Anterior Superior Pancreaticoduodenal Vein Research Articles

A case in which the ileocolic vein draining into the gastrocolic trunk of Henle could be diagnosed preoperatively: a rare anatomical case report

BackgroundNumerous variations in vascular anatomy have been reported in the right colon. The ileocolic vein (ICV) generally drains directly into the superior mesenteric vein (SMV), and is an important landmark for laparoscopic surgery in right colon cancer. We present here a patient with a vascular anomaly of the ICV that was diagnosed on preoperative imaging.Case presentationA 65-year-old woman was diagnosed with transverse colon cancer by colonoscopy. Preoperative computed tomography scan showed that the ICV drained into the gastrocolic trunk of Henle (GCT) rather than the SMV. Single-incision laparoscopic transverse colectomy with D3 lymph node dissection was performed, dividing the middle colic vein (MCV) and preserving the right gastroepiploic vein (RGEV), anterior superior pancreaticoduodenal vein (ASPDV), GCT and ICV. The intraoperatively identified venous anatomy was consistent with the preoperative evaluation, and the RGEV, ASPDV and ICV were found to form the GCT.ConclusionWe report a rare vascular anatomical anomaly that was diagnosed preoperatively, facilitating safe and successful single-incision laparoscopic surgery with D3 lymph node dissection.

Vascular variants in laparoscopic extended right hemicolectomy with central vascular ligation for right colon cancer.

To evaluate the right colic vascularity, focusing on the confluences of veins. The subjects of this retrospective study were 100 patients who underwent laparoscopic extended right hemicolectomy (Lap-ERHC) between April 2015 and September 2020, at our hospitals. Veins draining into the superior mesenteric vein (SMV) included the ileocecal vein (ICV), the right colic vein (RCV), the middle colic vein (MCV), and the gastrocolic trunk of Henle (GCT). Veins draining into vessels other than the SMV were defined as accessory colic veins (aICV, aRCV or aMCV). The GCT, aRCV, and aMCV were found in 86, 89, and 15 patients, respectively. In 66 patients with one aRCV, drainage was split as the anterior superior pancreaticoduodenal vein (ASPDV) in 12, the right gastroepiploic vein (RGEV) in 7, and the GCT in 47. In 23 patients with two aRCVs, drainage was split as the ASPDV in 4, the RGEV in 1, the GCT in 11, and the ASPDV and GCT in 7. In 14 patients with one aMCV, drainage was split as the GCT in 8, the splenic vein in 5, and the first jejunal vein (FJV) in 1. One patient had two aMCVs, draining into the GCT and the FJV. The findings of our evaluation of vascular anatomy, focusing on confluences of the colic veins, provides useful information for colorectal surgeons.

Evaluating quality and completeness of gastrectomy for gastric cancer: review of surgical videos from the public domain.

YouTube® has provided a forum to share surgical videos in the public domain which may be used for education. The quality of surgery and accompanying educational material is unknown. YouTube® videos of gastrectomy with D2 lymphadenectomy (D2-LND) for gastric cancer were evaluated for quality and completeness. YouTube® was searched using the terms "D2 lymphadenectomy" and "Gastric Cancer" for open and laparoscopic videos. The Korean Laparoscopic Gastrointestinal Surgical Society (KLASS) outlined 22 steps that define quality and completeness of D2-LND. These guidelines were used to score D2-LND for each video. Four physician reviewers independently scored each surgical video. Scores were compared using Student's t-test. Ten laparoscopic and 10 open surgery videos were assessed. Each video was scored for quality and completeness and assigned a score out of 22. Mean score for open D2-LND was 15 (95% CI: 12.54-17.46). Mean score for laparoscopic D2-LND was 15.4 (95% CI: 14.34-16.46; P=0.77). The most consistently performed steps were the dissection of lymph node stations 1, 3, 4 and 5. The most commonly omitted steps were the dissection of lymph node station 6: exposure and identification of the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the lowest anterior superior pancreaticoduodenal vein; removal of the prepancreatic soft tissues above the level of the bifurcation of the anterior superior pancreaticoduodenal vein and right gastroepiploic vein. There is a wide range of quality and completeness of D2-LND videos. On average, D2-LND videos are only two-thirds complete.

