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Posterior gastric artery and its significance as seen in angiograms
Posterior Gastric Artery and its Significance As Seen in Angiograms
Liberato J. A. DiDio, MD, DSc, PhD, Toledo, A. John Christoforidis, Prem C. Chandnani,
MD, PhD, Toledo, MD, Toledo,
Ohio
Ohio
Ohio
The lack of attention to the blood supply of the posterior wall of the stomach [I] near the lesser curvature and the postoperative problems that occur pith partial or total gastrectomy, parietal cell vagotomy [2] and pancreatectomy led to an investigation of the posterior gastric artery in angiograms. A retrospective study was performed in 100 consecutive cases in the Department of Radiology of the Medical CIollege of Ohio. The results of this inyestigation are presented herein, discussed and evaluated for clinical implications in light of recent anatomic and surgical observations. Our findings will show, at the very least, that the posterior gastric artery, also called the ascending posterior esophagogastric branch, cardioesophageal branch or accessory left gastric artery [,3,4], can no longer be ignored or neglected.
Literature
Review
The following publications included information on the posterior gastric artery obtained by radiologic techniques. Franchi and Stuart [5] attempted to obtain a precise picture of the gastric arterial supply through radiographic methods to meet the requirements of modern surgery on the stomach. Among several findings was that gastric branches of the splenic artery supply as much blood to the stomach as to the spleen. These branches form the network of the fundus and to a lesser extent that of the corpus. An exceptional condition was observed in a monkey in which the posterior artery of the fundus, equal in From the Department of Anatomy and Radiology, Medical College of Ohio, ‘-okdo, Ohio. Reprint requests should be addressed to A. J. Christoforidis, MD, Department of Radiology. Medical College of Ohio, C.S. 10008, Toledo, Ohio 43699.
Volume 139, March 1980
caliber to the left gastric artery, alone supplied the stomach wall. Abrams [6] wrote a chapter on splenic arteriography based on the description by Michels [3,4] and that by Kupic et al [7]. He stated that Michels’s descriptions generally had been confirmed and amplified in vivo in his clinical studies. In a schematic diagram, he indicated the usual site pf origin (from the splenic artery) of the accessory left gastric artery and labeled it ALG, which corresponds to the posterior gastric artery. In the angiograms in his Figures 62-5 and 62-7, among variations in normal splenic arterial anatomy (in two women with abdominal pain aged 51 and 55 years), he indicated the presence of the accessory left gastric artery, which is clearly identifiable as the posterior gastric artery. The artery was also labeled in angiogram B of Figure 62-23 and corresponds to a case of fibromuscular hyperplasia (a 62 year old woman with hematemesis, epigastric distress and a widened duodenal loop). He performed angiographic analysis of the normal vessels and found (1) the accessory left gastric artery arising from the pancreatic segment (average 10.4 cm long) of the splenic artery (on the dorsal surface of the pancreas) in 13 of 38 cases, or 34 percent, and (2) the accessory left gastric artery originating from the prepancreatic segment (average 2.5 cm long) of the splenic artery (on the anterior surface of the pancreatic tail) in 1 of 38 cases, or 2.6 percent. The total incidence of the posterior gastric artery in the study by Kupic et al [7] was 14 of 38 cases, or 36.8 percent. Laude et al [8] studied 100 celiac and mesenteric arteriograms to correlate findings on dissection and angiographic images. A vessel corresponding to the posterior gastric artery, arising from the beginning of the splenic artery, was found in four cases.
333
DiDio et al
Figure 1. Selective catheterization of the celiac artery in a 52 year old man hospitalized because of intestinal bleeding. The posterior gastric artery, indicated by the two arrows, is distributed in the region of the posterior wall of the cardia and the lower esophagus.
