Comprehensive analysis of splenic artery variations using computed tomography angiography: development of the IPALGEA classification system.

BACKGROUND: The splenic artery, an essential component of abdominal vascular anatomy, exhibits significant variations with clinical implications in surgical and radiological procedures. The lack of a standardized classification system for these variations hinders comparative studies and surgical planning. This study introduces the IPALGEA classification system, based on computed tomography angiography (CTA) findings, to address this gap. METHODS: A retrospective analysis was conducted on 302 patients who underwent CTA at a tertiary university hospital between August 2021 and January 2022. The study focused on the evaluation of splenic artery variations, including the origin, course, terminal branching patterns, and the relationship between the inferior polar artery and the left gastroepiploic artery. The IPALGEA classification was developed to standardize the reporting of these variations. RESULTS: The study highlighted a significant prevalence of splenic artery variations, with the most common pattern being a superior course relative to the pancreas. The IPALGEA classification effectively categorized these variations, emphasizing the relationship between the inferior polar artery and the left gastroepiploic artery. The findings revealed that the bifurcation distance of the celiac trunk varied significantly between genders and that the presence of an inferior polar artery correlated with a shorter hilus distance. CONCLUSION: The IPALGEA classification offers a comprehensive and standardized approach to categorize splenic artery variations. This system enhances our understanding of abdominal vascular anatomy and has significant implications for surgical and radiological procedures, potentially reducing surgical complications and improving patient outcomes.

Anatomy of the splenic artery: what does the surgeon need to know?

OBJECTIVE: to determine the prevalence and describe the main morphological and metric variations of the splenic artery in terms of its origin, path and polar and terminal branches. METHODS: cross-sectional study, carried out at Hospital de Clínicas between July and November 2020. Computed tomography scans were analyzed with intravenous contrast of the patients seen at the Radiology and Diagnostic Imaging Service. The findings were categorized as to origin, path and splenic ramifications. RESULTS: 1,235 patients were evaluated. As for the origin, the splenic artery appears in the celiac trunk in 99.11% of the individuals. Of these, 5.95% have a bifurcated celiac pattern, 92.17% trifurcated and 1.88% tetrafurcated. The mean arterial diameter was 5.92mm (±1.2), the highest one being in white men. As for the path, the splenic artery was unique in the entire sample. The suprapancreatic course was found in 75.63% of the individuals, with a higher occurrence in women, 78.87% (p<0.001). The terminal splitting pattern of the splenic artery was characterized by the bifurcated type (95.47%). The terminal branches seen most frequently were those with three arteries (34.90%) and most individuals did not have polar branches. CONCLUSION: the splenic artery presents a highly variable pattern of origin and its average caliber is influenced by sex and color. The suprapancreatic path was the most characteristic and predominant in females. The bifurcated pattern of final division, with three terminal branches and the absence of polar arteries, occurs more frequently.

The left gastro-omental vessels are able to maintain the entire spleen blood supply / Os vasos gastromentais esquerdos são capazes de manter o suprimento sanguíneo de todo o baço

Abstract The spleen is supplied by blood flow through the splenic artery and vein. The purpose of this communication is to report an ectopic spleen supplied only by reverse flow through the left gastro-omental vessels. A 14-year-old boy presented with pelvic splenomegaly supplied only by the left gastro-omental artery and veins connected to the inferior polar vessels, which were the only vessels communicating with the spleen. After detorsion of the spleen and splenopexy, the spleen returned to normal dimensions. The patient had uneventful follow-up. In conclusion, the left gastroepiploic vessels are able to maintain the entire spleen blood supply.

Resumo O baço é suprido pelo fluxo sanguíneo da artéria e veia esplênicas. O objetivo desta comunicação é apresentar um baço ectópico suprido apenas pelo fluxo sanguíneo reverso proveniente dos vasos gastromentais esquerdos. Um paciente de 14 anos apresentou esplenomegalia pélvica suprida apenas por artéria e veia gastromentais esquerdas, conectadas aos vasos polares inferiores, que eram os únicos presentes nesse baço. Após a distorção do baço e a esplenopexia, o baço voltou às dimensões normais. Não houve intercorrências no acompanhamento do paciente. Em conclusão, os vasos gastromentais esquerdos são capazes de suprir o fluxo sanguíneo de todo o baço.

