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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 112-117

Rare anatomic variant: Celiac-mesenteric trunk in an Afro-Caribbean population


1 Lecturer, Department of Basic Medical Sciences, University of the West Indies, Kingston, Jamaica
2 Professor, Department of Surgery, Port of Spain General Hospital, Port of Spain, Trinidad and Tobago

Date of Submission01-May-2021
Date of Decision12-Jun-2021
Date of Acceptance02-Jul-2021
Date of Web Publication30-Jul-2021

Correspondence Address:
Shamir O Cawich
Department of Surgery, Port of Spain General Hospital, Port of Spain
Trinidad and Tobago
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_52_21

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  Abstract 


Background: The celiac-mesenteric trunk is an anatomic variant where there is a common origin for the superior mesenteric artery and celiac trunk. We sought to determine the prevalence of this variation in an Afro-Caribbean population. Methodology: Anatomic dissections were observed over 5 years, and specimens with celiac-mesenteric trunks were identified for detailed investigation. We measured celiac-mesenteric trunk diameters at their origin from the aorta. Results: Dissections were performed in sixty-nine cadavers at a mean age of 68 years (range 55–85). Only one celiac-mesenteric trunk (1.5%) was encountered in an Afro-Caribbean male. This cadaver had no other morphologic anomalies. The celiac-mesenteric trunk had an internal diameter of 13.06 mm at its origin (55% aortic diameter). Conclusion: In this Afro-Caribbean population, a celiac-mesenteric trunk was found in 1.5% of unselected cadavers. This formidable vessel was 55% of the aortic diameter. Therefore, healthcare professionals must be aware of this variant to avoid inadvertent injury during clinical interventions.

Keywords: Aorta, arterial, caribbean, coeliac, coeliaco-mesenteric, mesenteric, variants, vascular


How to cite this article:
Gardner MT, Cawich SO, Shetty R, Lodenquai P, Zheng Y. Rare anatomic variant: Celiac-mesenteric trunk in an Afro-Caribbean population. Natl J Clin Anat 2021;10:112-7

How to cite this URL:
Gardner MT, Cawich SO, Shetty R, Lodenquai P, Zheng Y. Rare anatomic variant: Celiac-mesenteric trunk in an Afro-Caribbean population. Natl J Clin Anat [serial online] 2021 [cited 2021 Sep 21];10:112-7. Available from: http://www.njca.info/text.asp?2021/10/3/112/322806




  Introduction Top


Celiac trunk is one of the major branches of Abdominal aorta given at the level of T12 vertebra. The 3 main branches of it are left gastric artery, splenic artery and common hepatic artery. Variations in the celiac trunk and its branches is of great research interest.

Lipshutz was the first to describe ramifications of the celiac trunk in 83 cadaveric dissections.[1] He identified two cadavers with a single origin for superior mesenteric artery and celiac trunk and coined the term “truncus celiaco-mesenterica.”[1] We investigated this variation in an Afro-Caribbean population from Jamaica.


  Materials and Methods Top


We carried out an observational study on cadaveric dissections by postgraduate surgical residents between September 1, 2004, and August 30, 2009. At dissection, the left hemi-liver was mobilized by interrupting coronary, triangular, and gastro-hepatic ligaments. The stomach, pancreas, and duodenum were transected to achieve wide exposure of the upper abdominal aorta. Any cadaver that demonstrated a celiac-mesenteric trunk was selected for detailed review.

In this study, aortic branches were described in keeping with classic anatomic patterns where celiac and mesenteric trunks originate separately at T-12 and L-1 vertebral levels, respectively as outlined in [Figure 1].[1],[2] Three main branches then ramify from the celiac trunk to form an arterial trifurcation.[1],[2] A celiac-mesenteric trunk was present when there was a single common origin for celiac and superior mesenteric trunks.[1]
Figure 1: Cadaveric dissection demonstrating the normal branch pattern of the ventral abdominal aorta. The most cephalad branch is the CT at T-12 vertebral level, SMA at L-1 vertebral level and then IMA at L-3 vertebral level. The aorta then bifurcates at L-4 vertebral level into CI arteries. Other structures present are the IVC, LRV, G and A veins. IMA: Inferior mesenteric artery, CT: Celiac trunk, CI: Common iliac, IVC: Inferior vena cava, LRV: Left renal vein, G: Gonadal, A: Adrenal

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In each specimen, the ventral aortic branches were observed and all their ramifications were followed to determine their territorial supply. Two researchers measured the diameter of the ventral branches at their origin from the aorta with calipers and their average was the final dimension used.


