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目的荟萃分析胃结肠静脉干的组成形式、出现概率及其属支构成比例,强调其在临床手术尤其是腹腔镜扩大右半结肠癌D3根治术中的意义。方法计算机检索中国生物医学文献数据库(CBMdisc)、维普中文科技期刊数据库(VIP)、中国期刊全文数据库(CNKI)、万方数据库(WF)、PubMed和EMbase,辅以手工检索,收集统计描述胃结肠干及肠系膜上静脉解剖学研究的文献,按照纳入标准由两名研究者独立筛选试验并提取资料,按新的分类方法统计胃结肠静脉干的组成形式。结果胃结肠静脉干的总出现率为89.1%。胃结肠干、胃胰干、胃胰结肠干的出现率分别为24.8%、16.8%和52.6%。胃结肠干的主要组成形式是右结肠静脉和胃网膜右静脉两支合干。在胃胰干的胰十二指肠前静脉属支中,胰十二指肠上前静脉比胰十二指肠下前静脉更常见。胃胰结肠干的出现率最高,其属支构成复杂,以右结肠静脉、胃网膜右静脉和胰十二指肠前静脉三支合干的构成形式为主。胃结肠静脉干平均外径为5.0(2～10)mm,平均长度为14.0(2～47)mm。结论绝大多数人体中存在胃结肠静脉干,按照器官来源和临床应用将其分为三类,胃胰结肠干是最常见的一类。牢固掌握胃结肠静脉干的解剖学分布对临床手术尤其是腹腔镜扩大右半结肠切除术有重要意义。     

A Nondraining Saphenous System Is a Factor of Poor Prognosis for Long-Term Results in Surgery of Great Saphenous Vein Recurrences

OBJECTIVE: The objective was to examine the evolution of superficial venous disease after the suppression of every principal or accessory saphenous trunk. METHODS: To achieve this aim, the long-term results of complete ablation of saphenous trunks and varicose veins during redo surgery for recurrent great saphenous veins have been assessed. Of 170 extremities (137 patients), 4.9 years of follow-up data based on physical and ultrasound examinations were obtained for 119 extremities (100 patients). RESULTS: No varicose veins could be observed for 27.7% of extremities. For 45.3% diffuse varicose veins without reflux between the deep and superficial system could be observed. For 26.8% varicose veins and a new reflux had developed between the deep and superficial venous system. After 5 years, recurrent varicose veins were significantly associated, before operation, with the absence of insufficient residual saphenous trunk and with the presence of diffuse varicose veins (p=0.015) and, during redo surgery, with a higher number of phlebectomy incisions (p=0.02). CONCLUSIONS: The absence of superficial venous drainage (complete removal of varicose veins and saphenous trunk) leads to appearance of rerecurrences in the surgery of great saphenous vein recurrences, 72.3% of the cases show still new varices at the 5-year follow-up. This poor prognosis probably suggests the presence of a nondraining superficial venous system.     

Segmental pancreatic autotransplantation in the pig

The pig has been considered unsuitable for experimental pancreatic transplantation. In order to develop a model for segmental transplantation, the vascular anatomy was studied in 41 pigs. No variation in venous drainage of the pancrease was found. In contrast, 3 variations of arterial supply were noted. In 29 of the pigs (71% [95% confidence limits 64-84]), 1 main pancreatic artery to the body and tail of pancreas arose from the splenic artery about 1-2 cm from its origin from the coeliac trunk (type 1). In 6 pigs (14.5%, 6.5-29.2), 1 main pancreatic artery emerged from the splenic artery very close to its origin from coeliac trunk (type 2). In 6 pigs (14.5%, 6.5-29.2), the only pancreatic artery supplying the body and tail of pancreas came from the common hepatic artery (type 3). Taking the vascular anatomy into account, 37 pigs were totally pancreatectomized and autotransplanted segmentally. The graft consisted of the body and tail and corresponded to approximately 60% of the entire gland. The pancreatic duct was occluded with neoprene. The left kidney was removed in all animals. In 19 of the grafts, the venous drainage was to the portal vein. In the remaining 18, the renal vessels were used for vascular anastomosis to the graft. The success rate was 68.42% and 72.22%, respectively. The median follow-up was 9 months (3-15). All transplanted pigs were normoglycemic. It is concluded that the pig is suitable for experimental pancreatic autotransplantation studies if the vascular variations are adequately dealt with.     

