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。     

Arterial reconstruction of the pancreatic allograft for transplantation

The shortage of organs is particularly acute in whole pancreas transplantation, because the liver and pancreas often share a common arterial supply, making combined procurement of both organs difficult. A previously described technique of simultaneous whole liver and pancreas procurement depended on "classic" hepatic arterial anatomy, which is present just over half the time. We describe herein our experience with three Y-reconstructions of the splenic and superior mesenteric arteries of the pancreatic allograft using donor allograft internal and external iliac arteries. In situ Doppler ultrasound examination of the pancreatic allograft after surgery demonstrated a patent reconstruction without evidence of stenosis or turbulent flow patterns. We believe this reconstruction is a safe, alternative method to provide arterial flow to the whole donor pancreas.     

Characteristics of anastomoses between the celiac trunk and the superior mesenteric artery

Duodenum and pancreas are two deep abdominal viscerae with multiple arterial sources and complex vascular relations, that impose peculiar surgical techniques. The dissection of 120 corpses and the examination of selective angiographies revealed the variants of the anastomoses between the superior pancreaticoduodenal arteries (that receive blood from the celiac trunk) and the inferior pancreaticoduodenal arteries (belonging to the collateral subsystem of the superior mesenteric artery). The pancreaticoduodenal arches are the main anastomosis around the pancreatic head, and supply the duodeno-pancreatic complex. During this study I found the absence of this anastomosis of the antero-inferior duodenopancreatic arch 5 cases (4.16%), and the lack of anastomosis of the postero-superior duodenopancreatic arch in 11 cases (9.16%). In these situations, the superior and the inferior duodenopancreatic arteries give off the vasa recta and the pancreatic branches, as normally. I found different variants of accessory duodenopancreatic arches, and I analyzed their impact on the surgical techniques on duodenum and pancreas. This study pinpoints the importance of the anastomotic subsystem in the arterial supply of the duodeno-pancreatic complex, reveals the necessity of the preoperative angiographic exam in order to choose the most opportune surgical technique.     

Arterial blood supply of horseshoe kidneys with special reference to percutaneous lithotripsy

The arterial blood supply of six horseshoe kidneys has been examined in respect to percutaneous lithotripsy, i.e. puncture of the renal pelvis in its dorsolateral aspect including nephroscopic extraction of renal calculi. The blood supply of horseshoe kidneys is presupposed by evolution. Besides the definitive renal arteries there are accessory arteries which may be regarded as persistent mesonephric arteries. We distinguish between proper accessory arteries entering the horseshoe kidney at its hilum and aberrant accessory arteries which reach either the upper extremities or the zone of fusion. The latter derive form the abdominal aorta or the bifurcation respectively, the common iliac arteries, the left renal artery, the inferior mesenteric artery or the median sacral artery. Despite the variability of the renal arteries we didn't find any larger vessels in the area of puncture. The anatomical investigations showed that there is no increased risk of hemorrhage performing percutaneous lithotripsy on horseshoe kidneys. During the last two years 8 patients with horseshoe kidneys have been operated because of relapsing calculi using this method, showing no intra- or postoperative complications.     

Vascularity of the lateral calcaneal flap: a cadaveric injection study

OBJECTIVE: To describe the arterial blood supply of the subcutaneous tissues of the lateral hindfoot and define the relationships between these arteries and the lateral extensile incision used for open reduction and internal fixation of calcaneal fractures. DESIGN: Human cadaveric lower extremity specimens, doubly injected with India ink and latex, were used to demonstrate the location of the arteries of the subcutaneous tissues of the lateral hindfoot. SETTING: Anatomy laboratory. PATIENTS/PARTICIPANTS: Twenty-four randomly obtained, cadaveric elderly lower extremity specimens. INTERVENTION: India ink and then latex were injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. Transtibial amputation specimens were manually debrided of the skin and chemically debrided of subcutaneous tissues with sodium hypochlorite to demonstrate the arterial supply to the soft tissues of the lateral hindfoot. MEAN OUTCOME MEASUREMENTS: The location of the three major arteries was determined relative to the lateral malleolus. The proximity of these vessels to the typical extensile lateral incision was determined radiographically with vascular clips applied along each artery and skin staples placed along the path of the typical skin incision. RESULTS: Three arteries, the lateral calcaneal artery, the lateral malleolar artery, and the lateral tarsal artery, were consistently found along the lateral aspect of the hindfoot. The lateral calcaneal artery appeared to be responsible for the majority of the blood supply to the corner of the flap and, because of its proximity to the vertical portion of the typical incision, it appeared most likely to be injured from inaccurate placement of the incision. CONCLUSIONS: The development of wound complications following open reduction and internal fixation of the calcaneus is multifactorial. Disruption of the blood supply to the surgically created flap may play a larger role in the development of wound complications than previously thought. An understanding of the local vascular anatomy may decrease the rate of wound complications during the operative treatment of intraarticular calcaneal fractures.     

