pain is often associated with chronic pancreatitis and pancreatic cancer. Often times opioids are used to treat pain; however, the use of opioids is frequently difficult. Endoscopic ultrasound-guided celiac plexus block and celiac plexus nuerolysis are safe and effective modalities used to alleviate pain. Celiac plexus block is a transient interruption of the plexus by local anesthetic, while celiac plexus neurolysis is prolonged interruption of the transmission of pain from the celiac plexus using chemical ablation. Celiac plexus block is generally performed in the unilateral position, while celiac plexus neurolysis is performed in the unilateral or bilateral position.

Celiac plexus block in the management of chronic abdominal pain.

Chronic abdominal pain is a devastating problem for patients and providers, due to the difficulty of effectively treating the entity. Both benign and malignant conditions can lead to chronic abdominal pain. Precision in diagnosis is required before effective treatment can be instituted. Celiac Plexus Block is an interventional technique utilized for diagnostic and therapeutic purposes in the treatment of abdominovisceral pain. The richly innervated plexus provides sensory input about pathologic processes in the liver, pancreas, spleen, omentum, alimentary tract to the mid-transverse colon, adrenal glands, and kidney. Chronic pancreatitis and chronic pain from pancreatic cancer have been treated with celiac plexus block to theoretically decrease the side effects of opioid medications and to enhance analgesia from medications. Historically, the block was performed by palpation and identification of bony and soft tissue anatomy; currently, various imaging modalities are at the disposal of the interventionalist for the treatment of pain. Fluoroscopy, computed tomography (CT) guidance and endoscopic ultrasound assistance may be utilized to aid the practitioner in performing the blockade of the celiac plexus. The choice of radiographic technology depends on the specialty of the interventionalist, with gastroenterologists favoring endoscopic ultrasound and interventional pain physicians and radiologists preferring CT guidance. A review is presented describing the indications, technical aspects, and agents utilized to block the celiac plexus in patients suffering from chronic abdominal pain.

Celiac plexus block and neurolysis for pancreatic cancer.

Neurolytic celiac plexus blocks (NCPB) have been performed for many years for the treatment of cancer and some non-cancer pain conditions associated with the upper gastrointestinal tract. The block can provide adequate pain relief from the area of the distal esophagus to the transverse colon, and can be approached from a variety of ways. This is a review of the anatomy, patient selection, technique, medications used, possible complications, and efficacy of the treatment.

CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment.

The celiac plexus is the largest visceral plexus and is located deep in the retroperitoneum, over the anterolateral surface of the aorta and around the origin of the celiac trunk. It serves as a relay center for nociceptive impulses that originate from the upper abdominal viscera, from the stomach to the proximal transverse colon. Celiac plexus neurolysis, with agents such as ethanol, is an effective means of diminishing pain that arises from these structures. Percutaneous imaging-guided celiac plexus neurolysis has been established as an invaluable therapeutic option in the management of intractable abdominal pain in patients with upper abdominal malignancy. The use of multidetector computed tomography (CT) for imaging guidance has superseded other modalities and allows direct visualization of the spread of the neurolytic agent in the antecrural space. Accurate depiction of the retroperitoneal anatomy and the position of the needle tip helps avoid crucial anatomic structures such as the pancreas, aorta, celiac artery, and superior mesenteric artery. Proper patient education, meticulous preprocedure planning, use of optimal multidetector CT techniques, adjunctive CT maneuvers, and postprocedure care are integral to successful celiac plexus neurolysis. Celiac plexus neurolysis does not completely abolish pain; rather, it diminishes pain, helping to reduce opioid requirements and their related side effects and improving survival in patients with upper abdominal malignancy.

Mesopancreas: myth or reality?

CONTEXT: A recently published study hypothesized the concept of 'mesopancreas', defining it as a firm, well-vascularized structure extending from the posterior surface of the pancreatic head to behind the mesenteric vessels. OBJECTIVE: To verify and define mesopancreas from resection specimens obtained from fresh cadavers. DESIGN: Postmortem anatomical-pathological study. SETTING: Department of Surgery in conjunction with the Departments of Forensic Medicine and Pathology, Government Medical College and Hospital, Jabalpur, MP, India. PARTICIPANTS: Twenty fresh adult cadavers without any intra-abdominal injury or gross intra-abdominal pathology. INTERVENTIONS: Specimens containing the entire duodenum, pancreatic head and neck, gallbladder, cystic duct, common bile duct, superior mesenteric vessels, inferior vena cava and aorta were removed en-bloc. Gross and histopathological examinations of the specimens were carried out. MAIN OUTCOME MEASURES: To look for a fibrous sheath or fascia around the retropancreatic structure purported to be a mesopancreas. RESULTS: Loose areolar tissue, adipose tissue, peripheral nerve, nerve plexus, lymphatic and capillaries were found in the retropancreatic tissue, extending from the head, neck and uncinate process of pancreas to the aorto-caval groove but no fibrous sheath or fascia was found around these structures. CONCLUSIONS: The concept of 'mesopancreas' is anatomically unfounded.

