Journal of Research in Medical and Dental Science 2020, Volume 8, Issue 4, Page No: 110-117 Copyright CC BY-NC 4.0 Available Online at: www.jrmds.in eISSN No. 2347-2367: pISSN No. 2347-2545

Modification of Prudhomme’s Classification of Retro-Duodenal Bilio- Arterial Relations and Their Significance in the Operative Management of Hemorrhagic Duodenal Ulcer-An Anatomosurgical Study

Nasser A. N. Alzerwi Department of Surgery, College of Medicine, Majmaah University, Ministry of Education, Al-Majmaah City, 11952, P. O. Box 66, Riyadh Region, Kingdom of Saudi Arabia

ABSTRACT Background: The modern lifestyle and stress have been known to impact on everyday life. The duodenal ulcers are one such example and are a direct result of the above-mentioned influences. This condition can be due to infectious or non-infectious origin. Duodenal Anatomy is quite complex, and all credit goes to its embryological origin. Duodenal ulcers are quiet commonly encountered in the clinical and surgical practice. Hemorrhagic ulcers are one complication of the posteriorly penetrating duodenal ulcers. Treating a hemorrhagic ulcer is challenging as there are a number of ways, which has been described and many of which are actually followed in the standard surgical treatment which might endanger the during ligation of the gastroduodenal artery. Knowing the relationship between the common bile duct and gastroduodenal artery is very important in the surgical management of the duodenal ulcers. This study puts in an effort for the same. Methods: This study is intended to be of great help to the practicing surgeons. The cadavers were selected and dissected, from July 1st, 2018 to December 31st, 2019, Department of Anatomy, JNUIMSRC. Duodenal morphometry, Origin of the gastroduodenal artery, mean distance between gastroduodenal artery and pylorus, relationship of gastroduodenal artery with bile duct in a transverse plane, Presence of pancreatic tissue between the gastroduodenal artery and bile duct was also observed. And findings were compared with Prudhomme’s classification for validation and modification. Result: Common bile duct is always posterior in position when compared to gastroduodenal artery. And in majority of the cases they will diverge from one another. The presence of pancreatic tissue was found in all cases. Two new variants were found, and the original Prudhomme’s classification was modified accordingly. Conclusion: Variant III and IV are the most vulnerable variation for inadvertent injury to the common bile duct during deep blind ligation of the gastroduodenal artery for a hemorrhagic penetrating bulbar duodenal ulcer. The relations of these two important structures to the 1st part of is especially important and should be known to the practicing surgeons as prompt diagnosis and treatment will be the need of the hour in such emergencies. Key words:

Relationship, Common bile duct, Gastroduodenal artery, Cross sectional, Descriptive, Cadaveric

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: Nasser Alzerwi, Modification of Prudhomme’s Classification of Retro-Duodenal Bilio-Arterial Relations and Their Significance in the Operative Management of Hemorrhagic Duodenal Ulcer-An Anatomosurgical Study, J Res Med Dent Sci, 2020, 8 (4):110-117.

Corresponding author: Nasser Alzerwi described and many of which are actually e-mail: [email protected] followed in the standard surgical treatment, that Received: 01/07/2020 might inadvertently injure the common bile duct Accepted: 20/07/2020 during deep blind ligation of the gastroduodenal artery [2]. The Duodenum is a retroperitoneal INTRODUCTION curving around head of . First part Duodenal ulcers are quiet commonly organ except for first 2-3cm. It is C-shaped and encountered in the clinical and surgical practice traverses right arising from the pyloric part of [1]. Treating a hemorrhagic ulcer is challenging theof duodenumgastric antrum is around and meets 50 mm the in2nd length. part of It as there are a number of ways, which has been

