Gastric Branches Research Articles

An interesting change in the branching pattern of abdominal aorta artery in abdominal cavity

Anatomical changes of the abdominal aorta artery are highly important in the liver, pancreas, bile ducts, liver transplantation, and abdominal radiological interventions, and knowing about them can reduce the risk of complications from surgery. In this case, an 80-year-old man had anatomical changes in the superior mesenteric and celiac arteries. This person had a celiac arterial trunk, which had a left gastric branch, a splenic branch, and a branch to the diaphragm. In addition to its main branches, the upper mesenteric artery had a hepatic artery (HA) moving toward the liver. Knowing the changes in the celiac trunk and HA is highly essential for designing some abdominal surgeries, including liver transplants, pancreatoduodenectomy, biliary reconstruction, gastrectomy, and other abdominal disorders.

Challenging arterial pattern of foregut and its potential impact on surgery.

Anticipating a wide range of morphological variations of arterial anatomy of foregut derivatives beyond the classical pattern, a precise understanding is pertinent to preoperative diagnosis, operative procedure and to avoid potentially devastating post-operative outcome during various traumatic and non-traumatic vascular insult of foregut. The study aimed to revisit the morphological details and update unusual configurations of arteries of foregut to establish clinico-anatomical correlations. This study described the detailed branching pattern of coeliac trunk (CT) as principal artery of foregut with source & course of hepatic, gastric, duodenal and pancreatic branches in 58 cadaveric dissections. Based on morphology, different types and subtypes were made. The descriptions were explained using figures and pertinent tables. Among classical branches of CT, splenic artery was found as most stable whereas other two branches were found to be most variable with missing common hepatic artery in 11 cases. In addition to classical trifurcation (65.52%), different types of bifurcation (12.07%) and tetrafurcations (22.41%) of CT were observed. Regarding variations of hepatic arteries (27.59%), both non-classical origin and accessory hepatic branches were found. In case of gastric branches, more variant origins were seen with right gastric (50%) as compared to left gastric artery (34.48%). Other morphological variations included non-classical origin of gastro-duodenal artery (18.96%) along with presence of accessory pancreatic (17.13%) and duodenal arteries (6.38%). Awareness of anatomical variations regarding circulatory dynamics of foregut is worth knowing in order to facilitate successful planning of surgery involving upper abdominal organs with least complications.

Vagus nerve damage increases alcohol intake and preference in a nonpreferring rat line: Relationship to vagal regulation of the hypothalamic-pituitary-adrenal axis.

Clinical and preclinical research indicates that gastric weight loss surgeries, such as Roux-en-Y gastric bypass surgery, can induce alcohol use disorder (AUD). While numerous mechanisms have been proposed for these effects, one relatively unexplored potential mechanism is physical damage to the gastric branch of the vagus nerve, which can occur during bypass surgery. Therefore, we hypothesized that direct damage to the gastric branch of the vagus nerve, without altering other aspects of gastric anatomy, could result in increased alcohol intake. To test this hypothesis, we compared alcohol intake and preference in multiple models in male Sprague-Dawley rats that received selective gastric branch vagotomy (VX) with rats who underwent sham surgery. Because the vagus nerve regulates hypothalamic-pituitary-adrenal (HPA) axis function, and alterations to HPA function are critical to the escalation of non-dependent alcohol intake, we also tested the hypothesis that gastric VX increases HPA function. We found that VX increases alcohol intake and preference in the every-other-day, two-bottle choice test and increases preference for 1 g/kg alcohol in the conditioned place preference test. The effects were selective for alcohol, as sucrose intake and preference were not altered by VX. We also found that VX increases corticotropin releasing factor (CRF) mRNA in the paraventricular nucleus of the hypothalamus (PVN), increases putative PVN CRF neuronal action potential firing, and increases corticosterone levels. Overall, these findings suggest that the vagus nerve may play a critical role in regulating HPA axis function via modulation of PVN CRF mRNA expression and putative PVN CRF neuronal activity. Furthermore, disruptions to vagal regulation of HPA axis function may increase alcohol intake and preference.

