Metastatic Spread via the Peritoneal Ligaments

The major ligamentous attachments of the upper abdomen include the lesser omentum, the gastrosplenic ligament, and the splenorenal ligament. The lesser omentum is subdivided into the gastrohepatic ligament and the he-patoduodenal ligament. In the embryo, the gastrosplenic ligament gives rise to the gastrocolic ligament (also known as the greater omentum) and the transverse meso-colon.

Gastrohepatic Ligament

The gastrohepatic ligament can be recognized on computed tomography (CT) scanning as a fatty plane, which joins the lesser curvature of the stomach to the liver. It extends from the fissure for the ligamentum venosum to the porta hepatis and contains the left gastric artery, the coronary vein, and associated lymphatics. The criterion for nodal enlargement in this region is somewhat smaller than for elsewhere in the abdomen; nodes in the gas-trohepatic ligament are generally considered abnormal when they exceed 8 mm in diameter [2]. On occasion, pathology in the gastrohepatic ligament may be mimicked by unopacified bowel loops, the pancreatic neck, or the papillary process of the caudate lobe of the liver projecting into the expected plane of the gastrohepatic ligament [3, 4].

The gastrohepatic ligament provides an important conduit of disease from the stomach to the liver, in that the subperitoneal areolar tissue within the ligament is continuous with the Glisson capsule (the perivascular fibrous capsule within the liver). Thus, gastric malignancy can spread via this pathway directly into the left lobe of the liver and vice-versa. Common neoplasms spreading via the gastrohepatic ligament include nodal metastases from gastric, esophageal, breast, pancreatic, and lung cancer as well as nodal involvement of lymphoma. Gastric and esophageal cancer can directly invade this ligament and spread into the left hepatic lobe [2].

Hepatoduodenal Ligament

The hepatoduodenal ligament is the free edge of the gastrohepatic ligament along its rightward aspect. It contains important structures of the porta hepatis including the common bile duct, the hepatic artery, and the portal vein. The hepatoduodenal ligament extends from the flexure between the first and second duodenum to the porta hepatis; the foramen of Winslow is immediately posterior to this ligament, permitting communication between the greater and lesser sacs [5]. Nodes of the foramen of Winslow, or portocaval space, have an unusual morphology such that their transverse dimension is greater than their antero-posterior (AP) dimension. Generally, the upper limits of normal for the AP dimension is 1.0-1.3 cm, whereas the transverse dimension can be up to 2.0 cm in width. Size criteria are somewhat less helpful than in other lymph nodes. In the absence of frank enlargement, a more spherical shape or central necrosis suggests the presence of tumor within these nodes (Fig. 1) [6, 7].

Portacaval Lymph Node
Fig. 1. Invasive pancreatic carcinoma arising from the pancreatic tail with numerous hematogenous metastases to the liver. A portacaval lymph node at the base of the hepato-duodenal ligament (arrow) is not enlarged by size criteria but contains metastatic disease as evidenced by its central necrosis

A broad range of tumors may spread via the hepatoduodenal ligament. Liver or biliary cancer, whether primary or metastatic, may spread in an antegrade fashion through lymphatics in the hepatoduodenal ligament to deposit in periduodenal or peripancreatic lymph nodes. Similarly, malignant disease in the nodes about the superior mesenteric artery (commonly involved with pancreatic and colon cancer) can spread in a retrograde fashion up the lymphatics in the hepatoduodenal ligament. Lymphoma can involve these nodes as well. Primary gastric cancer arising in the lesser curvature of the stomach can directly spread through the gastrohepatic ligament to the hepatoduodenal ligament and then to peripancreatic and periduodenal nodes. Vascular complications related to the portal vein and hepatic artery can result; portal venous thrombosis and hepatic arterial pseudoaneurysms can occur in advanced cases owing to their coexistence in the hepatoduodenal ligament [1, 5].

Gastrosplenic and Splenorenal Ligaments

In the embryo, the gastrosplenic ligament is a long liga-mentous attachment between the stomach and the retroperitoneum which gives rise to the gastrocolic ligament (greater omentum) and the transverse mesocolon. In the adult, the gastrosplenic ligament is a thin ligamentous attachment between the greater curvature of the stomach and the splenic hilus (Fig. 2). It contains the left gas-troepiploic and short gastric vessels, as well as associated lymphatics. The gastrosplenic ligament is continuous with the gastrocolic ligament inferiorly and medially and is continuous with the splenorenal ligament posteriorly

Splenorenal Ligment Metastases

Fig. 2. The gastrosplenic ligament (GSL) and splenorenal ligament (SRL) comprise the left wall of the lesser sac and provide a conduit for the spread of metastatic disease from the greater curvature of the stomach to the retroperitonium and vice versa. LK, left kidney (Reprinted with permission from [8])

Fig. 2. The gastrosplenic ligament (GSL) and splenorenal ligament (SRL) comprise the left wall of the lesser sac and provide a conduit for the spread of metastatic disease from the greater curvature of the stomach to the retroperitonium and vice versa. LK, left kidney (Reprinted with permission from [8])

and medially [9, 10]. As such, it provides an important pathway of communication between the stomach, the spleen, and the retroperitoneum. Gastric malignancies commonly spread through this ligament (Fig. 3). Such diseases can involve the spleen and ultimately result in disease about the tail of the pancreas. Conversely, pancreatic neoplasms may spread via the splenorenal ligament to the gastrosplenic ligament and involve the greater curvature of the stomach [1].

