Anatomic association between the gastrocolic trunk of Henle and right colic artery by high-quality CT venography

doi:10.21203/rs.3.rs-4853520/v1

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Anatomic association between the gastrocolic trunk of Henle and right colic artery by high-quality CT venography

https://doi.org/10.21203/rs.3.rs-4853520/v1

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In hepatic flexure and transverse colon cancer surgeries, mobilizing the right mesocolon and precisely dissecting the gastrocolic trunk of Henle (GTH) are crucial. Previous classifications of GTH tributaries do not guide radical right hemicolectomy due to post-procedural anatomical acquisition. This study analyzed vessel associations, including the middle colic vein (MCV) converging site, right colic artery (RCA) presence, and other GTH tributaries, using ultra-thin CT for reconstruction. GTH anatomy was categorized into medial and lateral types based on colic tributary convergence relative to ASPDV. Results showed the colic tributary joined GTH lateral to ASPDV in 45.81% and medial in 54.19% of cases. RCA presence was strongly linked to the lateral GTH type (56.76% vs. 43.24%, p < 0.001) when RCA was absent. MCV converged into the superior mesenteric vein (SMV) on the left side in 23.15% of cases, correlating with the right colic vein presence (odds ratio = 3.563, p = 0.007). This novel GTH variation pattern via high-level CT venography significantly correlates with RCA presence, aiding surgeons in anticipating GTH anatomy during laparoscopic radical right hemicolectomy.

Health sciences/Anatomy

Health sciences/Gastroenterology

Health sciences/Medical research

CT venography

Anatomic variation

Gastrocolic trunk of Henle

Middle colic vein

Within surgeries for cancer at hepatic flexure and transverse colon, mobilizing the right mesocolon and precisely dissecting the colonic tributary of gastrocolic trunk of Henle (GTH) were the key steps^1–4. However, due to the thin wall and complex variation of GTH tributaries, inadvertent traction can result in life-threatening bleeding and poor lymph node harvest. Although classifications of GTH by tributary number and origin organs have been reported ^5–8, the tributary pattern cannot be reliably predicted before or during surgery. Therefore, further investigation into the association between GTH anatomy and surrounding anatomy is necessary to aid in real-time GTH anticipation and subsequent procedures.

One of the tributaries of GTH, the accessory right colon vein (ARCV), is responsible for draining the blood flow from the hepatic flexure and upper ascending colon. During mesocolon separation from the head of the pancreas, the ARCV is the first vein to come under tension and lacks an accompanying artery for tension buffering, leading to a higher vulnerability than the other two tributaries^6,8. Therefore, in this study, we focused mainly on the ARCV drainage as the primary variable for GTH pattern, rather than considering the three branches as a whole body.

Although CT reconstruction has been proposed as a feasible method to investigate GTH anatomy in a large sample size, inconsistent results have been reported, particularly with regards to the anatomy of the anterior superior pancreaticoduodenal vein (ASPDV). This is mainly due to the challenge of capturing the peak scanning delay for portal vein reconstruction, which varies depending on the individual's gastrointestinal re-circulation speed ^5,9–14. In this study, we overcame this challenge by optimizing the scanning delay for portal vein enhancement, achieving an attenuation value of 300 HU sufficient for coronary and cranial reconstruction ^15,16. With this improved method, we focused on observing the variation of ARCV drainage within the GTH in a large sample size, aiming to develop a potential strategy to anticipate GTH anatomy during surgery.

Baseline characteristics and high quality veno-graphy

A total of 203 patients were enrolled in this study, with 113 males (55.7%) and 90 females (44.3%). The mean age was 56.49 ± 11.71 years (range 23-87 years). The average delay for the portal phase scanning was 46.35 ± 4.60 s. The attenuation values at the root of GTH, main trunk of portal vein, splenic vein, the portal-splenic vein junction, and middle third of ileocolic vein were 312.01 ± 47.25 HU, 286.53 ± 44.48 HU, 308.89 ± 56.42 HU, 311.54 ± 57.46 HU, and 272.08 ± 63.14 HU, respectively. These were similar to the level of coronary arterial reconstruction and much higher than previous GTH radiological studies (Table 1).

