Unraveling Variations in Celiac Trunk and Hepatic Artery by CT Angiography to Aid in Surgeries of Upper Abdominal Region

Understanding of variations in the course and source of abdominal arteries is crucial for any surgical intervention in the peritoneal space. Intricate surgeries of the upper abdominal region, such as hepato-biliary, pancreatic, gastric and splenic surgeries, require precise knowledge of regular anatomy and different variations related to celiac trunk and hepatic artery. In addition, information about the origin of inferior phrenic artery is important in conditions such as hepatocellular carcinoma and gastroesophageal bleeding management. The present study gives an account of anatomical variations in origin and branching pattern of celiac trunk and hepatic artery by the use of CT (computed tomographic) angiography. The study was performed on 110 (66 females and 44 males) patients in a north Indian population. Results unraveled the most common celiac trunk variation as hepatosplenic trunk with left gastric artery, which was observed in 60% of cases, more common in females than in males. Gastrosplenic and hepato-gastric trunk could be seen in 4.55% and 1.82% cases respectively. Gastrosplenic trunk was more commonly found in females, whereas hepato-gastric trunk was more common in males. A gastrosplenic trunk, along with the hepato-mesenteric trunk, was observed in 1.82% cases and was more common in males. A celiacomesenteric trunk, in which the celiac trunk and superior mesenteric artery originated as a common trunk from the aorta, was seen only in 0.91% of cases, and exhibited an origin of right and left inferior phrenic artery from the left gastric artery. The most common variation of hepatic artery, in which the right hepatic artery was replaced and originated from the superior mesenteric artery, was observed in 3.64%, cases with a more common occurrence in males. In 1.82% cases, the left hepatic artery was replaced and originated from the left gastric artery, which was observed only in females. Common hepatic artery originated from the superior mesenteric artery, as observed in 1.82% cases, with slightly higher occurrence in males. These findings not only add to the existing knowledge apart from giving an overview of variations in north Indian population, but also give an account of their correlation with gender. The present study will prove to be important for various surgeries of the upper abdominal region.

P-OGC97 Development and piloting of surgical quality assurance methods for randomised controlled trials (RCTs): an example from a trial comparing laparoscopically assisted oesophagectomy vs. open oesophagectomy

Background RCTs in surgery are frequently criticised because the standard to which operations are performed (quality assurance - QA) is not considered during study design and delivery, risking performance bias. Lack of clarity about surgical QA may also influence the successful implementation of RCT results into routine practice, because it is unclear how procedures were undertaken. We developed QA measures for an RCT comparing laparoscopically assisted and open oesophagectomy (LAO and OO). Methods Five QA categories were developed during the pilot and applied to the main trial, using data from patients receiving their randomized allocation in each group: i) entry criteria for centres; ii) entry criteria for surgeons; surgical protocols for key components of LAO and OO with mandated, prohibited and flexible components, monitored using iii) case report forms (CRFs) to record protocol adherence; and iv) intra-operative photographs to demonstrate protocol adherence (using the visible anatomical structures to determine if the component had been fully completed); and v) lymph node count and length of oesophagus. Results 8 centres and 39 surgeons participated and met entry criteria. 145 (LAO) and 149 (OO) patients underwent their randomized surgical procedure. Key procedural components were reported as complete in CRFs at similar rates in both groups, with >70% undergoing mandated components. However, adherence assessed using photographs was consistently lower than the CRFs. For example, left gastric artery lymphadenectomies were reported as complete in > 98% CRFs (LAO and OO) whereas photographs found this to be complete in 42% (OO) and 54% (LAO). Median nodal count was similar in both groups (145 LAO=24.7, SD = 10.6 and 149 OO = 26.4, SD = 10.2) as was length of resected oesophagus. Conclusions Assessing surgical QA in a multi-centre trial is logistically challenging but feasible. Whilst video data from laparoscopic cases could be collected and assessed, it was not possible with open surgery. Understanding adherence to the study protocol using photographs in addition to CRFs was important because of marked differences between what surgeons reported had been undertaken and images of what had been achieved. It is recommended that surgical trials include QA processes to understand protocol adherence and examine performance bias between groups.

