胰十二指肠切除术中治疗腹腔干狭窄的一项新技术

腹腔血管造影发现12．5～49．7％患者腹腔干阻塞，此时可通过发育良好的胰腺血管来维持胃、脾及肝脏的动脉血供。在胰十二指肠切除术中可能破坏侧支循环，但仅小部分患者发生肝、胃及脾脏缺血。如果术前没有施行血管造影，在结扎血管之前应进行胃十二指肠动脉阻断试验，于试验前后们摸肝动脉。腹腔干阻塞时，肝动脉搏动减弱、或者发生上腹部器官缺血，需要对腹腔动脉施行再血管化手术。一般可采用静脉移植物在腹主动脉与腹腔干分支之间重建血流通路。本文介绍的一种新方法是将结肠中动脉与十二指肠动脉行端端吻合。如果暂时阻断结肠中动脉后…     

腹腔干分支变异及研究进展

腹腔干是一短而粗的动脉干,约于第一腰椎高度发自腹主动脉前壁。继则分为3支,即胃左动脉、肝动脉及脾动脉,分别供给腹腔上部脏器（胃、肝、脾、胰及十二指肠等）。然而以上3支的起点变化较多,国内外学者根据自己的见解,将腹腔动脉的分支列为若干类型,并相互补充。本文从腹腔干的分支变异类型、分型发展及其意义3方面进行探讨,以期为临床提供参考。作者根据胃左动脉、脾动脉和肝动脉的起源对变异类型进行分类,主要分为肝胃脾干型、肝脾干型、肝胃干型及胃脾干型,其他包括肝脾肠系膜干型、肝胃脾肠系膜干型、肝胃脾结肠干型、肝胃脾胰干型、胃脾干加肝肠系膜干型、肝胃脾肝左干型、肝胃脾胰十二指肠干型和肝胃干加肝脾干型等。从Lipshutz、Adachi、Michels分型及张年甲分型等介绍腹腔干变异分型的发展。     

352例胆道疾病病人腹腔干-肠系膜上动脉系统影像解剖学研究及其临床意义北大核心CSCD

目的开展胆道疾病病例腹腔干-肠系膜上动脉系统影像解剖学研究,并探讨其临床意义。方法回顾性分析2016年12月至2021年5月海军军医大学第三附属医院胆道一科收治的352例胆道疾病病人薄层CT扫描图像资料并构建三维数字影像,归类分析腹腔干-肠系膜上动脉及其主要分支影像学形态特点。结果影像学形态完全符合经典解剖学著作描述者仅64例(18.1%)。288例(81.8%)存在动脉异位起源(肝动脉25.6%,胰腺动脉支5.7%,右膈动脉6.3%,胃十二指肠动脉0.6%,胆囊动脉0.6%,胃左动脉0.6%,胃右动脉0.3%,胃网膜左动脉0.3%)、副肝动脉(9.7%)、异位走行(肝动脉、异位起源肝动脉及副肝动脉31.0%,异位起源胰腺动脉支5.7%,异位起源胃十二指肠动脉0.6%,异位起源胆囊动脉0.6%)、异常共干(腹腔干-肠系膜上动脉共干2.8%;其他动脉共干0.9%)、异常交通支(Bühler弓4.8%)以及动脉缺如(2.6%)等单一或多态并存的非经典解剖学形态。结论腹腔干-肠系膜上动脉系统解剖形态多样。充分了解腹腔干-肠系膜上动脉系统解剖形态特点,将有助于合理规划胆道疾病外科手术方案、降低术中出血风险以及提高术后出血性并发症救治成功率。     

犬胰和十二指肠的血供

通过动脉灌注，在４１例标本上研究犬胰和十二指肠的血供。犬胰的血供分为四组：胰械叶由胃十二指肠动脉、脾动脉主干及其尾侧干的胰支供应；胰角由胃十二指肠动脉和胃网膜右动脉的胰支供应；胰右叶头侧头由胰十二指肠头侧动脉的胰支供应；胰右叶属侧部由胰十二指肠头，尾侧动脉的胰动供应。十二指肠主要由十二指肠上动脉和胰十二指肠头，尾侧动脉的十二指肠支供应。本研究对犬的胰腺切除术及胰腺移植术提供了解剖学资料。     

