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Endoscopic projection of the gastroduodenal artery: Anatomical implications for bleeding management
P Wilhelm1, D Stierle2, J Rolinger1
1University Clinic for Visceral, General and Transplant Surgery, University Hospital Tübingen, Tübingen, Germany.
Insights
Understanding the gastroduodenal artery
Area of Science:
- Gastroenterology
- Surgical Anatomy
Background:
- Peptic ulcers cause significant upper gastrointestinal bleeding, with large vessel bleeds, like gastroduodenal artery erosion, leading to higher mortality.
- Posterior duodenal wall ulcers pose the greatest risk for gastroduodenal artery erosion.
- Endoscopic management of bleeding ulcers is complicated by anatomical variations and insufflation, leading to high rebleeding rates.
Purpose of the Study:
- To correlate the macroscopic anatomy of the gastroduodenal artery with its endoscopic appearance.
- To assess the implications of this correlation for clinical management of bleeding peptic ulcers.
Main Methods:
- Dissection of the gastroduodenal artery in 10 anatomical specimens.
- Marking arterial contact points on the posterior duodenal wall with needles.
- Recording needle positions via gastroscopy and creating 3D virtual reconstructions.
Main Results:
- The gastroduodenal artery's proximal and distal contact points with the duodenum were measured relative to the pylorus.
- The artery's course runs adjacent to the duodenal wall, projecting towards the gastroscope tip endoscopically.
- Specific measurements: proximal contact 27.2mm (range 15-30mm), distal contact 15mm (range 10-20mm).
Conclusions:
- The gastroduodenal artery's extraluminal course directs arterial blood flow toward the gastroscope during endoscopy.
- Bleeding control strategies may need to be applied "aboral" (further from the stomach) to the bleeding site.
- This anatomical understanding aids in optimizing endoscopic interventions for bleeding ulcers.
Introduction:
Peptic ulcers account for 50% of upper gastrointestinal bleeding incidents. Bleedings from large vessels, such as the gastroduodenal artery, are associated with increased mortality. Ulcers located on the posterior wall of the duodenum show the highest risk for erosion of the gastroduodenal artery. Endoscopic management is challenging and rebleeding rates are high due to internal and external confounding factors such as anatomical variability and gastric insufflation. We aimed to correlate macroscopic and endoscopic anatomy for assessment of implications for clinical management.
Material And Methods:
The gastroduodenal artery was dissected in 10 anatomical specimens. The points of contact of the artery with the posterior wall of the duodenum were marked with needles. The endoluminal position of the needles was recorded by standardized gastroscopy and a 3-dimensional virtual reconstruction was carried out for visualization of the artery's course.
Results:
The artery's proximal and distal points of contact with the duodenum were 27.2mm (range 15-30mm; SD 6.7mm) and 15mm (range 10-20mm; SD 3.5mm), respectively, from the pylorus. The gastroduodenal artery branches from the common hepatic artery within the omentum minus running adjacent to the duodenal wall to the head of the pancreas. From endoscopic perspective, the gastroduodenal artery's course was directed towards the tip of the gastroscope.
Conclusion:
Due to the peculiar extraluminal course of the gastroduodenal artery the arterial blood flow projects into the direction of the gastroscope during endoscopic intervention. Measures for bleeding control might have to be applied aboral from the bleeding site.
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