Anatomic study of the superior right colic vein: its relevance to pancreatic and colonic surgery

BACKGROUND: This study was designed to describe the precise anatomic venous tributaries of the superior mesenteric vein with special emphasis on the superior right colic vein (SRCV), which is seldom mentioned in the literature. METHODS: Nine adult cadavers were dissected to define the venous tributaries of the superior mesenteric vein. The SRCV, middle colic vein, and right colic vein (RCV) were defined as those that drained from the marginal vein of the right flexure of the colon, the transverse colon, and the ascending colon, respectively. RESULTS: The SRCV was observed to drain from the right flexure of the colon to the confluence of the right gastroepiploic and superior pancreaticoduodenal veins and present the gastrocolic trunk of Henle (GTH) in 8 of 9 cases. The RCV terminated into the GTH in 4 cases. The SRCV, the RCV, and the middle colic vein formed a confluence and entered into the GTH in 1 case. CONCLUSIONS: The SRCV exits and drains from the right colonic flexure to the GTH in 89% of cases.     

Hypothesis of human penile anatomy, erection hemodynamics and their clinical applications

Aim： To summarize recent advances in human penile anatomy, hemodynamics and their clinical applications. Methods： Using dissecting, light, scanning and transmission electron microscopy the fibroskeleton structure, penile venous vasculature, the relationship of the architecture between the skeletal and smooth muscles, and erection hemodynamics were studied on human cadaveric penises and clinical patients over a period of 10 years. Results： The tunica albuginea of the corpora cavernosa is a bi-layered structure with inner circular and outer longitudinal collagen bundles. Although there is no bone in the human glans, a strong equivalent distal ligament acts as a trunk of the glans penis. A guaranteed method of local anesthesia for penile surgeries and a tunical surgery was developed accordingly. On the venous vasculature it is elucidated that a deep dorsal vein, a couple of cavernosal veins and two pairs of para-arterial veins are located between the Buck＇s fascia and the tunica albuginea. Furthermore, a hemodynamic study suggests that a fully rigid erection may depend upon the drainage veins as well, rather than just the intracavemosal smooth muscle. It is believed that penile venous surgery deserves another look, and that it may be meaningful if thoroughly and carefully performed. Accordingly, a penile venous surgery was developed. Conclusion： Using this new insight into penile anatomy and physiology, exact penile curvature correction, refined penile implants and promising penile venous surgery, as well as a venous patch, for treating Peyronie＇s deformity might be performed under pure local anesthesia on an outpatient basis. （Asian J Androl 2006 Mar; 8： 225-234）     

Drainage patterns of middle lobe vein of right lung: an anatomical study.

OBJECTIVE: The purpose of the present study was to determine the variations in the drainage patterns of middle lobe vein of the right lung. METHODS: Right lungs of 30 formalin fixed cadavers, were dissected carefully to expose the variations in the venous drainage of their middle lobes. After identifying the pulmonary veins for each lobe, middle lobe vein (MLV) drainage patterns were followed to their openings. The diameters of the MLV and its lateral and medial parts were measured with a caliper. The length of the MLV trunk was also evaluated. RESULTS: Five different types of venous drainage patterns were observed. Type-I: Union of medial and lateral parts to form MLV as a trunk and opening of this vein to the right superior pulmonary vein (RSPV) (53.3%). Type-II: Opening of medial and lateral parts to the RSPV separately (16.6%). Type-III: Union of medial and lateral parts to form the MLV trunk and opening of this vein into the left atrium (16.6%). Type-IV: Opening of medial and lateral parts into the left atrium separately (10%). Type-V: Union of medial and lateral parts to form MLV trunk and opening of this vein to the right inferior pulmonary vein (3.3%). CONCLUSION: The venous drainage patterns of right middle lobe reveals great number of variations. Knowing the frequency of different types of drainage patterns classified in this study is extremely important for the surgeons performing pulmonary surgery, atrial fibrillation and imaging techniques.     

