十二指肠乳头肿瘤局部切除术应用解剖

目的：为十二指肠乳头部肿瘤局部切除术提供解剖学资料。方法：50例正常成人腹部标本，解剖观测胆总管、胰管、肝胰壶腹和乳头区长度、宽度，胆总管与胰管的夹角，肝胰壶腹区的血管分布，十二指肠大乳头位置、乳头小孔开口位置、胆胰管开口形式等。结果：肝胰壶腹和十二指肠乳头区的营养动脉平均为2．2支，均来源于胰十二指肠上动脉、下动脉，其中肝胰壶腹和十二指肠乳头区9—12点钟处的营养动脉出现率为45．9％（50支）。胆总管、胰管、壶腹末端的长度分别为（32．1±8．7）mm、（9．9±4．1）mm、（12．6±2．8）mm；宽度分别为（7．3±2．1）mm、（3．2±0．7mm）、（7．3±1．2）mm。胆总管和胰管之间的夹角平均为35．6°。十二指肠大乳头位于十二指肠降部上1／3段占8．45％±4．39％，中1／3段占72．33％±6．72％，下1／3段占19．22％±4．12％；乳头小孔开口于十二指肠纵襞占74．3％±6．68％。有十二指肠小乳头占41．43％±3．65％。胆胰管开口呈V型占37．1％±7．43％，Y型占62．9％±6．32％。结论：本实验结果为临床在十二指肠乳头部肿瘤切除过程中选择切开部位和切开深度等提供了解剖学依据，对防止术后并发症具有重要意义。     

十二指肠大乳头血供的临床解剖学研究

目的　为内窥镜下十二指肠乳头括约肌切开术( EST) 与内镜乳头气囊扩张术 (EPBD)取结石术提供形态学依据。 方法　(1)20例乳胶动脉血管灌注胰腺十二指肠标本,解剖观测十二指肠大乳头血供的来源、数量,营养血管起始处直径、至Vater壶腹和十二指肠大乳头开口的距离。前、后弓最凸处与十二指肠内缘、肝胰壶腹、十二指肠大乳头的距离。(2)按胰十二指肠正常解剖学位置摆放,以十二指肠大乳头的开口为圆心,十二指肠大乳头背面纵轴为12~6点轴,横轴为9~3点轴,顺时针依次定点,观察动脉分布特点。 结果　(1) 胰十二指肠前、后动脉弓各发出2支营养血管至十二指肠大乳头。前弓2支血管起始处直径分别为（1.3±0.1、1.0±0.2）mm,至Vater壶腹和十二指肠大乳头开口的距离分别为（5.7±0.6、6.0±0.4）mm、（16±0.9、16±1.5）mm。后弓2支血管起始处直径分别为（0.62±0.02、0.98±0.06）mm,至Vater壶腹和十二指肠大乳头开口的距离分别为（20±1.5、16.4±0.4）mm、（25±1.2、19.2±0.6）mm。前、后弓最凸处与十二指肠内缘、肝胰壶腹的距离分别为（4.05±0.1、3.1±0.15）mm、（10.5±1.5、13.2±1.6）mm。(2)十二指肠大乳头前壁第1支血管位于9~10点钟方位,第2支位于2~3点钟方位;后壁第1支动脉血管位于8~9点钟方位,第2支位于4~5点钟方位;8~10点钟方位血管最集中,2~5点钟方位血管次之,11~1、6~7点钟方位血管供应最少。 结论　临床EST Oddi括约肌切开和EPBD取结石时,易损伤十二指肠大乳头血管,需小心保护。EST可在11~1或6~7点钟方位行乳头切开。     

十二指肠的某些资料

对50例成年尸体的十二指肠进行了观测。十二指肠平均长209mm,外径在29.2—34.7mm之间。十二指肠乳头、副乳头和十二指肠纵襞的出现率分别为100％,48％和96％。十二指肠乳头与幽门的平均距85.5mm,副乳头与乳头的垂直间距平均16.5mm。十二指肠乳头与纵襞的关系,除已有的记载外,乳头还可位于纵襞的左侧或右侧。十二指肠乳头上方纵行隆起的基质有26％是胆总管,而在更多的标本中无胆管样结构。     