Radioembolization with yttrium-90 microspheres work up: Practical approach and literature review

Radioembolization (RE) is a selective internal radiotherapy technique in which yttrium-90 blended microspheres are infused through the hepatic arteries. It is based on the fact that primary and secondary hepatic tumors are vascularized mostly by arterial blood flow whereas healthy hepatocytes obtain their blood supply mostly from the portal network. This enables high radiation doses to be delivered, sparing the surrounding non-malignant liver parenchyma. Most of the complications are caused by unexpected particles passing into the gastrointestinal tract through branches originating from the main hepatic arterial supply. Knowledge of this hepatic arterial network and of its variations and the technical considerations this raises are required in preparation for treatment. This work describes the specific anatomical features and techniques for this anatomy through recent literature illustrated by cases from our own experience.     

肝癌肝外动脉供血的形成机制与介入治疗的研究

目的研究肝癌肝外动脉供血的形成机制 ,旨在指导介入治疗。方法 10 38例肝癌经动脉化疗栓塞 (TACE)前常规腹腔动脉和肠系膜上动脉造影 ,对癌灶临近膈肌的 10 2例加作选择性膈下动脉造影 ,分析肝癌肝外动脉供血特征。结果 14 7例肝外动脉供血来源于膈下及右肾上腺动脉 5 4例 (36 7% ) ,胃十二指肠及网膜动脉 5 0例 (34 0 % ) ,胃左动脉 2 2例 (15 0 % ) ,胰十二指肠动脉弓 18例 (12 2 % ) ,结肠右动脉 3例 (2 1% )。其中 ,97例为肝癌本身固有的寄生性供血(6 6 0 % ) ,37例为TACE后肝动脉闭塞所致的肝外侧枝循环 (2 5 2 % ) ,其余为肝切缘网膜粘附供血(8 8% )。肝外动脉供血与癌灶的部位和大小密切相关 ,肝外供血支的插管成功率为 82 3%。结论明确肝癌肝外动脉供血的形成机制对临床准确和彻底阻断肝癌多动脉供血 ,提高肝癌介入治疗的效果具有重要的意义。     

原发性肝癌肝外动脉供血及其临床治疗意义

目的:探讨原发性肝癌肝外动脉供血类型的分类、一般供血规律及其对临床治疗的意义。方法:回顾性分析185例原发性肝癌患者行经导管肝动脉化疗栓塞(TACE)术的DSA检查结果,对肝外动脉供血类型进行分类。结果:185例患者中存在215条肝外供血动脉,采用三分类法将其分为3类:1.变异肝动脉供血130条,占60.47%;2.肝动脉通畅肝外侧支供血35条,占16.28%;3.肝动脉闭塞或狭窄肝外侧支供血50条,占23.26%。其中后2类为非肝动脉供血。第1类以第1次TACE术时发现为主,第2类及第3类以第3次及以后TACE术时发现为主。非肝动脉供血与肝动脉通畅与否有关系。结论:原发性肝癌肝外动脉供血三分类法是一种较新的分类方法,具有简洁明晰的特点,对分析其类型与TACE术次数及肝动脉通畅与否的关系、指导肝癌的临床治疗具有重要作用。     

胰腺血供及其移植血管重建的研究

目的了解胰腺动脉及其变异情况,为胰腺移植动脉重建提供理论依据。方法回顾性分析中南大学湘雅二医院2000年1月至2006年2月300例胰腺动脉造影片,统计胰腺动脉的变异情况,并分析其结果。结果(1)300例造影中,仅1例能辨认胰十二指肠上动脉;胰十二指肠上前动脉及上后动脉的变异率分别为6.33%和5.06%。(2)胰十二指肠下动脉及其分支(胰十二指肠下前动脉、胰十二指肠下后动脉)的主要变异是发自第一空肠动脉,其发自第一空肠动脉的变异率分别是19.51%、17.54%及12.28%。(3)胰背动脉变异情况较为复杂,其变异率为23.61%。结论胰腺动脉走行复杂,在胰腺移植供胰的血管重建过程中,所重建的血管应既要能保证全胰十二指肠移植完整的血供又要能够减少术后血栓等外科并发症的发生。     

