新生儿肝外胆道的应用解剖学研究

本文对50例新生儿的肝外胆道作了解剖学观察,其中包括肝左、右管的汇合特点及与肝门的关系;肝左、右管的长度、外径;副肝管的出现、走行及长度;胆囊管与肝总管的汇合情况、各部长度及外径等,并结合临床手术应用进行了讨论。     

胆囊管汇入肝右管伴右副肝管一例

肝外胆道系的形态学变异已有许多报道,但胆囊管汇入肝右管并伴右副肝管的变异少见,作者在制作一例成人肝脏标本时遇见一例,现报道如下:该例胆囊管以锐角直接汇入肝右管,胆囊管长约1cm,汇合下行约1cm 与肝左管汇合成胆总管。沿肝左管和肝右管向肝门追踪解剖,见肝右管上端有—来自肝方叶的肝管注入,为右副肝管。该副肝管注入处距肝右管与胆囊管汇合     

无柄胆囊合并肝外胆道闭锁畸形1例

胆囊管缺如时称无柄胆囊 ,较罕见。在解剖一男性新生儿尸体时发现一例 ,同时伴有肝外胆道畸形闭锁。为积累国人畸形变异资料 ,现报道如下 :该例肝脏明显增大 ,表面平滑 ,质硬 ,实质呈暗绿色。肝右管较长 ,其长度为 1.8ｃｍ ,于横沟右端出肝实质后横行向左 ,与肝左管汇合。距汇合处 0 .2ｃｍ ,有一极细副肝管自尾状叶注入肝右管后壁 ,其管径约为 0 .5ｍｍ。胆囊位于肝左、右管夹角之间 ,其胆囊管缺如 ,于胆囊颈处闭锁 ,闭锁处膨大。距闭锁处 0 .4ｃｍ发出一副胆囊管 ,长度为 0 .5ｃｍ ,管径 1ｍｍ ,于肝左管与肝右管的夹角内走行 ,注入肝左、…     

活体造影法肝内胆管的解剖学研究及临床意义

目的　通过经皮胆道直接造影,研究肝内胆管的解剖与变异的类型与分布。 方法　经皮胆道造影50例, 用20 ml注射器接体外引流管进行造影,胆管充分显影的状态下,旋转拍摄胆管,观察胆管解剖与变异。 结果　50例成像中胆管变异42.0％（21例）。12.0% (6例)显示右前叶肝管、右后叶肝管及肝左管呈三分叉状汇合形成肝总管。8.0% (4例) 肝左管先和右前叶肝管汇合,在肝门处与右后叶肝管汇合。20.0% (10例) 肝左管先和右后叶肝管汇合,在肝门处与右前叶肝管汇合。2.0% (1例)多个肝管在肝门处汇合。 结论　胆管解剖与变异的分析对术前手术方式的确定有一定的临床意义。     

腹腔镜胆囊切除术3265例胆囊管变异的临床总结

目的总结中国人群胆囊管变异的临床情况并结合近20年的手术经验,为腹腔镜胆囊手术预防胆管损伤提供临床依据。方法对重庆医科大学附属第二医院及重庆重钢总医院1993年4月至2011年12月总共20 000例腹腔镜胆囊切除术患者的临床资料进行回顾性分析。结果胆囊管变异3 265例,变异率为16.33%,其中胆囊管汇入点变异3 200例,短胆囊管51例,胆囊被肝组织包绕14例。胆囊管汇入点的变异占绝大部分,其中胆囊管与肝总管平行低位汇合371例,占11.36%;胆囊管横过肝总管前面汇入995例,占30.47%;胆囊管绕过肝总管后面再汇入643例,占19.69%;胆囊颈部之囊状凸与胆总管粘在一起963例,占29.49%;胆囊管与胆总管高位汇合228例,占6.98%。结论中国人群胆囊管变异以胆囊管汇入点异常为主;临床医师术中应熟悉胆囊管变异的分型,术中仔细认清解剖结构,必要时采取术中胆道影像学检查并且掌握好中转开腹指征。     

肝外胆道系统管道异常扩张1例

在解剖一成年男性尸体时发现肝外胆道系统(除胆囊外)异常扩张。报道如下:肝脏外形形态正常,肝外胆道各管径变粗,与周围组织无粘连,肝左管、肝右管、肝总管、胆囊管、胆总管的管径异常扩张(表1,图1)。     