Journal of Research in Medical and Dental Science | Vol. 8 | Issue 4 | June 2020the duodenum at a flexure. The first part 110of the Nasser Alzerwi et al J Res Med Dent Sci, 2020, 8 (4):110-117 duodenum is related to the liver and the gall film which is commonly used to diagnose the the duodenum is related to the gastroduodenal acuteand hemorrhage abdomen cases [3]. Themay erector may chest not X-rayhelp arterybladder which anteriorly. is in Posteriorlyturn a branch the firstof common part of as free air in the peritoneum can be missed hepatic artery in majority of the cases. The other in approximately half of cases [5]. The gold part of duodenum posteriorly are the bile duct both as a diagnostic and therapeutic modality andimportant the portal structures vein. The that bile are duct related along to withthe first the standard is the GI endoscopy as it may be used pancreatic duct opens in the posterior wall cause of duodenal ulcers. of the duodenum. The opening is called as [3]. H. Pylori infections are also quite common Antibiotic regimes combined with proton the major duodenal papilla and the structure inhibitors or antacids can be used for the medical is protected by a fold of mucosa called as the management of this condition [2]. Sometimes plica. This opening in a majority of articles penetration into the posterior wall cause profuse and textbooks has been quoted to be about ten bleeding due to erosion into the gastroduodenal centimeters from the pylorus. The opening is also important from an embryological point of part of the duodenum [6]. This can present as view. That is, it is the point at which the foregut artery that is related posteriorly to the first of the duct marks the point of junction between ulcerhematemesis cases there (vomiting are chances of blood) of or hemorrhage it can pass meets the midgut. In other words, the opening the foregut and the midgut. Actually, the liver in stool (melena). In around 20-25% of duodenal and pancreas develop from the hepatic and hemorrhagic penetrating duodenal bulbar [7]. The most preferred surgical option for wonderful to imagine these parts upside down pancreatic bud from these points [3]. So, it is when embryology of these parts is concerned. ulcer that’s refractory to nonoperative medical treatment (Intravenous fluid resuscitation, very important because the chyme that enters instability,Blood transfusion is duodenotomy and endoscopic and transluminal hemostatic Physiologically the first part of the duodenum is measures) and associated with hemodynamic fact the chyme is mixed thoroughly by the origins most commonly hydrochloricfrom the acid iswhich rich inis acidicsecreted content, by the in- deep blind hemostatic U-stitch [8, 9]. parietal cells of the stomach. This acid in fact Gastroduodenal artery helps in conversion of the pro enzyme that is celiacfrom Commontrunk is T12 Hepatic vertebra. artery, According which to is a againstudy it a secreted by the chief cells i.e., the pepsinogen maybranch also of arise Celiac from trunk. the Vertebral following level in the of following origin of conversion to the active enzyme pepsin. Thus, the auto catalytic action takes place. The other important thing is that the parietal cells also percentages, Left hepatic artery (4-11%) or right secrete bicarbonate to neutralize this acid. These Thishepatic artery artery along (7%) with orits branches Superior gives mesenteric arterial cells are less in number in the duodenum which supplyartery via to stomach,a replaced duodenum hepatic trunk and (4-11%) pancreas [10]. [1]. to the acid ulcerogenic insult. The second part is makes the first part of the duodenum vulnerable and morbidity in case of duodenal ulcer as it GDA hemorrhage is a leading cause of mortality lifeprotected and is bymore bile commonsecretion in [4]. males. Duodenal The classiculcers common bile duct and head of pancreas making are more common in the 3rd to 5th decade of itis susceptible closely related to injury to firstduring part course of duodenum, of disease symptom of pain after having food (post- and obstruction caused by duodenal ulcers are and surgery [3, 11]. Severe bleeding, perforation, byprandial) duodenal is a well-known ulcers. The fact. most[1]. The commonly duodenal encounteredbulb of first part parts is the are most the commonlyanterior andaffected the surgery may include bleeding, anastomotic managed surgically. Complications of duodenal posterior part. Stress and cigarette smoking are also known causes that precipitate this objective of treatment plan of complicated situation [2]. The signs and symptoms range duodenalleak or stricture, ulcer bileis ductarrest injury of [12].hemorrhage Primary from simple bloating or feeling fullness to life and eradication of ulcer [10]. Knowledge threatening complications like perforations of anatomy of variant of gastroduodenal

Journal of Research in Medical and Dental Science | Vol. 8 | Issue 4 | June 2020 111 Nasser Alzerwi et al J Res Med Dent Sci, 2020, 8 (4):110-117 artery and its relation with bile duct is vital Ethical considerations: Ethical clearance was relationsfor surgeons of retroduodenal and gastroenterologists common [13].bile obtained from King Fahad Medical City. ductPrudhomme and gastroduodenal et al studied artery the anatomicaland found Institutional review board IRB log number: 20- 293E. Materials and methods relationship of common bile duct with gastroduodenalfour distinct patternsartery is very [7]. important Knowing as thefar The study was conducted at Department as the surgical management of the duodenal ulcers is concerned to avoid inadvertent cadaversof Anatomy, were Kanachur dissected. Institute Midline of incision Medical andSciences, transverse Mangalore, incision India. was Thirtytaken, embalmedand then threateninginjury to CBD hemorrhage during the “blind”from a transluminalpenetrating bulbarsurgical duodenal ligation ofulcer. the ThisGDA studyin emergency investigates life anterior abdominal wall was retracted into 4 the need for modifying it. parts. The porta hepatis was identified and the the validity of Prudhomme classification and tobile identify duct was the identified. gastroduodenal Then the artery. duodenum Then METHODOLOGY duodenalwas identified. morphometry Careful was dissection taken, origin was of done the gastroduodenal artery was traced, Mean distance Study design: between gastroduodenal artery and pylorus was study. taken, relationship of gastroduodenal artery with Observational cross-sectional Study setting: Department of Anatomy, Kanachur bile duct in a transverse plane was checked and noted, presence of pancreatic tissue between the gastroduodenal artery and bile duct was also Embalmed cadavers InstituteStudy ofpopulation: Medical Sciences, Mangalore.

