氟尿嘧啶经胃左动脉和外周静脉化疗的药代动力学比较

目的 探讨胃左动脉区域灌注化疗治疗胃癌的合理性。方法 比较氟尿嘧啶（５－ＦＵ）经胃左动脉和外周静脉给药后的药代动力学变化。结果 胃左动脉给药组的门静脉 血中５－ＦＵ浓度为外周静脉给药组的４￣２００倍,而且５－ＦＵ高浓度的维持时间明显延长;癌组织和癌旁淋巴组织中５－ＦＵ水平分别为静脉给药组的１９倍和２３倍。结论 胃左动脉区域灌注化疗可明显增加癌肿局部的化疗药物浓度,提高化疗疗效。     

胃左动脉区域灌注化疗治疗胃癌的药代动力学研究

目的 探讨胃左动脉区域灌注化疗治疗胃癌的合理性。方法 观察５－Ｆｕ经胃左动脉和外周静脉给药后的药代动力学变化。结果 胃左动脉给药，门静脉血中５－Ｆｕ浓度为外周静脉给药组的４～４０倍，而且维持５－Ｆｕ高浓度的时间明显延长；癌组织和癌旁淋巴细胞中５－Ｆｕ水平分别为外周静脉给药组１９倍和２３倍。结论 胃左动脉区域灌注化疗可明显提高癌肿局部的化疗药物浓度。     

氟尿嘧啶经胃左动脉和外周静脉化疗的药代动力学比较

目的探讨胃左动脉区域灌注化疗治疗胃癌的合理性.方法比较氟尿嘧啶(5-FU)经胃左动脉和外周静脉给药后的药代动力学变化.结果胃左动脉给药组的门静脉血中5-FU浓度为外周静脉给药组的4～200倍,而且5-FU高浓度的维持时间明显延长;癌组织和癌旁淋巴组织中5-FU水平分别为静脉给药组的19倍和23倍.结论胃左动脉区域灌注化疗可明显增加癌肿局部的化疗药物浓度,提高化疗疗效.     

胰腺癌区域化疗最佳动脉途径选择的临床研究

目的 为胰腺癌区域化疗选择合理的动脉途径提供理论依据。方法 胰腺癌开腹后控查不能切除的病例39例，男20例，女19例。年龄45－66岁，分为五组，Ⅰ组：腹腔干组，由男左动脉插管进入腹腔干5例；Ⅱ组；胃十二指肠组，24例；其中ⅡA组9例，由胃网膜右动脉插管进入胃十二指肠动脉，ⅡB组15例，插管直接进入胃十二指肠动脉；Ⅲ组：胃网膜右动脉组，直接插入该动脉，5例；Ⅳ组：脾动脉组，进行脾动脉逆行插管，5例。结果 注入亚甲基蓝5min腹腔干组可见胃大弯近贲门处染色；ⅡA组见胃大弯染色自幽门至胃网膜左右交界处，大网膜／十二指肠起始部、降部及胰头部明显染色；脾动脉组见胰尾染色。注入亚甲基蓝30例钟后腹腔干组见胰头及十二指肠起始部及降部淡染；ⅡB组见一例体部染色，另外14例染色范围无改变；脾动组无明显改变。结论 胰头癌以胃十二指肠动脉为首选，可根据情况选择直接插管或经胃网膜右动脉进入该动脉。胰体尾癌应通过脾动脉插管化疗。     

胃左动脉置泵灌注联合腹腔化疗治疗中晚期胃癌

目的 探讨胃癌手术后经胃左动脉灌注联合腹腔化疗和静脉化疗治疗中晚期胃癌的远期疗效。方法 病人随机分为联合化疗组（63例）和静脉化疗组（53例），对比研究患者毒副反应及生存率。结果 毒副反应中肝、肾功能损害两组差异无显著性（P＞0．05）；与静脉化疗组比较，联合化疗组的恶心呕吐、脱发及骨髓抑制症状较轻，而腹痛腹胀较严重（均P＜0．05）；联合化疗组5年生存率显著高于静脉化疗组（P＜0．05）。结论 对中晚期胃癌患者行胃左动脉灌注联合腹腔化疗，其毒副作用小，并可提高患者生存率。     

全腹腔镜下远端胃癌根治术三角吻合术

先确定肿瘤位置,沿横结肠边缘超声刀游离横结肠系膜前叶,向右游离至结肠肝曲,左至脾曲,离断网膜左血管,清扫4sb,4d淋巴结;沿结肠中动脉及其分支分离,向上暴露肠系膜上静脉、右结肠静脉、胃网膜右静脉,骨骼化胃网膜右动脉于根部切断;裸化十二指肠下缘,暴露胃十二指肠动脉,肝总动脉胃左脾动脉和腹腔干,切断胃左动脉清扫第7.8.9.11p组淋巴结;向下剥离裸化肝十二指肠韧带,清扫第12a组淋巴结,并向上彻底清扫第1,3,5组淋巴结,使用内镜下直线切割吻合器离断十二指肠球部,胃体。扩大脐部穿刺孔至取出标本,缝合切口。重建气腹,行胃大弯和十二指肠后壁三角吻合。     