Variations of GTH tributaries

The average length of GTH was 8.84 ± 4.64 mm, and the average diameter was 5.69 ± 1.21 mm. GTH was 21.73 ± 6.70 mm above the inferior border of pancreas, and 44.59 ± 8.62 mm above duodenum.

In 81.8% (166/203) of the cases (Table 2, Supplementary Table 1), GTH was the gastro-pancreato-colic trunk (GPCT), composed by RGEV, ASPDV and varied colic components. Specifically, the colic tributary was a single ARCV in 56.2% (114/203, Figure 1A), a single MCV in 3.5% (5/203), ARCV+RCV in 11.8% (24/203, Figure 1B), ARCV + MCV in 11.3% (23/203), ARCV + ICV in 1.5% (3/203), and ARCV + MCV + ICV in 0.5% (1/203, Figure 1C). In 16.3% (33/203) of the cases, GTH was the gastro-pancreatic trunk (GPT) formed by RGEV and ASPDV, without colic vessel (Figure 1D). In this subtype, the colic vein from right-sided colon drained into lateral (45.45%, 15/33) and medial .(54.55%, 18/33). GTH was not found in 4 patients that RGEV, ASPDV and ARCV separately joined SMV (Figure 1E).

GTH classifications and its association analysis

Since the colic vessel showed higher variation as illustrated above, ARCV drainage was classified into lateral type (lateral to ASPDV, Figure 2B and 2D) and medial type (medial to ASPDV, Figure 2C and 2E). Medial type of drainage was found in most of the cases (54.19%, 110/203).

The ARCV drainage pattern was highly correlated with RCA anatomy that, when RCA was absent (54.68%, 111/203), ARCV was in much higher chance of being the lateral rather than the medial type . When RCA was present, most ARCV joined GTH at medial (67.39.% vs 32.61%,OR = 2.712, p = 0.001), and none of them were escortrd by RCA. After multivariate regression, the present of RCA (OR=2.558, p=0.004),GTH length > 8.24 (OR=0.512, p=0.039), D_{GTH to pan} > 21.49 (OR=0.311, p=0.049) were independently associated with the medial )type of GTH (Table 3). An example of lateral type GTH when RCA was absent was illustrated in figure 3 by CTV reconstruction and intra-operative confirmation.

MCV drainage classification and its association analysis

MCV was found in all the cases, with one trunk in 87.7% (178/203), two trunks in 12.3% (25/203) of the cases. The drainage site of MCV into portal vein system also varied that MCV joined SMV in 59.6%(121/203), GTH in 9.4%(19/203), IMV in 8.4%(17/203), FJV in 7.4%(15/203), SV in 3.0%(6/203). Classified by the left verge of SMV, the converging site of MCV was classified as right-sided in 76.85%, and left-sided in 23.15% of the cases (Table 4, Figure 4). The left-sided drainage of MCV was associated with the presence of RCV (OR=3.563, p=0.007) (Table 5).

The management of the colonic component of GTH is a crucial aspect of radical resection for hepatic flexure and transverse colon cancer, as inadvent torn during surgery could result in severe complications ¹⁶. In this study, we found a novel GTH variation pattern that was highly correlated with surrounding anatomy. Our findings could potentially contribute to the development of new strategies for anticipating GTH anatomy during surgery and reducing surgical complications.

In this study, we proposed a new classification system for GTH variations based on the drainage of the ARCV, which builds upon previous classification systems that were based on the number of origin organs or vessels¹⁷. The use of ARCV drainage as a variable for classification is supported by the fact that variations of the ARCV are more common than those of the RGEV or ASPDV, as found in both our study and previous research ¹⁷. This is likely due to the variable extent of cecum rotation and the relatively fixed position of the stomach and pancreas during embryonic development¹⁸. Furthermore, during radical right hemicolectomy, the colonic tributary of GTH is often the first vein that comes under tension during mesocolon separation from the head of the pancreas^6,8. Therefore, our classification system is more practical for surgeons as it serves as a reminder of the variation and helps to prevent the risk of bleeding during surgery.

