A Rare Clinical Case of Celiac Trunk Anatomy in a Patient with Siewert III Cardioesophageal Junction Cancer

doi:10.21203/rs.3.rs-2870312/v1

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A Rare Clinical Case of Celiac Trunk Anatomy in a Patient with Siewert III Cardioesophageal Junction Cancer

https://doi.org/10.21203/rs.3.rs-2870312/v1

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Purpose: The normal anatomy of the celiac trunk (CT) is characterized by splitting into three branches in approximately 80% of cases. In other cases, multiple anatomical variations can be observed. The purpose of this study was to review the clinical case featuring an extremely rare location of common hepatic artery (CHA) and to emphasize the importance of being familiar with possible anatomical variations of the hepatic artery through preoperative imaging in preparation for oncological surgery.

Methods: We report a rare anatomical variation of replaced common hepatic artery, when it is located as VI type of Hiatt^’s classification – CHA branching from abdominal aorta (AA). It was discovered during contrast-enhanced computed tomography and illustrated by 3D reconstruction of vascular architectonics of the celiac trunk.

Results: A 71-year-old patient presented with Siewert III cardioesophageal junction cancer with liver metastases (T2N2M1, stage IV). Preoperative contrast-enhanced computed tomography (CECT) showed that the CHA branched from the AA. The operation included the proximal resection of the stomach and abdominal esophagus, D2 lymph nodes dissection, peritumoral liver resection, and extramucosal pyloroplasty.

Conclusion: This case shows the importance of preoperative preparation using CECT to identify anatomical variations of the CHA, particularly for patients with locally advanced and metastatic cancer. This is due to the fact that the CHA is an important intraoperative landmark in the process of lymph nodes dissection, and awareness of its rare anatomical variation allowed us to shorten the operation time and reduce the risk of intra- and postoperative complications.

Celiac trunk

vascular anatomy

computed tomography

3D reconstruction

surgical oncology.

The first variation of the celiac trunk was described by Haller in 1756, which showcased the normal anatomical appearance of the CT, splitting into three branches: left gastric artery (LGA), common hepatic artery (CHA), and splenic artery (SA). This variation occurs in approximately 80% of cases [3, 7]. In other cases, we can observe multiple variations as well illustrated in the Hiatt^’s classification based on a compilation of 1,000 cases in 1994 [2].

Awareness of the celiac trunk anatomy variations is clinically important and mandatory in the planning and performance of abdominal surgery. Lack of awareness of these variations may mislead surgeons and interventional radiologists, potentially resulting in unexpected complications during the operation. The new imaging technologies increased the accuracy of preoperative identification of vascular anatomical variations.

We present the case of a 71-year-old male patient diagnosed with Siewert III cardioesophageal junction cancer, histologically identified as moderately differentiated adenocarcinoma, T2N2M1 (metastases to the liver, retroperitoneal lymph nodes), stage IV (TNM Classification of Malignant Tumours, 8th Edition) [1]. The patient's overall preoperative status according to the Eastern Cooperative Oncology Group (ECOG) was 1.

In November 2020, the patient was diagnosed with a cardiac gastric tumor during gastroscopy. Subsequent abdominal CT scan with IV contrast revealed multiple liver metastases, retroperitoneal lymph node involvement, and hepatomegaly. In December 2020, the patient started receiving monochemotherapy (mCT) with Capecitabine. Immunohistochemistry revealed a moderately differentiated HER2/neu 3 + tubular gastric adenocarcinoma, which resulted in supplementing the treatment with Trastuzumab. From February 18, 2021, to September 1, 2021, the initial chemotherapy was adjusted to include 8 cycles of XELOX chemotherapy. Favourable trend was observed, including a reduction in liver metastases and stabilization of the gastric tumor. Since November 2021, the patient has been undergoing mCT with Capecitabine and Trastuzumab.

In July 2021, an esophagogastroduodenoscopy (EGD) with biopsy revealed a low-grade gastric adenocarcinoma, HER2 negative. The patient was offered surgical treatment, and he underwent a repeat CT scan with IV contrast. The CT scan identified a rare anatomical variation of the celiac trunk, in which the common hepatic artery (CHA) branches directly from the abdominal aorta. Only the splenic artery (SA) and left gastric artery (LGA) branch from the celiac trunk. A 3D reconstruction of the abdominal CT angiography clearly illustrates this vascular architecture (Fig. 2).

The patient underwent a laparoscopic-assisted proximal gastric resection, abdominal esophageal resection, D2 lymph node dissection, peritumoral liver resection, and extramucosal pyloroplasty.

