Gastrocolic Ligament

The gastrocolic ligament extends inferiorly from the greater curvature of the stomach to suspend the transverse colon and is traversed by the gastroepiploic vessels (Fig. 4-22). It inserts in relationship to the taenia omen-talis, and injection studies and clinical observations have documented that spread of gastric lesions down the gas-

Hepatoduodenal Ligament Contains

Fig. 4—18. Inflammatory thickening of the hepatoduodenal ligament.

Secondary to a penetrating post-bulbar duodenal ulcer with obstructive jaundice, there is mural thickening of the duodenum (D) and inflammatory thickening of the hepatoduodenal ligament (small arrows), which contains the dilated common bile duct (large arrow).

(Reproduced from Meyers et al.9)

Ligamentum Gastrocolicum

Fig. 4—19. Nodal metastases in the hepatoduodenal ligament from carcinoma of the head of the pancreas.

The pancreatic carcinoma has spread around the hepatic artery and portal vein along the hepa-toduodenal ligament to the porta hepatis (arrows).

Fig. 4-20. Lymphomatous involvement of the portal vein and hepatoduodenal ligament.

Ultrasonography demonstrates mixed hypo- and hyperechoic mass along the hepatoduodenal ligament (arrows). Note the collateral pathways (arrowheads). (Reproduced from Fukuda T, et al: Radiologic imaging of perihepatic ligament. Jpn J Diagn Imaging 1997, 17:245-247.)

Fig. 4-20. Lymphomatous involvement of the portal vein and hepatoduodenal ligament.

Ultrasonography demonstrates mixed hypo- and hyperechoic mass along the hepatoduodenal ligament (arrows). Note the collateral pathways (arrowheads). (Reproduced from Fukuda T, et al: Radiologic imaging of perihepatic ligament. Jpn J Diagn Imaging 1997, 17:245-247.)

Gastrocolic Ligament Anatomy

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Fig. 4—21. Cavernous transformation of the portal vein within the hepatoduodenal ligament secondary to pancreatic carcinoma.

(a) A carcinoma arising from the neck of the pancreas (P) invades the hepatoduodenal ligament as well as the gastric antrum and first portion of the duodenum.

(b) The portal vein, superior mesenteric vein, and splenic vein are also encased by tumor at their confluence with prominent venous collaterals (cavernous transformation of the portal vein) seen as brightly enhancing veins (arrows) within the hepatoduodenal ligament.

(Courtesy of James Brink, M.D., Yale University School of Medicine, New Haven, CT.)

trocolic ligament involves first and predominantly the superior haustral row of the transverse colon1,5,41,42 (Fig. 4-23), with highly characteristic changes on barium enema study. The wall becomes fixed and straightened,

Gastrocolic Ligament

Fig. 4—22. Sagittal section showing the mesenteric reflections to the transverse colon (C) from the stomach (S ) and the pancreas (P).

Note that the gastrocolic ligament (GC) inserts superiorly and the transverse mesocolon (TrM) posteroinferiorly. (Reproduced from Meyers and McSweeney.1)

with selective loss of the contour of the haustral saccu-lations and most characteristically, the mucosal folds are conspicuously tethered (Figs. 4-24 through 26). The term "tethering" is used to indicate that the mucosal folds lose their parallel orientation to each other, and their axes, which are normally perpendicular to the lu-

Gastrocolic Ligament

Fig. 4—23. Sagittal section through the transverse colon, demarcated into its three constituent haustral rows by the taenia omentalis (TO), taenia mesocolica ( TM), and taenia libera ( TL).

Extension of a malignancy from the stomach (S) through the gastrocolic ligament spreads preferentially to the TM-TO haustral row. This constitutes the superior border of the transverse colon. P = pancreas. (Reproduced from Meyers et al.42)

Fig. 4—23. Sagittal section through the transverse colon, demarcated into its three constituent haustral rows by the taenia omentalis (TO), taenia mesocolica ( TM), and taenia libera ( TL).

Extension of a malignancy from the stomach (S) through the gastrocolic ligament spreads preferentially to the TM-TO haustral row. This constitutes the superior border of the transverse colon. P = pancreas. (Reproduced from Meyers et al.42)

Scirrhous Cancer

Fig. 4—24. Direct invasion of the transverse colon along the gastrocolic ligament from a scirrhous carcinoma of the stomach ( S ).

There is fixation and angulation of the mucosal folds along the superior contour (arrows) involving the TM-TO haustral row. The fixation results in pseudos-accular outpouchings from the uninvolved haustral row on the inferior border.

(Reproduced from Meyers and McSweeney.1)

Fig. 4—25. Carcinoma of the stomach extending down the gastrocolic ligament involves first the TM-TO row on the superior contour of the transverse colon (arrowheads). Nodular irregularities are associated with tethering of the mucosal folds.

(Reproduced from Meyers et al.42)

Sma Syndrome

Fig. 4—26. Gastric carcinoma spreading down the gastrocolic ligament.

(a) Fixation and mucosal tethering along the entire superior border of the transverse colon. Prominent haustral pseudosaccu-lations project from the uninvol-ved inferior contour.