Notably, this classification also revealed potential surgical guiding value. Specifically, our ARCV-based GTH pattern was found to be independently associated with the presence of RCA and RCV. This finding could be particularly useful in laparoscopic radical right hemicolectomy under caudal-cephalic approach. After ICA ligation, the presence of RCA could help the surgeon anticipate the subsequent anatomy of GTH. If RCA was absent (45.32%), ARCV drainage was more likely to be lateral to ASPDV(56.76% vs. 43.24%). This could be explained by the variable extent of cecum rotation during embryonic development. If the cecum was not prolonged long enough to call for RCA development from SMA, the ascending colon would not need to form a distant and medial drainage to SMV (medial type) and would instead necessitate its convergence with ASPDV (lateral drainage).

An unexpected finding of this study was the left-sided drainage of the MCV in 23.15% of cases, which converged into the portal vein system via the splenic vein(7/47), inferior mesenteric vein(21/47)), or first jejunal vein(19/47). This novel pattern of MCV drainage is concerning in radical resection for hepatic flexure or transverse colon cancer, as the left-sided MCVs could be inadvertently torn and cause life-threatening bleeding during specimen removal. Interestingly, the left-sided drainage of MCV was found to be independently associated with the presence of RCV, which could serve as a useful reminder for surgeons to be cautious during dissection of the MCV in these cases.

An additional strength of our study was the high-quality imaging for mesenteric venous reconstruction. Due to individual variations in gastrointestinal recirculation speed, the optimal peak scanning delay for accurate GTH reconstruction is challenging to determine manually, and this may lead to inconsistent results for ASPDV in previous radiological studies ^7,17–20. To overcome this limitation, we developed a novel model to predict the optimal scanning delay, achieving a mean attenuation value of 312.01 ± 47.25 HU within the GTH. This value is comparable to that used for precise coronary and cranial computed tomography angiography (CTA) reconstruction^15,16. Together with the use of ultra-thin images (0.5 mm) and maximum intensity projection (MIP) reconstruction for fine vessel delineation, the tributary of GTH could be accurately visualized²¹.

One limitation of this study is the absence of intra-operative confirmation. A prospective study with strict control over surgical procedures and a larger sample size would be necessary to confirm the association between RCA and GTH. Future studies with intra-operative confirmation are warranted to further validate the findings and refine the proposed classification. This would outreach the framework of this proof of concept study, and can be carried out in the future. However, it should be noted that when the intra-vessel attenuation value reaches 300 HU, the anatomical accuracy is high^22,23.

In conclusion, this study demonstrated a novel pattern of GTH variation using high-level CT venography, which showed a significant correlation with the presence of RCA. These findings have the potential to aid surgeons in anticipating the GTH anatomy during laparoscopic radical right hemicolectomy. However, further studies are needed to confirm these findings and to explore their clinical utility in surgical decision-making.

Patients

In this study, patients receiving abdominal and pelvic enhancement CT at the Sixth Affiliated Hospital of Sun Yat-Sen University from 2018 to 2019 were enrolled. Patients with previous abdominal surgery, severe intestinal obstruction, younger than 18 years and with poor image quality were excluded.

CT protocols

All examinations were performed with Toshiba Aquilion ONE 640-slice CT. Scanning parameters included 100-120 kV tube voltage, tube current controlled by automatic milliampere technology, 0.5 mm layer thickness, and an open detector of 80 × 0.5 mm. The patient was required to fast (4-6 h) and drink water (500-800 ml) before the inspection. The patient was put in a supine position. Scanned was the diaphragmatic roof to the level of the ischial tuberosity. After plain scanning, iopromide (concentration 370 mg/ml) was injected through the median cubital vein with a dose of 1.3 ml/kg and a rate of 3-4 ml/s. The scanning time during the portal venous phase was generated by an in-house app that calculates the patient's physiological parameters ^24,25. After the scanning was completed, the data were transmitted to Vitrea 6.3 (Vital Images, Minneapolis, Minnesota, USA) for storage and reconstruction. Maximum intensity projection (MIP) reconstruction was performed using the RadiAnt DICOM Viewer 5.0.1 (Medixant, Poznan, Poland). The bolus arrival time of venous phase scan (T_bolus-scan) was also recorded. The CT images under 250 HU were excluded.