胆囊三角局部解剖和胆囊切除术

目的 本文观察胆囊三角局部解剖与胆囊切除术的关系。方法 总结近年来作者所施行的543例胆囊切除术。结果 胆囊管的汇合方式呈角型占84.9％,平行型占8.8％,其他占6.3％。胆囊动脉的起源来自右肝动脉占80％。副肝管的出现率是4.3％。结论 胆囊三角局部解剖对胆囊切除术是很重要的,掌握胆囊三角的局部解剖,弄清胆囊动脉、胆囊管与肝总管三者之间的关系,是手术成功的关键,并时常想到胆囊三角区结构变异的可能,就会预防术后发生并发症。     

肝右管变异1例

在解剖一具约 60岁左右的男性尸体标本时 ,见其右肝管为 3支型变异 ,现报道如下 :在肝门下方右肝管 3支型 (分别辊称为上、中、下支 ,附图 )。上支肝右管为肝右管主干 ,长 11.9ｍｍ ,外径为 5.9ｍｍ ,与肝左管汇合成肝总管 ;中支肝右管长为 19.8ｍｍ ,外径为 3.0ｍｍ ,注入到肝总管中段 ;下支肝右管长为 2 5.5ｍｍ ,外径为 3.4ｍｍ ,注入到肝总管下段。胆囊管长为 17.8ｍｍ ,外径为 3.9ｍｍ。肝总管长为 33.5ｍｍ(从右上肝管与左肝管汇合处到肝总管与【作者简介】王鹏 (1 975 - ) ,女 (回族 ) ,天津人 ,助教 ,学士 ,主要从事解剖学的教学及…     

胆囊下肝管的解剖及其临床意义

对135例屍体中出现的15例胆囊下肝管进行了研究,其出现率为11.1%,全部均为单支,位于胆囊窝右侧。胆囊下肝管最大外径5mm,最长5cm,与肝外胆道汇合的形式有三种,分别注入右肝管及肝总管内。本文针对胆囊下肝管来源于肝右前叶胆囊窝内的浅层肝管,提出临床上剥离胆囊时应注意的要点。     

肝外胆道血供来源和分布及其临床意义

手术显微镜下解剖观测了４０例成人标本，结果表明，肝外胆道的血供来源于多条动脉，主要有胆囊动脉、胰十二指肠上后动脉、肝右动脉和门静脉后动脉，占肝外胆道血供的９４．５％。在胆道不同部位，血供分布比例不同，其中分布于胆总管十二指肠后段、上段及肝总管的比例最低，占１３．１％；而胆囊和胆囊管则高达５１．３％。探讨了肝外胆道动脉的分布规律及临床意义。     

利用微血管铸型技术研究肝外胆管动脉的分布特征

目的　统计分析肝外胆管的血供来源和分布以及在十二指肠上段胆管的吻合动脉链之间的多环形血管网,为胆管外科手术提供临床解剖学理论依据。 方法　以丙烯酸树脂为动脉填充剂灌注6例肝外胆管动脉制备铸型标本,使用photoshop测量法测量微小血管内径,观测和分析肝外胆管的血供来源和分布情况。 结果　肝固有动脉左、右支在肝总管上方存在弓型交通支,十二指肠上段胆管左右边缘的吻合动脉链间有丰富的横向动脉,吻合动脉链的供血约53%来自下方,来自上方的约占46%,1%来自中段肝固有动脉。通过对每条横向动脉中部的内径和两侧起始部的内径测量,发现肝总管中段和上段的横向动脉较粗,中部的平均内径分别为（0.26±0.02）mm和（0.24±0.04）mm,与两侧的内径比也比较大,上段比值最大,为1.09,中段其次,为1,下段中部的平均内径为（0.14±0.03）mm;与两侧的内径比值为0.74。 结论　肝外胆管上、下方的血供来源比例相对均衡;肝外胆管手术应尽可能于动脉吻合相对较少的胆总管十二指肠上段和血管相对较细小肝总管下部做纵行小切口,以降低肝外胆管血供的损伤;肝总管段的血供丰富,支持现行原位肝移植离断部位在胆囊管汇合处上方的主张。     

正常人胆管壁组织构筑的研究

对5例正常人胆道系统的组织构筑及平滑肌、弹性纤维、胶原纤维的分布进行了面积计量研究.从胆总管胰后段至左右肝管汇合部,平滑肌的面积分数从13.56±0.65%降至3.34±0.32%,弹性纤维的含量以肝总管和左右肝管汇合部为高,与胆总管胰后段和十二指肠上段比较,差别有显著性.胶原纤维的含量在肝外胆管各段之间和肝内胆管各段之间无显著差异,但肝内胆管与肝外胆管之间的差异显著.肝内与肝外胆管壁的组织构筑存在一定的差异,说明它们的生理功能有所不同.     

