ANOMALOUS BRANCHING PATTERN OF COELIAC TRUNK
–
A CASE
REPORT
Deena Usha Kumari1, Teki Surekha2, D. Asha Latha3, L. Lakshmi Sailaja4, Vanju V. V. Lakshmi5
HOW TO CITE THIS ARTICLE:
Deena Usha Kumari, Teki Surekha, D. Asha Latha, L. Lakshmi Sailaja, Vanju V. V. Lakshmi. ” Anomalous Branching Pattern of Coeliac Trunk – A Case Report”. Journal of Evidence based Medicine and Healthcare;
Volume 2, Issue 33, August 17, 2015; Page: 5058-5062, DOI: 10.18410/jebmh/2015/704
ABSTRACT: While doing a routine dissection in an 85 years old cadaver, it was observed that the coeliac trunk arised as gastro splenic trunk and the common hepatic artery arised from the superior mesenteric artery instead of the coeliac trunk. Knowledge of anatomical variants of coeliac trunk, hepatic vascular structures is of great importance in general surgery, especially hepatic surgery. As coeliac trunk supplies the foregut, the anomaly and morphometric variation may lead to abnormalities of the foregut and its derivatives. This leads to anatomical, surgical and clinical complications. This knowledge is also of great importance with regard to liver transplantations, laparoscopic surgeries, radiological procedures, and the treatment of penetrating injuries involving the peri-hepatic area.
KEYWORDS: Coeliac trunk, Spleno-gastric trunk, Common hepatic artery, Superior mesenteric artery.
INTRODUCTION: The coeliac trunk is one of the well-documented arterial trunks, with many researchers pondering on the topic, as well as providing detailed studies and an impressive number of specimens. The first description of normal and aberrant coeliac trunk anatomy was published in 1756 by Haller. Anatomical variations of the coeliac trunk were first classified by Adachi.[1] in 1928, based on 252 dissections of Japanese cadavers, where six types of divisions of
the coeliac trunk and superior mesenteric artery were described. The trifurcation of the celiac trunk was first described by Haller 1756 as Tripus Halleri. This “tripus Halleri” was and is still considered to be the normal appearance of the CT. The word coeliac means - of or in or belonging to the cavity of the abdomen. The CT arises just below the aortic hiatus at the level of thoracic 12–lumbar 1 (T12–L1), and is the first anterior branch of abdominal aorta. It divides into the left gastric, common hepatic and splenic arteries. The abdominal vessels, especially Coeliac Trunk and Superior mesenteric artery, frequently show diverse anomalies in their origin and course. Adachi (1928).[1]) Despite accurate studies based on large groups of subjects, there are
still some rare coeliac trunk variations which are not found in these classifications. They are the benchmark for all subsequent contributions in this area. Each and every description of anomalous celiac trunk branching is of great importance.
stomach. The common hepatic artery has not given right gastric artery. The common hepatic artery gave rise to superior pancreatico- duodenal artery as the first branch instead of gastro-duodenal artery. The rest of its course is normal.
The abdominal vessels, especially Coeliac Trunk and Superior mesenteric artery, frequently show diverse anomalies in their origin and course. The CT is a wide ventral visceral branch of the aorta arising just below the aortic hiatus superior to the pancreas. In 75–90% of individuals, it runs horizontally forward for approximately 1.25cm. The trunk may be shorter or longer than usual and the length of this trunk varies between 8 and 40mm. Although the CT, in general, divides into three arteries, namely Left Gastric, Splenic and Common Hepatic Artery, one of the components of the CT sometimes arises directly from the abdominal aorta. In rare cases, all three components arise independently from the aorta. In addition, it has been reported that the CT unites with the SMA at their origins to form a common trunk, the coeliacomesenteric trunk (CMT). Coeliac trunk supplies the parts of the foregut. Variations in the branching pattern of the coeliac trunk are therefore having immense surgical importance.
IMAGE 1: Coeliac Trunk and Its 3 Branches (Normal Branching Pattern).
1.Coeliac Trunk. 2. Left Gastric Artery. 3. Splenic Artery.
4. Common Hepatic Artery.
IMAGE 2: Showing Variation in the Branching Pattern Of Coeliac Trunk (Splenogastric Trunk) (Hepatic Artery Arising From Superior Mesenteric Artery).