Definition of the vessels

In this study, we defined the gastrocolic trunk of Henle (GTH) as the confluent vessel of the anterior superior pancreaticoduodenal vein (ASPDV), right gastroepiploic vein (RGEV), and the colic veins from the right-sided colon. The accessory right colic vein (ARCV) was defined as the vein that drains blood from the hepatic flexure and ascending colon into the GTH (as shown in Fig. 1A). The right colic vein (RCV) was defined as the vein that drains the ascending colon directly into the superior mesenteric vein (SMV). The middle colic vein (MCV) was defined as the vein that drains the transverse colon. The first jejunal vein (FJV) was defined as the first vein that drains the medial part of the jejunum. The right colic artery (RCA) was defined as the artery that originates from the superior mesenteric artery (SMA) alone and supplies the ascending colon. In addition, we also defined the artery originating from the medial third of the ileocolic artery (ICA) and supplying the right-side colon as the RCA. Finally, the ICA and ileocolic vein (ICV) were defined as the vessels that originate from the SMA/SMV and approach towards the cecum.

Anatomical measurements and classifications

The attenuation value was measured at various locations including the main portal vein, root of GTH, splenic vein, the junction of splenic vein and portal vein, and middle third of ileocolic vein. The length and diameter of GTH were also measured, as well as the distance from the lower border of pancreas and duodenum to the lower border of GTH. Relative positions between ICA and ICV were recorded as well.

GTH was classified into two types: lateral and medial, based on the converging site of its colic tributary relative to the position of ASPDV. The lateral type was defined as the colic tributary joining GTH lateral to ASPDV, or being absent. The medial type was defined as the colic tributary joining GTH medial to ASPDV or directly into SMV (refer to Figure 2).

The MCV was also classified based on the converging site of its left branch/main trunk into the portal vein system. The right-sided drainage site included SMV and GTH, while the left-sided drainage included FJV, IMV, and splenic vein (SV).

Statistical analysis

Categorical data were reported as the number (percentage). Continuous variables were grouped by means if Gaussian distributed, and by medians if non-Gaussian distributed. Univariate and multivariate logistic regression analyses were performed. All of the analyses were performed on the R (version 3.6.3). p value less than 0.05 was considered statistically significant.

Ethics declaration

This study received approval from the Ethics Committee of the Sixth Affiliated Hospital , Sun Yat-sen University. All experiments were conducted in accordance with relevant guidelines and regulations and informed consent was obtained from all participants and/or their legal guardians.

Data availability statement

The datasets generated during and/or analysed during the current study are not publicly available due to participant privacy protections but are available from the corresponding author on reasonable request.

Acknowledgements:

We extend our sincere gratitude to all the patients who participated in this research study. This study was supported by National Key Clinical discipline ,National Natural Science Foundation of China [grant numbers 81970452, 81770656], the program of Guangdong Provincial Clinical Research Center for Digestive Diseases [grant number 2020B1111170004],Sun Yat-Sen University Clinical Research 5010 Program [grant number 2019022], and China Crohn’s & Colitis Foundation （CCCF）under Grant No. CCCF-QF-2022B71-13, The Sixth Affiliated Hospital，Sun Yat⁃sen University Clinical Research 1010 Program 1010CG(2023)-08.