Analysis of the arterial supply of the extrahepatic bile ducts and its clinical significance

The purpose of this study is to describe the arterial supply of the entire extrahepatic bile duct system. The cross‐sectional area of all arteries that supply the ducts is measured under an operating microscope in 50 adult cadavers injected with red latex through the aorta. The extrahepatic bile duct system is divided into four topographic portions: cystic duct and gallbladder, right and left hepatic ducts, bile (common) duct and including its supra‐retroduodenal parts, and the pancreatic and intraduodenal portions. The arterial supply to each portion is carefully detailed. The ducts are supplied by more than seven arteries, of which the major arteries are the cystic artery, posterior superior pancreaticoduodenal artery, right hepatic artery, and retroportal artery. Collectively they provide 94.5% of the blood supply to the ducts. Arteries form three types of anastomotic patterns on the walls of the ducts, suggesting that ductal incisions can be made in ways that least disturb the blood supply. The patterns are: a network, a longitudinal anastomotic chain, and an arterial circle. These data emphasize the importance of the arterial supply in biliary surgery and especially the treatment of hemobilia. Clin. Anat. 12:245–249, 1999. © 1999 Wiley‐Liss, Inc.     

Extrahepatic biliary schwannomas: a case report

Benign schwannomas arise in neural crest-derived Schwann cells. They can occur almost anywhere in the body, but their most common locations are the central nervous system, extremities, neck, mediastinum, and retroperitoneum. Schwannomas occurring in the biliary tract are extremely rare and mostly present with obstructive jaundice. We recently experienced a case of extrahepatic biliary schwannomas in a 64-yr-old female patient who presented with intra- and extrahepatic bile duct and gallbladder stones during a screening program. To the best of our knowledge, extrahepatic biliary schwannomas associated with bile duct stones have not been reported previously in the literature.     

Primary follicular lymphoma of the extrahepatic bile duct mimicking a hilar cholangiocarcinoma: case report and review of the literature

We report a case of a 53-year-old Asian woman who presented with abdominal pain, bloating, dysphagia, and signs of incomplete biliary obstruction, having elevated liver function tests but without increased bilirubin. Imaging studies revealed a mass measuring 6.0 × 8.0 cm at the porta hepatis extending to the right lobe of the liver and obstructing the common hepatic duct, causing mild to moderate intrahepatic biliary dilation and variable occlusion of the right portal vein. At laparotomy, an infiltrative neoplasm was noted at the hilum that involved the common bile duct, right and left hepatic ducts, and the right lobe of the liver. Extended right hepatectomy and resection of the extrahepatic bile duct and right portal vein was performed. Histologic examination revealed a high grade follicular lymphoma (grade 3A) with a predominantly follicular pattern of growth. Portal lymph nodes and a staging bone marrow biopsy showed no evidence of lymphoma. The patient subsequently received chemotherapy. Postoperative follow-up of more than 4 years has been uneventful, without disease recurrence. To the best of our knowledge, this is the third report of a primary extranodal follicular lymphoma of the extrahepatic biliary system.     

A new method of three-dimensional computer assisted reconstruction of the developing biliary tract

A three-dimensional (3-D) computer assisted reconstruction of the biliary tract was performed in human and rat embryos at Carnegie stage 23 to describe and compare the biliary structures and to point out the anatomic relations between the structures of the hepatic pedicle. Light micrograph images from consecutive serial sagittal sections (diameter 7 mm) of one human and 16 rat embryos were directly digitalized with a CCD camera. The serial views were aligned automatically by software. The data were analysed following segmentation and thresholding, allowing automatic reconstruction. The main bile ducts ascended in the mesoderm of the hepatoduodenal ligament. The extrahepatic bile ducts: common bile duct (CD), cystic duct and gallbladder in the human, formed a compound system which could not be shown so clearly in histologic sections. The hepato-pancreatic ampulla was studied as visualised through the duodenum. The course of the CD was like a chicane. The gallbladder diameter and length were similar to those of the CD. Computer-assisted reconstruction permitted easy acquisition of the data by direct examination of the sections through the microscope. This method showed the relationships between the different structures of the hepatic pedicle and allowed estimation of the volume of the bile duct. These findings were not obvious in two-dimensional (2-D) views from histologic sections. Each embryonic stage could be rebuilt in 3-D, which could introduce the time as a fourth dimension, fundamental for the study of organogenesis.     