The postoperative period was uncomplicated, and the patient was discharged on the 8th day following surgery. Based on the results of the pathomorphological examination, tubular adenocarcinoma of the gastroesophageal junction of the intestinal type with areas of mucinous differentiation, Borrman type I growth pattern, with invasion to the submucosal layer, was diagnosed. No invasion into the esophagus was detected. Lymphovascular invasion was observed. Perineural and vascular invasion were not reliably detected. A total of 20 lymph nodes were examined, with no tumor growth detected, and resection margins were negative. The greater omentum was intact. No tumor growth was found in the liver parenchyma (pT1b pN0 L1V0Pn0 R0). An oncology board was consulted, and the patient is scheduled to continue chemotherapy and immunotherapy.

In 1904, Tandler provided an embryological explanation for celiac trunk anomalies [9]. During embryogenesis, the fetus has two aortas - ventral and dorsal, connected by 6 pairs of vascular arches. The dorsal aortas fuse during the fourth and fifth weeks of intrauterine life, forming an abdominal aorta. Each dorsal aorta gives rise to numerous bilateral ventral segmental arteries that supply the abdominal organs and later fuse longitudinally along the midline, forming a ventral anastomosis while preserving the 3 main branches, namely CA, SMA, and IMA. The unusual embryological development of these arteries, along with certain parts of the longitudinal anastomosis, can result in substantial variations [3, 9]. These variations are comprehensively categorized in the Hyatt classification, which delineates six categories: the normal anatomy - type I, replaced or accessory left hepatic artery (LHA) - type II, replaced or accessory right hepatic artery (RHA) - type III, replaced or accessory LHA + RHA - type IV, CHA from superior mesenteric artery (SMA) - type V, CHA from AA - type VI. [2]

Our clinical case is based on type VI, when CHA branches from AA. This condition has been reported in the literature to occur in approximately 0.2–0.6% of cases (Table 1) [8, 6, 10, 11, 5].

During surgery, unawareness of such anatomical variations may lead to technical challenges, increasing the risks of intra- and post-operative complications. The CHA is the primary anatomical landmark for dissecting the No. 8a and 8p lymph nodes. Awareness of such anatomical variations is crucial for preventing vascular damage and inaccurate lymph node dissection [4].

Identifying anatomic vascular variations preoperatively through imaging techniques and awareness of CHA anatomy is crucial to avoid a longer operative time and increased rates of postoperative morbidity and mortality. This approach enhances the accuracy of preoperative identification of similar anatomical variations.

Table 1

Frequency of Type VI occurrence (CHA branching from AA) according to Hiatt JR's classification.
Author (year)	n	Frequency of CHA branching from AA (%)
Eaton (1917)	206	1(0.48)
Hiatt et al. (1994)	1000	2 (0.2)
Soin et al. (1996)	527	1(0.19)
Koops et al. (2004)	604	1 (0.17)
Chen et al. (2009)	974	5 (0.51)
Song et al. (2010)	5002	11 (0.22)
Löschner et al. (2014)	1297	4 (0.31)
Kobayashi S et. al	1200	7(0.6)
Zaki et al. (2019)	500	2(0.4)
Zhang et al. (2020)	218	1(0.46)

The technical complexity of mobilization and lymph node dissection stages increases significantly in patients with upper gastrointestinal tract tumors, particularly in the case of locally advanced cancer and lesions of regional lymph nodes. This determines the need for a detailed study of vascular architecture in each individual case. Therefore, the use of contrast-enhanced computed tomography to build a 3D model of vessels allows the surgeon to plan the course of the operation and avoid severe intraoperative complications.

Ethical approval: The research was conducted ethically in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki). Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests: The authors declare no competing interests.

Authors' contributions: Tatyana Khorobrykh, Ivan Ivashov, Alexey Spartak: performed surgery; Alexey Spartak, Ivan Ivashov and Victoriia Reiter: manuscript preparation, data collection and analysis, literature search; Polina Pronina and Anton Grachalov manuscript revision; Victoriia Reiter writing/editing and translated the manuscript. All authors read and approved the final manuscript.

Funding: The authors did not receive support from any organization for the submitted work.

Availability of data and materials: All data generated or analysed during this study are included in this article [and/or] its supplementary material files. Further enquiries can be directed to the corresponding author.

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No competing interests reported.

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A Rare Clinical Case of Celiac Trunk Anatomy in a Patient with Siewert III Cardioesophageal Junction Cancer

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