Gastrocolic Ligament

The gastrocolic ligament (or greater omentum) joins the greater curvature of the stomach to the transverse colon. On the left it is continuous with the gastrosplenic ligament, and on the right it ends at the gastroduodenal junction near the hepatoduodenal ligament. It results from fusion of the anterior and posterior leaves of the gastros-plenic ligament in the embryo, therefore it contains the four layers of peritoneum that invest the stomach, and has a potential space within it (Fig. 4). The gastrocolic ligament contains the gastroepiploic vessels and associated lymphatics. It provides an important conduit of malignant disease from the greater curvature of the stomach to the transverse colon and vice versa. When viewed in concert with the transverse mesocolon, a conduit exists between the greater curvature of the stomach and the retroperi-toneum. In addition to direct spread of disease between

Fig. 3. Gastric adenocarcinoma invading the spleen via the gastros-plenic ligament. a Initial contrast-enhanced CT scan reveals circumferential tumor involving the gastric fundus. b Six months later, a repeat CT scan shows invasion and dissection of the spleen secondary to tumor spread via the gastrosplenic ligament

Fig. 3. Gastric adenocarcinoma invading the spleen via the gastros-plenic ligament. a Initial contrast-enhanced CT scan reveals circumferential tumor involving the gastric fundus. b Six months later, a repeat CT scan shows invasion and dissection of the spleen secondary to tumor spread via the gastrosplenic ligament

Fig. 4. The gastrocolic ligament (GCL) joins the greater curvature of the stomach (G) to the transverse colon (TC). In concert with the transverse mesocolon, a pathway of disease is formed between retro-peritoneal structures such as the pancreas (P) and the duodenum (D) to the anterior aspect of the intraperitoneal cavity. RDS, right peritoneal space (lesser sac); J, jejunum. (Modified from [11])

Fig. 5. Pancreatic islet-cell tumor arising in the pancreatic tail (a) and metastatic to liver (b) has resulted in splenic vein thrombosis with secondary short gastric venous collaterals in the gastrosplenic and splenorenal ligaments (b) and gastroepiploic venous collaterals (arrow) in the gastrocolic ligament (a)

Fig. 5. Pancreatic islet-cell tumor arising in the pancreatic tail (a) and metastatic to liver (b) has resulted in splenic vein thrombosis with secondary short gastric venous collaterals in the gastrosplenic and splenorenal ligaments (b) and gastroepiploic venous collaterals (arrow) in the gastrocolic ligament (a)

the stomach, transverse colon, and pancreas, the gastrocolic ligament serves as an important nidus for the peritoneal metastases that commonly occur with ovarian, gastric, colon, and pancreatic cancer [12, 13]. Finally, dilated veins within this ligament may represent gastroepi-ploic collaterals resulting from splenic venous compromise that might occur in the setting of invasive pancreatic tumors, or intraperitoneal tumors, which spread to the retroperitoneum via the transverse mesocolon (Fig. 5).

Transverse Mesocolon

The transverse mesocolon serves as a broad conduit of disease across the mid-abdomen; bare areas link the pancreas to the transverse colon, the spleen, and the small bowel. On the right, the transverse mesocolon is continuous with the duodenocolic ligament; in the middle, it is continuous with the small bowel mesentery; and on the left, it is continuous with the phrenicocolic and splenorenal ligaments (Fig. 6). It contains the middle colic vessels and associat-

Fig. 6. The transverse mesocolon (TM) provides an important conduit for the spread of disease across the mid-abdomen. It is continuous with the splenorenal ligament (SRL) and phrenicocolic ligament (PCL) on the left and with the duodenocolic ligament on the right. In its mid-portion, it is continuous with the small bowel mesentery (SBM). (Reprinted with permission from [8])

Fig. 6. The transverse mesocolon (TM) provides an important conduit for the spread of disease across the mid-abdomen. It is continuous with the splenorenal ligament (SRL) and phrenicocolic ligament (PCL) on the left and with the duodenocolic ligament on the right. In its mid-portion, it is continuous with the small bowel mesentery (SBM). (Reprinted with permission from [8])

ed lymphatics. On CT, it may be recognized as a fatty plane at the level of the uncinate process. Pancreatic tumors often spread ventrally into the transverse mesocolon to involve the transverse colon. In addition, they have the propensity to continue through the gastrocolic ligament to involve the stomach (Fig. 7). Alternatively, they may spread through the transverse mesocolon to involve

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Responses

  • pirkko tuimala
    What does metastatic gastrohepatic ligament look like?
    3 years ago

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