Malignant tumours of gallbladder and extrahepatic bile ducts

Biliary tract neoplasms are divided into cancers of the gallbladder (GB) and intrahepatic and extrahepatic bile ducts (EBD). GB and EBD tumours are closely related, although they show marked differences in epidemiology, aetiology and clinical presentation. GB neoplasms are uncommon in North America but endemic in South America and Asia, whereas EBD tumours show no geographic predilection. Both gallbladder cancer (GBC) and extrahepatic bile duct cancer (EBDC) present at an advanced stage, and are associated with an aggressive course and poor prognosis. These tumours occur primarily in older patients and are strongly associated with chronic inflammation of the biliary epithelium. GBC is more common in women while EBDC is slightly more common in men. Over 90% are carcinomas, usually of the pancreaticobiliary type. Histologic grade, histologic type and stage of disease are useful prognostic indicators. Compared with other histologic variants, papillary carcinomas at both sites have a more favourable prognosis. Despite the common embryologic and histologic features of the bile duct and gallbladder, the natural history and management of cancer arising from these structures have both similarities and major differences.     

Angioarchitecture of the rabbit extrahepatic bile ducts and gallbladder

The angioarchitecture of extrahepatic bile ducts and gallbladder of the miniature rabbit was studied by scanning electron microscopy (SEM) of vascular corrosion casts. Light microscopy of Masson-stained, paraffin-embedded transverse tissue sections served to attribute cast vascular structures to defined layers of bile ducts and gallbladder. In all segments of the bile tract, a mucosal and a subserosal vascular network was found. In glandular segments, the mucosal network was composed of a meshwork of subepithelial and circumglandular capillaries, which serve the mucosal functions. Differences in the angioarchitectonic patterns existed only in the subserosal networks as hepatic ducts own one supplying arteriole only, while the common bile duct owns a well-defined rete arteriosum subserosum. A well-developed dense subserosus venous plexus was present throughout the bile tract. Vascular patterns of the gallbladder body resembled those of the bile duct, whereby the dense subserous venous plexus was located close to the mucosal capillary network. The subserosal network in the neck of the gallbladder resembled that of the cystic duct. Spatial changes of the mucosal vascular network during volume changes of the gallbladder were documented. Measurements from tissue sections revealed bile tract diameters of 220-400 microm (extrahepatic ducts), 500-650 microm (cystic duct), and 4-6 mm (common bile duct). Data gained from high-powered SEM micrographs of vascular corrosion casts revealed vessel diameters of 200 microm (cystic artery), 90-110 microm (cystic vein), 30-40 microm (feeding arterioles), and 25-110 microm (subserosal venules). Crypt diameters in the filled gallbladder were 300-1,500 mum; those in the contracted organ were 100-600 microm.     

Traumatic neuroma of the bile ducts with intrahepatic extension causing obstructive jaundice

Most traumatic neuromas of the biliary tract occur in the cystic duct stump after cholecystectomy and produce no symptoms. The authors report the rare occurrence of traumatic neuroma of the bile ducts that arose from injury to the duct occurring during cholecystectomy. The neuroma blocked the common hepatic duct and extended into the left hepatic duct, causing obstructive jaundice. The pseudotumor was removed from the common hepatic duct, but intrahepatic extension prevented complete removal. The patient remains well ten years after the surgical procedure.     

Embryology of Extra‐ and Intrahepatic Bile Ducts,the Ductal plate

In the human embryo, the first anlage of the bile ducts and the liver is the hepatic diverticulum or liver bud. For up to 8 weeks of gestation, the extrahepatic biliary tree develops through lengthening of the caudal part of the hepatic diverticulum. This structure is patent from the beginning and remains patent and in continuity with the developing liver at all stages. The hepatic duct (ductus hepaticus) develops from the cranial part (pars hepatica) of the hepatic diverticulum. The distal portions of the right and left hepatic ducts develop from the extrahepatic ducts and are clearly defined tubular structures by 12 weeks of gestation. The proximal portions of the main hilar ducts derive from the first intrahepatic ductal plates. The extrahepatic bile ducts and the developing intrahepatic biliary tree maintain luminal continuity from the very start of organogenesis throughout further development, contradicting a previous study in the mouse suggesting that the extrahepatic bile duct system develops independently from the intrahepatic biliary tree and that the systems are initially discontinuous but join up later. The normal development of intrahepatic bile ducts requires finely timed and precisely tuned epithelial–mesenchymal interactions, which proceed from the hilum of the liver toward its periphery along the branches of the developing portal vein. Lack of remodeling of the ductal plate results in the persistence of an excess of embryonic bile duct structures remaining in their primitive ductal plate configuration. This abnormality has been termed the ductal plate malformation. Anat Rec, 291:628–635, 2008. © 2008 Wiley‐Liss, Inc.