1. Coeliac trunk. 2. Left gastric artery. 3. Splenic artery.
4. Common hepatic artery. 5. Superior mesenteric artery.
DISCUSSION: These coeliac trunk and the mesenteric artery anomalies were embryologically explained by Tandler,[2] Morita,[3] Sato [4] and Wustinger.[5] Morita and Sato did their study on
human adults, whereas Tandler did it on human embryos and Wustinger did it on sheep. While Morita cited the disappearance of the roots of the primitive ventral splanchnic arteries and their anastomoses as the reasons for this type of anomaly, Sato,[4] cited mid gut rotation with a
consequential disappearance and the persistence of various anastomoses between the arteries of the right, middle and left liver rudiments as an explanation towards these type of coeliac-mesenteric variations. Disappearance of the proximal part of the 2nd and 3rd roots and the longitudinal anastomosis between them led to the formation of the gastro-splenic trunk and its branches (Formed by the entire 1st root, the distal part of the 2nd root and the anastomosis between them) and the hepato-mesenteric trunk and its branches (Formed by the entire 4th root, the distal part of the 3rd root and the anastomosis between them). Subsequently, the distal part of the 1st root formed the left gastric artery, the distal part of the 2nd root formed the splenic artery, the distal part of the 3rd root formed the common hepatic artery and the distal part of the 4th root formed the superior mesenteric artery. The proximal part of the 1st root and the 4th root formed the gastro-splenic trunk and the hepato-mesenteric trunk respectively. This can explain the variation in the present case.
CLINICAL ASPECTS: Coeliac artery compression syndrome has been studied in detail by Loukas et al[6] coeliac artery compression syndrome (Dunbars syndrome) is due to an overlying large
medium arcuate ligament of the diaphragm. Patients with cirrhosis and portal hypertension are at risk for developing splenic artery aneurism. Hepatic artery diameter is important in hepatic
arterial infusion chemotherapy for treatment of hepatic metastatic tumors, so the correct size of the catheter can be safely chosen. Gastro duodenal artery steal syndrome during liver transplantation was reported by Nishida et al.[7] Arterial diameter of celiac trunk hepatic branches
are important especially due to development of techniques for Liver transplantation (Use of partial graft) Hepatic artery thrombosis is one of the most devastating postoperative living related liver transplantation complication and this risk is related to the use of small diameter arteries (<2mm) for vascular reconstruction some authors exclude donors with <3mm arteries. The right lobe grafts has been the main type of partial liver grafts for adult–to–adult living donor liver transplantation.
CONCLUSION: With the advances in the surgical techniques, increased concern for the post-operative cosmetic appearance and the advent of still new horizons of treatment like laparoscopic operations, surgeons may not have the opportunity of seeing the entire surgical operative area, which necessitates well planned pre-operative investigations and an appropriate knowledge of the possible anomalies of that particular region. This will avoid or at least reduce the risk of inadvertently damaging the blood vessels, thereby preventing the conversion of a lifesaving operation to a life threatening one. Moreover, the knowledge on the hepatic arterial vascularization and its variations has a significant relevance in the daily practice because the classical arterial anatomy is seen only in 55-77% of the population. Keeping these facts in view, this anomaly stands significant.
REFERENCES:
1. Adachi B. Das arterien aystem der japaner, Band II. Kyoto: Verlag der Keiserlich-Japanischen Universitat zu Kyoto, Maruzen Publishing Co; 1928.pp.28,38,54..
2. Tandler J. Uber dieVarietaten der Arteia coeliaca and deren Entwicklung. Anat Hefte 1094; 25:473-500.
3. Morita M. Reports and conception of three anomalous cases of the celiac and the superior mesenteric arteries. Igaku Kenkyu 1935; 9:1993-2006.
4. Sato Y, Takeuchi R, Kawashuma T, et al. On the branches of the celiac trunk. J Kyorin Med Soc 1993; 24:75-92.
5. Wustinger J. Developmental anomaly of the hepatic artery in sheep. Folia Morphol (Warsz) 1978; 37:99-102.
6. Loukas M, Pinyard J, Vaid S, et al. Clinical anatomy of coeliac artery compression syndrome: a review. ClinAnat 2007; 20:612-7.
4. Assistant Professor, Department of Anatomy, Andhra Medical College, Visakhapatnam.
5. Assistant Professor, Department of Anatomy, Andhra Medical College, Visakhapatnam.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR: Dr. Teki Surekha,
58-24-46/1, Butchirajupalem, Visakhapatnam-530027. E-mail: tekisurekha@gmail.com
Date of Submission: 23/07/2015. Date of Peer Review: 24/07/2015. Date of Acceptance: 06/08/2015. Date of Publishing: 17/08/2015.
AUTHORS:
1. Deena Usha Kumari 2. Teki Surekha 3. D. Asha Latha 4. L. Lakshmi Sailaja 5. Vanju V. V. Lakshmi
PARTICULARS OF CONTRIBUTORS: 1. Associate Professor, Department of
Anatomy, Andhra Medical College, Visakhapatnam.
2. Senior Resident, Department of Anatomy, Andhra Medical College, Visakhapatnam.