软腭动脉血供的应用解剖学研究

目的　为在修复腭裂时正确地设计和切取腭部组织瓣 ,保证其存活和肌肉恢复功能 ,对软腭血供进行了解剖学研究。方法　对 14例头颈标本做了腭部动脉的解剖学观察 ,10例胎儿标本做了造影 ,6例胎儿头标本做了组织学连续切片观察。结果　证实软腭血供具有多源性 ,主要来源于腭升动脉。该动脉前、后支均是肌粘膜穿支血管。供应软腭的其他动脉均为直接粘膜支 ,包括腭小动脉、咽升动脉腭支和扁桃体动脉。供应软腭的血管在粘膜下及肌筋膜层形成丰富的相互吻合的血管网。腭裂时 ,腭升动脉腭支随腭帆提肌向前外移位。结论　保护好腭部动脉 ,特别是腭升动脉在软腭内的分支 ,对腭裂手术的设计、伤口愈合及术后功能的恢复都十分重要。     

Cervical transforaminal injection and the radicular artery: variation in anatomical location within the cervical intervertebral foramina

BACKGROUND: Recent articles have detailed the adverse events associated with transforaminal steroid injections into the radicular arteries. Guidelines on strict transforaminal epidural techniques have been described to limit complications. There remains limited information regarding the cervical level of entry, location within the intervertebral foramina, and prevalence of the radicular arteries within the population. METHODS: With the aid of premortem angiography and postmortem latex-injected vasculature, a single detailed cadaveric dissection was performed to elucidate the specific anatomic location of the radicular arteries within the intervertebral foramina and the anastomoses of the arteries to the anterior spinal artery. RESULTS: Five radicular arteries (C5, C6, two at C7, C8) were traced entering the foramina either anteriorly or posteriorly to supply the anterior and posterior spinal arteries. Radicular arteries received blood supply from either the deep cervical (C8) or vertebral arteries. The C8 radicular artery entered the lateral aspect of the foramen and penetrated the dural sleeve within the inferior portion of the foramen, directly inferior to the exiting spinal nerve, to supply the anterior spinal artery. This artery was of a large enough caliber to be entered by a 22-gauge needle. CONCLUSIONS: A larger population is necessary to characterize the range of anatomic variations in arterial supply within the foramina. Available studies support the current technique of fluoroscopic needle insertion. Yet, there is wide anatomic variation in the origin and location of these vessels, and even with strict adherence to technique, it is feasible that a properly placed needle could penetrate a radicular artery.     

Intraoperative assessment of tissue oxygen saturation of the remnant stomach by near-infrared spectroscopy in two cases of pancreatectomy following gastrectomy

IntroductionObjective and quantitative intraoperative methods of bowel viability assessment could decrease the risk of postoperative ischemic complications in gastrointestinal surgery. Because the remnant stomach and the pancreas share an arterial blood supply, it is often unclear whether the remnant stomach can be safely preserved when performing pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) post gastrectomy. We herein report two cases in which the remnant stomach was safely preserved using near-infrared spectroscopy to assess the regional saturation of oxygen (rSO2) in the remnant stomach during operation.Presentation of caseThe first patient, a 68-year-old man, was diagnosed with cancer of the pancreatic head and underwent PD a year after proximal gastrectomy for gastric cancer. The remnant stomach was safely preserved by evaluation of the rSO2 before and after reconstruction of the arteries. The second patient, an 82-year-old woman with a history of distal gastrectomy for gastric cancer 40 years previously, was diagnosed with a main duct intraductal papillary mucinous neoplasm of the pancreatic body, requiring DP. As in the previous case, we could safely preserve the remnant stomach through assessing the intraoperative rSO2 of the remnant stomach.DiscussionThrough comparing changes in the rSO2 during surgery, near-infrared spectroscopy provides objective and quantitative assessments of intestinal viability to predict ischemic complications.ConclusionThis method may be a viable option to evaluate the blood supply to the alimentary tract.     

探讨肝癌肝外供血的形成规律及介入治疗

目的探讨肝癌的肝外动脉供血规律,插管技术,旨在指导介入治疗。方法分析46例肝癌患者54条肝外动脉供血的特征,对肝外动脉供血支超选插管,并行动脉化疗栓塞术。结果肝外动脉供血与肿瘤部位、大小密切相关;RH、Cobra导管配合SP导管使用,肝外动脉供血支插管成功率为81%。4~6周复查,CT显示肿瘤缩小,碘油沉积致密完全。结论肝癌可有丰富的肝外动脉供血,明确肝癌肝外动脉供血的形成机制对临床准确和彻底阻断肝癌的动脉供血,提高肝癌介入治疗的效果具有重要的意义。     

Urologic complications in renal transplantation.