机器人根治性远端胃次全切除术

术中在横结肠上缘切开胃结肠韧带,将横结肠系膜前叶分离,向右分离,显露胃网膜右动脉由胰十二指肠动脉分支根部并离断,清除周围淋巴结。将胃翻向上方,在胰腺上缘肝总动脉之起始部找到胃左动脉。分别显露胃左动脉和静脉。先切断静脉,再切断胃左动脉,剥离胰腺背膜,并切除周围脂肪,清除肝总动脉及胰腺上缘之淋巴结,向右继续清除幽门上淋巴结群。在胃十二指肠动脉分出胃右动脉处切断胃右动脉,清除肝固有动脉周围之淋巴结,离断十二指肠。向右继续清除脾动脉周围之淋巴结及脂肪组织,将胃向上翻起,清除贲门淋巴结及脂肪组织。余步骤辅助小切口完成胃肠Roux-en-Y重建。     

胰腺和胰周间隙的活体解剖学特点及其对腹腔镜远端胃癌D2切除术的启示

目的观察胰腺和胰周间隙的活体解剖学特点,为腹腔镜远端胃癌D2切除术提供技术指导。方法按照腹腔镜远端胃癌D2切除术的基本步骤,对132例胃癌患者进行腹腔镜下活体解剖学观察。结果患者的大网膜与横结肠系膜之间的间隙在胰腺下缘与胰前间隙和胰后间隙相通,后两者在胰腺上、下缘相互贯通并向周围延伸。在胰尾上缘的胰前间隙,可定位胃网膜左血管。在胰颈下缘的胰后间隙,可定位肠系膜上静脉;在胃窦下方的胃系膜和胰前间隙中,可定位胃网膜右血管。在胃窦-胰头间隙,可定位胃十二指肠动脉,并依此追溯肝总动脉。在胰体上缘的胰后间隙,可定位肝总动脉、胃左动脉、腹腔动脉和脾动脉。肝胰襞和胃胰襞是定位肝总动脉和胃左动脉的解剖标志。这些血管及其鞘内间隙是相互延续的整体。结论腹腔镜远端胃癌D2切除术中,胰腺是总的中心标志,胃周血管主干和分又是具体和局部标志,各向延伸的胰前间隙和胰后间隙是宏观外科平面,相互延续的胃周血管鞘内间隙是微观外科平面。     

腹腔镜胃癌根治术

应用电钩沿横结肠与大网膜附着处分离大网膜分别至结肠脾曲及结肠肝区。用超声刀沿胰腺被膜分离,至胰腺上缘显露近脾门处的脾动静脉主干向脾门解剖,清扫第10、11组淋巴结;显露胃网膜左血管根部并离断,向上离断部分胃短血管后,裸化胃大弯,清扫第4组淋巴结。沿胰腺下缘胰后间隙解剖,显露肠系膜上静脉,清扫14v组淋巴结,于胃网膜右静脉汇入胃结肠静脉干处夹闭,显露胃网膜右动脉根部并夹闭,清扫第6组淋巴结。沿胰腺上缘打开胃胰皱襞进入胰后间隙解剖肝总动脉及腹腔动脉干,游离并显露胃左动、静脉,脾动脉及部分肝总动脉,根部切断胃左动、静脉,清扫7、8、9组淋巴结。显露肝总动脉,清扫第8a组淋巴结,显露肝固有动脉,显露胃右动脉根部,夹闭切断胃右动脉,清扫第5、12组淋巴结。沿小网膜与胃小弯前壁附着处切除小网膜,裸化胃壁,清扫第3、5组淋巴结。     

术后胃缺血

胃的动脉血供有5个来源,即腹腔动脉干的胃左动脉、来自肝动脉的胃右动脉、胃十二指肠动脉的胃网膜右动脉、脾动脉的胃网膜左动脉,以及脾动脉的胃短动脉,故术后一般很少发生胃缺血.Michels研究了200具人尸体,发现胃的动脉血供还可来自胰十二指肠上动脉, wilkie十二指肠上动脉、十二指肠后动脉、胰横动脉、胰背侧动脉或左隔下动脉.Suzuki还证实胃后动脉的血供,它来自脾动脉的中1/3段(占62%),     

Surgical implications of the posterior gastric artery

The posterior gastric artery was identified during gastrectomy in 43 of 51 patients with distal gastric cancer. Two female patients had two posterior gastric arteries that originated separately from the splenic artery. Of these 45 arteries, 6 originated from the proximal third of the splenic artery, 35 from the mid third, and 4 from the distal third. These vessels coursed upward behind the posterior parietal peritoneum. The anterior and posterior walls of the remnant stomach were stained blue after injection of methylene blue solution into the splenic artery. The surgical importance of the posterior gastric artery is obvious because of its high frequency and deep origin and course. In addition, it is another source of blood supply to the stomach, and the lymphatics around this vessel form one of the primary routes draining the gastric fundus.     