Preoperative evaluation using multi-slice spiral CT angiography of right-side colon vascular in laparoscopic radical operation for right colon cancer

Objectives: To examine the value of multi-slice spiral CT angiography (MSCTA) in the analysis of anatomical variation and structural classification of right colon vessels. Methods: From August 2015 to August 2017, 198 patients (96 of whom underwent laparoscopic radical resection of right colon cancer) at Department of General surgery of Peking University First Hospital were retrospectively collected, and the results of abdominal enhanced CT scan were collected and three-dimensional reconstruction of blood vessels was performed. There were 104 males and 94 females. The age was 64(27) years (M(Q(R)), range: 19 to 87 years). Right gastroepiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein (RCV), superior right colonic vein, ileocolon artery or vein (ICA or ICV), middle colon artery or vein (MCA or MCV) and Henle trunk were observed and recorded respectively. The anatomical relationship between the positions of blood vessels, the length of Henle trunk and surgical trunk were measured. Results: ICV and ICA were the most constant anatomic structures. The ICV/ICA of all patients came directly from SMV/SMA, 36.9% (73/198) ICV going in front of SMV and 63.1% (125/198) behind SMV. 72.2% (143/198) of the patients had RCV imported into Henle trunk and the rest into SMV. Middle colonic vein (MCV) could be observed in 81.3% (161/198) of the cases. 81.4% (131/161) of MCV were imported into SMV, 16.8% (27/161) into Henle trunk, 1.2% (2/161) into the first jejunal vein and 0.6% (1/161) into the splenic vein. Henle trunk was divided into 4 types, among which the occurrence probability of gastric node and pancreatic trunk was the highest. The dry length of Henle trunk was (0.82±0.39) cm (range: 0.37 to 1.68 cm). The length of surgical trunk was (2.54±0.83) cm (range: 1.57 to 3.95 cm). Accuracy of MSCTA results was 96.9%(93/96). Conclusions: Anatomical variation of blood vessels in the right colon is common. Abdominal CT angiography can accurately determine the anatomical structure of the blood vessels in the right colon.

Gastrocolic trunk of Henle and its variants: review of the literature and clinical relevance in colectomy for right-sided colon cancer.

Venous vascular anatomy of the right colon presents a high degree of variability. Henle's Gastrocolic Trunk is considered an important anatomical landmark by colorectal surgeons. The classical description concerns a bipod vascular structure or tripod, but several variants are associated to it. The aim of this study is to merge the most updated literature on the anatomy knowledge of the Gastrocolic Trunk by evaluating all possible variants, as well as to underline its surgical importance due to its topographical relationships. Twelve studies describing the anatomy of the gastrocolic trunk were selected, each of them dealing with a more or less extensive series of cases. A distinction was drawn between the gastropancreatic trunk, devoid of the colonic component, and the gastrocolic trunk; and then the frequency of the different resulting variants was reported. The data obtained from cadavers and radiological studies were analyzed separately. The Gastrocolic Trunk is found in 74% of cadaver studies, and in 86% of radiological studies. Its most frequent configuration is represented by the union of right gastroepiploic vein + anterior superior pancreaticoduodenal vein + superior right colic vein, respectively, 32.5% and 42.5%, followed by the right colic vein which replaces (26.9%, 12.3%) or is added (10%, 20.1%) to the superior right colic vein. The superior right colic vein joins the right gastroepiploic vein and the anterior superior pancreaticoduodenal vein thus forming, in most cases, the gastrocolic trunk. The anatomical knowledge of vascular structures forms the basis for both the interpretation of preoperative radiological images and the surgical procedure itself, despite the considerable anatomical variability of tributaries.

The venous trunk of henle (gastrocolic trunk): A systematic review and meta-analysis of its prevalence, dimensions, and tributary variations.