Variations in the origin of the infrapyloric artery: A systematic review and meta-analysis

BackgroundThe infrapyloric artery (IPA) supplies the pylorus and the large curvature of the antrum. Its common origin points include the gastroduodenal artery (GDA) and right gastroepiploic artery (RGEA). The prevalence of variations in IPA origins can be of interest to gastric cancer surgeons who wish to increase their understanding of this vessel. The primary aim of this study was to perform a systematic review and meta-analysis on the origin of the IPA. The secondary aims were to assess imaging identification accuracy, to identify IPA morphological features, and to explore the relationship of IPA origin and clinicopathological characteristics. MethodsElectronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched through March 2023. There were no constraints based on language, publication status, or patient demographics. Database search, data extraction and risk of bias assessment were performed independently by two reviewers. The point of origin of the IPA was the primary outcome. Secondary outcomes were imaging identification accuracy, relationship between IPA origin and clinicopathological characteristics, and IPA morphological features. A random-effects meta-analysis of the prevalence of different IPA origins was conducted. Secondary outcomes were narratively synthesized given the heterogeneity of studies reporting on these. ResultsA total of 7279 records were screened in the initial search. Seven studies were included in the meta-analysis, assessing 998 patients. The IPA arose most frequently from the anterior superior pancreaticoduodenal artery (ASPDA), with a pooled prevalence of 40.4% (95% CI 17.1–55.8%), followed by the RGEA with a pooled prevalence of 27.6% (95% CI 8.7–43.7%), and the GDA with a pooled prevalence of 23.7% (95% CI 6.4–39.7%). Cases of multiple IPAs had a pooled prevalence of 4.9% (95% CI 0–14.3%). The IPA was absent in 2.6% (95% CI 0–10.3%) of cases and arose from the posterior superior pancreaticoduodenal artery (PSPDA) in the remaining 0.8% (95% CI 0 – 6.1%). Distance between the pylorus and the proximal branch of the IPA and distance from the pylorus to the first gastric branch of the RGEA when the IPA originated from the ASPDA and RGEA were longer than when the IPA originated from the GDA. The IPA is a small vessel (<1 mm), and its origin is not related to clinicopathological characteristics including patient sex, age, and tumor stage and location. ConclusionsSurgeons must be aware of the most common origin points of the IPA. Recommendations for future study include the stratification of IPA origin according to demographic characteristics, and further investigation into IPA morphological parameters such as tortuosity, course and relation to adjacent lymph nodes, aiding the creation of a standardized classification system pertaining to the anatomy of this vessel.

Hemodynamics in the right gastroepiploic artery and its practical application

To study functional anatomy of the right gastroepiploic artery (RGEA), its gastric and omental branches and practical significance of these anatomical features. We analyzed 20 cadaveric organ complexes (11 men and 9 women, aged 49-85 years) between 2018 and 2019. The organ complexes consisted of the stomach, proximal duodenum and large omentum. RGEA catheterization at the level of pylorus was followed by selective real time angiography. We assessed the following parameters of RGEA: total length, diameter at the level of pylorus, number and diameter of gastric and omental branches. To objectify the study, we visually divided RGEA into 5 equal segments between pylorus and the last branch arising from this artery. The RGEA looks like a gradually and evenly narrowing tube. Mean diameter of the artery at the level of pylorus was 2.2±0.68 mm, mean length - 23.6±3.7 cm. Mean number of gastric and omental branches was 16.2±4.8 and 8.6±2.6, respectively. The number of gastric branches in the distal part of the RGEA increased, while the diameters of the gastric branches did not significantly differ. The number of gastric branches in distal RGEA increased, while diameters of gastric branches were similar. The greatest number of omental branches with the largest diameter was observed in the 2nd and 3rd segments of the artery. Considering these data, we formulated the equation for RGEA hemodynamics and developed the technique for optimal blood supply to proximal part of the gastric transplant during esophagogastroplasty. Anatomical features of the right gastroepiploic artery can be used in reconstructive surgery of abdominal cavity and chest.

Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography

BackgroundTo perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data.MethodsPerigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery.ResultsOf the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively.ConclusionsPreoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.