  Results Top


There were 69 cadaveric dissections performed in 39 male and 30 female cadavers at a mean age of 68 years (range 55–85). There was only one cadaver with a celiac-mesenteric trunk (1.5%). This occurred in a middle-aged Afro-Caribbean male, in whom the cause of death was not specified. There were no direct pathologic sequalae from the celiac-mesenteric trunk (e.g., aneurysms, occlusion, etc.,).

The celiac-mesenteric trunk arose at the level of the first lumbar vertebral body. At this level, the abdominal aorta had an internal diameter of 23.77 mm. The internal celiac-mesenteric trunk diameter was 13.06 mm at its origin (55% of the aorta) and extended for 6.12 mm before bifurcating [Figure 2].
Figure 2: Cadaveric dissection demonstrating a celiac-mesenteric trunk. Dissecting forceps separate the abdominal aorta (broken red line) from the celiac-mesenteric trunk. The celiac-mesenteric trunk then bifurcates into SMA and CT. In this dissection, the SA and CHA can be seen arising from the celiac trunk. CT: Celiac trunk, SA: Splenic artery, CHA: Common hepatic artery

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At its origin, the celiac trunk had an internal diameter of 9.35 mm and coursed cephalad forming a false tripod. The left gastric artery came off first 13.21 mm from the coeliac trunk origin (internal diameter 3.22 mm). The celiac trunk then bifurcated 26.89 mm from celiac trunk origin into splenic (internal diameter 7.86 mm) and common hepatic arteries (6.23 mm). The further ramifications of the celiac trunk branches appeared to follow a normal course [Figure 3].
Figure 3: In this dissection, a red pin separates the abdominal aorta (broken red line) from the celiac-mesenteric trunk. The celiac-mesenteric trunk then bifurcates into SMA and Coeliac Trunk (CT). The celiac trunk then trifurcates into SA, CHA, LGA. This dissection also shows the GDA and PHA arteries branching from the common hepatic artery. SMA: Superior mesenteric artery, SA: Splenic artery, CHA: Common hepatic artery, LGA: Left gastric artery, GDA: Gastro-duodenal artery, PHA: Proper hepatic artery

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At its origin, the superior mesenteric artery had an internal diameter of 11.45 mm and immediately coursed caudally, giving off inferior pancreatico-duodenal and middle colic arteries that followed a normal course [Figure 4].
Figure 4: In this dissection, the instrument points to the common origin for the celiac and superior mesenteric. In this dissection, duodenum (d) remains in situ and partially covers superior mesenteric branches (1). However, the three main celiac branches and their normal courses are seen: splenic (2), Left gastric (3), common hepatic (4), gastroduodenal (5), proper hepatic (6) and right gastric (7) arteries

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  Discussion Top


In this cadaveric study, the majority of specimens demonstrated conventional branching at the upper abdominal aorta. In existing reports, this classic pattern exists in 55%[2]–91%[3] of persons. The celiac-mesenteric trunk is a rare anatomic variant that is reported to be present in 0.42%[4]–2.7%[5] of individuals. We encountered the celiac-mesenteric trunk in 1.5% of cadavers.

It is believed to occur because of incomplete separation of the primitive ventral anastomosis in utero. During embryogenesis, a primitive dorsal abdominal aorta gives rise to four aortic roots that originate from a longitudinally-oriented ventral anastomosis.[6] The fourth primitive aortic root eventually separates to form the superior mesenteric artery, while the remaining three roots remain anastomosed to form the celiac trunk. When the primitive roots fail to separate in embryogenesis, the result is a common origin known as the celiac-mesenteric trunk.[1],[6] There are two recognized variants: the complete celiac-mesenteric trunk involves the superior mesenteric artery plus all 4 celiac branches[7],[8],[9],[10],[11] while an incomplete trunk involves the superior mesenteric artery and only 2 celiac branches.[11],[12],[13],[14] Some researchers interchange these terms with “classic versus variant” celiac-mesenteric trunk.[8]