(b) Spot film of hepatic flexure shows the appearance of cobblestone linear and transverse ulcers

Barium Enema Cobble Stone

Fig. 4—26. Gastric carcinoma spreading down the gastrocolic ligament.

(a) Fixation and mucosal tethering along the entire superior border of the transverse colon. Prominent haustral pseudosaccu-lations project from the uninvol-ved inferior contour.

(b) Spot film of hepatic flexure shows the appearance of cobblestone linear and transverse ulcers

Gary Ghahremani

men of the bowel, become randomly angulated. This change reflects the associated desmoplastic reaction within the gastrocolic ligament itself, acting in effect as a mass of adhesions. The uninvolved haustral contours of the inferior border of the transverse colon retain their pliability and are thrown into pseudosacculations (Figs. 4-25 and 4-26). Further distortion and fixed buckling of the mucosal pattern may occasionally produce the appearance of cobblestone linear and transverse ulcers (Fig. 4-26). The primary gastric carcinomas are usually scirrhous in nature and are frequently clinically occult. It is said that glandular adenocarcinomas spread mainly in the mucosa and submucosa with little serosal spread, whereas scirrhous carcinomas spread in submucosa and muscle coats, probably via lymphatics.8 The incidence of involvement of the gastrocolic ligament is over 90% once the cancer reaches the serosa.43 Initially, the complex of these features on a barium enema examination may be mistaken for an intrinsic inflammatory process, such as granulomatous colitis,44 since the processes share several pathologic and roentgenographic characteristics. These include unilateral mural involvement, nodular irregularities, pseudosaccular outpouchings, and the occasional appearance of ulcerations. However, the localization specifically to the superior border of the transverse colon and the identification of the tethered mucosal folds, a change not seen in granulomatous colitis, readily lead to the correct diagnosis.

A similar appearance may uncommonly be the result of seeded metastases on the gastrocolic ligaments,45 but this is almost invariably accompanied by contiguous changes upon the greater curvature of the stomach and characteristic changes at other seeded sites.46

Even with extensive circumferential invasion, the greater degree of involvement with fixation and angu-lation of mucosal folds and mass effects tends to be maintained on the superior contour (Figs. 4-27 and 4-28.)

Computed tomography particularly, and more recently magnetic resonance imaging,47 documents that gastric carcinoma may extend into the ligament only partially, although certainly a sign of extramural spread, to perhaps only indent the underlying colon (Fig. 429), or may spread down its length to invade the upper haustral contour clearly (Fig. 4-30), or progress to an-

Xray Scirrhous Carcinomas

Fig. 4—27. Circumferential invasion of the transverse colon from a scirrhous carcinoma of the stomach ( S ).

The nodular masses (arrows) remain predominant on the superior contour.

Fig. 4—27. Circumferential invasion of the transverse colon from a scirrhous carcinoma of the stomach ( S ).

The nodular masses (arrows) remain predominant on the superior contour.

Annular Ligament

Fig. 4—28. Annular invasion of the transverse colon from gastric carcinoma.

Double-contrast study shows nodular masses and infiltration predominate on the superior contour.

(Reproduced from Gore and Meyers.24)

Fig. 4—29. Extension of gastric carcinoma along gastrocolic ligament.

(a) A large mass (M) representing carcinoma extends from the stomach (St).

(b) The mass extends inferiorly within the gastrocolic ligament to displace and compress the transverse colon (TC). (Reproduced from Meyers et al.9)

Gastrocolic Ligament

nular involvement of the transverse colon (Figs. 4-31 through 4-33).

The limit of anatomic continuity of the mesenteric reflections toward the left is at the level of the phreni-cocolic ligament,48 which extends from the anatomic splenic flexure to the diaphragm. At this point, the mes-enteric transverse colon continues as the extraperitoneal descending colon. Spread of the process thus typically ends abruptly at the anatomic splenic flexure of the colon, just below the tip of the spleen (Figs. 4-34 through 4-36). A mass may further develop within the phreni-cocolic ligament itself (Fig. 4-37).

As evidence of the "two-way street" provided by the ligament, carcinoma of the transverse colon can extend superiorly to involve the greater curvature of the stomach49 (Fig. 4-38). Further invasion may result in a malignant gastrocolic fistula (Fig. 4-39).

Ultrasonography and computed tomography may show not only abnormal mural thickening but also the intraabdominal tumor extension.50-54 These modalities further refine capabilities in staging tumors, assessing surgical resectability, evaluating tumor response, and detecting postoperative recurrence.

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Pic Gastrocolic Mass

Fig. 4—30. Extension of gastric carcinoma along gastro-colic ligament to the transverse colon with involvement of the upper haustral row.

(a) A prominent mass (M) representing an annular carcinoma compresses the gastric lumen.

(b) The mass extends inferiorly into the gastrocolic ligament. An incidental left renal cyst is noted. (Continued)

Fig. 4-30. Continued. (c) At a level through the superior haus-tral row of the midtransverse colon (TC), early infiltration by the mass is seen. (d) At a level through lower haustral sacculations of the transverse colon, no further involvement by the malignant extension is present.