Hepatocellular Carcinoma Supplied by the Inferior Phrenic Artery or Cystic Artery: Anatomic and Technical Considerations.

Intra-arterial treatment has been identified as one of the mainstays in the management of unresectable hepatocellular carcinoma. A thorough knowledge of tumor arterial supply enables selective therapy, which improves both safety and efficacy. The inferior phrenic artery (IPA) is the most common extrahepatic collateral artery that feeds hepatocellular carcinoma. The bilateral IPAs are known to have a specific vascular anatomy. A systemic-to-pulmonary shunt and a gastric branch from the IPAs may be present and should not be confused with tumor blush. The supraceliac aorta and celiac trunk are the common origin sites of the IPAs, and their orifice may be compressed by the diaphragm. Various techniques and catheters are used for catheterization of the IPAs, depending on their origin sites. Because the IPA is normally connected with the intercostal, internal mammary, retroperitoneal, and hepatic arteries, its hemodynamics may be altered when its orifice is occluded. In general, superselective chemoembolization via the target branch of the IPA is safe and effective. When a systemic-to-pulmonary shunt from the IPA is adequately embolized with coils or particles, radioembolization through the IPA can be performed safely in most cases. The cystic artery branches into deep and superficial cystic arteries; deep cystic arteries often supply tumors near the gallbladder. Chemoembolization through the cystic artery is relatively safe, with transient embolic materials. Radioembolization through the cystic artery has been recently tried, with acceptable efficacy and toxicity results, but it requires further investigation. ©RSNA, 2022.

Impact of Vagotomy on Postoperative Weight Loss, Alimentary Intake, and Enterohormone Secretion After Bariatric Surgery in Experimental Translational Models.

Obesity may be treated by bariatric procedures and is related to enterohormone release modulation. Nevertheless, a majority of commonly used surgical procedures have a significant impact on vagus nerve function by breaking the connections with its gastric branches. In the case of an intragastric balloon (BAL), this interaction is unclear. However, BAL-induced weight reduction is not long-lasting. Interestingly, this method has not been used in combination with vagotomy (VAG). Thus, we evaluated, for the first time, the short- and long-term effects of combined BAL and VAG using the animal-based translational model and compared these effects with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Wistar rats were fed a high-calorie diet for 8weeks to induce obesity before SG, RYGB, BAL + / - VAG. Animals' weight and eating behaviors were monitored weekly. After 90days, serum samples were collected to evaluate postprandial and fasting GLP-1, GIP, PYY, ghrelin, glucagon, insulin, leptin, and pancreatic polypeptide concentrations by fluorescent assay. VAG, SG, RYGB, and BAL + VAG significantly reduced body weight 30 and 90days after surgery. BAL alone induced temporal weight reduction observed after 30days, reversed after 90days. Calories intake was reduced at the first half of the observation period in all groups. Fluid intake was reduced in all groups except SG and BAL. Enterohormone profile for BAL + VAG was comparable to SG and RYGB but not BAL. VAG and BAL + VAG but not BAL alone maintain weight reduction, alimentary intake changes, and enterohormone release after long-term observation. VAG may improve the effectiveness of bariatric procedures for obesity treatment in clinical practice.

Predominant role of gut-vagus-brain neuronal pathway in postoperative nausea and vomiting: evidence from an observational cohort study