Material
and Methods
We studied angiograms of 100 consecutive patients who presented with a variety of ailments but whose diagnosis entirely justified angiographic procedures and did not influence the incidence of the posterior gastric artery. Of these patients, 52 were male and 48 female. Eighty-six patients (45 male and 41 female) were Caucasian and 14 (7 male and 7 female) were Negro. Ages ranged from 13 years (male, Caucasian) to 85 years (male, Caucasian). The majority were adults. Angiograms were taken of the superior mesenteric artery and the celiac trunk, and others were obtained after selective injections of radiopaque substance into the splenic
334
Figure 2. Selective catheterization of the celiac artery. The patient, a 79 year old man, was referred with the clinical diagnosis of a mass in the right upper quadrant. The posterior gastric artery originates from the splenic artery approximately 5.5 cm from the trifurcation of the celiac trunk and is distributed in the upper part of the posterior wall of the lesser curvature of the stomach and also on the posterior wall of the cardia and lower esophagus.
artery after a flash injection into the abdominal aorta for orientation and detection of possible anomalies. In all but two cases, the femoral artery approach (retrograde technique) was used with the application of the Seldinger technique. In the remaining two cases, the axillary artery approach (anterograde technique) was used because of advanced atheromatosis of the femoral artery. Preshaped Cordis Ducor@ catheters, usually no. 7 and occasionally no. 6, were used for catheterization of the splenic artery. The amount of contrast medium injected into the celiac trunk was approximately 40 to 60 ml of 76 percent diatrizoate meglumine (Hypaquea), depending on body weight, whereas the amount of contrast material injected into the superior mesenteric artery varied from 35 to 40 ml. When selective injection into the splenic artery was made,
The American Journal of Surgery
Posterior
TABLE I
Race
Sex Male (no. = 52) (no. = 48)
Total
Artery
Sex and Race Distribution of Patients in Whom Posterior Gastric Artery Was Identified
Individuals
Female
Gastric
Caucasian (no. = 45)
Posterior Gastric Artery Present Absent
Negro (no. = 7)
22 2 19 3
23 5 22 4
100
46
54
Negro (no. = 7)
Caucasian (no. = 41)
ART.
*./.... -
superior portion of the stomach and definitely unrelated to the spleen. When in doubt, we considered the posterior gastric artery as absent in the angiograms. The posterior gastric artery was detected angiographically (Figures 1 to 3) in 46 of 100 persons (46 f 4.9 percent), and it was absent, in 54 persons (46 f 4.9 percent). The sex and racial distribution of patients in whom the artery was identified is given in Table 1. The relatively small number of observations in each group and subgroup prevented conclusions regarding the difference in incidence of the artery with respect to sex and race. Comments
Figure 3. Selective celiac injection in a 65 year old woman investigated for liver tumor. Note the serpiginous course of the posterior gastric artery with distribution along the posterior wall of the gastroesophageat junction. H originates approximately 4.5 cm from the origin of the splenic artery.
20 to SO ml of contrast medium were administered. The Schonander cut-film changer in film sizes 14 by 14 ixches was used. Injection rates ranged from 6 to 8 ml/ approximately
second. The filming program was two/second for 4 seconds, one/second for 4 additional seconds and then one film every :? seconds for a total of 20 seconds. Results
We were able to identify the posterior tery as a branch of the splenic artery near of the splenic artery from the celiac trunk, v,ertically or obliquely toward the left to
Volume
139, March 1980
gastric arthe origin ascending supply the
The posterior gastric artery, so named by Haller [9] after its discovery by Walther [IO], was rediscovered several times, as pointed out by Suzuki et al [I 1, but received scant attention from anatomists, radiologists and surgeons who failed to emphasize its practical importance. The fact that the posterior gastric artery may in some cases supply the posterior wall of the abdominal esophagus justifies the name ascending posterior esophagogastric branch used by Michels [3,4], who included it as one of the most frequent and independent types of accessory left gastric artery. We believe that in order to avoid confusion the name postrlrior gastric artpry should he adopted, following Haller 191, who first) named this artery in 1745, Soemmerring [I I], Piquand [ 121, Anile [IS], Versari [14], Chiarugi [15], Levasseur and Couinaud 1161and Barbin and Guntz [ 171. The incidence of the posterior gastric artery, under this or any other name, as reported in the anatomic literaurre, varies as follows: Leriche and Villemin [IX] 12.7 percent; Helm [29], 16 percent; Adachi [20], 21.6 percent:; Tanigawa [21], 36 percent (adults); Weisz and Bianco [22], 48 percent; Rio-Branco [23], 50 percent; 1,evasseur and Couinaud [lb’], 50 percent; Suzuki et al [I], 62.3 percent; Delteil et al [24], 64.3