Congenital Visceral Vascular Variation Causing Gastrointestinal Hemorrhage: A Case Report

Variations in the visceral vasculature are often encountered, but rarely cause clinical symptoms. We report a 12-year-old girl with portal hypertension caused by congenital variations in visceral vessels. The clinical manifestations included gastrointestinal hemorrhage and ascites. The common hepatic artery and splenic artery stem shared the same trunk from the aorta, and the common hepatic artery was directly connected with the main portal vein to form an arteriovenous fistula. In addition, the left hepatic artery and the left gastric artery shared a common trunk termed the “hepatic-gastric trunk” which originated from the anterior wall of the aorta, while the right hepatic artery originated from the superior mesenteric artery and supplied the right liver. The patient was treated with interventional embolization and remained in good condition throughout the follow-up and at the time of publication.

Ruptured Left Gastric Artery Aneurysm Associated with Fibromuscular Dysplasia

Background: Fibromuscular dysplasia is a non-inflammatory, non-atherosclerotic vascular disease that commonly affects renal and carotid arteries but involvement of virtually any vascular territory has been observed. Research Design/ Study sample: This is a case report of a ruptured left gastric artery aneurysm as the first presentation of fibromuscular dysplasia. Data collection: After written consent from the patient, relevant clinical notes and imaging were retrospectively reviewed and critically analysed. Purpose: This case reiterates the importance of considering fibromuscular dysplasia as an uncommon cause of visceral artery aneurysms. In addition, this case shows that the impact of visceral artery vasospasm on endovascular access should not be underestimated and subsequent attempts can be successful after a period of resuscitation. Results: After initial difficulty in endovascular treatment due to visceral vasospasm, the case was successfully managed with with staged open ligation and endovascular embolization after a period of resuscitation. Conclusions: FMD is an important differential diagnosis to consider in cases of visceral aneurysms.

Roles of Endothelial Motilin Receptor and Its Signal Transduction Pathway in Motilin-Induced Left Gastric Artery Relaxation in Dogs

Background: Motilin increases left gastric artery (LGA) blood flow in dogs via the endothelial motilin receptor (MLNR). This article investigates the signaling pathways of endothelial MLNR.Methods: Motilin-induced relaxation of LGA rings was assessed using wire myography. Nitric oxide (NO), and cyclic guanosine monophosphate (cGMP) levels were measured using an NO assay kit and cGMP ELISA kit, respectively.Results: Motilin concentration-dependently (EC50=9.1±1.2×10−8M) relaxed LGA rings precontracted with U46619 (thromboxane A2 receptor agonist). GM-109 (MLNR antagonist) significantly inhibited motilin-induced LGA relaxation and the production of NO and cGMP. N-ethylmaleimide (NEM; G-protein antagonist), U73122 [phospholipase C (PLC) inhibitor], and 2-aminoethyl diphenylborinate [2-APB; inositol trisphosphate (IP3) blocker] partially or completely blocked vasorelaxation. In contrast, chelerythrine [protein kinase C (PKC) inhibitor] and H89 [protein kinase A (PKA) inhibitor] had no such effect. Low-calcium or calcium-free Krebs solutions also reduced vasorelaxation. N-nitro-L-arginine methyl ester [L-NAME; nitric oxide synthase (NOS) inhibitor] and ODQ [soluble guanylyl cyclase (sGC) inhibitor] completely abolished vasodilation and synthesis of NO and cGMP. Indomethacin (cyclooxygenase inhibitor), 18α-glycyrrhetinic acid [18α-GA; myoendothelial gap junction (MEGJ) inhibitor], and K+ channel inhibition through high K+ concentrations or tetraethylammonium (TEA-Cl; KCa channel blocker) partially decreased vasorelaxation, whereas glibenclamide (KATP channel blocker) had no such effect.Conclusion: The current study suggests that motilin-induced LGA relaxation is dependent on endothelial MLNR through the G protein-PLC-IP3 pathway and Ca2+ influx. The NOS-NO-sGC-cGMP pathway, prostacyclin, MEGJ, and K+ channels (especially KCa) are involved in endothelial-dependent relaxation of vascular smooth muscle (VSM) cells.