Living donor liver transplantation for the patients with portal vein thrombosis: use of an interpositional venous graft passed posteriorly to the pancreatic parenchyma without using jump graft

Background

It is difficult to reconstruct the portal vein (PV) using a long interpositional venous graft in living donor liver transplant (LDLT) patients with portal vein thrombosis (PVT), which involves the confluence of the superior mesenteric vein (SMV) and splenic vein (SV). We successfully performed LDLT for three patients with PVT using an interpositional vascular conduit passing posterior to the pancreas without a jump graft.

Methods

Three of 130 patients who underwent LDLT in our hospital between March 2002 and June 2011 required this technique. After indentifying the location of the SMV, SV and gastrocolic trunk, we ligated and cut the posterior superior pancreaticoduodenal vein and other short branches from the PV. The PV was drawn inferiorly to the pancreas and transected at the confluence of SMV and SV. The external iliac vein or internal jugular vein was sacrificed as a graft for anastomosis to the cut end of the SMV using 6-0 polypropylene running sutures. Then the venous graft was drawn superiorly to the pancreas by passing it posterior to the pancreas parenchyma for anastomosis to the liver graft PV. The interpositional vein was placed posterior to the pancreas where the PV used to be.

Results

All three patients displayed favorable postoperative courses with the Doppler ultrasound demonstrating good portal flow perioperatively. The postoperative portogram demonstrated patency of the vascular graft.

Conclusion

This method is easy and helpful to treat portal vein thrombosis, by providing the shortest route between the PV of the donor and the SMV of the recipient.     

Surgical anatomy of the pancreas for limited resection

The fusion fascia of the head of the pancreas is called the "fusion fascia of Treitz" and that of the body and tail of the pancreas is termed the "fusion fascia of Toldt". The fusion fascia is histologically composed of a loose connective tissue membrane. All of the important pancreaticoduodenal arcades of arteries and veins are situated on this membrane, i.e., between this membrane and the pancreatic parenchyma. The topography of the head of the pancreas shows that, after departing from the gastroducodenal artery, the anterior superior pancreaticoduodenal artery runs toward a point 1.5 cm below the papilla of Vater, then turns to the posterior aspect of the pancreas to join the anterior inferior pancreaticoduodenal artery. For preserving the duodenum, the artery toward the papilla is very important. The artery toward the papilla of Vater runs along the right side of the common bile duct after departing from the posterior superior pancreaticoduodenal artery. The gastrocolic trunk of Henle has been reported to be found in about 60% of individuals. It is possible that the gastroepiploic vein and anterior superior pancreaticoduodenal vein (ASPDV) can be divided at pancreaticoduodenectomy, with preservation of the superior right colic vein, if this area is free of carcinoma. The ASPDV and anterior inferior pancreaticoduodenal vein form an arcade on the anterior surface of the pancreas. However, arcade formation was not found between the posterior superior pancreaticoduodenal vein and posterior inferior pancreaticoduodenal vein in many of the individuals examined. The vein joined by the inferior mesenteric vein was also investigated. Received: July 3, 2000 / Accepted: August 8, 2000     

Is the absence of Right Hepatic Vein opening into Inferior Vena Cava a contraindication for right lobe liver donation in Living Donor Liver Transplantation? Common hepatic venous trunk—A rare hepatic vein anomaly: A case report and review

IntroductionIn majority of the living liver donors, the left and the middle hepatic veins form a common trunk and the right hepatic vein drains by a separate trunk into the IVC forming two ostial openings. Presentation of Case: This report presents a rare challenge to the operating surgeon in which the three major hepatic veins form a common trunk and drain into the IVC through a single ostial opening. It was detected preoperatively by the routine donor imaging studies.DiscussionTo our knowledge, this type of rare venous anatomy in the setting of living donor liver transplantation has not been described in the literature before. A few studies have described similar anatomy in the cadaveric liver specimen of some particular ethnicity.ConclusionThis type of a rare anomaly poses challenge to the donor operation and requires a sound expertise on the knowledge of hepatic venous anatomy to perform the donor hepatectomy with the appropriate maneuvering.     

Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography

Background

It is important to be aware of mesenteric venous variants to perform peripancreatic surgery. We investigated the usefulness of 3-dimensional (3-D) portography.

Methods

Vessels were reconstructed using computer software in 102 patients undergoing multidetector-row computed tomography (MDCT) scheduled for gastrointestinal or hepatobiliary-pancreatic surgery.

Results

The superior mesenteric vein (SMV) was composed of single and double trunks around the splenoportal confluence in 78 and 24 patients, respectively. The inferior mesenteric vein joined the splenic vein (68.5%), SMV (18.5%), and splenoportal confluence (7.6%). The left gastric vein joined the splenic vein (46.3%), portal vein (39.0%), and splenoportal confluence (14.7%). Seventy-nine patients showed a gastrocolic trunk, mostly composed of the right gastroepiploic vein and veins from the colonic hepatic flexure. Intraoperative findings were identical to 3-D diagnosis in 68 gastrectomized and 9 pancreatectomized patients.

Conclusion

Although mesenteric venous tributaries are complex, 3-D portography is helpful for surgeons to safely perform peripancreatic surgery.     

A solution to organ shortage: vascular reconstructions for pancreas transplantation

Multiorgan harvesting (MOH) accounts for approximately 40% of all organ procurements in Poland. Simultaneous procurement of the pancreas and liver necessitates division of the vessels supplying both organs. Therefore, reconstruction of the pancreas vasculature is mandatory for proper function of the transplanted organ. The aim of this study was to present various methods of vascular reconstruction to prepare the pancreas for transplantation. Between January 1999 and April 2005, among 42 whole pancreas transplantations, 35 came from MOH necessitating arterial reconstruction. In 32 cases, the splenic artery (SA) and superior mesenteric artery (SMA) were sewn into a single trunk using the common iliac arterial bifurcation. Occasionally, the iliac Y-graft was unsuitable for vascular reconstruction due to atherosclerosis or iatrogenic injury. Therefore, the SA was anastomosed to the side of the SMA in two cases. In one case we utilized the brachiocephalic trunk bifurcation. Portal vein elongation employed an external iliac vein procured from the donor in all 35 cases. Good perfusion was achieved in all transplanted pancreata. During the early follow-up period, two venous and one arterial thromboses were noted. No negative effects of pancreatic vessel reconstruction were observed in postoperative graft function. Reconstruction of the pancreas vasculature did not affect the long-term function of the allograft while significantly increasing the available donor organ pool.     

胰腺癌十二指肠切除术

目的采用kocher手法，分离十二指肠降部与下腔静脉之间间隙；分离胃结肠韧带，不保留大网膜，进入小网膜囊，小网膜囊后壁下面即为胰腺前缘；分离横结肠系膜前叶及胰腺背膜，于胰腺下缘找到肠系膜上静脉，分离钳顺着肠系膜上静脉在胰腺后侧打洞分离，直至门静脉；解剖肝十二指肠韧带，游离肝门三管；分别于胃大弯和胃小弯游离韧带，于固定处用直线切割闭合器切断胃；于预定切除处断胰；仔细分离钩突与SMV之间的小静脉、以及可能出现的胃结肠干、胃网膜右静脉等血管；施行胰肠吻合、胆肠吻合、胃肠吻合。     