Mangalore. observed. Findings were compared to Prudhomme from Kanachur Institute of Medical Sciences, Sample size: classification [7] and any differences were added Prudhomme Classification: for dissection. as a modification of that classification. 30 embalmed cadavers selected Embalmed cadavers, standard Prudhomme et al. Study tool: Type 1: the tow structures separated [8] described his classification as follows: progressively with the artery on the left side of centimeter. flexible measuring tape marked to tenths of a the bile duct. Duration of the study: Type 2: the tow structures approached each Sampling technique: 18 months. other without crossing After the dissection the Data collection: Convenience sampling. at the level of D1. gastroduodenal artery, Mean distance between Type 3: the GDA crossed in front of the bile duct gastroduodenalDuodenal morphometry, artery and pylorus, Origin relationship of the and ran along its right side. of gastroduodenal artery with bile duct in a Type 4: the GDA crossed the bile duct below D1 RESULTS between the gastroduodenal artery and bile duct wastransverse also observed. plane, Presence data collection of pancreatic was done tissue and The mean length of between the pylorus and the

Descriptive statistics. analyzedData analysis: using SPSS version 23. superior duodenal angle was found to be 5.09 cms (Table 1 and Graph 1). The mean length of the Proximal segment (bulb) was found to Table 1: Mean length from pylorus to the superior duodenal angle, and mean length of Proximal segment (bulb) and Distal retroperitoneal segment. Mean length from pylorus to the superior duodenal angle Length 5.09 cm Proximal segment (bulb) 3.41 cm Distal retroperitoneal segment 1.5 cm

Journal of Research in Medical and Dental Science | Vol. 8 | Issue 4 | June 2020 112 Nasser Alzerwi et al J Res Med Dent Sci, 2020, 8 (4):110-117

Graph 1: Mean length from pylorus to the superior duodenal angle.

Table 2: Mean distance between gastroduodenal artery and pylorus. Distance Mean distance between gastroduodenal artery and pylorus 2.98 cm

retroperitoneal segment was found to be 1.5 puts the CBD at higher risk of inadvertent injury cms.be 3.41 cms and the mean length of the distal during GDA blind ligation than Prudhomme type 3. originated from the common hepatic artery. In all the 30 cases the gastroduodenal artery Right (Figure 2b): Type 4: Zerwi IV Early The mean distance between gastroduodenal Completely crossing Dextrally descending GDA (Note: Dextral=right), partially consistent with duodenalprudhomme bulb, type not 4,below as the D1 GDAas in in prudhomme this study artery and pylorus was found to be 2.98 cms There were four types of relation between crossed the cbd early on, at the mid-level of (Table 2). gastroduodenal artery and common bile duct inadvertent injury during deep blind ligation of that was encountered. type 4. This puts the CBD at a higher risk of

Zerwi modification of prudhomme classification GDA than Prudhomme type 4. bile duct and the gastroduodenal artery can be Figure 3 Shows the pointer pointed towards the

Left (Figure 1a): Type 1: Zerwi I Sinistrally seen above the pancreatic tissue. So it’s Zerwi descending divergent GDA (Left lying GDA, III Incompletely Crossing Anteriorly Descending note: Sinistral=Left): Where they diverge from GDA. each other, but the GDA stays to the left of CBD consistent with type 1 Prudhomme. Illustartion I shows the chances of injuring bile Right (Figure 1b): Type 2: Zerwi II Sinistrally duct in Gastroduodenal ligation procedure (deep descending convergent GDA (Left lying GDA, stitches) is highest for Zerwi III Incompletely note: Sinistrally=Left) Where they go along and Crossing Anteriorly Descending GDA. bile duct in gastroduodenal ligation procedure GDA stays left to the CBD, consistent with type 2 Illustartion II shows the chances of injuring Prudhomme. Left (Figure 2a): Type 3: Zerwi III Late (deep stitches) is higher for Zerwi IV“ Early” Incompletely crossing anteriorly descending completely crossing dextrally descending GDA, GDA, which is different from type 3 Prudhomme than for prudhomme type 4. transverselywhere the CBDand crosses obliquely completely rather the than CBD based on the relation between gastroduodenal anteriorly and to the right of CBD and continues arteryTable 3 and shows common the Frequency bile duct. of types encountered

