Medial coracoclavicular ligament revisited: an anatomic study and review of the literature

The medial coracoclavicular ligament (MCCL), up to now rarely reported in the literature, was studied in a formol-fixed cadaver by means of dissection, morphometry, and light microscopy. This entity represents a true ligament within the coracoclavicular fascia. Although longer and narrower than its lateral counterpart, the medial coracoclavicular ligament follows the same morphological pattern, including the cartilage at the level of the coracoidal attachment. Its clinical significance and implications together with a review of the literature is presente

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy

Background: The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: “Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography” in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed. Methods: Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews. Results: Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores. Conclusions: Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery.acceptedVersio

Arterial supply of the trigeminal ganglion, a micromorphological study

Background: In this study, we explored the specific microanatomical properties of the trigeminal ganglion (TG) blood supply and its close neurovascular relationships with the surrounding vessels. Possible clinical implications have been discussed. Materials and methods: The internal carotid and maxillary arteries of 25 adult and 4 foetal heads were injected with a 10% mixture of India ink and gelatin, and their TGs subsequently underwent microdissection, observation and morphometry under a stereoscopic microscope. Results: The number of trigeminal arteries varied between 3 and 5 (mean 3.34), originating from 2 or 3 of the following sources: the inferolateral trunk (ILT) (100%), the meningohypophyseal trunk (MHT) (100%), and from the middle meningeal artery (MMA) (92%). In total, the mean diameter of the trigeminal branches was 0.222 mm. The trigeminal branch of the ILT supplied medial and middle parts of the TG, the branch of the MHT supplied the medial part of the TG, and the branch of the MMA supplied the lateral part of the TG. Additional arteries for the TG emerged from the dural vascular plexus and the vascular network of the plexal segment of the trigeminal nerve. Uniform and specific intraganglionic dense capillary network was observed for each sensory trigeminal neuron. Conclusions: The reported features of the TG vasculature could be implied in a safer setting for surgical approach to the skull base, in relation to the surrounding structures. The morphometric data on TG vasculature provide anatomical basis for better understanding the complex TG blood supply from the internal and external carotid arteries

3D for D3 right colon resection: role of anatomy

The D3 right colectomy with extended lymphadenectomy has proven higher oncological quality. The prerequisites for such performing this radical operation are good anatomical knowledge of the lymph node and vessel distribution in the D3 area and a precise morphometric insight in the individual patient's three-dimensional vascular pattern of the superior mesenteric vessels, their branches and affluents. This is accomplished by engaging a professional anatomist in the multi-centric randomized, prospective clinical trial “Safe radical D3 right hemicolectomy for cancer through preoperative biphasic MDCT angiography”. A 3D vascular road mapping based on segmentation of high-resolution pre-operative CT can accurately present the multitude of vascular variations and anomalies, rendering the D3 surgical procedure safe and efficient. An anatomical micro-dissectional study has given valuable data concerning the actual morphometry and the 3D pattern of the colic artery lymphovascular bundle, i.e. defining the limits and extent of a sufficient lymphatic resection during D3 colectomy

Comment to Jejunal Diverticulitis Mimicking Small Bowel Perforation: Case Report and Review of the Literature

Dear Editor, I would like to congratulate the authors of this well written article and to thank them for the contribution to the literature. There is, however, one point that needs to be addressed, and that is the outcomes of surgical versus conservative treatment. Areview article1 has published data on 266 patients (106 patients derived from published case reports containing individual patient data, 113 patients derived from the Norwegian patient registry and data on 47 patients as historical controls from a previous publication and used as historical controls(Chendrasekhar et al2). It seems that conservatively treated patients had similar hospital length of stay as operated patients. Age did correlate with hospital stay, howeverno difference in outcomes for operated or non-operated patients was found. The historical control group did show a significantly higher mortality, implying that attempting conservative therapy after diagnosis through an abdominal CT scan (which often does show pneumoperitoneum) can only benefit this frail patient group

Left–Right Multimodal Morphometric Comparison of Human Submandibular Glands

This communication study integrates composite multimodal research on postmortem human submandibular glands, based on macromorphometry. The normal ductographic sialograms were pairwise analyzed using linear morphometry, whole-gland planimetry and fractal properties, such as main duct length, caliber and tortuosities, side branches and accessory ducts/lobes. All the examined parameters presented a significant correlation, i.e., symmetry between the left and the right submandibular glands. The morphometric data presented can serve as a valuable reference in clinical practice.</p

