# Lymphatic and vascular anatomy define surgical principles for radical treatment of distal duodenal and proximal jejunal tumors

## TL;DR

This study identifies surgical guidelines for treating tumors in the distal duodenum and proximal jejunum by analyzing blood vessel and lymphatic anatomy.

## Contribution

The study provides standardized surgical principles for ligation and lymphadenectomy based on detailed anatomical analysis.

## Key findings

- The superior jejunal artery (SJA) is present in 74.2% of cases and has a mean caliber of 3.4 mm.
- Ligation of the SJA at its origin is crucial for adequate lymphatic clearance.
- A D3 mesenterectomy is recommended to include lymphadenectomy along adjacent arteries to the first arcade.

## Abstract

The arterial ligation level and the lymphadenectomy extent for surgical treatment of distal duodenal/proximal jejunal tumors are not standardized.

To define morphometric and topographic specifics of the superior jejunal artery (SJA) and the superior jejunal vein (SJV), and the width of arterial lymphovascular bundles through lymphatic clearances. By extrapolating results from two methodologies, the goal is to determine the arterial ligation level and the lymphadenectomy extent for duodenojejunal tumor treatment.

The first series included an analysis of preoperative 3D-CT vascular reconstructions from 97 patients. The second series included 11 dissected cadavers where the course of the proximal mesenteric lymphatics was followed. The SJA was defined as the uppermost jejunal artery (JA) counted from the ileocolic artery (ICA) origin.

SJA proper was present in 72 cases (74.2%). The mean SJA caliber was 3.4 ± 1.2 mm. SJA originated 17.5 ± 16.8 mm cranial to the middle colic artery (MCA) origin and was found cranial to it in 84 cases. SJA originated caudal to the inferior pancreatic border in 80 cases (82.8%) and cranial in 17 (17.2%). SJV coursed anteriorly to the superior mesenteric artery in 29 cases (29.9%). The distances of the cranial and caudal lymphatics following SJA at the level of the arterial origin were 1.15 ± 0.53 mm and 0.6 ± 0.35 mm.

To achieve adequate lymphatic clearance, it is crucial to ligate the tumor-feeding SJA at its origin. The conical arrangement of the SJA lymphatics underscores the necessity of a mesenterectomy extending both cranially and caudally, including lymphadenectomy along the adjacent JA to the level of the first arcade.

“Surgery with Extended (D3) Mesenterectomy for Small Bowel Tumors” registered at https://classic.clinicaltrials.gov/ct2/show/NCT05670574 NCT05670574

The online version contains supplementary material available at 10.1007/s00464-025-11909-9.