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a) b)

Figure 1: Cross sectional anatomy. Note: (As seen from cephalad to caudad in a prone position). L1: At the upper border of the duodenal bulb. L2: At the lower border of the duodenal bulb. Illustration to understand the relation between the duct and the artery. Grey coloured structure: Duodenum. Blue coloured structure: Pancreas. Red coloured structure: Gastro - duodenal artery. Green coloured structure: The common bile duct.

Figure 2: (A) Structures crosses one another and (B) artery passes on the right of the duct. Note: (As seen from cephalad to caudad in a prone position). 2A-L1: At the upper border of duodenal bulb. L2: At the lower border of duodenal bulb. Illustration to understand the relation between the duct and the artery. 2B-L1: at the upper border of duodenal bulb. 2B-L2: through the middle section of duodenal bulb. 2B-L3: at the lower border of duodenal bulb. Grey colored structure: Duodenum. Blue colored structure: Pancreas. Red colored structure: Gastro - duodenal artery. Green colored structure: The cystic duct.

Figure 3: Showing the pointer pointed towards the bile duct and the gastroduodenal artery can be seen above the pancreatic tissue. So it’s Zerwi III Incompletely Crossing Anteriorly Descending GDA.

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Illustration I: Chances of injuring bile duct in Gastroduodenal artery ligation procedure (deep stitches) is highest for Zerwi III Incompletely Crossing Anteriorly Descending GDA.

Illustration II: chances of injuring bile duct in gastroduodenal ligation procedure (deep stitches) is higher for Zerwi IV“ Early” completely crossing dextrally descending GDA, than for prudhomme type 4.

Table 3: Frequency of types encountered based on the relation between gastroduodenal artery and common bile duct. Type Frequency Percentage 1 17 56.70% 2 9 30.00% 3 2 6.70% 4 2 6.70%

DISCUSSION gastroduodenal artery and other branches of the coeliac trunk. The other parts below the ampulla From outside inwards the duodenum is made is supplied by the branches of the superior up of the serous coat which is a part of visceral mesenteric artery as it develops from the midgut peritoneum. Then the muscularis externa which [12]. The duodenum is the shortest and widest is contributed from the splanchnic mesoderm. This is a part of the lateral plate mesoderm. Then intraperitoneal and remaining is retroperitoneal the submucosa, also develops from the same. part of small intestine. Only the proximal 2.5 cm is The mucosal layer develops from the midgut. which is formed in embryogenesis makes a right The mucosa develops from the endoderm. The angled[14]. This ninety happens degree becauseturn to the the right, anterior a courtesy loop opening of the bile duct into the 2nd part of the of the rotation of the stomach and the liver which duodenum actually marks the junction of the fore gut with the midgut. Actually, development in which the peritoneum actually disappears or of mucous membrane of the duodenum above literallyis the main stitches culprit the [7]. duodenum After this there to the is posteriora process abdomen wall through a process called zygosis. endoderm of foregut and rest from the midgut This rotation makes the gastroduodenal artery [12].and including The total ampullalength of of the Vater duodenum takes place is around from and the common bile duct come posteriorly to

25 centimetres and is divided into 4 parts [14]. the first part of the duodenum [15]. andThe firstis supplied part and theby secondthe coeliac part whichtrunk includesand its gastroduodenal artery and common bile duct. branches.the ampulla This of Vaterpart is develops actually fromsupplied the foregutby the TheThus, other first partstructures of duodenum encountered lies anterior in here to arethe