Evaluación anatómica del tronco celíaco y sus ramas en una muestra de población mestiza colombiana / Anatomical evaluation of the celiac trunk and its branches in a sample of Colombian mestizo population

RESUMEN: El tronco celíaco (TC) es la rama de la arteria aorta abdominal (AA) que aporta la irrigación a la porción distal del esófago, parte media del duodeno, al estómago, páncreas, bazo y suple adicionalmente al hígado; sus diferentes expresiones anatómicas son reportadas en los diferentes grupos poblacionales con incidencia variable. Se evaluó las características morfológicas del TC y sus ramas en 26 bloques del piso supramesocólico de cadáveres masculinos adultos no reclamados, del grupo poblacional mestizo, a quienes se les practico autopsia en el Instituto de Medicina Legal de Bucaramanga - Colombia. Se observo el tipo I del TC en 23 especímenes (88,4 %), del cual correspondió 16 muestras (61,5 %). Al subtipo Ia con bifurcación y formación de tronco hepatoesplénico. Hubo un caso (3,8 %) en donde las ramas del T se originaron de manera independiente de la AA. El TC presentó una longitud promedio de 18,6 DE 7,53 mm y un diámetro externo de 7 DE 1,24 mm. De las ramas del TC, la AE presentó un diámetro promedio de 5,89 DE 1,04 mm sin diferencias estadísticamente significativa con relación al diámetro de la AHC, pero si con relación al diámetro de la AGI (P= 0,70; p<0,001 respectivamente). La gran mayoría de la muestra avaluada muestra la presencia de tronco hepatoesplénico seguido de la trifurcación en una verdadera configuración de trípode. El conocimiento de los patrones de ramificación del TC debe ser tomado en cuenta por cirujanos gastroenterólogos, radiólogos intervencionistas y oncólogos para evitar complicaciones durante los procedimientos quirúrgicos abdominales.

SUMMARY: The celiac trunk (CT) is the branch of the abdominal aorta artery (AA) that provides irrigation to the distal portion of the esophagus, the middle part of the duodenum, the stomach, pancreas, spleen and additionally supplies the liver; its different anatomical expressions are reported in the different population groups with variable incidence. The morphological characteristics of the CT and its branches were evaluated in 26 blocks of the supramesocolic floor of unclaimed adult male corpses, of the mestizo population group, who were autopsied at the Institute of Legal Medicine of Bucaramanga - Colombia. Type I CT was observed in 23 specimens (88.4 %), of which 16 samples (61.5 %) corresponded. to subtype Ia with bifurcation and formation of the hepatosplenic trunk. There was one case (3.8 %) in which the branches of the CT originated independently of the AA. The CT had an average length of 18.6 SD 7.53 mm and an external diameter of 7 SD 1.24 mm. Of the CT branches, the splenic artery presented an average diameter of 5.89 SD 1.04 mm without statistically significant differences in relation to the diameter of the AHC, but if in relation to the diameter of the IGA (P = 0.70; p <0.001 respectively). The vast majority of the sample evaluated shows the presence of a hepatosplenic trunk followed by trifurcation in a true tripod configuration. Knowledge of CT branching patterns should be taken into account by gastroenterological surgeons, interventional radiologists, and oncologists to avoid complications during abdominal surgical procedures.

Perceptions of porta-celiac vascular models for hepatic surgery and their use in residency training.

