Surg Radiol Anat (2012) 34:171–178 DOI 10.1007/s00276-011-0893-8 ORIGINAL ARTICLE Anatomical classification of the shape and topography of the stomach Franciszek Burdan • Ingrid Rozylo-Kalinowska • Justyna Szumilo • Krzysztof Zinkiewicz • Wojciech Dworzanski • Witold Krupski • Andrzej Dabrowski Received: 22 May 2011 / Accepted: 25 October 2011 / Published online: 6 November 2011 Ó The Author(s) 2011. This article is published with open access at Springerlink.com Abstract The aim of the study was to present the clas- paraesophageal, mixed-form and upside-down hiatal dia- sification of anatomical variations of the stomach, based on phragmatic hernias, as well as short esophagus, and the radiological and historical data. In years 2006–2010, the other diaphragmatic hernias, that were not found in the 2,034 examinations of the upper digestive tract were per- evaluated population. The second group includes the formed. Normal stomach anatomy or different variations of stomach cascade. The third and fourth groups comprise the organ shape and/or topography without any organic developmental variations and organ malformations that radiologically detectable gastric lesions were revealed in were not observed in evaluated patients. The last group 568 and 821 cases, respectively. Five primary groups were (V) encloses mixed forms that connect two or more pre- established: abnormal position along longitudinal (I) and vious variations. horizontal axis (II), as well as abnormal shape (III) and stomach connections (IV) or mixed forms (V). The first Keywords Stomach Á Anatomical variation Á Imaging Á group contains abnormalities most commonly observed Surgery among examined patients such as stomach rotation and translocation to the chest cavity, including sliding, Introduction & F. Burdan ( ) Á W. Dworzanski Classic anatomical textbooks describe the stomach as the Human Anatomy Department, Medical University of Lublin, 4 Jaczewskiego Str, 20-090 Lublin, Poland most dilated part of the digestive tract, located beneath the e-mail: [email protected] diaphragm in the left hypochondriac and epigastric region of the abdominal cavity [20, 30, 32]. Its shape and position F. Burdan Á W. Krupski are strongly associated with organogenesis. Any develop- Second Radiological Department, Medical University of Lublin, Lublin, Poland mental abnormality of the organ itself or nearby located viscera and peritoneum, as well as their vessels and nerves F. Burdan may influence stomach morphology [3, 20, 26, 29, 30]. The St. John’s Cancer Center, Lublin, Poland final topography depends also on contents of the stomach I. Rozylo-Kalinowska and surrounding viscera, respiratory phase, age and body Dental and Maxillofacial Radiology Department, type of the individual. The empty organ is characterized by Medical University of Lublin, Lublin, Poland a cylindrical form with a well-formed anterior and pos- terior wall, lesser and greater curvature as well as fundus, J. Szumilo Clinical Pathomorphology Department, cardia, body and pylorus (Figs. 1a, 2). In distended one, the Medical University of Lublin, Lublin, Poland anterior wall increases the area attached to the abdominal wall. During inspiration the organ is displaced downward, K. Zinkiewicz Á A. Dabrowski while elevated in expiration. Any abnormal fluid accumu- Second Chair and Department of General, Gastrointestinal Surgery and Surgical Oncology of Alimentary Tract, lation in the pleural and peritoneal cavity may change Medical University of Lublin, Lublin, Poland the stomach shape as well. Heavily build hypersthenic 123 172 Surg Radiol Anat (2012) 34:171–178 Fig. 1 Diagrams with the most common, anatomical variances of the stomach: typical shape of the stomach (a), malrotation (b), sliding hiatal hernia (c), paraesophageal hiatal hernia (d), mixed-form hiatal hernia (e), upside-down hernia (f), congenital short esophagus (g), cascade (h), lack of the whole organ (i), lack of the fundus (j), short body (k), advanced enlargement (l), congenital gastroduodenal (m) and gastroileal (n) fistula Classical anatomical description presented above, is not always seen in clinical practice. Different variations of the typical shape of the stomach are frequent. The aim of the study was to present classification of the shape and position of the unoperated stomach. Materials and methods The study was conducted on the retrospective data col- lected during various radiological examinations taken in 2006–2010 in the Second Radiological Department of the First University Hospital, Medical University of Lublin, Poland. All patients were sent for the checkup for various medical reasons with empty stomach. The examination was performed using Siregraph CF-System (Siemens, Ger- many) during single- or double-contrast fluoroscopy. Bar- ium sulfuricum