Blood supply of the stomach

1. Origin

• All principal arteries → branches of the coeliac trunk (T12)
• Left inferior phrenic artery → from the aorta; supplies the cardia and abdominal oesophagus

2. Course and relations

Left gastric artery (LGA)

• Smallest branch of the coeliac trunk; from the coeliac trunk in 90%
• Runs up and left in the gastropancreatic fold to the lesser curvature below the gastro-oesophageal junction
• Ascending branch → oesophageal branches
• Descending branch → anterior and posterior branches along the lesser curvature
• Ends → anastomosis with the right gastric artery
• Variant origins → common hepatic, splenic, superior mesenteric arteries, aorta
• Aberrant left hepatic artery from the LGA → 20–24%

Right gastric artery (RGA)

• Origin → proper hepatic (65%), left hepatic (25%), common hepatic artery (3%)
• Runs left along the lesser curvature, 0.5 cm from its margin
• Small vessel → often ligated with surrounding tissue

Right gastroepiploic artery (RGEA)

• Origin → gastroduodenal artery (GDA) behind the first part of the duodenum
• Runs left along the greater curvature in the gastrocolic ligament
• Largest vessel ligated in a distal gastrectomy

Left gastroepiploic artery (LGEA)

• Origin → distal splenic artery near the splenic hilum
• Runs right in the gastrosplenic and gastrocolic ligaments

Short gastric arteries

• Origin → splenic artery and its terminal branches
• Course → gastrosplenic ligament to the fundus

Posterior gastric artery

• Origin → splenic artery, proximal to the LGEA
• Present in 62%
• Supplies the posterior fundus

3. Branches / Parts

• Lesser curvature arcade → LGA ↔ RGA
• Greater curvature arcade → RGEA ↔ LGEA
• Omental arcade of Barkow → from both gastroepiploic arteries
• Fundus → short gastric, posterior gastric, left inferior phrenic arteries

4. Blood supply, venous and lymphatic drainage

Veins

• Follow the arteries → portal system
• Left gastric (coronary) vein → portal vein (70%) or splenic vein (30%)
  • Receives oesophageal veins → portosystemic anastomosis
• Right gastric vein → portal vein; receives the prepyloric vein of Mayo
• Right gastroepiploic vein → superior mesenteric vein (SMV)
  • Gastrocolic trunk of Henle (with right colic vein) → in 70%
• Left gastroepiploic and short gastric veins → splenic vein

Lymphatics

• Follow the arteries → perigastric nodes → coeliac nodes

5. Clinical significance

• Stomach survives ligation of all but one primary artery
• Total gastrectomy or ≥ 70% resection → LGA ligated at its origin above the pancreas
• Subtotal gastrectomy with LGA and short gastrics divided → posterior gastric artery may be the only supply to the remnant
• Splenectomy during gastric resection → remnant supply at risk
• Gastric conduit (oesophagectomy) → based on the RGEA
• Portal hypertension → coronary and short gastric veins form oesophageal and fundal varices
• Splenic vein thrombosis → isolated fundal varices
• Hemigastrectomy venous landmarks:
  • Lesser curvature → 3rd branch of the coronary vein below the cardia
  • Greater curvature → point where the left gastroepiploic vein comes closest to the wall