335
DiDio et al
percent (newborn); Rossi and Cova [25], 65.8 percent; Versari [14], 66 percent; Chiarugi [15], 66 percent; Tanigawa [21], 67.8 percent (fetuses); Aboltin [26], 77 percent; and Piquand [12], 99 percent. The percentages found by the few investigators using radiologic techniques also showed a wide range of variation: 36.8 percent by Kupic et al [7] and 4 percent by Laude et al [8]. (No percentage was given by Franchi and Stuart [5] in man.) Our result (46 percent) is not too far from that of Kupic et al [ 71 and, as expected, is lower than the percentages obtained by anatomic studies. In fact, the natural source of error is inherent in the interpretation of radiograms, in which the superimposition of images may influence the identification of an inconstant vessel and leads one to discard it as absent in all doubtful cases. On the contrary, dissection allows the investigator to gain the tridimensional view and to trace the vessel from origin to end. Failure of penetration of the contrast medium, for example, because of pathologic obliteration of the posterior gastric artery, will lead to a negative diagnosis from the radiogram, whereas surgical or anatomic dissection will detect the vessel. Although the small differences between percentages obtained by our predecessors can easily be explained on the basis of common variational samples, the large differences can be justified only by the diversity of the concept of the vessel under study. Considering both anatomic and radiologic studies, it is interesting to point out that most investigators had obtained a close or higher percentage than ours and that the incidence of the posterior gastric artery found in nine reports ranged from 48 to 67.8 percent. The surgical importance of the posterior gastric artery derives from its relatively high incidence, from being another source of blood supply to the superior portion of the posterior gastric wall and from having an almost hidden origin from the beginning of the splenic artery [I]. Inadvertent transection of the posterior gastric artery during gastrectomy, especially high gastric resection with associated splenectomy, pancreatoduodenectomy or pancreatectomy, may cause postoperative bleeding or necrosis of the residual gastric stump. To these cases we must add the technical complications of parietal cell vagotomy, as presented is by Jordan [2], b ecause this type of intervention considered the safest and more common surgical treatment for duodenal ulcer. As pointed out, however, necrosis of the lesser curvature is the most serious complication reported after parietal cell vagotomy, being fatal in four of five patients in which
336
it occurred [27-291. In Johnston’s [30] collected series of 4,557 patients, it was a fatal complication in 3 of 7 patients. The pathogenesis of such a complication may be the devascularization of the lesser curvature that necessarily accompanies highly selective vagotomy (Newcombe) or, according to Halvorsen et al [28], the relative paucity of blood supply to the submucous tela of the lesser curvature or, according to Jordan, the “inadvertent and unrecognized injury caused by the need for application of clamps close to the gastric wall.” We believe that inadvertent and unrecognized transection of the posterior gastric artery may be another cause of necrosis of the residual gastric stump, just aboral to the esophagogastric junction. The somewhat hidden origin of the posterior gastric artery, running behind a fold of the posterior parietal peritoneum of the omental bursa before reaching the posterior gastric wall and the esophagogastric junction, makes identification of this artery important. Its rather common incidence adds to the significance of the identification. The angiographic study, therefore, becomes very important and should certainly forewarn the surgeon in order to avoid one of the potential sources of postsurgical complications. Summary The posterior gastric artery was detected angiographically in 46 of 100 patients (46 percent). The importance of radiologic detection of the presence or absence of this artery is emphasized, especially in surgical procedures related to the stomach and immediately adjacent structures. Acknowledgment: We thank Marion C. Anderson, MD, chairman and professor, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, for valuable suggestions.