Navigating the mesentery: part III. Unusual anatomy of ileocolic vessels

Aim The ileocolic vessels are important landmarks in advanced surgery of the midgut. The aim of the present study is to present variations of ileocolic vessels relevant to complete mesocolic excision with D3 lymphadenectomy of the right colon, within their detailed and precise morphometric framework and deriving from a large and consistent series of operated patients. Methods An ongoing prospective trial ‘Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multidetector Computed Tomography Angiography’ was reviewed. The imaging datasets underwent manual segmentation and 3D reconstruction, and the results were validated at surgery. A total of 356 patients were included in the study. Results A cross-section of the series revealed five cases (1.4%) with variation of ileocolic vessels relevant to complete mesocolic excision or D3 extended mesenterectomy. There were two cases with absence of a true classical ileocolic artery, two cases with absence of a true classical ileocolic vein, and one case of precocious bifurcation of the ileocolic artery, left to the superior mesenteric vein. The entire D3 area in all the cases was thoroughly documented and analysed from the morphometric point of view (calibres, lengths of vessels, crossing patterns). Conclusion The preoperative visualization of a patient’s individual 3D anatomy is a powerful tool in identifying the variations whose negligence could have dire consequences in complete mesocolic excision of the right colon

Visible Lymph Affluents in the D3 Volume: An MDCTA Pictorial Essay

Background: There seems to be a gap in knowledge of the anatomy of mesenteric lymphatics between the superior mesenteric nodes and the intestinal trunk. To our knowledge, these central lymph vessels were not hitherto systematically searched for, described, or morphometrically analyzed. Our aim was to identify those vessels on the routine multidetector computerized tomography angiography (MDCTA), performed prior to right colectomy for cancer, with extended mesenterectomy, central vascular ligation, and D3 lymphadenectomy. Methods: A total of 420 MDCTA datasets were analyzed utilizing manual segmentation and 3D reconstruction, with the aid of image processing software Osirix, Mimics, and 3-matic. The 3D models and masks underwent a detailed topographic and morphometric analysis. Results: Significant vascular-like structures, having neither origin nor termination on the blood vessels, were noted in 18 cases (4.3%) in the D3 volume. The dimensions of visible lymph vessels varied, their mean diameter was 1.81 ± 0.61 mm, and the mean length was 38.07 ± 22.19 mm. In the vast majority of cases, the lymph vessels were situated in front of the superior mesenteric artery (SMA), coursing either longitudinally cranially (13 cases) or transversely/obliquely to the left (5 cases). In all cases but one, the lymph vessel passed at the left-hand side of the middle colic artery. As for the course shape, in seven cases, the lymph vessel appeared highly serpiginous. Conclusions: The regular MDCTA can provide valuable information on mesenteric lymphatics and aid in surgical planning.</p

Comment on: The Medial Border of Laparoscopic D3 Lymphadenectomy for Right Colon Cancer

We are impressed with the work presented by Zhou et al. There have been some recent retrospective publications stating the similar results, namely that time to recurrence was significantly longer after more extensive lymph node dissection (D3) compared to less extensive lymph node dissection; however, the extent of lymph node dissection alone did not have a significant impact on 5-year overall survival (OS). Moreover, it was noticed that vascular invasion and a high lymph node ratio significantly reduced the OS. This could also imply that the prognosis for subgroups of Stage III colon cancer patients can be good also without chemotherapy, which in turn bears a significant risk of morbidity and mortality. This also includes the patient’s anatomy as stated by Ishyama et al, when the ileocolic artery crosses posterior to the superior mesenteric vein. Another point we wish to address is the occurrence and prevention of chylous ascites. When the ongoing trial “Safe Radical D3 Right Hemi-colectomy for Cancer through Preoperative Biphasic Multi-Detector Computed Tomography (MDCT) Angiography” introduced a standardized personalized approach with central vessel ligation in the central mesentery both anterior and posterior to the superior mesenteric vessels a higher occurrence of chylous ascites was also noticed. The solution for this problem was a simple fat free diet administered in the first three postoperative days, and has very effectively neutralized the issue. We agree that intraoperative complications are somewhat higher in this D3 patient group