与EST有关的胰胆管及十二指肠大乳头应用解剖

在１０具成尸，１３具童尸（２－１０岁）标本上对胰胆管及十二指肠大乳头与ＥＳＴ有关的应用解剖进行了研究。十二指肠纵襞长：成人为２４．０±６．８８ｍｍ，２－１０岁１６．８±４．２ｍｍ；大乳开口上缘至纵襞上端长；成人为１１．１±２．２ｍｍ，２－１０岁７．７±１．７ｍｍ；胆总管第四段长：成人为１６．６±１．６ｍｍ，６－１０岁１３．０±２．２ｍｍ；十二指肠纵襞长轴与胆总管（左上）夹角为４０．１°±１１．８°     

内窥镜十二指肠乳头切开术的应用解剖

目的：为临床经内窥镜十二指肠乳头括约肌切开术（Ｅｎｄｏｓｃｏｐｉｃｓｐｈｉｎｃｔｅｒｏｔｏｍｙ,ＥＳＴ）提供形态学的依据。方法：３０例正常成人腹部标本,解剖观测胆总管、胰管、肝胰壶腹和乳头区长度、宽度,胆总管与胰管的夹角,肝胰壶腹区的血管分布。结果：肝胰壶腹及十二指肠乳头区的营养动脉平均为２．１支,均来源于胰十二指肠上动脉、胰十二指肠下动脉,其中肝胰壶腹区及十二指肠乳头区９～１２点钟处营养动脉的出现率为４６．１％（２９支）。测量胆总管、胰管、壶腹末端的长度分别为３２．１±８．９ｍｍ、９．９±３．９ｍｍ、１２．８±２．９ｍｍ;宽度分别为７．２±２．２ｍｍ、３．１±０．６ｍｍ、７．１±１．４ｍｍ。胆总管和胰管间的夹角７０％为２０°至４５°,平均３５．４°。结论：本实验的结果为临床在ＥＳＴ中选择切开部位和切开的深度等提供了理论依据,对防止术后并发症具有重要的临床意义。     

十二指肠内面结构的临床应用解剖研究

在100例（男48、女52）常规防腐的成人尸体上，观测了十二指肠内面结构的形态特点，结果是：①十二指肠球部粘膜无皱襞占40％、呈环状襞仅10％。②十二指肠大乳头位于十二旨肠降段内侧壁（按九个等分区）中央区占55％、后中区占11％。向上至幽门距离平均为7.3±1.72cm。③大乳头上方有头巾样皱襞占65％，下方有乳头下系带占63％，两项同时缺乏占23％。④小乳头出现率为33％（男13、女20），多数位于大乳头前上方，距大乳头为平均1.78±0.61cm。⑤十二指肠憩室出现率为10％。就上述发现结合临床应用进行了讨论。     

Oddi括约肌形态特征及其意义

目的研究Oddi括约肌(sphincterofOddi,SO)形态结构特点,为SO切开术及其病理生理意义提供形态学基础.方法对53例正常Vater区标本进行巨微解剖,免疫组化,Masson染色和体视学技术综合性观测.结果①SO可分为固有肌和十二指肠延续肌纤维两类,前者有内纵、外环两层;②SO与十二指肠环肌间有肌束联系;③自十二指肠大乳头尖至胆总管(commonbileduct,CBD)括约肌上界距离(15.92±4.97)mm;SO长(13.99±3.84)mm;从大乳头尖至CBD穿十二指肠肌层处间距(11.34±3.07)mm;SO最厚处(0.83±0.18)mm.结论SO形态特点可支持SO生理活动特征;为临床操作ERCP、SO压力检测和Oddi括约肌切开术等,提供解剖学资料.     