References 1. Suzuki K, Prates JC, DiDio LJA. Incidence and surgical im2. 3. 4. 5.
6. 7.
8.
portance of the posterior gastric artery. Ann Surg 1978; 187:134. Jordan PH. Current status of parietal cell vagotomy. Ann Surg 1976; 184:659. Michels NA. The variational anatomy of the spleen and splenic artery. Am J Anat 1942; 70:2 1. Michels NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. London: Pitman, 1955. Franchi M, Stuart C. La irrorazione arteriosa dello stomaco studiata con metodo radiografico. Atti Accad Fisiocr Siena 1952; 20:145. Abrams HL. Angiography, vol 2. 2nd ed. Boston: Little, Brown, 1971:1003. Kupic EA, Marshall WH, Abrams HL. Splenic arterial patterns. Angiographic analysis and review. Invest Radio1 1967; 2:70. Laude M, Libersa C, Rozan R. Radio-anatomie du tronc de
The American Journal of Surgery
Posterior
!a.
10. 1 1. 12. 1.3. 14. 15. 16.
17. 18. 19. 20. 21.
I’artere splenique chez I’homme. Bull Assoc Anat 154:1050, 1972. Hailer A. lncones anatomicae quibus praecipue aliquae partes corporis humani dekubeatae proponuntur et arteriarum potissimum historia continetur. Fast II. Gottingae: Vandenhoeck, 1745. Walther AF. De vena portae. Lipsiae, 1740. Soemmerring ST. Sulla struttura del corpo umano (Duca GB, Italian translation). Crema: Antonio Ronna, 1820. Piquand G. Recherches sur I’anatomie du tronc coeliaque et de ses branches. Bibliogr Anat 1910; 19:159. Anile A. L’anatomia sistematica dell’uomo con speciale riguardo alla practica medica. Napoli: Elpis. 1919. Versari R. Angiologia. In: Balli R et al, eds. Trattato di anatomia umana. 2nd ed. Milano: Vallardi, 1932. Chiarugi G. lstituzioni di anatomia dell’uomo. 9th ed. Milano: Vallardi and Sot. Editr. Libraria. 1959. Levasseur JC, Couinaud C. Etude de la distribution des arteres gastriques. lncidences chirurgicales (1). J Chir 1968; 95: 57. Barbin JY, Guntz M. La circulation arterielle viscerale. Essai de systematisation. Bull Assoc Anat 1972; 153:187. Leriche R, Villemin F. Recherches anatomiques sur les arteres de I’estomac. Bibliogr Anat 1907; 16:lll. Helm MH. The gastric vasa brevia. Anat Ret 1915; 9:637. Adachi B. Das arteriensystem der Japaner. Tokyo: Kenkyusha, 1928. Tanigawa K. lhidomyaku ni kansuru kenkyu. [On the arteria
Volume 139, March 1980
22.
23.
24.
25. 26.
27. 28.
29.
30.