Celiac plexus blockade in children using a three-dimensional fluoroscopic reconstruction technique: case reports.

BACKGROUND AND OBJECTIVES: We present three cases wherein a new radiologic technique was used to facilitate performance of retrocrural celiac plexus blockade. Three patients presented to our institution for performance of celiac plexus block for relief of intractable upper abdominal pain. One carried the diagnosis of chronic pancreatitis, one abdominal pain and gastrointestinal dysmotility, the other adrenocortical carcinoma. METHODS: We applied the technology used in 3-dimensional rotational angiography to determine spread of the injected medication in three dimensions, and facilitate the blocks. RESULTS: Three-dimensional rotational angiography was used with clinical success. CONCLUSIONS: Three-dimensional rotational angiography shows promise for understanding the spread of medication necessary to accomplish a successful block, and may help explain failures in cases where anatomic distortion may interfere with proper injectate flow.

Celiac trunk compression syndrome: a review / Una Revisión del Síndrome de Compresión del Tronco Celíaco

La presente revisión tiene por objetivo conocer tanto los aspectos anatómicos como clínicos y quirúrgicos relacionados con el síndrome de compresión del tronco celíaco causado por el ligamento arqueado mediano del diafragma. Se revisan los principales descubrimeinos del síndrome, tanto en el plano anatómico durante la disecación de cadáveres, como en la clínica-quirúrgica de la estenosis del tronco celíaco. Además, se revisa la relación de esta estenosis con los síntomas del paciente y cura después de la descompresión del tronco celíaco. Por otra parte, se explican los métodos no invasivos e invasivos utilizados en la descompresión; el efecto estenótico de los mecanismos fisiológicos del desplazamiento del ligamento arqueado mediano, aorta y tronco celíaco durante la respiración; anatomía del canal aórtico y plexo celíaco; el ligamento arqueado mediano y el plexo celíaco como agentes constrictores; la esquelotopía del tronco celíaco y del ligamento arqueado mediano y la predisposición para el síndrome. Finalmente, se hace una asociación del síndrome del tronco celíaco con anomalías morfológicas y metabólicas.

The purpose of the present review is to report the anatomic and the clinical-surgical aspects involved in the celiac trunk compression syndrome by the median arcuate ligament of the diaphragm, reviewing the major findings of the syndrome in the anatomic field during dissection of cadavers, followed by clinical-surgical findings of stenosis of the celiac trunk, the relationship of this stenosis with the patient's symptoms and healing after decompression of that artery; invasive and non-invasive methods used to diagnose compression; the stenotic effect of physiologic mechanisms of the median arcuate ligament, aorta and celiac trunk displacement during respiration; anatomy of the aortic channel and celiac plexus; the median arcuate ligament and the celiac plexus as constrict agents; skeletopy of the celiac trunk, the median arcuate ligament and predisposition to syndrome; association of the syndrome with morphological and metabolic aspects.

Relationship of the celiac trunk with median arcuate ligament of the diaphragm

RESUMEN: En el presente trabajo se investigaron las posiciones del ligamento arqueado mediano con relación al tronco celíaco, y las medidas de sobreposición y distancia entre estas dos estructuras. Además, fueron realizadas medidas de algunas variables como la longitud y el diámetro del tronco celíaco, estudios histológicos de los pilares del diafragma y de su ligamento arqueado mediano. Utilizamos 63 cadáveres fijados en solución de formalina al 10% y 20 cadáveres no fijados, adultos, de ambos sexos. Las disecciones del área del tronco celíaco fueron realizadas después de disecar la cavidad peritoneal, en los laboratorios de la Disciplinas de Anatomía de la UNIFESP-EPM, UNILUS y UNISA, y durante las necropsias en los Servicios de Verificación de Óbitos de la UNIFESP-EPM y USP, Brasil. Para el análisis morfológico, a nivel de microscopía de luz, de tres cadáveres no fijados escogidos al azar, fueron retirados fragmentos del ligamento arqueado mediano de 0.5 cm de alto por 1.5cm de largo. Luego fueron procesados según técnicas tradicionales de inclusión. Se efectuaron cortes de 5 µm, los cuales fueron teñidos con hematoxilina-eosina y tricrómico de Masson. Los resultados obtenidos permitieron llegar a las siguientes conclusiones: 1) Las posiciones del ligamento arqueado mediano en el tronco celíaco fueron independientes del sexo. En 12 (14.46%) de 83 cadáveres, se pudo observar al tronco celíaco distante del ligamento arqueado. En 35 (42.17%) este ligamento era tangente al tronco celíaco y en 36 (43.37%) se sobreponía a este vaso. El promedio de la distancia entre el ligamento arqueado mediano y el tronco celíaco fue de 0.94 cm y la de sobreposición 0.42 cm; 2) los resultados histológicos del análisis del ligamento arqueado mediano mostraron al tejido conjuntivo denso, infiltrado por células adiposas, vasos sanguíneos y nervios. Fueron observadas fibras musculares estriadas, entremezcladas con fibras colágenas.