BACKGROUND: Primary aspect of hepatic navigation surgery is the identification of source vascular details to preserve healthy liver which has a vascular anatomy quite challenging for the young surgeons. The purpose was to determine whether three-dimensional (3D) vascular pattern models of preoperative computed tomography (CT) images will assist resident-level trainees for hepatic surgery. METHODS: This study was based on the perception of residents who were presented with 5 different hepatic source vascular patterns and required to compare their perception level of CT, and 1:1 models in terms of importance of variability, differential of patterns and preoperative planning. RESULTS: All residents agree that models provided better understanding of vascular source and improved preplanning. Five stations provided qualitative assessment with results showing the usefulness of porta-celiac models when used as anatomical tools in preplanning (p = 0.04), simulation of interventional procedures (p = 0.02), surgical education (p = 0.01). None of the cases had scored less than 8.5. Responses related to understanding variations were significantly higher in the perception of the 3D model in all cases, furthermore 3D models were more useful for seniors in more complex cases 3 and 5. Some open-ended answers: "The 3D model can completely change the operation plan" One of the major factors for anatomical resection of liver transplantation is the positional relationship between the hepatic arteries and the portal veins. CONCLUSION: The plastic-like material presenting the hepatic vascularity enables the visualization of the origin, pattern, shape, and angle of the branches with appropriate spatial perception thus making it well-structured.

Morphometric analysis of the splenic artery using contrast-enhanced computed tomography (CT).

PURPOSE: To evaluate the morphology and course of the splenic artery, which might impact the surgical implantation of systems that stimulate the nerves surrounding the splenic artery. Experimental studies indicate that these nerves play an important part in immune modulation, and might be a potential target in the treatment of autoimmune diseases. METHODS: This retrospective cohort study made use of contrast-enhanced CT images from 40 male and 40 female patients (age 30-69) that underwent a CT examination of the aorta, kidneys or pancreas. Anatomic features were described including total splenic artery length, calibers, tortuosity, the presence of arterial loops and the branching pattern of the splenic artery. RESULTS: No age-gender-related differences could be found related to tortuosity or branching pattern. The length of splenic artery in contact with pancreatic tissue decreased with increasing age, but was not different between genders. Artery diameters were wider in male compared to female subjects. Loops of variable directions, that represent a part of the artery that curls out of the pancreatic tissue, were identified in each age-gender category and were present in nearly all subjects (86%). CONCLUSION: This study suggests that although some anatomic features of the splenic artery are subject to factors as age and gender, the tortuosity of the splenic artery is not age dependent. Most subjects had one or multiple loops, which can serve as a target for neuromodulatory devices. Future studies should investigate whether splenic nerve stimulation is safe and feasible.

Splenic artery loops: Potential splenic plexus stimulation sites for neuroimmunomodulatory-based anti-inflammatory therapy?

INTRODUCTION: The splenic plexus might represent a novel neuroimmunomodulatory therapeutic target as electrical stimulation of this tissue has been shown to have beneficial anti-inflammatory effects. Tortuous splenic artery segments (splenic artery loops), including their surrounding nerve plexus, have been evaluated as potential stimulation sites in humans. At present, however, our understanding of these loops and their surrounding nerve plexus is incomplete. This study aims to characterize the dimensions of these loops and their surrounding nerve tissue. MATERIALS AND METHODS: Six formaldehyde fixed human cadavers were dissected and qualitative and quantitative macro- and microscopic data on splenic artery loops and their surrounding nerve plexus were collected. RESULTS: One or multiple loops were observed in 83% of the studied specimens. These loops, including their surrounding nerve plexus could be easily dissected free circumferentially thereby providing sufficient space for further surgical intervention. The splenic plexus surrounding the loops contained a significant amount of nerves that contained predominantly sympathetic fibers. CONCLUSION: The results of this study support that splenic artery loops could represent suitable electrical splenic plexus stimulation sites in humans. Dimensions with respect to loop height and width, provide sufficient space for introduction of surgical instruments and electrode implantation, and, the dissected neurovascular bundles contain a substantial amount of sympathetic nerve tissue. This knowledge may contribute to further development of surgical techniques and neuroelectrode interface design.

Unusual development of the celiac trunk and its clinical significance / Desenvolvimento incomum do tronco celíaco e sua importância clínica

Abstract We describe a case of unusual development of the celiac trunk observed in the cadaver of 1-year old male child. The celiac trunk branched into five vessels: the splenic, common hepatic and left gastric arteries, the left inferior diaphragmatic artery, and a short trunk that branched into the right inferior diaphragmatic artery and right accessory hepatic artery. Additionally, the manner of branching of the vessel was unusual: it was possible to distinguish two branching points that corresponded to its s-shaped trajectory. There were also other variations of vascular supply, such as the presence of a left accessory hepatic artery, an additional superior pancreatoduodenal artery, and others. It should be noted that multiple developmental variations can be common in clinical practice and clinicians should be aware of them during diagnostic and interventional procedures.