Intrathoracic revascularization of the stomach in gastroplastic reconstruction of the esophagus

Reconstruction of the thoracic esophagus after esophagectomy is usually achieved using the stomach which, after gastrolysis through an abdominal approach, is pulled into the right thoracic cavity and anastomosed to the esophagus. After gastrolysis by conventional methods, the blood supply of the stomach exclusively depends on the right gastric and epiploic arteries. In some cases, these arteries cannot ensure sufficient blood supply to the fundus of the stomach, which is at higher risks from a vascular point of view, since it depends on the intraparietal capillary anastomoses between the gastric branches on the left inferior gastric artery, the intraparietal rami of the short gastric arteries, which have been cut, and the parietal rami of the anterior cardiotuberous artery. When macroscopic signs of ischemic disorders of this area are observed intraoperatively, resection of the fundus of the stomach would considerably reduce the length of the organ that could be used for gastric esophagoplasty. To avoid this, we have been implementing an intrathoracic revascularization technique consisting in anastomosing the left gastric artery, either directly with the right internal mammary artery, or through a shunt with the saphenous vein between the subclavian artery and the left gastric artery itself. Finally, the intensification of the venous circle is performed by anastomosing the left gastric vein and the azygos vein. Details of the surgical technique, as well as the results obtained, are illustrated.     

肝海绵状血管瘤血供来源研究方法的讨论

目的 探讨肝海绵状血管瘤供血来源及研究方法的科学性。方法 对５例病人,经肝右动脉支结扎后,分别行门静脉连续造影和注入亚甲兰肝染色,观察门静脉与瘤体关系;对２２例肝动脉支插管造影;２例切除肝叶经静脉行血管铸型标本观察。结果 门静脉造影在门静脉期,门静脉支被瘤体稚移,造影剂不进入瘤内;肝实质期,瘤体区形成低密度区,亚甲兰染色,仅见肝实质染色,瘤区不被染色,界限分明,血管铸型标本见瘤体完全腐蚀脱落、无静     

Assessment of the blood flow in various gastric tubes for esophageal substitutes

Comparative studies were done on canine gastric tubes of various widths with the objective of obtaining the maximal blood flow at the proposed area of anastomosis, when the gastric tube was to be used as an esophageal substitute. The left and the right gastric arteries and veins and the short gastric artery and vein were divided, and the lesser curvature side was variously dissected in parallel to the greater curvature. The tissue blood flow, as determined by the hydrogen clearance method, revealed the highest value in the 3-cm-wide gastric tube. The vascular network was well preserved in various sized gastric tubes, except in those of 1.5 cm. These findings suggest that a gastric tube of potential length with a sufficient blood supply can be realized by optimal tailoring.     

左外区活体肝移植动脉的临床应用解剖研究

目的 观察肝左区肝动脉解剖结构，模拟肝左外区活体肝移植动脉切取方法。方法 解剖非肝病死亡之成人甲醛固定尸体肝脏标本30例，观察新鲜成人尸体肝脏铸型标本30例，测量肝左及左外区动脉长度、管径及属支分布情况。结果 左半肝动脉的血供来自肝固有动脉、肝左动脉、肝中动脉，肝外迷走动脉支有左膈下动脉、胃左动脉和胃右动脉，并于不同部位发出后分别进入左外区上、下段。结论 左半肝动脉主要有5种类型，因此解剖变异较多，左外区活体取肝前应仔细研究其结构特点，设计合理的切取模式；移植前肝动脉需进行必要的整形，以便与受体动脉吻合。     

肝海绵状血管瘤供血方式的临床研究

目的 研究肝海绵着血管瘤的血供,探讨经肝动脉,门静脉治疗ＣＨＬ。方法 综合使用中美兰染色,离体标本造影,剔除与肿瘤相邻的正常肝脏组织检查血管与肿瘤的关系,组织病理学连续切片等方法研究ＣＨＬ供血血管的特点２。结果美尘染色及造影显示肝动脉,门静脉参与供血,经肝静脉流出与肿瘤相邻的血管大多数为小静脉样结构;连续切片未发现血管直接出入肿瘤,肿瘤边缘包膜中断处理管较多,动静脉结构共存,扩张血窦与肝组织混杂存     