Distribution of lymphatic vessels in the neural plexuses surrounding the superior mesenteric artery.

OBJECTIVES: To investigate whether lymphatic vessels exist in the neural plexuses surrounding the superior mesenteric artery (SMA) and the ultrastructural relationship between neural plexuses and lymphatic vessels. METHODS: A total of 970 serial sections including the structure surrounding the SMA were obtained from 9 cadavers. They were subjected to conventional hematoxylin/eosin staining and immunostaining for the lymphatic marker D2-40. Epithelial membrane antigen and S100 were also immunostained to identify the perineurium and nerve bundles, respectively. RESULTS: Thin-walled, erythrocyte-free vessels staining with lymphatic markers (D2-40) were found in the neural plexuses surrounding the SMA along a full circumference. There seemed to be a distribution correlation between lymphatic vessels and neural plexuses. Lymphatic vessels were not identified within the nerve bundles. The plexuses contained no lymph nodes in any sections. CONCLUSIONS: To our knowledge we report the immunohistochemical visualization of lymphatic vessels in peri-SMA neural plexuses for the first time. Therefore, particular attention should be paid to the lymphatic vessels within neural plexuses as a possible route of invasion and the source of pancreatic cancer recurrence.

Surgical outcome of para-aortic lymph node dissection preserving neural tissue based on anatomical evaluations.

The anatomical distribution of the para-aortic lymph nodes was studied to establish an effective operative procedure that preserves neural tissue for patients with advanced gastric cancer. Para-aortic lesions were anatomically examined in 31 cadavers, and histologic preparations of 14 cadavers were used to evaluate the relationship between para-aortic lymph nodes and surrounding neural tissue. Surgical results were analyzed in patients with D3 gastrectomy based on anatomical findings (n = 33). Anatomically, the splanchnic nerves merged into the celiac ganglion, which consisted of either one ganglion (type I) or several ganglia (type II). The average number of lymph nodes were 17.4 in the area superior to the superior mesenteric artery (SMA) and 13.3 in the area inferior to the SMA. According to the number of metastatic lymph nodes (< or = 3, > or = 4), the median survival time was 14.7 and 9.7 months, respectively (P < 0.02). Patients either with or without metastatic lymph nodes behind the neural tissue had a median survival time of 14.7 and 9.7 months, respectively (P < 0.02). We conclude that para-aortic lymph node dissection preserving neural tissue is useful in patients with three or fewer para-aortic metastatic lymph nodes that are in front of the neural tissue.

A modified approach to transcrural celiac plexus block.

OBJECTIVES: Transcrural celiac block using the needle "walking off" the L1 vertebra technique may cause complications. We used patient-specific computed tomography (CT) images as a roadmap to perform the block under fluoroscopy. We present 1 case to describe the technique. CASE REPORT: The patient is a 63-year-old woman with refractory pain from pancreatic cancer. Her CT showed the celiac trunk at the upper L1 vertebra and 2 cm left to the midline. Needle trajectories were drawn on that film. The line representing the classic "walking off" the bone technique on the left side crossed the aorta. Two lines targeting the base of the celiac trunk were modified, thereby avoiding both the L1 vertebra and the surrounding organs. The following were measured: the distance from the midline to the left needle entry (2.5 cm), the angle for the left needle insertion (90 degrees), the distance (6 cm) and the angle (65 degrees) for the right needle entry, and the distance from the anterior margin of the L1 to the celiac trunk (2.6 cm). During the procedure, 2 needles were placed according to these measurements in a plane superior to the transverse process of the L1. No bony contact or needle redirection was made. Both needles reached 3 cm anterior to the anterior margin of the L1. X-ray contrast crossed the midline and silhouetted the target vasculature. Five milliliters of 0.2% ropivacaine followed by 10 mL of 6% phenol were injected on each side. The patient's pain level improved to 0 to 1/10 on a visual analog scale. CONCLUSIONS: The modified technique avoided painful needle contact on the bone, reduced needle redirections, and decreased the possibility of vital organ puncture.