Resumo Apresentamos um relato de caso de desenvolvimento incomum do tronco celíaco em um cadáver do sexo masculino de 1 ano de idade. O tronco celíaco ramificou-se para cinco vasos: as artérias esplênica, hepática comum e gástrica esquerda, a artéria diafragmática inferior esquerda e um tronco pequeno que se ramificou para a artéria diafragmática inferior direita e para a artéria hepática direita acessória. Além disso, a forma como o vaso se ramificou foi incomum: é possível distinguir dois pontos de ramificação que correspondem à trajetória em formato de S. Também houve outras variações do suprimento vascular, como a presença da artéria hepática esquerda acessória, da artéria pancreaticoduodenal superior acessória e outras. Cabe observar que a variação de desenvolvimento múltipla pode ser comum na prática clínica, e os médicos devem estar cientes dela durante os procedimentos de diagnóstico e intervenção.

Splenic artery tortuosity index on abdominal CT Scan: correlation with age, sex, BMI and abdominal cavity diameters / Índice de tortuosidad de la arteria esplénica en TC abdominal: correlación con la edad, el sexo, el IMC y los diámetros de la cavidad abdominal

Thorough knowledge of splenic artery course and morphology may help clinician to provide better practice. This Study aims at finding out if there was a relationship between splenic artery tortuosity index and age, sex, Body Mass Index (BMI) and abdominal cavity diameters. Routine abdominal Computerized Tomography (CT) scan images were retrospectively analyzed for 219 patients. Splenic artery tortuosity index was calculated. Abdominal cavity diameters were measured. Age, sex, and BMI were recorded. Splenic artery straight length (x) mean was 9.41 cm (SD 1.33). Splenic artery tortuous length mean was 15.15 cm (SD 3.31). Splenic artery tortuosity index mean was 1.63 (SD 0.36). Pearson correlation coefficient for Splenic artery tortuosity index vs. age was: 0.02 (P value 0.80). Splenic artery tortuosity index for females vs. males were 1.70 vs. 1.57 (P value 0.01). Pearson correlation coefficient for Splenic artery tortuosity index vs. BMI was 0.02 (P value 0.75). Pearson correlation coefficient for Splenic artery tortuosity index vs. abdominal cavity diameters were: Anterior-Posterior (AP) diameter -0.01 (P value 0.88) and transverse diameter 0.00 (P value 0.98). There may be a relationship between splenic artery tortuosity and female sex, but not with age, BMI and abdominal cavity diameters (AP and Transverse).

El conocimiento del curso y la morfología de la arteria esplénica puede ayudar al médico a proporcionar un diagnóstico y tratamiento oportuno al paciente. Este estudio tuvo como objetivo determinar si existe una relación entre el índice de tortuosidad de la arteria esplénica y la edad, el sexo, el índice de masa corporal (IMC) y los diámetros de la cavidad abdominal. Se tomaron imágenes retrospectivas, de rutina, de 219 pacientes de tomografía computarizada (TC) abdominal. Se calculó el índice de tortuosidad de la arteria esplénica. Se midieron los diámetros de la cavidad abdominal y se registró la edad, sexo y el IMC. La media de la longitud recta de la arteria esplénica (x) fue de 9,41 cm (DE 1,33). La longitud tortuosa de la arteria esplénica fue de 15,15 cm (DE 3,31). La media del índice de tortuosidad de la arteria esplénica fue de 1,63 (DE 0,36). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica vs. edad fue: 0,02 (valor de P 0,80). El índice de tortuosidad de la arteria esplénica para las mujeres frente a los hombres fue de 1,70 frente a 1,57 (valor de P 0,01). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica versus el IMC fue de 0,02 (valor de P 0,75). El coeficiente de correlación de Pearson para el índice de tortuosidad de la arteria esplénica frente a los diámetros de la cavidad abdominal fue: diámetro anterior-posterior (AP) -0,01 (valor P 0,88) y diámetro transversal 0,00 (valor P 0,98). Puede existir una relación entre la tortuosidad de la arteria esplénica y el sexo femenino, sin embargo no se encontró relación con la edad, el IMC y los diámetros de la cavidad abdominal (AP y transversal).