BackgroundPostoperative nausea and vomiting (PONV) as a clinically most common postoperative complication requires multimodal antiemetic medications targeting at a wide range of neurotransmitter pathways. Lacking of neurobiological mechanism makes this ‘big little problem’ still unresolved. We aim to investigate whether gut-vagus-brain reflex generally considered as one of four typical emetic neuronal pathways might be the primary mediator of PONV.MethodsThree thousand two hundred twenty-three patients who underwent vagus nerve trunk resection (esophagectomy and gastrectomy) and non-vagotomy surgery (hepatectomy, pulmonary lobectomy and colorectomy) from December 2016 to January 2019 were enrolled. Thirty cases of gastrectomy with selective resection on the gastric branch of vagus nerve were also recruited. Nausea and intensity of vomiting was recorded within 24 h after the operation.ResultsPONV occurred in 11.9% of 1187 patients who underwent vagus nerve trunk resection and 28.7% of 2036 non-vagotomy patients respectively. Propensity score matching showed that vagotomy surgeries accounted for 19.9% of the whole PONV incidence, much less than that observed in the non-PONV group (35.1%, P < 0.01). Multivariate logistic regression result revealed that vagotomy was one of underlying factor that significantly involved in PONV (OR = 0.302, 95% CI, 0.237-0.386). Nausea was reported in 5.9% ~ 8.6% vagotomy and 12 ~ 17% non-vagotomy patients. Most vomiting were mild, being approximately 3% in vagotomy and 8 ~ 13% in non-vagotomy patients, while sever vomiting was much less experienced. Furthermore, lower PONV occurrence (10%) was also observed in gastrectomy undergoing selective vagotomy.ConclusionPatients undergoing surgeries with vagotomy developed less PONV, suggesting that vagus nerve dependent gut-brain signaling might mainly contribute to PONV.

Modeling Vagal Nerve Compound Action Potential Parameters to Control Specific Nerve Fiber Pathways

Neuromodulation of the peripheral nervous system has shown potential as an effective targeted therapy for conditions such as Parkinson's disease, chronic pain and gastroparesis. Stimulation of the vagus nerve is of particular interest since the nerve stretches from the brain to the colon, and parasympathetically controls nearly every organ in between. Thus, a detailed understanding of the vagus nerve morphologies and their ideal stimulation parameters is vital to delivering effective neuromodulation therapy with predictable and reproducible outcomes. The primary goal of this project is to utilize a recently developed compound action potential (CAP) modeling tool to characterize the interplay between four key parameters for bipolar vagal nerve recordings: stimulus pulse shape, cuff length, conduction distance, and peak amplitude of the resulting CAP volley. Sample data from the model's optimization tool is shown in Figures 1-2 below, indicating that the optimal cuff length and conduction distance for maximizing the CAP peak amplitude from bipolar recordings in the vagal ventral gastric branch ranges from 1-4 mm and 0-2 mm, respectively. This data was collected from a CAP model that corresponds to particular subsets of nerve fibers within the vagus nerve that supply individual organs, in this case the ventral gastric branch of the stomach. Further research will break down this CAP feedback to identify individual vagal nerve fiber pathways and their effect on linked organs, ultimately helping create more functional and targeted stimulation therapies.

Effects of methyl methacrylate on the excitability of the area postrema neurons in rats

ObjectivesThe aim of the present study is to demonstrate the effects of inhaled methyl methacrylate (MMA) on the excitability of neurons in the area postrema (AP). We also investigated the relation between vagal afferent inputs and responding cells in the AP. MethodsWe set up two groups of experimental animals, such as rats inhaling MMA and rats inhaling room air. To visualize the changes of AP neuron excitability after inhalation of MMA for 90 min, c-Fos protein expression was identified and quantified by immunohistochemical analysis. Some rats receiving ventral gastric branch vagotomy were also subjected to the abovementioned experiment. ResultsThe number of c-Fos-immunoreactive (Fos-ir) cells in the MMA group was more than six times greater than that of the control group (statistically significant, p < 0.01). In vagotomized rats inhaling MMA, markedly smaller number of Fos-ir cells was identified in the AP compared to that of rats inhaling MMA without vagotomy. ConclusionsThese results indicate that inhalation of MMA increases neuronal excitability in the AP, suggesting that vagal afferent inputs are involved in the induction mechanism of Fos-ir cells by MMA.