suspension (TERPOL, Poland) or Prontobario HD (Bracco S.P.A., Italy) was applied as a positive contrast in unoperated patients. Water-soluble Fig. 2 A typical radiological shape and localization of the stomach contrasts such as Gastrografin (Berlimed S.A. Poligono Industrial Schering AG; Leverkusen, Germany) or Uro- polinum (Zakłady Farmaceutyczne POLPHARMA; Staro- individuals with short thorax and long abdomen are likely gard Gdanski, Poland) were administered for operated to have stomach that is placed in higher position and more patients. Stomach air or pretreatment with Dougas (Bracco transversally. In persons with a slender asthenic physique, S.P.A., Italy) was used as a source of the negative contrast. the stomach is located lower and more vertical. More Each patient was typically examined in Trendelenburg vertical position and slightly left organ translocation— position, followed by supine, semirecumbent, antero-pos- secondary to a relatively large liver—are typical of young terior and lateral erect position. Any other positions were children, in particular in newborns [30]. used when needed. Single and serial pictures with 123 Surg Radiol Anat (2012) 34:171–178 173 acquisition time one up to 4–5 pictures per second were whole group 1,389 patients passed the criteria of the study. stored on the hard disc. Normal stomach anatomy was observed in 568 cases, while The classification was established exclusively for patients in 821 patients different variations of the organ shape and without any organic radiologically detectable stomach topography were reveled. lesions, i.e., severe gastric inflammations, ulcer disease, A regular, physiological position of the stomach—as neoplasms, etc. Five primary groups of the organ shape and presented at the introduction—was the most commonly topography were established: abnormal position along it observed among all the examined individuals (Figs. 1a, 2). longitudinal (I) and horizontal axis (II), as well as abnormal Abnormal anatomical variances were seen less frequently. shape (III) and connections (IV) or mixed forms (V). In unoperated patients the two main groups of the stomach Obtained results were evaluated only qualitatively, since variations were established: (I) abnormal positions along data were collected at a hospital that is highly specialized the longitudinal axis of the organ, and (II) abnormal in esophageal and stomach surgery and the group of positions along various horizontal axes (Table 1;Fig.1b–n). examined patients’ does not cover the general population. Two additional groups, i.e. (III) abnormal shape of the organ, (IV) abnormal congenital connections of the stomach could also be added, however, they were not observed in our Results department and they do not pass the criteria of ‘‘healthy’’ organ. The last group (V) contains mixed forms, which pass During evaluated period, 2,034 examinations of the upper criteria two or more primary groups (I–IV). part of digestive tract were performed. From among the The first group included the stomach rotation (Ia), and translocation to the chest cavity (Ib). Different degrees of Table 1 Morphological classification of the shape and topography of the stomach rotation were easily seen when position of the unoperated stomach pylorus and the lesser and greater curvatures were exam- ined (n = 84). In the extreme situation, a frontward I. Abnormal positions along the longitudinal axis of the organ (organoaxial) (n = 3/84) and backward (n = 11/84) direction of the Ia. Malrotation lesser curvature was found (Figs. 1b, 3). However, the Ib. Translocation to the chest cavity most common type of the anomaly in the first group was 1. Through the esophageal diaphragmatic hiatus (hiatal hernias) the sliding hiatal diaphragmatic hernia (n = 522) (Figs. 1c, Sliding hiatal hernia (type I)a 4a). Less frequently, the paraesophageal hiatal (n = 12) Paraesophageal hiatal hernia (type II)a (Figs. 1d, 4b), mixed-form (n = 43) (Figs. 1e, 4c) and Mixed form (type III)a upside-down hernias were found (n = 37) (Figs. 1f, 4d). Intrathoracic stomach—upside-down hernia (type IV)a Congenital short esophagus 2. Through other esophageal openings (diaphragmatic hernias) Posterolateral (Bochdalek) hernia Anterolateral (Morgagni) hernia Central (septum-transversum) hernia II. Abnormal positions along various horizontal axis (mesenteroaxial) Cascades (mesenteroaxial volvulus) III. Abnormal shape of the stomach Lack of the whole organ Lack of the fundus Short body Advanced enlargement (dilatation) IV. Abnormal congenital connection of the stomach Gastroduodenal fistula Gastrointestinal fistula (-ileal, -jejunal) Gastrocolic fistula Gastrocutaneous fistula Other, less common fistulas V. Mixed form of the stomach shape a According to the Akerlund classification [2]