Microsurgical anatomy of the insula and the sylvian fissure

OBJECT: The purpose of this study was to define the topographic anatomy, arterial supply, and venous drainage of the insula and sylvian fissure. METHODS: The neural, arterial, and venous anatomy of the insula and sylvian fissure were examined in 43 cerebral hemispheres. CONCLUSIONS: The majority of gyri and sulci of the frontoparietal and temporal opercula had a constant relationship to the insular gyri and sulci and provided landmarks for approaching different parts of the insula. The most lateral lenticulostriate artery, an important landmark in insular surgery, arose 14.6 mm from the apex of the insula and penetrated the anterior perforated substance 15.3 mm medial to the limen insulae. The superior trunk of the middle cerebral artery (MCA) and its branches supplied the anterior, middle, and posterior short gyri; the anterior limiting sulcus; the short sulci; and the insular apex. The inferior trunk supplied the posterior long gyrus, inferior limiting sulcus, and limen area in most hemispheres. Both of these trunks frequently contributed to the supply of the central insular sulcus and the anterior long gyrus. The areas of insular supply of the superior and inferior trunks did not overlap. The most constant insular area of supply by the cortical MCA branches was from the prefrontal and precentral arteries that supplied the anterior and middle short gyri, respectively. The largest insular perforating arteries usually arose from the central and angular arteries and most commonly entered the posterior half of the central insular sulcus and posterior long gyrus. Insular veins drained predominantly to the deep middle cerebral vein, although frequent connections to the superficial venous system were found. Of all the insular veins, the precentral insular vein was the one that most commonly connected to the superficial sylvian vein.     

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。     

A surgical case of lung cancer in a patient with the left superior and inferior pulmonary veins forming a common trunk.

The anatomical abnormalities of the pulmonary veins may have a serious impact on complications that may arise during pulmonary lobectomy. We present a surgical case of left lung cancer in a patient, who was a 69-year-old male, with the left superior and inferior pulmonary veins forming a common trunk outside the pericardium. In this present case, because of extensive adhesions, incomplete lobulation, and tumor infiltration of the main pulmonary artery, we could not identity the common trunk with certainty before excising the left upper lobe. Although this patient was fortunately discharged without complications, there was no choice but to perform pneumonectomy because of the interruption of the inferior pulmonary vein. Retrospectively, the preoperative CT films showed the anatomical anomalies involving the pulmonary veins. However, since the length of the common trunk outside the pericardium was short and the inferior pulmonary vein was thinner than usual and its venous distribution conformed to a normal structure, the anatomy appeared normal. In excising the pulmonary lobe, it is mandatory to ascertain the distribution of the vascular system prior to surgery.     

Predictors of hepatic venous trunk invasion and prognostic factors in patients with hepatocellular carcinomas that had come into contact with the trunk of major hepatic veins

PURPOSE: In this study, we tried to identify the preoperative predictors of hepatic venous trunk invasion and the prognostic factors in patients with hepatocellular carcinoma (HCC) that had come into contact with the trunk of a major hepatic vein over a distance of 1.0 cm or more. METHODS: Forty patients who had such HCCs resected were entered into this study and predictors of hepatic venous trunk invasion and prognostic factors were evaluated by univariate and multivariate analyses. RESULTS AND CONCLUSIONS: A combined resection of the HCC and the venous trunk was performed in 29 patients. Hepatic venous trunk invasion was observed in 12 patients, including 2 with inferior vena cava tumor thrombus. A stepwise logistic regression analysis indicated that tumors larger than or equal to 7 cm in diameter and tumors showing a poorly differentiated histological grade were independent predictors of hepatic venous trunk invasion. The survival of patients without venous trunk invasion was significantly better than that for patients with venous trunk invasion (P = 0.048). A univariate analysis revealed that Child-Pugh classification B (P = 0.002), a high des-gamma-carboxy prothrombin concentration (> or =400 mAU/ml, P = 0.023), a large HCC (> or =5.0 cm in diameter, P = 0.002), the presence of portal vein invasion (P < 0.001), the presence of venous trunk invasion (P = 0.048), the presence of intrahepatic metastasis (P < 0.001), and poorly differentiated HCC (P = 0.006) correlated with a worse overall survival after hepatic resection. In a multivariate analysis, however, only the presence of intrahepatic metastasis (P = 0.037, relative risk 8.25) was an independent predictor of poor overall survival. CONCLUSIONS: Large tumors (> or =7 cm in diameter) and poorly differentiated HCCs were more likely to be associated with hepatic venous trunk invasion and intrahepatic metastasis was an independent prognostic factor in patients with HCC that had come into contact with the trunk of a major hepatic vein.     