保留十二指肠胰头全切除术

保留十二指肠胰头全切除术要点：采用柯克手法将胰头从后腹膜分离,直至见到肠系膜下静脉。沿着肠系膜上静脉解剖直至胰颈。结扎切断Henle静脉干。游离、悬吊胃十二指肠动脉,暴露门静脉。缝扎胰腺上下缘、结扎胰头以减少横断胰颈时的出血。切断胰腺勾突,残端缝扎止血。沿着胰头部实质与十二指肠之间的疏松结缔组织解剖,结扎从胰十二指肠动脉弓到胰头的分支。沿着胰头与胆总管之间解剖。切断主胰管,残端用5/0普理灵线缝扎。胰管空肠吻合采用胰管对粘膜吻合法。     

腹腔镜下迷走神经后干及其属支临床解剖研究

目的 观察、测量并分析腹腔镜手术迷走神经后干及其属支与胃左动脉的解剖关系。方法 选择2017-11-13至2018-11-16大连医科大学附属第一医院胃肠外科行腹腔镜保留胃功能的胃切除术41例胃癌病人，腹腔镜下观察迷走神经后干及其属支与胃左动脉关系，并进行分型。测量迷走神经后干、腹腔支的长度以及神经与胃左动脉共干长度、胃左动脉长度。结果 迷走神经后干、腹腔支、胃支出现率为100%。迷走神经后干及其属支与胃左动脉关系分型：紧密型9例（22.0%）、中间型25例（61.0%）、游离型7例（17.0%）。远端切缘为（2.7±1.0）cm，近端切缘为（4.9±2.6）cm，胃左动脉长度为（4.0±0.6）cm，迷走神经后干长度为（5.1±1.2）cm，腹腔支长度为（4.2±0.6）cm，神经与胃左动脉共干长度为（2.1±0.9）cm。结论 充分了解迷走神经后干及其属支与胃左动脉的解剖关系对完成腹腔镜下保留幽门及迷走神经胃部分切除术有重要指导意义。     

在腹腔动脉干闭塞和胰十二指肠切除术中再血管化的作用

腹腔动脉干闭塞并非少见,危害不大,因在腹腔动脉平与肠系膜上动脉之间有丰富的侧支循环,由胰十二指肠动脉弓组成,其中胃十二指肠动脉（GDA）还必需是通畅的。但在胰十二指肠切除后,GDA也予切除,如存在腹腔动脉干闭塞,势必引起肝、胃、胰和各种吻合口缺血的威胁。为此,作者收集欧洲和北美17个单位的咨询表回音,总计上述单位每年施行胰十二指肠切除850～900例,其中注意到15例有腹腔动脉干闭塞,计男9例,女6例,平均69岁（48～79例）,胰腺手术的指征有胰头癌8例、慢性胰腺炎5例、壶腹癌及十H指肠绒毛状腺癌各1例。分析结果术中…     

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。     

内脏血管破裂引起腹内出血的若干问题

内脏血管破裂引起腹内出血的若干问题上海医科大学中山医院血管外科（２０００３２）陈福真腹腔内脏血管破裂引起的腹内出血即指腹主动脉的分支，如腹腔干、肝动脉、脾动脉、胃胰十二指肠动脉、胃左胃右动脉、胃网膜动脉、肠系膜动脉及其各级分支以及肾动脉等血管破裂所致...     