Splenic artery angiography: clinical classification of origin and branching variations of splenic artery by multi-detector computed tomography angiography method.

BACKGROUND: The splenic artery (SA) variations are rarely reported in the literature. Knowledge of the range of the SA and other arterial anomalies and their specific frequencies is very important ever for every visceral surgeon as well as for treatment of gastrointestinal bleeding, organ transplantation, transarterial chemoembolisation of neoplasm, infusion therapy, therapeutic arterial ligation, iatrogenic injuries. At the literature, there are more studies on the coeliac trunk, superior mesenteric artery and hepatic artery variations, but studies on the SA variations are uncommon. The studies on the SA variations are mostly in the form of case reports, but there are not many studies with large population on this issue. The purpose of this study was to evaluate the SA alone and to determine the variations determined separately from the other arteries. Accurate awareness of all the possible anatomic variations is crucial in the upper abdomen surgery. MATERIALS AND METHODS: Seven hundred fifty patients undergoing multi-detector computed tomography angiography between 2015 and 2017 were retrospectively evaluated for the SA variations. We created a new classification system to determine anatomic variations of the SA. RESULTS: Twenty-three different types were identified related to anatomic variations in the origin and branching pattern of the SA. While 596 (79.47%) patients had standard SA anatomy, 154 (20.53%) patients had variant SA anatomy. CONCLUSIONS: The SA has quite different variation types and the practical context of the issue is of primary importance in surgery, gastroenterology, oncology and radiology. Liver and pancreas transplantation, splenectomy, embolisation of tumours of the abdominal organs, as well as other numerous diagnostic and therapeutic procedures, require detailed anatomical knowledge.

Splenic artery denervation: target micro-anatomy, feasibility, and early preclinical experience.

This study sought to evaluate perisplenic artery nerve distribution and the feasibility of splenic artery denervation (SDN). The NEXION radiofrequency catheter was used to perform SDN in healthy and inflammatory arthritis pigs. Splenic artery anatomy, nerve distribution, and splenic norepinephrine (NEPI) levels were evaluated before and after SDN. Perisplenic artery nerves were primarily distributed within 2.5 mm of the arterial lumen and were largely sympathetic on the basis of tyrosine hydroxylase expression. The pancreas, tended to be circumferentially positioned around the proximal splenic artery, typically >2.5 mm from the lumen, ensuring that most of the nerves could be targeted without affecting this sensitive organ. The mid segment of the splenic artery was relatively free of contact with the adjacent pancreas. Splenic NEPI levels and nerve abundance followed a decreasing gradient from the proximal to distal splenic artery. SDN resulted in significant reductions in splenic NEPI levels at day 14 (60.7%, P = 0.024) in naïve pigs and day 45 (100%, P = 0.001) in inflammatory arthritis pigs. There was no significant effect of SDN on joint soft tissue injury or circulating inflammatory markers in the inflammatory arthritis model. The majority of perisplenic arterial nerves are within close proximity of the lumen and are primarily sympathetic efferent fibers. Nerves in the mid-segment may be the preferred SDN target given their proximity to the artery and paucity of periarterial off-target organs. SDN appears safe and effective at reducing splenic NEPI levels.

Splenic artery arising from hepatic artery proper in a patient with celiacomesenteric trunk: a rare anatomical variant.

We report an extremely rare case of splenic artery arising from hepatic artery proper in a patient with celiacomesenteric trunk variant. This anatomical variation was detected angiographically during hepatic mapping prior to transarterial radioembolization (TARE) for hepatocellular carcinoma in an 84-year-old man. TARE of hepatic tumors is one of the frequent procedures done by interventional radiologists. The identification of such rare vascular aberrations is of great importance not only in current interventional radiology procedures such as radioembolization but also in surgery and diagnostic radiology. To the best of our knowledge, this vascular variant is a novel discovery.