Journal of Research in Medical and Dental Science | Vol. 8 | Issue 4 | June 2020 115 Nasser Alzerwi et al J Res Med Dent Sci, 2020, 8 (4):110-117 the portal vein and a small part of the pancreas. occurs behind the duodenal bulb compared to behind the posterior wall of duodenum [11]. above D1 and continues obliquely, making it Gastroduodenal artery lies immediately vulnerablePrudhomme especially type 3 wherewhen the the surgeon crossing take occur the partGastroduodenal of duodenum, artery and at usually a distance arises of at0.5 the to to control the transverse pancreatic branch distance of 1.5 to 3 cm (range) above the first lower part of the U-stitch that’s usually made of duodenum consists of gastroduodenal, for technical failure and early recurrence of superior5 cm (range)from pancreaticoduodenal, the pylorus. Arterial inferior supply of the GDA which is the most common reason pancreaticoduodenal artery [6]. First part of duodenum is more prone to peptic ulcers [6]. rebleeding (Illustration I) [7, 9], another variant which was different from Prudhomme’s was type 4, where in this new variant (Figure IIb), the The first part of duodenum is supplied by end GDA crosses the CBD completely and continues arteries, which are supra-duodenal and retro- descending vertically to the right of the CBD as in arteryduodenal, is presence branches of of peptic gastro-duodenal ulcer in posterior artery. ofclassical duodenal Prudehomme’s bulb, rather type than 4, however, below itD1 does as wallOne ofof thethe causesduodenum. of erosion This arteryof gastroduodenal arises from so earlier in its course, at the mid-level border common hepatic artery and descends posteriorly to the 1st part of duodenum to the left of common described by Prudhomme’s, making it especially bile duct or it can arise from coeliac axis or right vulnerable to inadvertent injury during GDA or left hepatic artery. Two parts of the artery can ligation, as surgeons usually choose the mid- commonlevel of duodenal bile duct bulb from for athe U-stitch posterior (Illustration surface omentum and secondly in between the pancreas ofII) [8,distal 9]. Apart small of pancreaticduodenum tissue retroperitoneally, separates the be identified between the pancreas in the lesser which is also known as Duodenal tubercle or it from posterior surface of duodenum. These and the duodenum. Pancreatic tissue separates pancreaticOmental tubercle tissue forms of Wiarta protective [6]. Presencecurtain over of pancreaticparts are respectively. also termed The as intra-epiploiccommon bile duct and itthis [6]. There “inter-choledocho-duodenal are other variations that glandular” has been presentssupra-pancreatic different and kinds second of relationships as inter- duodeno- with the

reported [7, 17], such as absence of pancreatic GD artery [7]. mosttissue important between thething CBD that and an GDA, operating however, surgeon this finding was not replicated in our study. The There is variable relationship between Common bile duct and Gastroduodenal artery [6, 7, 16]. catastrophe can occur as the misplaced should remember is these variations. Otherwise Prudhomme classification of these relations hemostatic stitch may accidently catch other vital has been validated before [17], however this is structures, most commonly bile duct, though to the best of our knowledge, no such a complication inthe that first the study most to modifycommon it. variants This study described results are in agreement with Prudhomme’s study has been reported yet, however, there might be a publication bias, as negative outcomes are less likely to be reported. A pancreatic tissue is in Prudhomme’s classification (type 1 and 2) usually considered safe in between structures for(Figure a hemorrhagic Ia, and Ib) penetrating are also the bulbar least duodenal prone to but what if injury of the pancreatic tissue is accidental injury during deep blind GDA ligation replicated in our study, which might be due of the duodenum and also close by structures ulcer, however, the Prudhomme type 3 was not to the small sample size in both studies. This andcaused?, may this cause may greater cause autolysisharm than of thegood first to part the

encountered in our study i.e., that there is no study, however, found a new variant (figure course at lower border of the duodenal bulb, and pancreaticpatient. However, tissue which this varietycovers whichthe artery was and not IIa) where the GDA crosses the CBD later in its the duct, may be a blessing to the operating than crossing completely and obliquely to the descends anterior to the CBD vertically, rather discussed earlier it is important to understand above D1, making this variant riskier, as the andsurgeon know as the it is relations easy to handleof the gastroduodenal [7, 17]. But as right of the CBD as described by Prudhomme artery and the bile duct. This study clearly sheds

JournalCBD isof Research more in prone Medical to and injury, Dental Science as the | Vol. crossing8 | Issue 4 | June 2020 116 Nasser Alzerwi et al J Res Med Dent Sci, 2020, 8 (4):110-117 a light in understanding the different relations of the bile duct and the gastroduodenal artery. This and collecting the data. study also successfully shows the origin of the India, for their help in dissecting the cadavers REFERENCES gastroduodenal artery in relation to the pylorus and sheds effectively a light on the morphometry 1. https://www.s ciencedirect.com/topics/veterinary- helpful to the operating surgeon. 2. science-and-veterinary-medicine/gastroduodenal-artery of the first part of the duodenum to be very pathogenesis and treatment of perforated peptic ulcer CONCLUSION diseasePrabhu with V, evaluation Shivani A. of prognostic An overview scoring of in history, adults.

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