Modification of Prudhomme's Classification of Retro-Duodenal BilioArterial Relations and Their Significance in the Operative Management of Hemorrhagic Duodenal Ulcer-An Anatomosurgical Study
Author(s): Nasser A. N. Alzerwi*
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 common bile duct 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 and to the 1st part of duodenum 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.