十二指肠大乳头异位一例

成年女尸,其十二指肠的形态、位置均属正常。解剖发现胰管在胰头部走行与胰头长轴并非平行,而是距胰头右缘30毫米处以135度角走向右下,达十二指肠水平部后上方,在距肠壁5毫米处与沿胰头后方垂直下降的胆总管又以25度夹角合成肝胰壶腹,穿十二指肠水平部后上壁,开口于十二指肠大乳头。大乳头的位置,距十二指肠降部与水平部所形成的夹角处12毫米,在肠系膜上血管右侧9毫米。未发现副胰管及十二指肠小乳头。其中胰头部的胰管直径6毫米,胆总管未端直径5毫米,长9厘米,肝胰壶腹直径7毫     

十二指肠小乳头的应用解剖

目的：为内镜下副胰管插管、十二指肠小乳头切开等提供解剖学基础。方法：在30例成人尸体上对十二指肠小乳头的形态、位置、开口以及与大乳头之间的关系进行解剖观察。结果：十二指肠小乳头的出现率为70%。可见明显开口的占55%。小乳头形态有半球形、圆锥形、半颗粒形、扁平形和不规则形。小乳头距离幽门、十二指肠第一环、大乳头的距离分别为(58．69±15．74)mm,(23．21±8．82)mm和(22．75±6．81)mm;大、小乳头开口连线与十二指肠纵襞纵轴线的夹角为(20．80±9．40)°。结论：十二指肠小乳头的出现率与副胰管的发育程度相关,本文结果为内镜下行十二指肠小乳头插管和小乳头切开术提供了参考。     

十二指肠和胰胆管汇合的应用解剖

作者在12具成尸、13具童尸标本上对十二指肠和胰胆管汇合进行了解剖观测。25例十二指肠上曲为83.4°±11.5°;十二指肠降部长:成人为68.2±12.6mm,2～10岁为41.8±9.1mm;24例胰胆共同管长为5.6±1.5mm。胆总管和胰管壁汇合后,被公共管壁分隔伴行,在十二指肠大乳头内两管开口汇合处有“锯齿状瓣膜”。文中探讨了公共管壁和锯齿状瓣膜的功能及临床意义。     

肝管的测量及其临床意义

在90具成人尸体上,测量了肝左管,肝右管及肝总管的长度,直径和有关的角度.肝左管平均长7.5mm,直径7.6mm,与肝总管形成的角度为34.9°;肝右管长9.6mm,直径6.2mm,与肝总管形成的角度为50.2°.结果表明肝左管粗、短而直,肝右管细,长而倾斜.肝管这种解剖形态学上的差异,似与临床上常见华枝睾吸虫病肝左叶肿大较多及肝左管结石较多有关。     

Surgical anatomy of sub-hepatic biliary system

IntroductionThe anatomy of liver and extra-hepatic biliary apparatus has always been the focus of attention among anatomists and surgeons. It has gained greater significance in the recent years in view of technical refinements in the field of cholecystectomy, hepatic surgery and transplantation. Present study emphasizes the normal as well as variations of extra-hepatic biliary apparatus, as most of the published work on the surgical anatomy of the extra-hepatic biliary apparatus refers various ethnic groups variations. Literature on this topic in western U.P. subjects is scanty.MethodA study was conducted on 59 individuals undergoing hepatobiliary surgery after informed consent in the Department of Surgery and on 30 cadavers in the Department of Anatomy, LLRM Medical College Meerut, and Saraswathi Institute of Medical Sciences, Hapur during September 2004 to May 2011.ResultThe study revealed that in all cases, the union of hepatic ducts was extra-hepatic, of which 10% were angular low union and 5% parallel low union. In 95% cases cystic duct had angular union and 4% had parallel type of union with common hepatic duct and in one case cystic duct united with accessory hepatic duct. 16% cases had short cystic duct i.e. 1–2 cm in length. 94% cases show usual relation in hepatoduodenal ligament and in 6% common bile duct was to the left of hepatic artery.DiscussionThe obtained results presented variations regarding certain parameters when compared to previous studies and they represent the ethnic parameters of western UP.     