Anatomy, immunohistochemistry, and numerical distribution of human splenic microvessels.

The microvascular architecture of the spleen plays an important role in the immunological function of this organ. The different types of vessels are related to different reticular cells each with their own immunomodulatory functions. The present study describes an immunohistochemical and morphometric analysis of the various types of vessels in 21 human autopsy non-pathological splenic samples. On an area of 785,656.37 µm2 for each sample, we classified and quantified the type and number of vascular structures, each according to their morphology and immunohistochemical profile, and obtained the ratios between them. The distribution of trabecular vessels and the characteristics of the venules are reviewed. In our material the so-called "cavernous perimarginal sinus" (anatomical structure previously described by Schmidt et al., 1988) was observed and interpreted as a curvilinear venule shaped by the follicle in contact with the trabecular vein. Our material comprised 261 trabeculae (containing 269 arterial sections and 508 venous sections), 30,621 CD34+ capillaries, 7739 CD271+ sheathed capillaries, 2588 CD169+ sheathed capillaries, and 31,124 CD8+ sinusoids. The total area (TA) (14,765,714.88 µm2) occupied by the sinusoidal sections of the 21 cases was much higher than the TA of the capillary sections (1,700,269.83 µm2). Similarly, the TA (651,985 µm2) occupied by the sections of the trabecular veins was much higher than the TA of the trabecular arteries (88,594 µm2). The total number of CD34+ capillaries and of sinusoids CD8+ was similar for the sum of the 21 cases, nevertheless there were large differences in each case. Statistically the hypothesis that the number of capillaries and sinusoids are present with the same frequency is discarded. In view of the absence of a numerical correlation between capillaries and sinusoids, we postulate that very possibly the arterial and the venous vascular trees are two anatomically independent structures separated by the splenic cords. We believe that this is the first work where splenic microvascularization is simultaneously approached from a morphometric and immunohistochemical point of view.

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.

Aberrant splenic artery rising from the superior mesenteric artery: a rare but important anatomical variation.

Aberrant splenic artery originating from the superior mesenteric artery (SMA) is extremely rare and recognition of this anomaly is important in the pre-operative planning of complex surgery such as pancreatic surgery, liver transplantation and vascular surgery. We present the case of an 80-year-old female diagnosed as septic shock due to mesenteric ischemia and obstructive pyelonephritis. Her splenic artery was originating from the SMA and the anomaly was readily appreciated on the pre-operative CT images. An explorative laparotomy associating extensive small bowel resection with endarterectomy of the proximal part of the SMA was performed. During intra-operative SMA control, we confirmed the aberrant splenic artery arising from SMA, and successfully avoid any arterial injury on the splenic artery with isolation and separated proximal and distal clamping. The anatomical vascular variation should be recognized in the pre-operative work-up of a determined surgical procedure to avoid potential intra-operative arterial injuries.

Rare anatomic variation of the hepatic arterial blood supply: case report and literature review.

PURPOSE: Our aim is to present a rare case of anatomic variation of the arterial blood supply to the liver because preoperative knowledge of hepatic vascular variations is mandatory in hepatic surgery and liver transplantation. METHODS: We present a case of unusual arterial blood supply to the liver, a right hepatic artery coming from the splenic artery, associated to a classical common hepatic artery and a left hepatic artery from the left gastric artery. Preoperative diagnosis was made using CT-scan and 3D reconstruction. RESULTS: The right hepatic artery was found behind the portal vein and its diameter showed its importance in the vascularisation of the liver. To our knowledge this type of variation has only twice been described before. The accuracy of the 3D reconstruction allowed us to adopt the best surgical strategy to avoid lesions of the two accessory arteries which proved important sources of blood supply. CONCLUSIONS: Precise preoperative evaluation of liver blood supply has great importance on surgical, transplantation strategy and outcome and rare anatomic variations have to be known to avoid lesions of potentially important arteries. New techniques of 3D reconstruction can ease the preoperative recognition of such difficult anatomic variations.