Muscle Along Transverse Colon Annular Ligament

Fig. 4—31. Annular invasion of transverse colon by extension of gastric carcinoma along gastrocolic ligament.

(a) Barium enema demonstrates circumferential mass narrowing of distal transverse colon. Note narrowing and distortion of gastric lumen.

(b and c) CT shows the thickened wall of the stomach (S) and its progression along the gastrocolic ligament (GCL) with direct annular infiltration of the transverse colon (TC).

(Courtesy of Gary Ghahremani, M.D., Ev-anston Hospital, Evanston, IL.)

Fig. 4—31. Annular invasion of transverse colon by extension of gastric carcinoma along gastrocolic ligament.

(a) Barium enema demonstrates circumferential mass narrowing of distal transverse colon. Note narrowing and distortion of gastric lumen.

(b and c) CT shows the thickened wall of the stomach (S) and its progression along the gastrocolic ligament (GCL) with direct annular infiltration of the transverse colon (TC).

(Courtesy of Gary Ghahremani, M.D., Ev-anston Hospital, Evanston, IL.)

c
Gastrocolic Ligament

Fig. 4—32. Spread of gastric carcinoma along gastrocolic ligament to the transverse colon and greater omentum.

(a and b) Antral carcinoma causing marked mural thickening of the stomach (St) spreads along the gastrocolic ligament (GCL) to strangulate the transverse colon (TC) and extends into the greater omentum (GO). Subtle peritoneal implants highlighted by ascites are noted as well (arrows).

(Reproduced from Gore and Meyers.24)

Fig. 4—32. Spread of gastric carcinoma along gastrocolic ligament to the transverse colon and greater omentum.

(a and b) Antral carcinoma causing marked mural thickening of the stomach (St) spreads along the gastrocolic ligament (GCL) to strangulate the transverse colon (TC) and extends into the greater omentum (GO). Subtle peritoneal implants highlighted by ascites are noted as well (arrows).

(Reproduced from Gore and Meyers.24)

Fig. 4—33. Spread of gastric carcinoma along the gastrocolic ligament to invade the transverse colon.

An engorged right gastroepiploic vein (arrowheads) is embedded in the extensive tumor infiltrate

(Reproduced from Auh et al.10)

Gastrocolic LigamentGastrocolic Ligament

Fig. 4—34. Direct invasion of the transverse colon from gastric carcinoma along the gastrocolic ligament.

(a) Invasive desmoplastic changes involve the distal transverse colon, stopping abruptly at the anatomic splenic flexure (arrows).

(b) Upper GI series documents a primary scirrhous carcinoma of the stomach.

Fig. 4—34. Direct invasion of the transverse colon from gastric carcinoma along the gastrocolic ligament.

(a) Invasive desmoplastic changes involve the distal transverse colon, stopping abruptly at the anatomic splenic flexure (arrows).

(b) Upper GI series documents a primary scirrhous carcinoma of the stomach.

Upper Gastric Radiology

Fig. 4—35. Annular strangulation of the transverse colon by spread from gastric carcinoma down the gastrocolic ligament.

The severe extension involves the entire length and typically stops abruptly at the anatomic splenic flexure (arrows).

Colon Flexure Ligament

Fig. 4—36. Extension of gastric carcinoma along gastrocolic ligament to anatomic splenic flexure of colon.

(a) Mural thickening (arrows) of stomach (St) secondary to carcinoma.

(b) Mass extension (M) into the gastrocolic ligament to the transverse colon (TC) ending on the left at the anatomic splenic flexure of the colon (SF).

Fig. 4—36. Extension of gastric carcinoma along gastrocolic ligament to anatomic splenic flexure of colon.

(a) Mural thickening (arrows) of stomach (St) secondary to carcinoma.

(b) Mass extension (M) into the gastrocolic ligament to the transverse colon (TC) ending on the left at the anatomic splenic flexure of the colon (SF).

Fig. 4—37. Extensive annular invasion along the length of the transverse colon from gastric carcinoma.

The changes end abruptly at the level of the phrenicocolic ligament. At this point along the lateral aspect of the anatomic splenic flexure of the colon, a prominent serosal mass has developed (arrow). (Reproduced from Meyers and McSweeney.1)

John Denver Plane CrashGastrocolic Ligament

Fig. 4—38. Transmural invasion of the stomach from colonic carcinoma.

(a) There is nodular infiltration along the greater curvature (arrow).

(b) Spread has occurred along the gastrocolic ligament from a large primary carcinoma of the transverse colon.

Fig. 4—38. Transmural invasion of the stomach from colonic carcinoma.

(a) There is nodular infiltration along the greater curvature (arrow).

(b) Spread has occurred along the gastrocolic ligament from a large primary carcinoma of the transverse colon.

Carcinoma of the pancreas may invade the gastrocolic ligament in exceptional cases, following mass infiltration of the transverse mesocolon (Fig. 4-40).

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