Anatomical Variations in the Extra Hepatic Biliary Ductal System

The aim of the study was to study the various anatomical variations occurring in the extra hepatic biliary ductal tract. The study material consisted of 40 adult specimens of liver, gallbladder with duodenum collected enmass from the forensic department. Out of the 40 specimens dissected we came across accessory hepatic ducts all arising from the right lobe of liver. These accessory right hepatic ducts drained into the common hepatic duct at different levels. Knowledge of these accessory ducts confirmed by various intra operative cholangiographic procedures is necessary for avoiding any serious complications during surgery. Hence we conclude that this study will be a useful guideline for the operating Surgeons and Radiologist working in that area.     

42例国人胆总管的解剖学调查

本文从临床实际出发，对４２例成人尸体的胆总管及各段进行了解剖调查。调查结果：胆总管长度及各段长度变异均较大，胆总管平均长度为７５．３±１３．３ｍｍ，壁内段平均长度为１６．５±４．０ｍｍ。胆总管在十二指肠降部的后内侧进入十二指肠，并开口于十二指肠大乳头。本文发现胰管与胆总管完全分开行走者仅４例，占９．５％，而胰管汇入胆总管者３８例，占９０．５％，３８例中，胰管大多在左侧与胆总管汇合。在其前后壁汇入者各２例，未见从右侧汇入者。本文通过对ｏｄｄｉ括约肌的观察，提出作Ｏｄｄｉ括约肌切开成形术时，应根据术前检查所见，决定具体切开之长度一般以不超过２５ｍｍ为宜。     

正中切口处理动脉导管的应用解剖学研究

本文从应用解剖学角度,在40具成体尸上对动脉韧带的位置、长度及其两端连结主、肺动脉干的部位和它的重要毗邻关系,动脉韧带的类型进行了观测。为在正中切口处理动脉导管时,如何迅速找出、压迫阻断动脉导管。进行该导管修补术时,在主动脉端或肺动脉端进行切口的部位选择做了讨论。指出有双动脉导管存在的可能性和注意保护动脉导管周围的重要结构的解剖学基础。     

Intraduktale Chemotherapie eines Gallengangskarzinoms mit 5-Fluorouracil

Summary The prognosis of bile duct cancer is still poor. Curative surgical therapy is possible in only 10%–20% of cases. Palliative effects of chemotherapy and radiation are small. Newer palliative techniques like iridium 192 wire radiation or hepatic artery infusion of chemotherapeutic agents seem to be more effective.Another new form of palliative local chemotherapy, intrabiliary application of 5-fluorouracil, is described. A 67-year-old woman with an adenocarcinoma of the left and common hepatic ducts received symptomatic therapy by an external biliaray drainage for 20 months. In the following 3 weeks the amount of drained bile diminished and finally stopped, while icterus occurred. Catheter cholangiography showed a right catheter position, the known obstruction of the common hepatic duct and the left bile duct, and a diffuse right-sided peripheral bile duct occlusion, regarded as multifocal tumor spreading. Intraductal application of 5-fluorouracil via the PTCD tube, 125–375 mg twice a week, effected a rising bile secretion after a few days, to a final volume of 1,000 ml/day. An X-ray control 34 days after start of the therapy showed a nearly complete reopening of the formerly occluded peripheral bile duct system and a filiform reopening of the common hepatic duct with sufficient flowing off into the common bile duct and the duodenum. Certain side effects of this therapy were not noticed. After successful reopening of malignant bile tract occlusion, other palliative therapeutic techniques like internal bile drainage or iridium 192 wire radiation can be applied.