Laparoscopic Left Gastric Artery-Preserving Subtotal Gastrectomy with D2 Lymphadenectomy in a Patient with Gastric Cancer and a Replaced Left Hepatic Artery

Introduction: An aberrant left hepatic artery (aLHA) may be seen in 8%–15% of cases1,2 and a replaced LHA (rLHA) may be seen in ~2%–11% of cases.1,3 An aLHA and a rLHA assume significant importance during gastric resections. A preoperative assessment of this anatomy is particularly important in laparoscopic surgery because of loss of tactile feedback of the arterial pulsation within the lesser omentum. When present, the artery of origin should be preserved. This video demonstrates a gastric resection for cancer where a diligent review of imaging identified a rLHA arising from the left gastric artery (LGA). An LGA preserving radical gastrectomy, without compromising oncologic principles, was performed. Methods: A 54-year-old male patient presented with melena and he underwent an upper endoscopy and was found to have an antropyloric lesion. Biopsy showed adenocarcinoma. A contrast-enhanced CT scan showed the tumor, perigastric lymph nodes, and a rLHA arising from the LGA—Michel's Type 2 anatomy.4 A laparoscopic LGA preserving subtotal gastrectomy with D2 lymphadenectomy was planned. The patient was operated in the French position with five ports, which included a 10-mm umbilical camera port, and 5- and 12-mm left and right working ports, respectively, in the midclavicular line. Standard steps of a subtotal gastrectomy with D2 lymphadenectomy were followed with modification to preserve the LGA. After dividing the greater omentum from the transverse colon, all the tissues around the left and right gastroepiploic, common hepatic, right gastric, proper hepatic, celiac axis, and proximal splenic arteries were meticulously cleared to remove all the lymph nodes en bloc. The lesser omentum was incised and the rLHA was identified along with the LGA. The LGA was circumferentially cleared and the gastric branches divided to complete the en bloc lymphadenectomy. Results: The patient had an uneventful recovery. He was tolerating solids by postoperative day 5. His postoperative liver function tests were normal. He was discharged on the eighth postoperative day. The histopathology was moderately differentiated adenocarcinoma pT1bN0 with 0/32 lymph nodes positive. Conclusion: During a laparoscopic gastric resection, it is pertinent to look for vascular anomalies, including a rLHA in the preoperative imaging to prevent accidental injury. When present, the vessel of origin should be preserved. A laparoscopic LGA sparing radical gastrectomy is feasible without compromising the oncologic safety. No competing financial interests exist. Runtime of video: 9 mins 51 secs

SPARC: A Hybrid Computational Approach to Classify Vagal C Fiber Functions

Neuroscience conventionally categorizes all unmyelinated fibers into an undifferentiated C fiber classification, implying a common function and impeding further classification. This is highly problematic, especially for autonomic nerves like the abdominal vagus, which contains &gt;99% unmyelinated C fibers. We require a modern classification framework to discriminate differences among these important, underappreciated messengers. One important and easily measurable property of C fibers is their conduction speed, which relates directly to their morphology or caliber. We present a hybrid computational modeling approach, integrating biophysical (HH‐type) and classical (e.g., Gasser, Erlanger and Grundfest) methods, to enable the classification of C fiber function according to fiber caliber/speed.The Hybrid Nerve Response Modeling and Classification System is a tool to classify C fiber functions with respect to fiber caliber and radial location within a nerve. Biophysical models of HH axons contribute a bottom‐up model of fiber activation that explains the influence of the electrode configuration and other factors on fiber activation threshold and the measured compound action potential (CAP) profile. Alternatively, modeled CAPs can be generated through superposition of individual axon contributions (single fiber action potentials; SFAPs), relating fiber caliber distribution data to SFAP shape and conduction properties; this classical model of the CAP accurately predicts the experimentally measured maximal CAP shape. Using published and novel nerve ultrastructure data, we unified the biophysical and classical modeling approaches in a new simulation framework that predicts graded CAP profiles in response to bipolar, constant‐current stimuli delivered through various cuff electrode configurations.In this work, we demonstrate how the Hybrid Model can be used to discern the spatial and size distribution of unmyelinated C fibers from the CAP of the ventral gastric branch of the rat vagus nerve. Through our web‐based user interface (Fig. 1), we will show how our system can predict the activation threshold of unmyelinated fibers in any nerve cross section as a function of the individual fiber size and spatial location within a common set of electrode geometries. We will provide examples of how this information may be used to accelerate our delineation of the various functions of C fibers using measured associations between nerve and organ responses to stimulation.Support or Funding InformationFunding AcknowledgmentsThis work was supported by NIH SPARC OT2 OD023847 (PI: Powley), NIH SPARC OT2 OD025340 (PI: Grill) and NIH SPARC OT2 OD026585 01 (PI: Havton)[LEFT] Web‐based interface for the Hybrid Model. [FAR RIGHT] Segmented electron micrograph of n = 4776 C fibers from a rat ventral vagal gastric branch. The user interface lets users track the location (e.g., spatial location in the nerve cross section and temporal location in the CAP response) and relative activation thresholds of C fibers with respect to observed changes in the downstream physiology of the organs and tissues they supply.Figure 1