Surgeons have recognized the clinical significance of the venous trunk of Henle during multiple pancreatic, colorectal, and hepatobiliary procedures. To date, no study has followed the principles of evidence-based anatomy to characterize it. Our aim was to find, gather, and systematize available anatomical data concerning this structure. The MEDLINE/PubMed, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science databases were searched. The following data were extracted: prevalence of the trunk of Henle, its mean diameter and length, the organization of its tributaries, method of anatomical assessment (cadaveric, radiological, or intraoperative), geographical origin, study sample, and known health status. Our search identified 38 records that included data from 2,686 subjects. Overall, the prevalence of the trunk of Henle was 86.9% (95% CI, 0.81-0.92) and the mean diameter was 4.2 mm. Only one study reported the length of the trunk (10.7 mm). The most common type of venous trunk (56.1%) was a vessel comprising three tributaries: gastric (right gastro-epiploic vein), pancreatic (most commonly the anterior superior pancreaticoduodenal vein), and colic (most commonly the superior right colic vein). The trunk of Henle is a common variant in the anatomy of the portal circulation. It is a highly variable vessel, but the most common type is a gastro-pancreato-colic trunk. In surgical practice, the presence of this venous trunk poses a high risk for bleeding, but it can also be a useful landmark during various abdominal procedures. Clin. Anat. 31:1109-1121, 2018. © 2018 Wiley Periodicals, Inc.

Value of the multi-slice spiral CT angiography, CT colonography and image fusion technology in preoperative evaluation of laparoscopic right colon cancer

Objective To observe the distribution and variation of right colonic vessels, and investigate the clinical value of computed tomography angiography (CTA), computed tomography colonography (CTC) and image fusion technology in preoperative evaluation of laparoscopic right colonic cancer (RCC). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 38 patients who underwent laparoscopic extended radical resection of RCC + D3 lymphadenectomy in the Affiliated Wuxi Second People′s Hospital of Nanjing Medical University between January 2015 and July 2017 were collected. Patients received preoperative plain and enhanced scans of abdominal and pelvic CT. The original images were reconstructed and fused by CTA and CTC, and then coming out with three-dimensional images of blood vessels and gut. Observation indicators: (1) branches of superior mesenteric artery (SMA); (2) positional relationship between SMA and superior mesenteric vein (SMV); (3) composition of gastrocolic venous trunk. Results Scan images of 38 patients had fused with scan images of vessels and primary tumors and reached the diagnostic standard, with a good imaging performance. Distribution of blood vessels of virtual reality (VR) images and were compared with that of naked blood vessels under intraoperative laparoscopy, showing a coincidence rate of 100.0%(38/38). (1) Branches of SMA: results of CTA and intraoperative anatomy showed that the occurrence rate of the right colonic artery, middle colonic artery and ileocolic artery were respectively 94.7%(36/38), 92.1%(35/38) and 100.0%(38/38). A right colonic artery was found in 28 patients. Ten patients had structure variation of right colonic artery, including 3 with 2 right colonic arteries and 2 without right colonic artery. The right colonic artery and middle colonic artery merged into the same trunk and then flowed into SMA were detected in 2 patients; the right colonic artery and ileocolic artery merged into the same trunk and then flowed into SMA were detected in 3 patients. (2) Positional relationship between SMA and SMV: results of CTA and intraoperative anatomy showed that the occurrence rate of both SMA and SMV was 100.0%(38/38). The SMA in 20 patients was located in the ventral side of SMV; SMA in 18 patients was located in the dorsal side of SMV. (3) Composition of gastrocolic venous trunk: results of CTA and intraoperative anatomy showed that 29 of 38 patients had gastrocolic venous trunks, which belonged to four sources, including right colonic vein, middle colonic vein, right gastric epiploic vein and anterior superior pancreaticoduodenal vein. Among 29 patients, 18 had 2- or 3-branch type of gastrocolic trunk that consisted of the right gastric epiploic vein, middle colonic vein and right colonic vein; 3 had 2-branch type of gastric pancreatic trunk that consisted of the right gastric epiploic vein and anterior superior pancreaticoduodenal vein; 8 had 3- or 4-branch type of stomach-pancreas-colon trunk that consisted of right gastric epiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein and middle colonic vein. Conclusion CTA, CTC and image fusion technology can intuitively show the anatomy and variation of right colonic vessels, with a high clinical value. Key words: Colonic neoplasms; Preoperative evaluation; Vascular reconstruction; Computed tomography angiography; Computed tomography colonography; Extend right hemicolectomy; Laparoscopy