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Abkürzungsvrzeichnis CEA Carcinoembryonales Antigen - ERP Endoskopisch retrograde Pancreaticographie - Gamma-GT Gamma-Glutamyltransferase - GOT Glutamat-Oxalazetat-Transferase - GPT Glutamat-Pyrovat-Transaminase - LDH Lactatdehydrogenase - PTC Percutane transhepatische Cholangiographie - PTCD Percutane transhepatische Cholangiodrainage - TPZ Thromboplastinzeit     

Anomalous pancreatico-biliary ductal union with cystic dilatation of the bile duct

We report, in an adult, an asymptomatic association between cystic dilatation of the bile duct (type IV A in Todani’s classification) and anomalous pancreatico-biliary ductal union (APBD) with stones in a long common channel. In APBD, the connection between the common bile duct and the main pancreatic duct is located outside the duodenal wall and is therefore not under the influence of the sphincter of Boyden. An abnormally long common channel is in excess of 15 mm. Two types of convergence anomalies are defined according to whether the bile duct opens into the main pancreatic duct (BP) or the main pancreatic duct into the bile duct (PB). In APBD, there is probably a reverse pressure gradient between the bile and pancreatic ducts, with regurgitation of pancreatic juice into the bile duct, repeated attacks of cholangitis, stenosis and cystic dilatation. A long common channel is associated with a higher incidence of carcinoma of the gall bladder or the bile duct.     

Submandibular gland with multiple ducts

Summary A morphological peculiarity was observed in the form of a submandibular gland having three ducts. These ducts opened separately into the oral cavity. Only the upper and the largest of these three ducts was in the usual position and had the expected relation to the lingual nerve. Such a condition is to be kept in mind by a surgeon or a radiologist performing sialography. Unless each of the duct in instilled he may miss pathological findings.

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Glande submandibulaire avec des conduits multiples

Résumé Une variation anatomique d'une glande submandibulaire présentant trois conduits excréteurs est rapportée. Les conduits débouchaient séparément dans la cavité orale. Seul le conduit supérieur, le plus important, était en situation normale et avait des rapports anatomiques habituels avec le nerf lingual. Une telle variation doit être connue du chirurgien ou du radiologue qui effectue une sialographie. L'absence d'infection de l'un des conduits multiples peut être à l'origine de la méconnaissance d'un état pathologique.

     

Female adnexal tumour of probable Wolffian origin

The clinical and pathological features of three adnexal tumours of probable Wolffian origin are reported. One case was an incidental finding in a patient who died from ovarian carcinoma; in the other two cases the patients presented with lower abdominal pain. The three tumours were well-circumscribed, solid masses arising in the leaves of the broad ligament and histological examination showed bland epithelial cells forming tubular, solid and microcystic patterns. The immunohistochemical profile of the tumours was similar to that of Wolffian duct remnants. They co-expressed cytokeratin and vimentin and lacked epithelial membrane antigen (EMA) reactivity, in contrast to tumours of Müllerian origin which usually express EMA. The differential diagnosis of female adnexal tumours is discussed.     

Biliary stent replacement cytology

Using fluoroscopic guidance, polyethylene biliary stents are replaced endoscopically or percutaneously when bile duct stenosis recurs. To improve the sensitivity of conventional biliary cytology, we examined cells recovered from removed stents. Biliary stents removed endoscopically from each of 11 patients were rinsed with saline; next, the rinse was centrifuged and the sediment smeared and Papanicolaou stained. Three patients with choledocholithiasis had biliary stent replacement cytology (BSRC) to exclude a neoplastic etiology. Eight patients with clinicoradiologic evidence of hepatobiliary or pancreatic carcinoma had BSRCs performed for pathologic documentation of carcinoma. BSRC from six of eight patients with clinicoradiologically malignant biliary strictures contained malignant cells, predominantly in loose clusters, but also singly (sensitivity 75%, specificity 100%; positive predictive value 75%, negative predictive value 60%). Reparative epithelial atypia was also present in all cases. BSRC from two patients with clinicoradiological evidence of carcinoma of the biliary region and from three with choledocholithiasis contained only bile pigment, leukocytes, and benign epithelial cells. The sampling of cells which have accumulated on, or in biliary stents, improves the sensitivity of biliary cytology. This is most applicable when 1) a patient is inoperable, 2) tissue biopsy is neither feasible nor diagnostic, 3) prior brush, suction, percutaneous, or endoscopic needle aspiration cytology is inconclusive, and 4) permanent metal stent is needed. Diagn. Cytopathol. 61:233–237, 1997. © 1997 Wiley-Liss, Inc.