Gastric
Artery
gastrolienalis branching from the lienal artery.] Fukuoka igaku zasshi (Fukuoka Acta Med) 1963; 54:592 (in Japanese). Weisz R, Bianco V. Ricerche anatomiche e considerazioni chirurgiche sull’arteria splenica. Boll Sot Piemont Chir 1957; 27:805. Rio-Branco PSP. Essai sur I’anatomie et la medecine operatoire du tronc coeliaque et de ses branches. Paris: Steinheil, 1912. Delteil C, Laffont J, LeGuyader A. Vascularisation arterielle de I’estomac du nouveau-ne Africain. Bull Sot Med Afr Noire Lang Fr 1967; 12:851. Rossi G, Cova E. Studio Morfologico delle arterie dello stomaco. Arch ltal Anat Embriol 1904; 3:485, 566. Aboltili M. Posterior gastric vein. Trudy lnstituta Eksperimentalnoi Klinicheskoi Meditainy Latviiskoi Akademii Nauk 1962; 20: 153 (in Russian). Newcombe JF. Fatality after highly selective vagotomy. Br Med J 1973; 1:610. Halvorsen JF. Heiman P, Solhaug JH. Jacobsen KB. Localized avascular necrosis of lesser curve of stomach complicating highly selective vagotomy. Br Med J 1975; 2:590. Kalaja E, Celmmesen I, Banke L, Kragelund E, Christiansen PM, Accidents and complications in selective and proximal gastric vagotomy. Surgery 1975; 77:140. Johnston D. Operative mortality and postoperative morbidity of highly selective vagotomy. Br J Surg 1975; 62:160.
337
Liberato J. A. DiDio, MD, DSc, PhD, Toledo, A. John Christoforidis, Prem C. Chandnani,
MD, PhD, Toledo, MD, Toledo,
Ohio
Ohio
Ohio
The lack of attention to the blood supply of the posterior wall of the stomach [I] near the lesser curvature and the postoperative problems that occur pith partial or total gastrectomy, parietal cell vagotomy [2] and pancreatectomy led to an investigation of the posterior gastric artery in angiograms. A retrospective study was performed in 100 consecutive cases in the Department of Radiology of the Medical CIollege of Ohio. The results of this inyestigation are presented herein, discussed and evaluated for clinical implications in light of recent anatomic and surgical observations. Our findings will show, at the very least, that the posterior gastric artery, also called the ascending posterior esophagogastric branch, cardioesophageal branch or accessory left gastric artery [,3,4], can no longer be ignored or neglected.
Literature
Review
The following publications included information on the posterior gastric artery obtained by radiologic techniques. Franchi and Stuart [5] attempted to obtain a precise picture of the gastric arterial supply through radiographic methods to meet the requirements of modern surgery on the stomach. Among several findings was that gastric branches of the splenic artery supply as much blood to the stomach as to the spleen. These branches form the network of the fundus and to a lesser extent that of the corpus. An exceptional condition was observed in a monkey in which the posterior artery of the fundus, equal in From the Department of Anatomy and Radiology, Medical College of Ohio, ‘-okdo, Ohio. Reprint requests should be addressed to A. J. Christoforidis, MD, Department of Radiology. Medical College of Ohio, C.S. 10008, Toledo, Ohio 43699.
Volume 139, March 1980
caliber to the left gastric artery, alone supplied the stomach wall. Abrams [6] wrote a chapter on splenic arteriography based on the description by Michels [3,4] and that by Kupic et al [7]. He stated that Michels’s descriptions generally had been confirmed and amplified in vivo in his clinical studies. In a schematic diagram, he indicated the usual site pf origin (from the splenic artery) of the accessory left gastric artery and labeled it ALG, which corresponds to the posterior gastric artery. In the angiograms in his Figures 62-5 and 62-7, among variations in normal splenic arterial anatomy (in two women with abdominal pain aged 51 and 55 years), he indicated the presence of the accessory left gastric artery, which is clearly identifiable as the posterior gastric artery. The artery was also labeled in angiogram B of Figure 62-23 and corresponds to a case of fibromuscular hyperplasia (a 62 year old woman with hematemesis, epigastric distress and a widened duodenal loop). He performed angiographic analysis of the normal vessels and found (1) the accessory left gastric artery arising from the pancreatic segment (average 10.4 cm long) of the splenic artery (on the dorsal surface of the pancreas) in 13 of 38 cases, or 34 percent, and (2) the accessory left gastric artery originating from the prepancreatic segment (average 2.5 cm long) of the splenic artery (on the anterior surface of the pancreatic tail) in 1 of 38 cases, or 2.6 percent. The total incidence of the posterior gastric artery in the study by Kupic et al [7] was 14 of 38 cases, or 36.8 percent. Laude et al [8] studied 100 celiac and mesenteric arteriograms to correlate findings on dissection and angiographic images. A vessel corresponding to the posterior gastric artery, arising from the beginning of the splenic artery, was found in four cases.