胰腺血管的影像学研究及在胰腺移植中的应用价值

目的研究胰头动脉的变异情况及其在临床胰腺移植中的应用价值。方法回顾性研究连续30（1例观测对象的数字减影血管造影的影像学资料,其中经腹腔干动脉造影192例,经肠系膜上动脉造影102例,二者联合造影6例。观察胰头血管的分布及变异特征。根据胰腺血管的影像学研究依据,对3例供胰进行了胃十二指肠动脉重建,并应用于临床胰腺移植。结果192例腹腔干动脉造影者中,典型的胃十二指肠动脉且胰十二指肠上动脉分支显影的有73例,显影率为38％;胰十二指肠上后动脉未与胰十二指肠下后动脉吻合3例,胰十二指肠动脉后弓中断1例,胰十二指肠上动脉前、后支和胰背动脉分别分布于胰头上半部,相互间无交通1例;胰十二指肠动脉弓的变异率为5／73（6．8％）。102例肠系膜上动脉造影者中,胰十二指肠下动脉显影42例,占41％,未见1例胰十二指肠动脉弓及胰十二指肠上动脉显影。在联合造影者中,6例胰十二指肠上动脉均显影,胰头前后动脉弓同时显影且完整者4例,占66．7％。3例进行了胃十二指肠动脉重建的供胰应用于胰腺移植后,受者血糖水平均正常,未出现外科并发症。结论胰十二指肠上动脉对胰头的血液供应可能优于胰十二指肠下动脉;胰头前、后动脉弓存在变异的可能。在胰腺移植中,有必要在供胰修整时重建胃十二指肠动脉,以保证胰头血液供应,使移植胰的存活及功能恢复都得到改善。     

An Alternative Technique in the Treatment of Celiac Axis Stenosis Diagnosed During Pancreaticoduodenectomy

Celiac compression is usually a benign condition, but when surgery necessitates division of collaterals from the superior mesenteric artery, it may cause life-threatening celiac organ ischemia. Celiac axis obstruction is found in 12.5% to 49.7% of patients during abdominal angiography. In such patients, the arterial blood supply to the stomach, spleen, and liver is sustained through extraordinarily welldeveloped pathways in the pancreas.Though collateral pathways may be sacrificed during pancreaticoduodenectomy, only a small proportion of patients develop hepatic, gastric and splenic ischemia during the procedure. If the appropriate angiographic studies have not been obtained before pancreatic resection, a test occlusion of the gastroduodenal artery, as recommended by Bull et al. [2], should precede its ligation. The hepatic arteries are palpated before and after the test occlusion. In the occasional patient in whom the pulse diminishes during occlusion or if there is evidence of upper abdominal visceral ischemia, revascularization of the celiac circulation may be required. Reestablishment of the celiac circulation may be accomplished by the use of a vein graft between the aorta and the celiac tributaries. This article describes an alternative technique for revascularization of the celiac circulation without the use of a venous graft.     

Pancreaticoduodenectomy with unusual artery reconstruction in a patient with celiac axis occlusion: report of a case

Celiac axis stenosis is a relatively common finding that may require major revascularization during pancreaticoduodenectomy. We present a patient that underwent pancreaticoduodenectomy for intraductal papillary mucinous neoplasm of the pancreatic head associated with celiac axis obstruction. To secure arterial blood flow to the upper abdominal organs, the superior posterior pancreaticoduodenal artery and the posterior-inferior pancreatic-duodenal artery were carefully preserved, and anastomosed. The postoperative course was complicated by a pseudoaneurysm of the splenic artery that was successfully treated with angiographic embolization through the vascular bypass. This may be a valid alternative procedure for revascularization of the common hepatic artery during pancreaticoduodenectomy in a patient with celiac axis stenosis.     

Impact of celiac axis stenosis on living donor hepatectomy

BACKGROUND: Celiac axis stenosis was once cited as a reason for exclusion from living donor liver transplantation. Donor hepatectomy, however, leaves the pancreaticoduodenal artery arcade untouched, and theoretically, celiac axis stenosis has no impact on otherwise possible donors. METHODS: Among 350 consecutive adult living donors of liver transplantation at Tokyo University Hospital, we experienced 11 (3%) donors with celiac axis stenosis or occlusion due to the median arcuate ligament. RESULTS: Harvesting of the right liver was the most common procedure (n = 8), followed by harvesting of segments II and III (n = 2), and left liver (n = 1). The postoperative course was uneventful in all of the donors. CONCLUSIONS: Our results indicate that donor hepatectomy can be safely performed in the presence of significant celiac artery stenosis.     

