Applied vascular anatomy of the colon and rectum: Clinical implications for the surgical oncologist

doi:10.1016/j.suronc.2007.03.002

Surgical Oncology

Volume 15, Issue 4, December 2006, Pages 243-255

https://doi.org/10.1016/j.suronc.2007.03.002 Get rights and content

Summary

Surgery remains the most radical method of treatment of many solid tumors, including colorectal cancer; in these tumors, surgery is the only method that can offer the chance of cure. To avoid early postoperative morbidity (mainly, anastomotic leak) and to achieve good long-term results (low incidence of tumor recurrence, long overall and disease-free survival, and optimal quality of life), the surgeon should have an in-depth knowledge of vascular anatomy of the colon and rectum. This essential requirement is based on the fact that the actual course followed by lymph fluid drainage from any part of the colon/rectum is determined by its blood supply; therefore, the extent of resection for colorectal cancer follows the principles of blood supply and lymphatic drainage. Knowledge of the colorectal vascular anatomy and its variations is of vital importance in the planning of radical surgical treatment and in appropriately performing colorectal resections, particularly in the patient who underwent in the past colectomy or aortic surgery that has changed the usual pattern of collateral blood supply to the colon. This review summarizes currently available data regarding vascular anatomy of the colon and rectum, from a surgical perspective.

Introduction

Radical surgical resection remains the basic method of treatment of many solid tumors, and offers the greatest chance for cure, especially when malignant disease has not disseminated. An in-depth knowledge of the anatomy is a basic requirement for the surgeon to optimize early and late results of surgery for malignant disease and to achieve not only low morbidity and mortality rates following even complicated surgical procedures, but also prolonged overall and disease-free survival, without recurrence of the tumor, thereby ameliorating patients’ quality-of-life.

Colorectal cancer represents the third most common type of cancer both in males as well as in females (excluding skin cancer); it accounts for 10% and for 11% of all types of cancers in men and women, respectively [1]. Colorectal cancer surgery represents a large part of the daily routine in many departments of surgery around the world. As is well known, the extent of surgical resection, but also the radicality in colorectal cancer surgery, specifically regarding the extent of lymphadenectomy, is closely related to vascular anatomy of the colon and rectum. Therefore, a thorough knowledge of the vascular anatomy of colon and rectum and the associated pattern of collateral variation is a mandatory prerequisite for colorectal resections. The aim of this work is to summarize and critically analyze currently available data regarding the vascular anatomy of the colon and rectum, from the perspective of a surgical oncologist.

Section snippets

Embryology

The formation of the aorta begins at the 3rd week of embryologic development, when two strands of cells migrate dorsally from the endocardial mesenchyme and elongate caudally along the neural groove to become the dorsal aortas. These two dorsal aortas remain separate from approximately 1 week but eventually fuse to form a single-aortic trunk that descends caudally. The mesenteric arteries originate from the primitive ventral segmental arteries. As development proceeds, there is regression of

Arteries supplying the colon

In the healthy state, the colon derives its blood supply from branches of the SMA and the IMA [2], [3], [4] (Fig. 1). The rectum and anal canal are supplied by branches of the IMA and the internal iliac arteries [4].

Comments

The exact extent of colonic resection is largely determined by the blood vessels that require division in order to remove the lymphatic drainage of the tumor-bearing part of the colon; the potential presence of nodal metastases requires high ligation of the arterial and venous supply of the colon [33]. The more radical the surgeon is in dealing with the lymphatic drainage, the greater the length of colon that will need to be resected [34]. There are few reports of controlled studies to assist

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Citation Excerpt :
Through this arrangement, it supplies the splenic flexure and the transverse and sigmoid colons. In addition to the MA, there are several other main anastomoses within the abdominal viscera which provide collateral circulation: the pancreaticoduodenal arteries, which communicate with the celiac axis and the SMA and supply the pancreas and duodenum; the middle and left colic arteries, which communicate with the SMA and IMA and supply the descending and transverse colon, respectively; the numerous sigmoid arteries within the mesentery which anastomose the SMA and IMA and aid in supplying the descending and sigmoid colon; and the Arc of Riolan, which is located proximally to the MA and communicates with the SMA and IMA to aid in supplying the descending colon, sigmoid colon, and rectum [25,28]. Given the variable anatomy of the MA, it is not surprising that the vessels supplying it with blood are also varied.
The marginal artery of Drummond (MA) is an anatomically variable blood vessel that forms a major anastomotic network between the superior and inferior mesenteric arteries. It vascularizes the transverse and descending colons and is a major contributor to the collateral circulation of left-colic structures.
To conduct a systematic review of the MA and highlight the current understanding of its anatomy and role in physiological and pathological vascularization.
The major online databases (Pubmed, Google Scholar, Embase, and Web of Science) were systematically assessed to reveal all available literature pertaining to the MA. Articles judged relevant by the authors were used for the final review.
The MA is a key player in the collateral circulation of left-colic structures in the setting of pathological processes affecting their normal vascularization. It helps to maintain perfusion in the event of obstructions and atherosclerosis, and in the cases of obliteration or congenital absence of the mesenteric vessels, it sustains adequate vascularization of the left-colon. The MA has come into increasing prominence as surgeons have become more aware of both iatrogenic injuries to it and its value in mitigating the effects of reduced patency of the mesenteric vessels.
The MA continues to become more important to surgeons as both an obstacle and an opportunity in abdominal procedures. Further exploration of its anatomical variability, for example through embryological and dissection studies, will further improve treatment outcomes during abdominal surgery.

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ReviewApplied vascular anatomy of the colon and rectum: Clinical implications for the surgical oncologist

Summary

Introduction

Section snippets

Embryology

Arteries supplying the colon

Comments

Surgical Clinics of North America

Surgical Clinics of North America

Best Practice and Research Clinical Gastroenterology

Surgical Clinics of North America

Surgical Clinics of North America

Surgical Clinics of North America

Surgical Clinics of North America

Cancer Statistics 2006

CA Cancer Journal for Clinicians

The mesenteric circulation

Surgical Clinics of North America

Langman's medical embryology

Topographic anatomy

Surgical anatomy of the arterial supply of the colon from the superior mesenteric artery based upon a study of 600 specimens

Surgery Gynecology and Obstetrics

Blood supply of the large intestine: its surgical considerations

Archives of Surgery

Intestinal ischemia

The variant blood supply to the small and large intestines: Its importance in regional resections

Journal International College of the Surgeons

Vascular disease of the gastrointestinal tract: pathophysiology, recognition and management

Surgical anatomy and physiology of the colon, rectum, and anus

The variant blood supply to the descending colon, rectosigmoid, and rectum, based on 400 dissections

Disease of the Colon and Rectum

Anatomy of the small bowel, colon and rectum

The surgical anatomy of the rectal and anal blood vessels

Langenbecks Archives of Surgery

The arterial supply of the rectum and pelvic colon

British Journal of Surgery

The meandering mesenteric artery of the colon

AJR American Journal of Roentgenology

Surgical anatomy of the colon and rectum

Colon and rectum

Intestinal ischemia

A critical evaluation of selective celiac and superior mesenteric angiography

Radiology

Review
Applied vascular anatomy of the colon and rectum: Clinical implications for the surgical oncologist