SPARC: Transcutaneous Auricular Vagal Nerve Stimulation Increases Antroduodenal Motility in Rat within a Narrow Range of Stimulus Parameters

Transcutaneous auricular vagus nerve stimulation (taVNS) is a promising, non‐invasive approach to modulate activity in the central nervous system, heart, lungs, stomach and other organs that receive projections from the vagus nerve. The optimal stimulus parameters for modulating stomach function are unknown, preventing further development of taVNS as a device‐based treatment for motility disorders like gastroparesis. We hypothesized that taVNS parameters could be tuned to preferentially modulate antroduodenal motility with fewer off‐target effects on the heart than cervical VNS. Using a custom‐made stimulation and recording system (Autonomous Neural Control, or ANC), we surveyed the taVNS‐mediated effects on cardiac, vagal (ventral gastric branch), antral and duodenal motility in male Sprague Dawley rats under isoflurane anesthesia (250–400 g; N = 14 rats). With custom carbon gel electrodes, we stimulated the left cymba concha at 1 or 10 Hz using 28 combinations of stimulus pulse currents and durations (0, 0.2, 0.4, 0.6, 0.8, 1.0 and 1.2 mA pulse currents in combination with 0.1, 0.2, 0.4 and 0.8 ms pulse durations), while measuring the electrocardiogram, antral electrogastrogram, and antral/duodenal motility with implanted strain gauges. The ANC software applied each stimulus parameter combination in a random order in 60 s cycles (20 s ON/40 s OFF). Stimulus pulse durations less than 0.4 ms were not associated with any significant effects on cardiac (measured from the electrocardiogram) or gastric activity (measured from the antral electrogastrogram as well as antral and duodenal strain gauge recordings), but did produce notable increases in nerve activity at the level of the ventral gastric branch (measured with an implanted bipolar cuff electrode). A pulse duration of 0.8 ms produced the most robust and consistent decrease in heart rate, increase in heart rate variability, increase in antral smooth muscle activity, and increase in antroduodenal motility, as is expected from an increase in vagal outflow. In contrast to cervical VNS, where the optimal parameters for increasing antral motility largely overlapped with those that induced severe bradycardia, the optimal taVNS parameters that increased antroduodenal motility at 1 or 10 Hz (Pulse Current: 0.2–0.6 mA | Pulse Duration: 0.4–0.8 ms) required less current, on average, than the stimulus parameters that produced the greatest reduction in heart rate and increase in heart rate variability (Pulse Current: 0.4–1.0 mA | Pulse Duration: 0.4–0.8 ms). Pulse currents greater than 0.6 mA did not have any significant effect on antroduodenal motility, supporting the value of our parameter search approach in sorting the useful from the useless stimulus parameters. These results strongly support taVNS as a viable approach to modulate gastrointestinal activity with greater specificity and control over stomach function than cervical VNS.Support or Funding InformationThis work was supported by NIH SPARC OT2 OD023847

A new described mechanisms of intestinal glandular atrophy induced by vagal nerve/Auerbach network degeneration following subarachnoid hemorrhage: The first experimental study