333
DiDio et al
Figure 1. Selective catheterization of the celiac artery in a 52 year old man hospitalized because of intestinal bleeding. The posterior gastric artery, indicated by the two arrows, is distributed in the region of the posterior wall of the cardia and the lower esophagus.
Material
and Methods
We studied angiograms of 100 consecutive patients who presented with a variety of ailments but whose diagnosis entirely justified angiographic procedures and did not influence the incidence of the posterior gastric artery. Of these patients, 52 were male and 48 female. Eighty-six patients (45 male and 41 female) were Caucasian and 14 (7 male and 7 female) were Negro. Ages ranged from 13 years (male, Caucasian) to 85 years (male, Caucasian). The majority were adults. Angiograms were taken of the superior mesenteric artery and the celiac trunk, and others were obtained after selective injections of radiopaque substance into the splenic
334
Figure 2. Selective catheterization of the celiac artery. The patient, a 79 year old man, was referred with the clinical diagnosis of a mass in the right upper quadrant. The posterior gastric artery originates from the splenic artery approximately 5.5 cm from the trifurcation of the celiac trunk and is distributed in the upper part of the posterior wall of the lesser curvature of the stomach and also on the posterior wall of the cardia and lower esophagus.
artery after a flash injection into the abdominal aorta for orientation and detection of possible anomalies. In all but two cases, the femoral artery approach (retrograde technique) was used with the application of the Seldinger technique. In the remaining two cases, the axillary artery approach (anterograde technique) was used because of advanced atheromatosis of the femoral artery. Preshaped Cordis Ducor@ catheters, usually no. 7 and occasionally no. 6, were used for catheterization of the splenic artery. The amount of contrast medium injected into the celiac trunk was approximately 40 to 60 ml of 76 percent diatrizoate meglumine (Hypaquea), depending on body weight, whereas the amount of contrast material injected into the superior mesenteric artery varied from 35 to 40 ml. When selective injection into the splenic artery was made,
The American Journal of Surgery
Posterior
TABLE I
Race
Sex Male (no. = 52) (no. = 48)
Total
Artery
Sex and Race Distribution of Patients in Whom Posterior Gastric Artery Was Identified
Individuals
Female
Gastric
Caucasian (no. = 45)
Posterior Gastric Artery Present Absent
Negro (no. = 7)
22 2 19 3
23 5 22 4
100
46
54
Negro (no. = 7)
Caucasian (no. = 41)
ART.
*./.... -
superior portion of the stomach and definitely unrelated to the spleen. When in doubt, we considered the posterior gastric artery as absent in the angiograms. The posterior gastric artery was detected angiographically (Figures 1 to 3) in 46 of 100 persons (46 f 4.9 percent), and it was absent, in 54 persons (46 f 4.9 percent). The sex and racial distribution of patients in whom the artery was identified is given in Table 1. The relatively small number of observations in each group and subgroup prevented conclusions regarding the difference in incidence of the artery with respect to sex and race. Comments
Figure 3. Selective celiac injection in a 65 year old woman investigated for liver tumor. Note the serpiginous course of the posterior gastric artery with distribution along the posterior wall of the gastroesophageat junction. H originates approximately 4.5 cm from the origin of the splenic artery.