Author contributions:

H.Zhao, X. Zhao, J. Ke contributed to study concept and design, acquisition, analysis, interpretation of data and drafting of the manuscript. H.Zhang, D.Kong, H.Zhao, X.Meng,F.Gao contributed to data collections and interpretation of data and critical revision of the manuscript for important intellectual content. J.Ke supervised the study. All authors read and approved the final manuscript.

Conflicts Disclosures:

The authors declare no competing interests.

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Table 1. CT attenuation values in this and other GTH anatomical studies and coronary arterial study.

Reconstruction	Reference	Cases	Hounsfield Units
Portal vein	Shigeki Itoh & 2004 13	48	153.30±58.80
	Qi Wang & 201314	50	178.29±30.84
	Keisuke Miyoshi & 2020 15	55	228.42±38.15
	Gastrocolic trunk of Henle^*	203	312.01 ± 47.25
	Main portal vein^*	203	286.53 ± 44.48
	Splenic vein^*	203	308.89 ± 56.42
	Portal-splenic vein junction^*	203	311.54 ± 57.46
	Middle third of ileocolic vein^*	203	272.08 ± 63.14
Coronary artery	Filippo Cademartiri &200830	170	339±63
Coronary artery	Xiaolu Fei &2008 31	1080	350

^*this study

Table 2. Former classification of GTH by origin organ and tributary number

Variations	N=203
Gastro-pancreatic-colic trunk	170 (83.74%)
1 colic vein
ARCV	114 (56.17%)
MCV	5 (2.46%)
2 colic veins
ARCV+aMCV	32 (15.76%)
ARCV + MCV	14(6.90%)
ARCV + ICV	3 (1.47%)
3 colic veins
ARCV + MCV + ICV	1 (0.49%)
ARCV + MCV + aMCV	1 (0.49%)
Gastro-pancreatic trunk	31 (15.27%)
Absence	2 (0.99%)
ARCV = accessory right colic vein; MCV = middle colic vein; ICV = ileocolic vein.

Table 3. Univariate and multivariate analysis of GTH classification by the converging site of ARCV

Anatomical features	Group	Lateral type (N=93)	Medial type (N=110)	Univariate analysis			Multivariate Analysis
				OR	CI	p.value	OR	CI	p.value
Gender	Male	50(44.25%)	63(55.75%)	0.867	0.497-1.513	0.616
	Female	43(47.78%)	47(52.22%)
Age	≤ 56.49 y	50(43.48%)	55(56.52%)	1.01	0.987-1.035	0.405
	> 56.49 y	43(43.88%)	55(56.12%)
RCA	Absent	63(56.76%)	48(43.24%)	2.712	1.536-4.865	0.001	2.558	1.422-4.671	0.002
	Present	30(32.61%)	62(67.39%)
RCV	Absent	93(51.10%)	89(48.90%)	-	-	-
	Present	0(0.0)	21(100.0%)
GTH length	≤ 8.24 mm	42(40.00%)	63(60.00%)	0.532	0.286-0.97	0.042	0.512	0.268-0.958	0.039
	> 8.24 mm	51(52.04%)	47(47.96%)
GTH diameter	≤ 5.69 mm	52(47.27%)	58(52.73%)	0.667	0.299-1.431	0.306
	> 5.69 mm	41(44.09%)	52(55.91%)
D_{GTH to pan}	≤ 21.49 mm	47 (47.00%)	53(53.00%)	0.246	0.069-0.695	0.015	0.311	0.085-0.916	0.049
	> 21.49 mm	46(44.66)	57(55.34%)
D_{GTH to duo}	≤ 44.6 mm	54(51.92%)	50(48.08%)	0.752	0.384-1.45	0.399
	> 44.6 mm	39(39.39%)	60(60.61%)
D_{GTH to icv}	≤ 34.8 mm	48(46.60%)	55(53.40%)	0.809	0.458-1.421	0.462s
	> 34.8 mm	45(45.00%)	55（55.00%）
The trajectory of ICA	Posterior	49 (46.67%)	56 53.33%)	1.074	0.618-1.869	0.801
	Anterior	44 (44.90%)	54 (55.10%)
Former classification	Gastro-pancreatic-colic trunk	78(45.88%)	92(54.12%)	Ref
	Gastro-pancreatic trunk	13(41.94%)	18(58.06%)	1.174	0.544-2.593	0.685
	Absence	2(100%)	0(0%)	0	NA-2.104	0.988
RCA = right colic artery; GTH = gastrocolic trunk of Henle; D_{GTH to pan}= distance from GTH to inferior border of pancreas; D_{GTH to duo} = distance from GTH to inferior border of duodenum; D_{GTH to icv} = distance from GTH to ileocolic vein; ICA = ileocolic artery; * indicates significant differences.