Avaliação da distância entre a origem do tronco celíaco e da artéria mesentérica superior (nota prévia) / Distance evaluation between the origin of the celiac trunk and from the superior mesenteric artery (advance notice)

Os autores, em decorrência das controvérsias existentes na literatura e tendo em vista a necessidade de parâmetros confiáveis, os quais são cada vez mais solicitados, avaliaram a distância entre o tronco celíaco e a artéria mesentérica superior, pela face interna da artéria aorta abdominal em 25 casos.

As result of the controverses that exists in the literature andconsidering the necessity for reliable standards, which are moreand more demanded, the authors measured the distance betweenthe celiac trunk and the superior mesenteric artery, through theinternal side of the abdominal aorta in 25 cases.

Can intestinal innervation be preserved in pancreatoduodenectomy for cancer? Results of an anatomical study.

Twenty dissections were carried out, in all of which the splanchnic nerves, celiac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus was formed from two bundles, the first taking its origin from the right celiac plexus, the second from the superior mesenteric plexus. These two bundles joined together just behind the head of the pancreas. Two preganglionic bundles, a ganglion and two postganglionic bundles composed the superior mesenteric plexus. Postganglionic bundles received fibers from both right and left celiac plexuses. In small cancers a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhea from intestinal denervation. This study has provided anatomical evidence that a part of the mesenteric plexus, which receives fibers from both left and right celiac plexuses, maintains a sufficient intestinal innervation.

Investigación y revisión conceptual de la inervación gastro-duodeno-pancreática en ratas / Investigation and conceptual revision of the gastro-duodeno-pancreatic innervation in rats

En la disección anatómica macroscópica de la inervación gastro-duodeno-pancreática ratas, es posible resaltar: Una estructura conectivo-nerviosa que vincula la unión antro-fúndica con el píloro, la banda diagonal antral (BDA); dos láminas que, como telones superpuestos, cubren el espacio entre el hígado, duodeno, estómago y esófago; la más superficial de ésta, es la hépato-gastro-duodenal (HGD) y la subyacente o profunda, es la pre-post-esófago-gástrica (P-PEG). Por su riqueza neuronal, se describen dos centros autonómicos, el antro-fúndico y el peri-vateriano, este último considerado como la región más sensible del gatillo pancreático. Además, se describe en la cara anterior del colédoco, un nódulo plexual precoledociano, verdadero entrecruzamiento o carrefour de fibras nerviosas de diversas fuentes. Respecto de los nervios vagos, el izquierdo o anterior comanda la cara anterior del estómago, el segmento supra-Vateriano del duodeno y la cabeza del páncreas. Mientras, el vago derecho o posterior rige la cara posterior del estómago y el segmento córporo-caudal del páncreas. Finalmente, los carriles de la pista plexual entérica (en las paredes gástrica y duodenal) y las fibras nerviosas que saltan la hendidura duodeno-pancreática constituyen la vía de transmisión de impulsos nerviosos hacia y desde el páncreas

Origin of the thoracic duct and pancreaticoduodenal lymphatic pathways to the para-aortic lymph nodes.

We investigated the afferent and efferent connections of the para-aortic lymph nodes (group 16 nodes) relative to the origin of the thoracic duct in 85 postmortem cadavers. The origin was usually restricted to groups 16b1-inter and -latero nodes (type I; 90.6%), regardless of whether the union of their efferents occurred at the abdominal or thoracic level. We also occasionally observed thick collecting vessels originating from the dorsal aspect of the pancreaticoduodenal region, running along the right side of and superficial to the celiac plexus and emptying into group 16b1 nodes. The thoracic duct originated occasionally not only from group 16b1 nodes but also from group 16a2 nodes (type II; 9.4%). Moreover, in all 85 specimens, the group 16a2-inter node often received afferents from the celiac plexus itself or the tight connective tissue between the plexus and diaphragmatic crus, or both. The results support the reliability of the extended D2 lymphadenectomy (D2 + group 16b1 nodes + group 16a2-inter node) for curative cancer surgery in the pancreaticoduodenal region.