Celiac artery compression syndrome

Celiac artery compression syndrome occurs when the median arcuate ligament of the diaphragm causes extrinsic compression of the celiac trunk. We report a case of a 65-year-old woman who presented with a three-month history of postprandial abdominal pain, nausea and some emesis, without weight loss. There was a bruit in the upper mid-epigastrium and the lateral aortic arteriography revealed a significant stenosis of the celiac artery. At operation, the celiac axis was found to be severely compressed anteriorly by fibers forming the inferior margin of the arcuate ligament of the diaphragm. The ligament was cut and a vein by-pass from the supraceliac aorta to the distal celiac artery was performed. The patient remains well and free of symptoms two and a half years since operation.In this report we discuss the indications and the therapeutic options of this syndrome as well as a review of the literature is being given.     

Ligation of symptomatic celiac artery aneurysm without vascular reconstruction: Utilizing the natural collateral circulation of the celiac axis: A case report

IntroductionCeliac artery aneurysm is very rare visceral artery aneurysm. Symptomatic and ≥ 2.5 cm sized aneurysm requires treatment. Excision and revascularization is the most commonly employed procedure.Case presentationWe report a case of ligation and excision of celiac artery aneurysm extending onto the splenic and hepatic arteries without vascular reconstruction. The patient was a 52 year old lady who was evaluated for abdominal pain and was found to have a celiac artery aneurysm involving the hepatic and splenic arteries. She was evaluated with computerized tomography and digital subtraction angiography of the abdominal vessels. These confirmed good natural collaterals from the branches of superior mesenteric artery supplying the liver, stomach and spleen. We performed ligation and excision of the aneurysm and ligation and division of hepatic, splenic and left gastric arteries as the aneurysm was extending on to these vessels, without any vascular reconstruction, utilizing the natural collaterals from the superior mesenteric artery.DiscussionLigation of celiac artery aneurysm without revascularization is often done in emergency situations. Excision and revascularization is the treatment of choice to ensure adequate blood supply to liver, spleen and stomach. We could utilize the natural collateral circulation of celiac artery from superior mesenteric artery avoiding a complex procedure of revascularization.ConclusionWe present this because of the rarity of the disease as well as rarity of the technique of not performing vascular reconstruction. We emphasize on the pre-operative and operative evaluation of collateral circulation with conventional angiography and intraoperative Doppler respectively.     

Right gastroepiploic artery occlusion test for resection of recurrent lesion after esophageal reconstruction using a gastric tube

BACKGROUND: Blood supply to a reconstructed gastric tube after esophagectomy is mainly through the right gastroepiploic artery (RGEA); therefore, a recurrent lesion involving the RGEA is thought to be unresectable, or if possible, resectable combined with a whole gastric tube. METHODS: We developed a new method of right gastroepiploic artery occlusion test for evaluation of the blood circulation of a reconstructed gastric tube in a patient who has a recurrent lesion involving the RGEA. A balloon occlusion catheter is inserted into the RGEA through the celiac trunk through a 7 Fr angiographic catheter, and the balloon is inflated. Celiac angiography and color Doppler endoscopic ultrasonography can evaluate intragastric blood flow from the right gastric artery during occlusion of the RGEA. RESULTS: We present a case of successful resection of celiac lymph node metastasis invading the RGEA and the celiac trunk after esophageal reconstruction using a gastric tube. CONCLUSIONS: When ligation of the right gastroepiploic artery is needed, the test is safe and simple to perform; and findings can be reliably evaluated by angiography and color Doppler endoscopic ultrasonography.     