20 to SO ml of contrast medium were administered. The Schonander cut-film changer in film sizes 14 by 14 ixches was used. Injection rates ranged from 6 to 8 ml/ approximately
second. The filming program was two/second for 4 seconds, one/second for 4 additional seconds and then one film every :? seconds for a total of 20 seconds. Results
We were able to identify the posterior tery as a branch of the splenic artery near of the splenic artery from the celiac trunk, v,ertically or obliquely toward the left to
Volume
139, March 1980
gastric arthe origin ascending supply the
The posterior gastric artery, so named by Haller [9] after its discovery by Walther [IO], was rediscovered several times, as pointed out by Suzuki et al [I 1, but received scant attention from anatomists, radiologists and surgeons who failed to emphasize its practical importance. The fact that the posterior gastric artery may in some cases supply the posterior wall of the abdominal esophagus justifies the name ascending posterior esophagogastric branch used by Michels [3,4], who included it as one of the most frequent and independent types of accessory left gastric artery. We believe that in order to avoid confusion the name postrlrior gastric artpry should he adopted, following Haller 191, who first) named this artery in 1745, Soemmerring [I I], Piquand [ 121, Anile [IS], Versari [14], Chiarugi [15], Levasseur and Couinaud 1161and Barbin and Guntz [ 171. The incidence of the posterior gastric artery, under this or any other name, as reported in the anatomic literaurre, varies as follows: Leriche and Villemin [IX] 12.7 percent; Helm [29], 16 percent; Adachi [20], 21.6 percent:; Tanigawa [21], 36 percent (adults); Weisz and Bianco [22], 48 percent; Rio-Branco [23], 50 percent; 1,evasseur and Couinaud [lb’], 50 percent; Suzuki et al [I], 62.3 percent; Delteil et al [24], 64.3
335
DiDio et al
percent (newborn); Rossi and Cova [25], 65.8 percent; Versari [14], 66 percent; Chiarugi [15], 66 percent; Tanigawa [21], 67.8 percent (fetuses); Aboltin [26], 77 percent; and Piquand [12], 99 percent. The percentages found by the few investigators using radiologic techniques also showed a wide range of variation: 36.8 percent by Kupic et al [7] and 4 percent by Laude et al [8]. (No percentage was given by Franchi and Stuart [5] in man.) Our result (46 percent) is not too far from that of Kupic et al [ 71 and, as expected, is lower than the percentages obtained by anatomic studies. In fact, the natural source of error is inherent in the interpretation of radiograms, in which the superimposition of images may influence the identification of an inconstant vessel and leads one to discard it as absent in all doubtful cases. On the contrary, dissection allows the investigator to gain the tridimensional view and to trace the vessel from origin to end. Failure of penetration of the contrast medium, for example, because of pathologic obliteration of the posterior gastric artery, will lead to a negative diagnosis from the radiogram, whereas surgical or anatomic dissection will detect the vessel. Although the small differences between percentages obtained by our predecessors can easily be explained on the basis of common variational samples, the large differences can be justified only by the diversity of the concept of the vessel under study. Considering both anatomic and radiologic studies, it is interesting to point out that most investigators had obtained a close or higher percentage than ours and that the incidence of the posterior gastric artery found in nine reports ranged from 48 to 67.8 percent. The surgical importance of the posterior gastric artery derives from its relatively high incidence, from being another source of blood supply to the superior portion of the posterior gastric wall and from having an almost hidden origin from the beginning of the splenic artery [I]. Inadvertent transection of the posterior gastric artery during gastrectomy, especially high gastric resection with associated splenectomy, pancreatoduodenectomy or pancreatectomy, may cause postoperative bleeding or necrosis of the residual gastric stump. To these cases we must add the technical complications of parietal cell vagotomy, as presented is by Jordan [2], b ecause this type of intervention considered the safest and more common surgical treatment for duodenal ulcer. As pointed out, however, necrosis of the lesser curvature is the most serious complication reported after parietal cell vagotomy, being fatal in four of five patients in which
336
it occurred [27-291. In Johnston’s [30] collected series of 4,557 patients, it was a fatal complication in 3 of 7 patients. The pathogenesis of such a complication may be the devascularization of the lesser curvature that necessarily accompanies highly selective vagotomy (Newcombe) or, according to Halvorsen et al [28], the relative paucity of blood supply to the submucous tela of the lesser curvature or, according to Jordan, the “inadvertent and unrecognized injury caused by the need for application of clamps close to the gastric wall.” We believe that inadvertent and unrecognized transection of the posterior gastric artery may be another cause of necrosis of the residual gastric stump, just aboral to the esophagogastric junction. The somewhat hidden origin of the posterior gastric artery, running behind a fold of the posterior parietal peritoneum of the omental bursa before reaching the posterior gastric wall and the esophagogastric junction, makes identification of this artery important. Its rather common incidence adds to the significance of the identification. The angiographic study, therefore, becomes very important and should certainly forewarn the surgeon in order to avoid one of the potential sources of postsurgical complications. Summary The posterior gastric artery was detected angiographically in 46 of 100 patients (46 percent). The importance of radiologic detection of the presence or absence of this artery is emphasized, especially in surgical procedures related to the stomach and immediately adjacent structures. Acknowledgment: We thank Marion C. Anderson, MD, chairman and professor, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, for valuable suggestions.