Key vessels assessment and operation highlights in laparoscopic extended right hemicolectomy

Laparoscopic radical colectomies have been more widely used gradually, among which laparoscopic extended right hemicolectomy is considered as the most difficult procedure. The difficulty of extended right hemicolectomy lies in the need to dissect lymph nodes along the superior mesenteric vein (SMV) and disconnect numerous and possible aberrant vessels. To address this problem, we emphasize two points in key vessel assessment: getting familiar with the anatomy along the medial-to-lateral approach and having a good understanding about the preoperative imaging presentations. An accurately preoperative imaging assessment by abdominal enhanced CT can help the surgeon understand the relative position of the key vessels to be dealt with during operation and the situation of the possible aberrant vessels so as to guide the procedure more effectively and facilitate the prevention and management of the intraoperative complications. During operation, the operator should pay special attention to the management of the vessels in the ileocolic vessel region, Henle's trunk and middle colon vessels. The operation highlights of the key vessels are as follows: (1) The ileocolic vessels: identifying the Toldt's gap correctly and opening the vascular sheath of the SMV securely; making sure that the duodenum is well protected. (2) Henle's trunk: dissecting along the surface of the Henle's trunk; preserving the anterior superior pancreaticoduodenal vein (ASPDV) and main trunk of the Henle's trunk; disconnecting the roots of the right colic vein (RCV) and right gastroepiploic vein (RGEV), and then dissecting lymph nodes along the surface of the pancreas. (3) The middle colon vessels: identifying the root of the middle colon vessel along the lower edge of the pancreas; avoiding entering behind the pancreas; mobilizing the transverse mesocolon sufficiently along the surface of the pancreas. Finally, we discuss and analyze the disputes currently existing in laparoscopic extended right hemicolectomy, including dissection of No.6 lymph nodes, naking the SMA and dissecting lymph nodes around the roots of the branches of SMA. This article shares our experience about laparoscopic extended right hemicolectomy, hoping that it could help beginners master the technique more safely and skillfully.

Three-Dimensional Reconstruction of the Peripancreatic Vascular System Based on Computed Tomographic Angiography Images and Its Clinical Application in the Surgical Management of Pancreatic Tumors

This study aimed to investigate the clinical significance of 3-dimensional (3D) reconstruction of peripancreatic vessels for patients with suspected pancreatic cancer (PC). A total of 89 patients with PC were included; 60 patients randomly underwent computed tomographic angiography. Based on the findings of 3D reconstruction of peripancreatic vessels, the appropriate method for individualized tumor resection was determined. These patients were compared with 29 conventionally treated patients with PC. The rate of visualization was 100% for great vessels around the pancreas. The detection rates for anterior superior pancreaticoduodenal artery, posterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, posterior inferior pancreaticoduodenal artery, dorsal pancreatic artery, superior marginal arterial branch of the pancreatic head, anterior superior pancreaticoduodenal vein, posterior superior pancreaticoduodenal vein, anterior inferior pancreaticoduodenal vein, and posterior inferior pancreaticoduodenal vein were 86.6%, 85.0%, 76.6%, 71.6%, 91.6%, 53.3%, 61.6%, 55.0%, 43.3%, and 51.6%, respectively. Forty-three patients who had undergone 3D reconstruction underwent surgery. Of the 29 conventionally treated patients, 19 underwent surgery. The operative time, blood loss, length of hospital stay, and complication incidence of the 43 patients were superior to that of the 19 patients. A peripancreatic vascular reconstruction can reveal the vascular anatomy, variations of peripancreatic vascular, and tumor-induced vascular changes; the application of the simulation surgery platform could reduce surgical trauma and decrease operative time.

