Comment on: Relevance of Posterior Gastric Vessel in Bariatric Surgery

First of all, we would like to congratulate the authors on a well-written brief communication describing the anatomy of the posterior gastric artery (PGA) and its relevance in bariatric surgery [1]. Though this artery was first identified more than two centuries ago [2], it has not been described universally in the literature, and incidence varies from as low as 4% to as high as 99%. This variability in incidence may be due to the variation in the definition of PGA. Most of the studies were performed on the cadavers. Okabayashi et al. in their study identified PGA in all 50 patients on multidetector CT. They noted that in 98% of the patients, the artery arose from the splenic artery and in only one patient, the artery arose from the main coeliac trunk. The length and diameter of the artery ranged from 4.2 to 14.3 cm and 0.5 to 2.1 mm respectively [3].

The authors in their study have retrospectively reviewed the videos of 100 consecutive bariatric surgeries which included 63 sleeve gastrectomy (LSG) and 37 Roux-en-Y gastric bypass (RYGB). PGA was noted in 88 patients. In the RYGB group, PGA was noted in 91.9% (34/37) patients. Out of 34 times, the vessel was divided only thrice while the procedure was performed 31 times after retracting the vessel laterally [1].

In our experience, though PGA is frequently encountered while performing LSG, it seldom comes in the way while creating a gastric pouch in RYGB. During LSG, it is encountered during the posterior mobilization of the stomach. This dissection is of paramount importance as it enables us to mobilize the fundus properly and to form an adequately sized sleeve and also avoid inadvertent injury to PGA leading to bleeding. In RYGB, we stay absolutely close to the left crus RYGB in order to form a micro gastric pouch and a very limited posterior dissection is required. In RYGB, complete fundal mobilization is not required; thus, the identifying PGA during RYGB may not be of much relevance.

The importance of the vessel has been described in some studies in patients with gastric carcinoma where lymph nodes have been identified along its course [4].

Apart from this, the authors have identified PGA and its origin in the retrospective analysis of the recorded videos. This may not give us an accurate idea regarding the origin of the artery and its nomenclature. A prospective study with CT angiography as well intraoperative assessment may give us a better understanding of the anatomy of PGA of the artery as well as its relevance in different bariatric procedures specially RYGB.

References

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Correspondence to Tarun Mittal.

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Mittal, T., Ahuja, A., Dey, A. et al. Comment on: Relevance of Posterior Gastric Vessel in Bariatric Surgery. OBES SURG (2021). https://doi.org/10.1007/s11695-021-05229-9

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