The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.     

改良的保留十二指肠胰头全切除术

目的总结分析我中心近年来对胰头部良性病变实施改良的保留十二指肠胰头全切除术的效果。方法回顾性分析我中心2004年6月至2008年6月实施了改良的保留十二指肠胰头切除术的27例患者的临床资料。对该术式的手术方式,并发症及术后近期生存质量进行评价。结果患者手术死亡0例,术后发生胰瘘2例,十二指肠瘘1例,胆瘘1例,其并发症发生率为14．81％,平均手术时间约4h,术后平均住院日为16d。结论保留十二指肠的胰头切除术通过保留胰十二指肠上动脉后支及其血管弓,仅在十二指肠乳头及胆总管后壁残留少许胰腺组织,手术切除彻底,术后并发症发生率低,手术操作简便,患者术后恢复快,住院时间短。该改良术式可以作为治疗胰头部良性病变的重要术式。     

The vascular supply to the spinal cord and its relationship to anterior spine surgical approaches

Background contextThe understanding of vascular supply to the spinal cord is important given that the evolution of surgical approaches to the spine may bring along the potential for more frequent complications, especially a rare but devastating complication: that of spinal cord ischemia or infarction. To maximally avoid this complication, the relationship between the spinal cord vascularity and the anterior spine surgical approach needs further study.PurposeTo provide a theoretical basis that will allow the spinal surgeon to take appropriate steps to avoid spinal cord ischemia during anterior spinal surgery through anatomic means.Study designSpinal cord vascular casting assessment with cadaveric specimen.MethodsTwenty adult cadaveric specimens (11 men and 9 women) were obtained for the latex perfusion and vessel dissection. In addition, nine patients (seven men and two women) underwent superselective angiography of the spinal cord. The segmental arterial anastomosis and radiculomedullary vessels in the thoracolumbar region were shown and reviewed.ResultsThere were approximately 21 pairs of segmental arteries in the thoracolumbar region. Adjacent segmental arteries were networked with each other. The latex infusion specimens demonstrated 72 anterior radiculomedullary arteries and 177 posterior radiculomedullary arteries in all 20 samples. The anterior and posterior spinal arteries were also networked with each other at several levels. Superselective spinal angiography was consistent with the latex infusion specimens showing.ConclusionsThe variety of anatomy of spinal cord arterial networks is shown, and the relation between the blood supply of certain spinal levels and the potential ischemic complications during the anterior surgical approach is discussed. It is hopefully of benefit to surgeons, after fully understanding the anatomy of these spinal vascular supply structures, that there may be even greater avoidance of vascular compromise in these challenging operations.     

Results of a technique of pancreaticojejunostomy that optimizes blood supply to the pancreas

Background: Anastomotic failure after pancreaticojejunostomy is still a common problem. Failure rates have not decreased perceptibly in the past 3 decades. The neck of the pancreas is a vascular watershed between celiac and superior mesenteric arterial systems. Prior attempts to reduce anastomotic failure at pancreaticojejunostomy have not focused on issues related to blood supply of the pancreas. The aim of this study was to determine whether pancreaticojejunostomy performed using a technique that included optimization of blood supply to the pancreas, would result in a low anastomotic failure rate.

Methods: The technique was prospectively evaluated in 40 patients having pancreaticojejunostomy, 39 during pancreaticoduodenectomy and 1 after traumatic transection of the neck of the pancreas. Blood supply to the pancreatic neck was evaluated clinically and by Doppler techniques. When blood supply was considered marginal, the pancreas was re-resected 1.5–2.0 cm to the left, away from the vascular watershed.

Results: Blood supply at the cut margin of pancreas was judged as brisk in 24 patients and marginal in 16 patients. Resecting a segment of pancreas in these 16 patients resulted in brisk bleeding from the new cut margin in all but 1 patient who had an anomalous artery that had to be sacrificed for oncologic reasons. The only fistula in the series occurred in this patient. There were no intraabdominal abscesses.

Conclusions: A technique that includes ensuring adequate blood supply to the pancreas can result in a very low rate of anastomotic failure.     