64层螺旋CT血管造影及融合技术对胃周动脉的评价

目的探讨64层螺旋CT血管成像（64-MSCTA）及融合技术对胃周动脉的显示能力和临床应用价值。方法对2011年4—8月间收治的53例患者行腹部64层螺旋CT扫描．其中26例胃癌患者行手术治疗。采用容积再现（VR）技术分别重建胃周动脉和胃,并使之相融合,观察腹腔干分型和10条胃周动脉的起源和走行及其与胃的空间关系：将手术患者的术前MSCTA资料与术中所见对比,评价64-MSCTA的准确性、敏感性和特异性。结果53例MSCTA均清晰显示腹腔干,其中MichelsI型（肝脾胃干型）46例（86．8％）。通过融合技术可任意角度清晰显示胃周动脉和胃的空间解剖关系,胃左动脉和胃网膜右动脉显示率均为100％（53／53）,胃网膜左动脉94_3％（50／53）．胃右动脉83．0％（44／53）,胃短动脉58．5％（31／53）,胃后动脉49．1％（26／53）,替代肝左动脉15．1％（8／53）。副肝左动脉、副胃左动脉及替代肝右动脉显示率均为7．5％（4／53）。CTA术前预测各动脉的准确性为84．6％。100％．敏感性为82．6％～100％．特异性均为100％。结论64．MSCTA可清晰显示胃周动脉．采用融合技术使胃周动脉和胃相融合．可真实显示活体胃及胃周血管解剖,指导手术安全进行。     

肝癌动脉血供初步研究

目的分析肝癌的动脉供血特点。方法分析有完整血管造影资料的肝癌患者366例,肝右叶肿瘤287例,肝左叶肿瘤49例,横跨左右叶者30例。常规行腹腔动脉、肠系膜上动脉数字血管造影,对可疑病例加行膈动脉、胃左动脉、脾动脉、右肾动脉、胸廓内乳动脉、支气管动脉等数字血管造影。结果参与肿瘤供血动脉,1条者157例(42.90%),2条者136例(37.16%),3条者57例(15.57%),4条者14例(3.82%),6条者2例(0.55%)。肝右动脉占50.71%(319/629),肝左动脉占26.39%(166/629),肝中动脉占1.27%(8/629),左膈动脉占0.79%(5/629),右膈动脉占6.20%(39/629),肠系膜上动脉占2.86%(18/629),胃左动脉占6.36%(40/629),胃十二指肠动脉占4.29%(27/629),右肾上腺动脉占0.64%(4/629),右支气管动脉、脾动脉、右胸廓内乳动脉均各占0.16%(1/629)。结论肝癌的血供来源以多动脉为主,除肝动脉供血外,非肝动脉分支的寄生供血也常见。     

Preoperative imaging of surrounding arteries by three-dimensional CT: is it useful for laparoscopic gastrectomy?

One of the difficulties in laparoscopic gastrectomy is the identification of the feeding artery of the stomach. Recently, 3-dimensional computed tomographic angiography has enabled the noninvasive visualization of arteries surrounding the stomach. Preoperative 3-dimensional computed tomographic angiography may facilitate laparoscopic gastrectomy by obtaining a road map of the arteries of the stomach. Twenty-nine cases of gastric cancer were evaluated using 3-dimensional computed tomographic angiography before surgery. Three-dimensional computed tomographic angiography showed the left gastric artery in 29 patients (100%), the right gastroepiploic artery in 29 patients (100%), the right gastric artery in 24 patients (82.8%), and the left gastroepiploic artery in 21 patients (72.4%). The aberrant hepatic artery was detected in 6 patients, and the variant of the right gastric artery and the variant of the left gastric artery were detected in 5 cases and 1 case, respectively. All laparoscopic gastrectomy procedures were performed successfully without conversion to open surgery. Preoperative 3-dimensional computed tomographic angiography was considered to be useful for laparoscopic gastrectomy.     

Ischemic Gastropathy After Distal Pancreatectomy with Celiac Axis Resection

Purpose Stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric arteries is a radical operation performed for locally advanced cancer of the pancreatic body. However, it is not known whether the collateral pathways that develop immediately from the superior mesenteric artery to the gastroduodenal and hepatic arteries provide sufficient blood flow to support the hepatobiliary system and the stomach. This article examines the ischemic gastropathy that can occur after this procedure and identifies the predisposing conditions.Methods Between 1997 and 2001, nine patients underwent stomach-preserving distal pancreatectomy with en bloc resection of the celiac, common hepatic, and left gastric arteries. Concomitant resection of the right gastric artery or gastroduodenal artery was performed due to cancer infiltration in three patients.Results Irregular, shallow, and wide ulcerations thought to be ischemic in origin developed in these three patients, but all the ulcerations healed in 1–2 weeks with antiulcer medication. None of the other six patients had evidence of gastric ischemia.Conclusions Ischemic gastropathy is rare after distal pancreatectomy with celiac axis resection alone; however, division of additional arteries supplying the stomach may predispose to ischemic gastropathy.