腹腔镜后入路胰十二指肠切除术的应用解剖学研究

【摘要】〓目的〓探讨腹腔镜后入路胰十二指肠切除术(paLPD)切除过程中相关血管和外科平面的局部解剖学特点。方法〓通过对我院25例接受paLPD患者手术过程的回顾以及15具尸体标本进行解剖学观察,总结有助于在腹腔镜视野下对paLPD切除过程中相关血管进行准确定位的解剖标志和显露方法,并寻找安全的外科平面。结果〓胰十二指肠后方与肾前筋膜的无血管间隙、胰颈后方与肠系膜上静脉前面之间的无血管间隙、胰腺钩突与肠系膜血管之间、腹腔干和肝十二指肠韧带区域是paLPD切除过程中重要的四个外科平面,手术相关血管全部涵盖在这四个外科平面内。paLPD中循正确的外科平面进行操作,不仅可以减少血管损伤的几率,提高手术效率,也更加符合肿瘤“整块切除”的原则。 结论〓paLPD是LPD中安全可行的一种手术入路,掌握腹腔镜视野下相关血管的解剖学特点,依正确的外科平面进行操作,可提高手术的安全性和效率。     

Surgical experience with 50 transplantations of neoprene-occluded segmental pancreas. Technique and postoperative complications

Since the beginning of our pancreas transplantation program in November, 1987, 50 patients have received a segmental intraperitoneal neoprene-occluded pancreas graft and a contralateral kidney graft. The aim of this study is to present our surgical technique and the postoperative complications encountered. Operation in the donor: subtotal pancreatectomy is performed. A venous patch is preserved at the end of the splenic vein. The splenic artery is removed with a patch taken from the end of the celiac trunk and the origin of the common hepatic artery, even in case of right (n = 1) or left (n = 4) hepatic artery. The canal is injected with neoprene (2 to 3 cc) ex vivo and the pancreatic parenchyma is recut after stappling. Operation in the recipient: the transplant is inserted in an extraperitoneal location, between the bladder and the pubic arch, then anastomosed to the external iliac vessels. Results: All pancreas grafts functioned immediately. All patients but 3 are alive at present. Seven pancreas transplants were lost postoperatively due to venous thrombosis (n = 3), hemorrhage (n = 3) and death at D27 (n = 1). Many patients developed peripancreatic fluid collections and/or fistulae (the most frequent complication, probably due to the extraperitoneal site of transplantation). The actuarial survival rate of the patients, kidneys and pancreas after 2 years is 96%, 92% and 80%, respectively.     

腹腔镜下右半结肠血管解剖及血管并发症分析

目的探讨腹腔镜下右半结肠的血管解剖关系及血管相关并发症。方法收集2008年9月至2011年10月间南方医科大学南方医院普通外科实施的55例腹腔镜扩大右半结肠癌D3根治术的手术录像．研究右半结肠血管的解剖关系及术中明确出血的血管。结果55例患者均存在肠系膜上动、静脉和回结肠动脉及中结肠动脉。右结肠动脉出现率为45．5％（25／55）,胃结肠静脉干的出现率为74．5％（41／55）。腹腔镜扩大右半结肠癌根治术中,血管出血的总概率为43．6％（24／55）,胰头前区域血管（包括胃网膜右动脉、胃结肠静脉干及其属支）术中出血概率（16．4％,9／55）略高于中结肠血管（14．5％．8／55）,术中出现血管并发症可明显延长术中淋巴结清扫时间（P=0．014）和腹腔镜手术时间（P=0．042）。亚组分析显示,胰头前区域血管的出血不会明显延长术中淋巴结清扫和手术时间（P〉0．05）：而中结肠血管出血可明显延长术中淋巴结清扫时间（P=0．011）和手术时间（P=0．004）。结论腹腔镜扩大右半结肠癌D3根治术中需处理的血管复杂多变,术中血管出血概率较高。清楚了解腹腔镜下右半结肠血管的解剖关系,有利于降低术中血管并发症的发生率。