Tronco hepato-espleno-mesentérico: descripción de una disposición anómala del tronco celíaco / Hepato-splenic-mesenteric trunk: description of an abnormal disposition of the celiac trunk

El estudio de los patrones arteriales de distribución vascular requiere un conocimiento preciso de las variaciones anatómicas, tanto de origen y distribución de las arterias, como de sus correspondientes ramas arteriales. En este trabajo se describe la presencia de un tronco hepato-espleno-mesentérico, disposición arterial altamente infrecuente. El conocimiento de las distintas posibilidades de disposición de las arterias correspondientes al tronco celíaco y sus ramas será de importancia para la interpretación adecuada de estudios imagenológicos, como así también para la planificación precisa de actos quirúrgicos e intervencionistas en la región abdominal.

The study of arterial patterns of vascular distribution requires a precise knowledge of the anatomical variations of both origin and distribution of the corresponding arteries and arterial branches. In this work, the presence of a hepatosplenic-mesenteric trunk is described, a highly infrequent arterial disposition. The knowledge of the different possibilities of disposition of the arteries corresponding to the celiac trunk and its branches will be of importance for the adequate interpretation of imaging studies, as well as for the precise planning of surgical and interventional acts in the abdominal region.

Three-dimensional computed tomography analysis of the vascular anatomy of the splenic hilum for gastric cancer surgery.

PURPOSE: Splenic infarction may occur if the splenic branches are injured or ligated accidentally during gastrectomy. We used three-dimensional computed tomography (3D-CT) imaging to distinguish the vascular anatomy of the splenic hilum in individual patients, focusing on the splenic polar branches and the gastric branches. METHODS: The subjects of this study were 104 patients who underwent computed tomography (CT) with intravenous contrast before gastrectomy. SYNAPSE 3D® (Fujifilm Medical, Tokyo, Japan) was used to generate the 3D-CT images. The total spleen volume and the area supplied by the superior polar artery (SPA) in each patient were estimated using the "liver analysis" function. RESULTS: The SPA without the gastric branch (supplying only the spleen), the SPA with the gastric branch (supplying both the stomach and the spleen), and the posterior gastric artery (supplying only the stomach) were present in 14, 45, and 18% of the patients, respectively. The SPA supplied 12% of the total spleen volume on average; however, it supplied over 30% in two patients. CONCLUSION: We identified the vascular anatomy around the splenic hilum in over 100 patients. Based on our findings, we recommend preservation of the SPA when it is supplying a large area of the spleen. Preoperative 3D-CT analysis provides useful information to optimize safe gastrectomy.

The anatomical configuration of the splenic artery influences suprapancreatic lymph node dissection in laparoscopic gastrectomy: analysis using a 3D volume rendering program.

BACKGROUND: The aim of this study is to categorize splenic artery and vein configurations, and examine their influence on suprapancreatic lymph node (LN) dissection in laparoscopic gastrectomy. METHODS: Digital Imaging and Communications in Medicine images from 169 advanced cancer patients who underwent laparoscopic gastrectomy with D2 dissection were used to reconstruct perigastric vessels in 3D using a volume rendering program (VP Planning®). Splenic artery and vein configuration were classified depending on the relative position of their lowest part in regard to the pancreas. Number of resected LNs and surgical outcomes were analyzed. RESULTS: The splenic artery was categorized as superficial (36.7%), middle (49.1%), and concealed (14.2%), and the splenic vein was categorized as superior (6.5%), middle (42.0%), and inferior to the pancreas (51.5%). The number of resected LNs around the proximal half of the splenic artery (#11p) and the proportion of the splenic vein located inferiorly to the pancreas were significantly higher in splenic arteries of concealed types. LN metastasis of station #7 was an independent risk factor of LN metastasis in station #11p (p = 0.010). Concealed types showed a tendency towards longer operating times, more blood loss, longer hospital stays, and a higher postoperative morbidity. CONCLUSION: Concealed types of splenic artery are associated with an increased difficulty in the dissection of LN station #11p around the splenic artery. A 3D volume rendering program is a useful tool to rapidly and intuitively identify individual anatomical variations, to plan a tailored surgical strategy, and to predict potential challenges.