Table 4. Drainage variations of middle colic vein

Variables	1 MCV		2 MCVs
Cases, n (%)	178(87.7%)		25 (12.32%)
Drained into, n (%)	SMV	121 (59.6%)	SMV & GTH	9 (4.4%)
	GTH	19 (9.4%)	SMV & SMV	7 (3.4%)
	IMV	17 (8.4%)	SMV & FJV	3 (1.5%)
	FJV	15 (7.4%)	SMV & SV	2 (1.0%)
	SV	6 (3.0%)	SMV & IMV	1 (0.5%)
			GTH & IMV	2 (1.0%)
			GTH & FJV	1 (0.5%)
MCV = middle colic vein; SMV = superior mesenteric vein; GTH = gastrocolic trunk of Henle; FJV = first jejunal vein; IMV = inferior mesenteric vein; SV = splenic vein.

Table 5. Univariate and multivariate analysis of MCV classification by its converging into SMV

Anatomical features	Group	Right-sided	Left-sided	Univariate analysis
		(n=156)	(n=47)	OR	CI	p.value
Gender	Male	91 (80.53%)	22 (19.47%)	1.591	0.827-3.083	0.163
	Female	65 (72.22%)	25 (27.78%)
Age	≤ 56.49 y	83 (79.05%)	22 (20.95%)	1.292	0.672-2.484	0.442
	> 56.49 y	73 (74.49%)	25 (25.51%)
RCA	Absent	83(74.77%)	28(25.23%)	0.772	0.393-1.488	0.443
	Present	73(89.02%)	19(10.98%)
RCV	Absent	145(79.67%)	37(20.33%)	3.563	1.387-9.09	0.007
	Present	11(52.38%)	10(47.62%)
GTH length	≤ 18.7 mm	151(76.26%)	47(23.74%)	0	NA-4.86024513137387e+41	0.989
	> 18.7 mm	5(100.00%)	0(0.0)
GTH diameter	≤ 4.3 mm	17(78.83%)	7(21.17%)	0.699	0.28-1.914	0.459
	> 4.3 mm	139(77.65%)	40(22.35%)
D_{GTH to pan}	≤ 15.7 mm	24(66.67%)	12(33.33%)	0.53	0.244-1.193	0.114
	> 15.7 mm	132(79.04%)	35(20.96%)
D_{GTH to duo}	≤ 39.3 mm	37(68.52%)	17(31.48%)	0.549	0.274-1.119	0.093
	> 39.3 mm	119(79.87%)	30(20.13%)
D_{GTH to icv}	≤ 41.6 mm	112(74.67%)	38(25.33%)	0.603	0.256-1.303	0.218
	> 41.6 mm	44(83.02%)	9(16.98%)
The trajectory of ICA	Posterior	112(74.77%)	38(74.77%)	1.156	0.601-2.229	0.663
	Anterior	44(74.77%)	9(74.77%)
RCA = right colic artery; GTH = gastrocolic trunk of Henle; D_{GTH to pan}= distance from GTH to inferior border of pancreas; D_{GTH to duo} = distance from GTH to inferior border of duodenum; D_{GTH to icv} = distance from GTH to ileocolic vein; ICA = ileocolic artery; * indicates significant differences.

No competing interests reported.

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Anatomic association between the gastrocolic trunk of Henle and right colic artery by high-quality CT venography

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