Surgical anatomy of the pancreas for limited resection.

The fusion fascia of the head of the pancreas is called the "fusion fascia of Treitz" and that of the body and tail of the pancreas is termed the "fusion fascia of Toldt". The fusion fascia is histologically composed of a loose connective tissue membrane. All of the important pancreaticoduodenal arcades of arteries and veins are situated on this membrane, i.e., between this membrane and the pancreatic parenchyma. The topography of the head of the pancreas shows that, after departing from the gastroducodenal artery, the anterior superior pancreaticoduodenal artery runs toward a point 1.5 cm below the papilla of Vater, then turns to the posterior aspect of the pancreas to join the anterior inferior pancreaticoduodenal artery. For preserving the duodenum, the artery toward the papilla is very important. The artery toward the papilla of Vater runs along the right side of the common bile duct after departing from the posterior superior pancreaticoduodenal artery. The gastrocolic trunk of Henle has been reported to be found in about 60% of individuals. It is possible that the gastroepiploic vein and anterior superior pancreaticoduodenal vein (ASPDV) can be divided at pancreaticoduodenectomy, with preservation of the superior right colic vein, if this area is free of carcinoma. The ASPDV and anterior inferior pancreaticoduodenal vein form an arcade on the anterior surface of the pancreas. However, arcade formation was not found between the posterior superior pancreaticoduodenal vein and posterior inferior pancreaticoduodenal vein in many of the individuals examined. The vein joined by the inferior mesenteric vein was also investigated.

Anterior Tributaries of the Portal Vein at the Superior Margin of the Pancreas: Is "Tunneling" Procedure Safe During Pancreatic Surgery?

It is widely believed that using the "tunneling" procedure during pancreatoduodenectomy is a safe maneuver because the anterior tributaries of the portal vein (PV) are absent or very rare. The head of the pancreas with the duodenum and the common bile duct (CBD) was obtained from 22 autopsy cases. Three colors of silicon-polymerase dyes were injected into the pancreatic artery, PV, and bile duct. The tributaries of the PV at the superior margin of the pancreas were studied. There was no anterior branch of the intrapancreatic PV. The anterior superior pancreaticoduodenal vein (ASPDV) gave a definite branch to the anterior aspect of the PV at the superior margin of the pancreas in 4 of 22 cases. When the posterior superior pancreaticoduodenal vein (PSPDV) was located in front of the CBD (5 of 22 cases), the ASPDV and PSPDV had a thick common trunk at the right side of the PV. In these 5 cases, no individual branch from the ASPDV was found at the anterior aspect of the PV. PV sometimes has a definite anterior tributary at the superior margin of the pancreas; this must be kept in mind to perform the tunneling procedure during pancreatic surgery.

Small peripancreatic veins: improved assessment in pancreatic cancer patients using thin-section pancreatic phase helical CT.

Recent studies have shown evaluation of the small peripancreatic veins to have potential in improving pancreatic cancer staging. This study was performed to determine the effectiveness of thin-section pancreatic phase helical CT images in visualizing these veins. Seventy-two patients (30 with pancreatic adenocarcinoma and 42 with no pancreatic disease) underwent dual-phase helical CT with thin-section pancreatic phase acquisition (40-70 sec after i.v. contrast initiation at 3 ml/sec) and hepatic phase acquisition (70-100 sec). Visualization (with diameter measurement) or nonvisualization of the posterior superior pancreaticoduodenal vein (PSPDV), anterior superior pancreaticoduodenal vein (ASPDV), and gastrocolic trunk was recorded for both acquisitions. We also correlated surgical tumor resectability with the status of the small peripancreatic veins. Visualization of peripancreatic veins was significantly better on pancreatic phase images than on hepatic phase images for both healthy individuals (PSPDV, 88% of the veins visualized on the pancreatic phase images versus 50% on the hepatic phase images; ASPDV, 93% on the pancreatic phase images versus 48% on the hepatic phase images; gastrocolic trunk, 98% on the pancreatic phase images versus 76% on the hepatic phase images) and for pancreatic cancer patients (PSPDV, 97% on the pancreatic phase images versus 57% on the hepatic phase images; ASPDV, 77% on the pancreatic phase images versus 43% on the hepatic phase images) (p < .05). The exception was the gastrocolic trunk in cancer patients (83% on the pancreatic phase images versus 77% on the hepatic phase images) (p > .05). In pancreatic cancer patients, 11 dilated peripancreatic veins were identified on the pancreatic phase images compared with six on the hepatic phase images. However, only one of the 11 dilated peripancreatic veins was in a patient with surgically resectable disease. In a dual-phase helical CT protocol, thin-section pancreatic phase images provided visualization of the small peripancreatic veins that was superior to hepatic phase images, providing further support for the use of this protocol in pancreatic cancer evaluation.