In our study, we encountered a cadaver with a complete/”classic” celiac-mesenteric trunk. Some authors have attempted to classification systems to define variations of the celiac-mesenteric trunk,[1],[7],[11],[12],[13],[15],[16],[17],[18] but there appear to be multiple classifications without any consensus on their use. For example, the variant we encountered could be classified as Pangouli Type IV,[7] Wang Type 2,[12] Tang Type sIa,[13] Adachi Type IV,[15] Uflacker Type VI,[16] Morita Type 1[17] and Osman Type IV.[18] [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7] outline the classification systems and demonstrate how the nomenclature of the variant we encountered differs in each classification.
Table 1: Lipshutz' classification of the celiac trunk[1]

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Table 2: Panagouli's classification[7]

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Table 3: Wang's classification[12]

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Table 4: Tang's classification[13]

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Table 5: Adachi's classification[15]

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Table 6: Uflacker's classification of the coeliac trunk[16]

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Table 7: Morita's classification[17]

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Table 8: Osman's classification[18]

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Regardless of the nomenclature used, the celiac-mesenteric trunk has clinical significance. First, in our case, the common trunk was large at 55% aortic diameter and 13.06 mm diameter. This was in keeping with the existing reports. For example, Bordei et al. reported that the diameter of the common trunk in their study ranged from 9 to 13 mm, which was between 40% and 58% of the aortic diameter.[19] This vessel is at risk of iatrogenic injury during operations in the retroperitoneum, especially during a Whipple's pancreaticoduodenectomy when the pancreatic neck partially obscures its origin from the aorta. In the event that such a formidable artery is injured, it could lead to significant intra-operative hemorrhage, hepatic ischemia, and death.

In addition, when the celiac-mesenteric trunk originates from an aberrant location on the ventral aorta or its ramifications follow aberrant routes, they can be damaged by the unsuspecting surgeon. In our cadaver, the common trunk originated at the level of L1 vertebral body and the further arterial ramifications appeared to follow normal routes to their end organs. However, it is not unusual for these vessels to be in unexpected locations. For example, Bordei et al. reported that in 42% of cases, the celiac-mesenteric trunk had a low origin at L1/2 intervertebral disk level.[19] Multiple authors have also reported associated arterial anomalies when a celiac-mesenteric trunk is present.[4],[7],[8],[9],[11],[12],[13]

Radiologists should also be aware of the presence of a celiac-mesenteric trunk because it will impact the performance of interventional procedures such as selective angiography to detect the source of gastrointestinal bleeding, embolization of splenic injuries in trauma patients, and trans-arterial hepatic chemotherapy infusions in oncology patients. Fortuitously, this anatomic variant can be readily detected on modern contrast-enhanced computerized tomographic scanning.[3],[4],[5],[6],[7],[8],[9]

Many authors have identified celiac-mesenteric trunks in persons of Asian,[12],[13],[15],[20],[21],[22],[23],[24],[25],[26] Caucasian[1],[2],[3],[7],[27],[28],[29],[30],[31] and Indian descent.[8],[32],[33] In our study, 96% of cadavers were from the African diaspora – The worldwide collection of communities descended from Africa's peoples, particularly descendants of West and Central Africa. Therefore, we sought to compare our data with studies from the African diaspora. Mburu et al.[34] evaluated coeliac artery variations in 123 Kenyan cadavers and identified the combined gastro-splenic plus hepato-mesenteric trunk (4.9%), but no cases of the celiac-mesenteric trunk were identified. It would be interesting to compare our data with other African populations, but we found no other published reports evaluating variations in the African diaspora.

The size of our sample limits the statistical power of our study. It is theoretically possible that more celiac-mesenteric trunks may have been identified if there were more dissections performed, but this was limited by the cadavers available in this institution.


  Conclusion Top


In this Afro-Caribbean population, the coeliac-mesenteric trunk was found in 1.5% of unselected cadavers. This formidable vessel was 55% of the aortic diameter and at risk for injury. Therefore, healthcare professionals must be aware of this variant during clinical interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Wang Y, Cheng C, Wang L, Li R, Chen JH, Gong SG. Anatomical variations in the origins of the celiac axis and the superior mesenteric artery: MDCT angiographic findings and their probable embryological mechanisms. Eur Radiol 2014;24:1777-84.  Back to cited text no. 12
    
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Tang W, Shi J, Kuang LQ, Tang SY, Wang Y. Celiomesenteric trunk: New classification based on multidetector computed tomography angiographic findings and probable embryological mechanisms. World J Clin Cases 2019;7:3980-9.  Back to cited text no. 13
    
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