Stress ulcers is a trouble complication of subarachnoid hemorrhage (SAH). Although gastrointestinal ulcerations may be attributed to increased HCL secretion in SAH; the exact mechanism of that complication has not been investigated definitively. We studied if vagal network degeneration may cause intestinal atrophy following SAH. Study was conducted on 25 rabbits, with 5 control group (Group-A), 5 SHAM group (Group-B), and 15 SAH group via injection of autologue blood to cisterna magna. Seven animals followed for seven days (Early Decapitated-Group-C) and eight animals followed 21 days (Late Decapitated-Group-D). The vagal nodosal ganglia (NGs), Auerbach plexuses and goblet cells of duodenums were examined by current stereological methods and compared statistically. The mean numbers of degenerated axon density/mm2 of gastric branches of vagal nerves was 8 ± 2, 34 ± 11, 189 ± 49 and 322 ± 81 in the Group A, B, C, and D respectively. The mean numbers of degenerated neuron density/mm3 of NGs was 5 ± 2, 54 ± 7, 691 ± 87 and 2930 ± 410 in the Group A, B, C, and D respectively. The mean numbers of degenerated Auerbach neurons 2 ± 1, 4 ± 1, 12 ± 3 and 27 ± 5/mm3 in the Group A, B, C, and D respectively. The mean numbers of degenerated goblet cells/mm3 were 4.3 ± 1.02, 11.5 ± 0.26, 143 ± 26 and 937 ± 65 Group A, B, C, and D respectively. Statistical analysis showed that vagal network ischemia could cause intestinal bleeding and so atrophy in SAH progression. Statistical analyses of groups were; Group-D/Group-A < 0.001, Group-D/Group-B < 0.005, Group-C/Group-A < 0.005. Undiscovered effect of ischemic vagal network injuries should be regarded as a major cause of stress ulcerations following SAH which has not been mentioned in the literature.

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

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. 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. 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. 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.

Congenital Absence of the Splenic Artery Presenting as Massive Gastric Hemorrhage

Gastric bleeding due to collateral arteries from a congenital absence of the splenic artery is very rare. To the best of our knowledge it has been reported only three other times in literature. Treatment of these difficult to visualize vessels can be challenging as the unknown vascular anatomy can lead to an unsure diagnosis and hesitant treatment during emergent endoscopy. We present a case of massive gastrointestinal bleeding from an aberrant artery in the fundus in the absence of the splenic artery treated with coli embolization and endoscopic ultrasound (EUS) guided placement of over the scope clip (OTSC). A 66-year-old male presented with hematemesis and hemorrhagic shock. Within the last eight years, the patient had undergone previous endoscopies for hematemesis and melena without evidence of active GI bleeding at time of endoscopy. However, the presence of thickened folds in the fundus, suggestive of isolated gastric varices, had been noted but no further investigations performed. Emergent upper endoscopy this time revealed a large clot within the fundus that was unable to be cleared. Blakemore tube was placed to while the patient was further stabilized. Computerized tomography (CT) showed no evidence of cirrhosis, portal hypertension or splenic vein thrombus though it did show an ongoing arterial bleed in the fundus around the gastric balloon of the Blakemore tube. Visceral angiogram found an absence of the splenic artery with collateral flow of short gastric vessels. The left and right gastric arteries were hypertrophied and there was active bleeding at the left gastric branch vessel at the fundal level. Coil embolization at the mid-distal left gastric artery resulted in successful hemostasis. Over the next few days the patient remained hemodynamically stable but had a down trending hemoglobin level. In hopes to localize and direct endoscopic intervention an upper endoscopy with EUS was performed. There was an area of tortuous and thicken folds with ulceration in the fundus with evidence of oozing and an OTSC was placed. The patient remained stable and was discharged three days later. This case describes a rare condition of a congenital absence of the splenic artery that lead to massive gastrointestinal hemorrhage from aberrant arterial vessels. Quick diagnosis and the use of both endoscopic and interventional radiologic treatments resulted in a successful outcome without the need for surgery.

A Detailed Study of Multiple Vascular Variations in the Upper Part of Abdomen.