Concurrent treatment of acute pancreatitis and multiple visceral artery aneurysms using endovascular techniques

Multiple aneurysms involving the celiac axis are extremely rare. Celiac artery aneurysms account for only 4% of all visceral aneurysms with 40% having concomitant aneurysms such as gastroduodenal artery (GDA) aneurysms. Development of a GDA aneurysm is associated with pancreatitis. If a GDA aneurysm ruptures, traditional repair is through open surgical techniques with significant morbidity and mortality as up to 50% occur in the setting of chronic pancreatitis. However, a ruptured GDA aneurysm causing pancreatitis has not been described previously. We report a case of successful endovascular treatment of a ruptured GDA aneurysm and concomitant celiac artery aneurysm leading to the resolution of acute pancreatitis.     

Arterial Reconstruction during Pancreatoduodenectomy in Patients with Celiac Axis Stenosis—Utility of Doppler Ultrasonography

Celiac axis stenosis is found at an incidence of 2%–24% in the general population. During pancreatoduodenectomy in patients with celiac axis stenosis, division of the gastroduodenal artery from the common hepatic artery may cause acute ischemia of the upper abdominal organs, such as the liver, stomach, or spleen. Under these circumstances, the clinical indications of arterial reconstruction remain controversial. Between 1994 and 2003, seven patients with celiac axis stenosis (n = 4) or occlusion (n = 3) underwent pancreatoduodenectomy at our hospital. Arterial reconstruction, including division of the median arcuate ligament, was conducted in two patients; the replaced right hepatic artery was preserved in one patient, and no vascular refinement was undertaken in the remaining four of the seven patients. In two of the four patients without arterial reconstruction or preservation, the serum levels of liver enzymes were markedly elevated (> 800 IU/l) on postoperative day 1, and these patients subsequently developed liver abscesses. Two patients who underwent arterial reconstruction and three patients who showed no decrease in intrahepatic arterial flow under Doppler ultrasonography after clamping of the gastroduodenal artery developed no ischemic complications. Although our experience is limited, when intraoperative Doppler ultrasonography indicates a decrease in the hepatic arterial signals, we believe that reconstruction of the hepatic artery will be necessary to minimize ischemic complications in the liver in patients with celiac axis stenosis.     

Emergency Celiac Revascularization for Supramesocolic Ischemia During Pancreaticoduodenectomy: Report of a Case

Occlusive atherosclerotic disease of the celiac artery may be diagnosed late during pancreatic resection, inducing a sudden ischemic threat to the liver, stomach, pancreas, and new anastomoses. Failure to identify and correct the insufficient supramesocolic flow can result in serious morbidity. We report the case of a 64-year-old man in whom sudden and unexpected visceral ischemia occurred while Whipples procedure was being performed to resect a cephalopancreatic mass. We diagnosed occlusion of the celiac trunk and achieved celiac revascularization by performing an end-to-side transposition of the celiac artery onto the superior mesenteric artery, which had been dissected during the lymphadenectomy. We describe this technique as an alternative treatment for acute supramesocolic ischemia caused by celiac axis occlusion. It is important that surgeons performing pancreatic surgery are aware of the possibility of this complication because the test occlusion of the gastroduodenal artery, which must always precede its ligation, can be negative.     

腹腔干动脉瘤九例的诊断与治疗

目的 探讨腹腔干动脉瘤的诊断与治疗方法。方法 回顾总结9例腹腔干动脉瘤的诊治情况。结果 本组腹腔干动脉瘤9例,位于起始部2例。主干2例,分叉处5例,术前经CTY下实5例,行磁共振造影（MRA）检查证实2例,数字减影动脉造影（DSA）证实5例,均予手术治疗,其中肝动脉重建例,肝动脉及脾动脉结扎、脾切除2例,腹腔干重建4例,本组围手术期无死亡。结论 腹腔干动脉诊断一旦明确,应尽早手术治疗,行腹腔干或肝动脉重建术是最佳的手术方式。