References 1. Suzuki K, Prates JC, DiDio LJA. Incidence and surgical im2. 3. 4. 5.
6. 7.
8.
portance of the posterior gastric artery. Ann Surg 1978; 187:134. Jordan PH. Current status of parietal cell vagotomy. Ann Surg 1976; 184:659. Michels NA. The variational anatomy of the spleen and splenic artery. Am J Anat 1942; 70:2 1. Michels NA. Blood supply and anatomy of the upper abdominal organs with a descriptive atlas. London: Pitman, 1955. Franchi M, Stuart C. La irrorazione arteriosa dello stomaco studiata con metodo radiografico. Atti Accad Fisiocr Siena 1952; 20:145. Abrams HL. Angiography, vol 2. 2nd ed. Boston: Little, Brown, 1971:1003. Kupic EA, Marshall WH, Abrams HL. Splenic arterial patterns. Angiographic analysis and review. Invest Radio1 1967; 2:70. Laude M, Libersa C, Rozan R. Radio-anatomie du tronc de
The American Journal of Surgery
Posterior
!a.
10. 1 1. 12. 1.3. 14. 15. 16.
17. 18. 19. 20. 21.
I’artere splenique chez I’homme. Bull Assoc Anat 154:1050, 1972. Hailer A. lncones anatomicae quibus praecipue aliquae partes corporis humani dekubeatae proponuntur et arteriarum potissimum historia continetur. Fast II. Gottingae: Vandenhoeck, 1745. Walther AF. De vena portae. Lipsiae, 1740. Soemmerring ST. Sulla struttura del corpo umano (Duca GB, Italian translation). Crema: Antonio Ronna, 1820. Piquand G. Recherches sur I’anatomie du tronc coeliaque et de ses branches. Bibliogr Anat 1910; 19:159. Anile A. L’anatomia sistematica dell’uomo con speciale riguardo alla practica medica. Napoli: Elpis. 1919. Versari R. Angiologia. In: Balli R et al, eds. Trattato di anatomia umana. 2nd ed. Milano: Vallardi, 1932. Chiarugi G. lstituzioni di anatomia dell’uomo. 9th ed. Milano: Vallardi and Sot. Editr. Libraria. 1959. Levasseur JC, Couinaud C. Etude de la distribution des arteres gastriques. lncidences chirurgicales (1). J Chir 1968; 95: 57. Barbin JY, Guntz M. La circulation arterielle viscerale. Essai de systematisation. Bull Assoc Anat 1972; 153:187. Leriche R, Villemin F. Recherches anatomiques sur les arteres de I’estomac. Bibliogr Anat 1907; 16:lll. Helm MH. The gastric vasa brevia. Anat Ret 1915; 9:637. Adachi B. Das arteriensystem der Japaner. Tokyo: Kenkyusha, 1928. Tanigawa K. lhidomyaku ni kansuru kenkyu. [On the arteria
Volume 139, March 1980
22.
23.
24.
25. 26.
27. 28.
29.
30.
Gastric
Artery
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