Reconstruction of the hepatic artery with the middle colic artery is feasible in distal pancreatectomy with celiac axis resection: A case report

Despite the advance of diagnostic modalities, carcinoma in the body and tail of the pancreas are commonly presented at a late stage. With unresectable lesions, long-term survival is extremely rare, and surgery remains the only curative option for pancreatic cancer. An aggressive approach by applying extended distal pancreatectomy with the resection of the celiac axis may increase the resectability and analgesic effect but great care must be taken with the arterial blood supply to the liver and stomach. Sometimes, accidental injury to the pancreatoduodenal artery compromises collateral blood flow and leads to fatal complications. Therefore, knowledge of any alternative restoration of the compromised collateral flow before surgery is essential. The present case report shows a patient with a pancreatic body cancer in whom the splenic, celiac, and common hepatic arteries were involved with the tumor, which extended almost to the root of the gastroduodenal artery. We modified the procedure by reanastomosis between the proper hepatic artery and middle colic artery without vascular graft. The postoperative course was uneventful, and the patient was discharged on post-operative day 19. The patient was immediately free of epigastric and back pain.     

胰肾联合移植术麻醉方法的选择

目的 探讨适合胰肾联合移植手术的麻醉方法。方法 选择30例胰肾联合移植的患者，根据其术中麻醉方法分为硬膜外阻滞复合持续静脉镇静麻醉（EA组）和静脉输注联合吸入复合全身麻醉（GA组），每组15例。观察各组患者的手术时间、液体出入量、以及血管活性药、葡萄糖和胰岛素的用量，监测术中的心电图（ECG）、血氧饱和度（SpO2）、平均动脉压（MAP）、中心静脉压（CVP）、动脉血气和血糖水平，术后观察移植物功能和肺部并发症。结果 胰肾联合移植术中，EA组胰岛素用量较GA组少，但其葡萄糖及血管活性药物的用量较GA组多（P〈0．05）；EA组术中血流动力学波动较大，与GA组比较，差异有统计学意义（P〈0．05）。EA组术后有5例患者发现明显的肺部并发症，GA组有8例。EA组有8例患者术后1d内使用胰岛素，而GA组仅有4例。结论 胰肾联合移植手术中选择连续硬膜外阻滞复合静脉镇静麻醉，可减少术后肺部并发症，有利于胰腺功能的恢复，但须注意其对血流动力学的影响。     

Pharmacologic manipulation of the microcirculation in cutaneous and myocutaneous flaps in pigs

The vascular effects of isoxsuprine, diazoxide, and isoproterenol were studied in arterial buttock flaps and latissimus dorsi myocutaneous flaps in pigs. Capillary blood flow to the skin and muscle of these flaps was measured by the radioactive microsphere (15-mu diameter) technique 6 hours postoperatively under pentobarbital anesthesia. It was observed that isoproterenol, a beta-adrenergic receptor agonist, was not effective in augmentation of skin blood flow in the arterial buttock flaps. However, isoproterenol significantly increased capillary blood flow to the arterialized portion of latissimus dorsi myocutaneous flaps compared with controls. Isoxsuprine and diazoxide (vascular smooth muscle relaxants) significantly (p less than 0.05) increased total capillary blood flow to the skin of arterial buttock flaps and to the skin and muscle of the latissimus dorsi myocutaneous flaps. However, the increase in capillary blood flow occurred mainly in the arterialized portion of these flaps. The capillary blood flow, which was supplied by the small arteries in the distal portion of the arterial buttock and latissimus dorsi flaps, was not increased by treatment with isoxsuprine or diazoxide. Therefore, there was also no increase in the maximum distance of capillary blood flow from the pedicle to the distal end of the flaps. These observations led us to hypothesize that different sizes (diameters) of arteries in the skin and muscle have different reactivity (or sensitivity) to vasodilatory drugs. In the present experiment, the large dominant artery of the arterial buttock and latissimus dorsi flaps responded to isoxsuprine or diazoxide (vascular smooth-muscle relaxants), resulting in an increase in blood supply to the capillaries in the proximal portion of the flaps. On the other hand, the small arteries in the distal portion (random portion) of these flaps were not sensitive to isoxsuprine or diazoxide. Therefore vasodilation did not occur, and there was no increase in blood supply to the capillaries in the distal portion of arterial buttock and latissimus dorsi flaps. This explanation also lent support to our previous report that treatment with isoxsuprine did not augment skin viability in the distal portion of arterial buttock and latissimus dorsi flaps. It is suggested that research in pharmacologic manipulation of skin blood flow and viability in skin flap surgery should emphasize the sensitivity of small arteries to various drug actions.(ABSTRACT TRUNCATED AT 400 WORDS)