Introduction:Knowledge of vascular variations near the kidney is of importance to many clinical disciplines such as nephrologists, radiologists, gastroenterologists, and general surgeons. Variant branches of the abdominal aorta and renal arteries are the victims of iatrogenic bleeding during surgery. We found multiple vascular variations in the upper part of the abdomen during our dissection classes.Methods:During the dissection classes of the abdomen for undergraduate medical students, we observed multiple vascular variations in the abdomen of an adult male cadaver. The vessels and surrounding viscera were cleaned using dissection instruments. Variations observed were photographed.Results:The right kidney had its hilum directed posteriorly. There were two right renal veins and a partially doubled left renal vein (LRV). The left suprarenal and gonadal veins drained into the upper LRV. There were two right renal arteries. Upper right renal artery gave origin to the right inferior phrenic and middle suprarenal arteries. There were two renal arteries on the left side also. The left upper renal artery gave a polar branch to the left kidney and divided into two branches before entering the kidney. The left inferior phrenic artery (IPA) gave two gastric branches to the fundus of the stomach.Conclusions:The variations noted by us are of tremendous surgical application. The variant vessels might get damaged during surgical procedures if the surgeons are not aware of these variations. The most important among the variations reported here is the gastric branch of the IPA, which has not been reported yet.

L-Arginine L-Glutamate Enhances Gastric Motor Function in Rats and Dogs and Improves Delayed Gastric Emptying in Dogs.

Amino acids are not only constituents of proteins, but also have multiple physiologic functions. Recent findings have revealed that ingested amino acids either activate luminal receptors or are metabolized, causing physiologic reactions in the gastrointestinal (GI) tract. We examined the effect of oral L-arginine L-glutamate (ArgGlu), a pharmaceutical amino acid salt used i.v. for the treatment of hyperammonemia, on gastric motor function in rats and dogs. Gastric emptying was determined using phenol red and 13C-breath test methods, whereas gastric relaxation was determined using the barostat method. ArgGlu (10-30 mg/kg, p.o.) dose-dependently promoted gastric emptying in rats. This effect was dependent on vagus nerve activation and comparable to that of the prokinetic mosapride. Intragastric ArgGlu (3-30 mg/kg intragastrically) also dose-dependently enhanced adaptive relaxation of rat stomachs, which was negated not by vagotomy of gastric branches, but by pretreatment with N omega-nitro-L-arginine methyl ester (20 mg/kg i.v.), a nitric oxide synthase inhibitor. Its relaxing effect on the stomach was also confirmed in dogs and was equally as efficacious as treatment with sumatriptan (1-3 mg/kg s.c.). ArgGlu (30 mg/kg p.o.) significantly reduced the half gastric emptying time in clonidine-induced delayed gastric emptying of solids in dogs, and its effect was comparable to that of cisapride (3 mg/kg p.o.). This study demonstrated that the pharmaceutical ingredient ArgGlu, currently used i.v., enhanced gastric motor function when administered orally, suggesting that it could be a new oral medicine indicated for treatment of upper GI hypofunction or dysfunction like functional dyspepsia.

Effects of intraperitoneally administered L-histidine on food intake, taste, and visceral sensation in rats.

To evaluate relative factors for anorectic effects of L-histidine, we performed behavioral experiments for measuring food and fluid intake, conditioned taste aversion (CTA), taste disturbance, and c-Fos immunoreactive (Fos-ir) cells before and after i.p. injection with L-histidine in rats. Animals were injected with saline (9ml/kg, i.p.) for a control group, and saline (9ml/kg, i.p.) containing L-histidine (0.75, 1.5, 2.0g/kg) for a L-histidine group. Injection of L-histidine decreased the average value of food intake, and statistically significant anorectic effects were found in animals injected with 1.5 or 2.0g/kgL-histidine but not with 0.75g/kgL-histidine. Taste abnormalities were not detected in any of the groups. Animals injected with 2.0g/kgL-histidine were revealed to present with nausea by the measurement of CTA. In this group, a significant increase in the number of Fos-ir cells was detected both in the area postrema and the nucleus tractus solitarius (NTS). In the 0.75g/kgL-histidine group, a significant increase in the number of Fos-ir cells was detected only in the NTS. When the ventral gastric branch vagotomy was performed, recovery from anorexia became faster than the sham-operated group, however, vagotomized rats injected with 2.0g/kgL-histidine still acquired CTA. These data indicate that acute anorectic effects induced by highly concentrated L-histidine are partly caused by induction of nausea and/or visceral discomfort accompanied by neuronal activities in the NTS and the area postrema. We suggest that acute and potent effects of L-histidine on food intake require substantial amount of L-histidine in the diet.