Carcinoma of the head of the pancreas: evaluation of the pancreaticoduodenal veins with dynamic CT--potential for improved accuracy in staging.

To determine if detection of abnormal dilatation of pancreaticoduodenal veins can improve the accuracy of computed tomographic (CT) staging of pancreatic adenocarcinoma. CT scans obtained during bolus administration of contrast material in 86 patients (aged 34-85 years) with pancreatic head carcinoma were reviewed. The diameter of the small veins that surround the head of the pancreas was measured (normal diameter of gastrocolic trunk, < or = 7 mm; of anterior superior pancreaticoduodenal vein, < or = 4 mm; of posterior superior pancreaticoduodenal vein, < or = 4 mm). Twenty-nine abnormally dilated peripancreatic veins were identified in 22 patients. Twenty-two of these dilated veins were in 16 patients with other CT criteria of tumor unresectability; seven dilated veins were in six patients with tumors deemed resectable at CT. All tumors in these latter six patients were unresectable at surgery. Although dilatation of these small peripancreatic veins without other CT criteria of tumor unresectability is an unusual finding, it may be a reliable sign of unresectable pancreatic carcinoma.

Venous anatomy of the pancreatic head: normal CT appearance in cadavers and patients.

This study was conducted to define the normal CT appearance of the four pancreaticoduodenal veins (anterior and posterior superior, and anterior and posterior inferior) in the head of the pancreas in injected cadaveric specimens and to assess the frequency with which these normal vessels are seen on dynamic contrast-enhanced CT scans. The appearance of the four pancreaticoduodenal veins was studied on CT scans of four cadavers in which the portal veins were injected in situ with radiopaque solutions. A computer-generated three-dimensional model of the pancreatic head and its venous drainage was then produced from one cadaveric examination to show the venous anatomy. After definition of the venous anatomy in the cadaveric specimen, the anterior superior pancreaticoduodenal vein, posterior superior pancreaticoduodenal vein, and gastrocolic trunk were analyzed retrospectively on dynamic bolus contrast-enhanced abdominal CT scans of 100 consecutive patients who had no evidence of pancreatic disease. The anterior and posterior superior pancreaticoduodenal veins were seen on 98% and 88% of scans, respectively. The veins had mean diameters of 2.1 mm. The gastrocolic trunk was seen on 89% of scans and had a mean diameter of 4.7 mm. The inferior pancreaticoduodenal veins are small and were not identified definitively. The anterior and posterior superior pancreaticoduodenal veins and gastrocolic trunk are routinely visualized on CT scans of patients without pancreatic disease. Consequently, assessment of the veins may be useful in staging pancreatic carcinoma.

Anatomy of the pancreatic veins. A post mortem and clinical phlebographic investigation.

The venous anatomy of 22 autopsy specimens of human pancreas was examined by dissection and radiography after injection of gelatin agent. The most constant findings were the posterior superior pancreaticoduodenal vein draining to the portal vein and the anterior superior pancreaticoduodenal vein draining to the gastrocolic trunk and superior mesenteric vein. Both veins were identified in 21 and 20 of 22 cases, respectively. All other pancreatic veins varied considerably in their course. The normal findings in clinical selective pancreatic phlebography based on 148 examinations are described.