胰十二指肠切除术中所见肝动脉变异4例报告

目的探讨肝动脉变异在胰十二指肠切除术中的处理。方法回顾性分析近5年来收治的43例胰十二指肠切除患者中4例肝动脉变异的临床资料。结果 4例肝动脉变异患者中,1例副肝左动脉起胃左动脉,1例肝右动脉起自肠系膜上动脉,2例肝固有动脉起自肠系膜上动脉。4例患者中3例完整保留变异肝动脉,其中包含2例贯穿胰腺实质的变异肝固有动脉;1例变异副肝左动脉直接切断结扎后无严重不良后果。结论术前完善的影像学检查和手术中的细致探查能够及时、准确了解肝动脉变异情况,合理手术操作可妥善处理各种肝动脉变异,避免损伤。     

腹腔镜胰十二指肠切除术中肝动脉变异的识别与处理：附9例报道

目的 探讨腹腔镜胰十二指肠切除手术中遇到的肝动脉变异及其意义。方法 回顾性收集2020年1月至2023年1月期间笔者所在团队收治的26例行腹腔镜胰十二指肠切除手术患者的临床资料，分析根据相关临床及影像学资料术前评估的肝动脉变异情况及其类型，以及术中采取的针对性措施和患者的预后。结果 根据术前腹部增强CT、动脉计算机断层扫描血管造影成像以及术中对肝十二指肠韧带骨骼化，26例行腹腔镜胰十二指肠切除手术患者中有9例存在肝动脉变异：1例为替代肝左动脉，2例为替代肝右动脉，2例为副肝左动脉，3例为肝总动脉起源于肠系膜上动脉；另1例为右肝动脉发自腹主动脉，该例动脉变异在传统分型中没有。对来源于肠系膜上动脉的变异肝动脉在术中采取后路入进行分离血管，对来源于胃左动脉的变异肝动脉术中则采用前路入的方式进行分离。9例肝动脉变异患者术后均恢复良好，均未出现严重并发症。结论 针对腹腔镜胰十二指肠切除手术中遇到的各种肝动脉变异，需要术前仔细评估；术中应根据血管直径大小以及阻断后肝脏血运变化情况决定是否保留该变异血管；术中进行合理操作，以避免损伤肝动脉。     

腹腔镜胰十二指肠切除术相关肠系膜上血管应用解剖学研究

目的:探讨肠系膜上血管的解剖特点,为钩突入路腹腔镜胰十二指肠切除术的实施提出可供参考的解剖学标志。方法:对4具成人尸体标本作解剖学观察,并分析96例上腹部64排螺旋CT血管成像资料与13例钩突入路腹腔镜胰十二指肠切除术的视频资料。结果:门静脉-肠系膜上静脉可分为3个部分,包括胰腺上段,左侧可有胃冠状静脉汇入(22.1%);胰腺段,有较多的属支汇入,主要有胃结肠干、胰十二指肠上后静脉、胰十二指肠下静脉等,并可有肠系膜下静脉汇入该段左侧(7.5%);十二指肠水平段,未见血管分支,且左侧与肠系膜上动脉紧密相邻。肠系膜上动脉在胰头十二指肠区域内走行于肠系膜上静脉的左后侧,胰十二指肠下动脉为其主要分支,另见有与第一空肠动脉共干起源者(33.0%)。肠系膜上动脉起源的替代肝右动脉2例(1.8%)。结论:充分认识肠系膜上血管及其相关血管的分布及走行对腹腔镜胰十二指肠切除术有重要的临床意义,肠系膜上静脉的十二指肠段可作为钩突入路的重要解剖标志。     

行径于胰实质内的肝总动脉

在胰腺肿瘤的手术时 ,有关肝动脉变异是一个值得注意的问题 ,从肠系膜上动脉分出肝总或肝右动脉是该区域的常见变异。Ｍｉｃｈｅｌｓ的解剖统计提示起自肠系膜上动脉的肝固有干而无源自腹腔动脉的肝总动脉占 4 .5% ,源自肠系膜上动脉的“变位”肝右动脉占 1 1 %。这些“变位”动脉常在胰头后方沿门静脉外侧行走 ,进入肝十二指肠韧带的右侧和胆总管的后外侧。作者遇及一例胰头腺癌病例 ,其中“变位”肝总动脉走自肠系膜上动脉在进入肝十二指肠韧带前进入胰头实质内而不是行走于其后方。患者为一 71岁老年男性 ,因梗阻性黄疸住院 ,ＣＴ扫描示…     

肠系膜上动脉变异肝动脉在肝癌及胃癌手术中的意义

目的 了解源自肠系膜上动脉的变异肝动脉走行特征,指导肝癌及胃癌手术操作.方法 研究选择广西医科大学第一附属医院2008年6月至2010年6月间400例经数字减影血管造影(digital subtraction angiography,DSA)及多层螺旋CT血管造影(multislice spiral computed tomography angiography,MSCTA)检查的肝癌患者以及86例术前经MSCTA检查的胃癌患者.术前通过影像学资料了解源自肠系膜上动脉的变异肝动脉的走行情况.将胃癌根治术中变异肝动脉周围组织分离后,行重组人细胞角蛋白20(recombinant human cytokeratin 20,CK20)、癌胚抗原(carcino-embryonic antigen,CEA)免疫组化判断淋巴结转移的发生.结果 全组486例患者中存在源自肠系膜上动脉变异者63例(12.96％),肝癌患者49例、胃癌患者14例.变异肝动脉走行于胰腺前方的2例(3.17％)、胰腺后方的61例(96.83％).胃癌患者变异肝动脉周围组织CK20、CEA免疫组化均为阴性,提示无转移发生.结论 源自肠系膜上动脉的变异肝动脉走行可分为胰前型和胰后型,以后者占多数.术前了解变异肝动脉的走行对于需行肝门部淋巴结清扫的肝癌及胃癌患者具有一定临床意义.     

胰十二指肠切除36例临床分析

对36例胰十二指肠切除术患者的临床资料进行回顾性分析。病理检查证实34例恶性，2例良性。术中发现5例肝动脉变异，即迷走肝右动脉，起源于肠系膜上动脉，肝左动脉起自腹腔动脉。术后并发症总发生率为11％，胰瘘发生率为2.7％，36例患者中35例痊愈，死亡1例（死于肝衰竭）。提示胰十二指肠切除对治疗十二指肠肿瘤是有效而安全的方法，但术后并发症较多，应予重视。     

激发性血管造影定位胰腺功能性胰岛细胞瘤的前瞻性研究

对胰岛细胞肿瘤病人采用术前影像学检查的价值仍不统一，作者自1993年起就开展激发性血管造影术以定位胰岛细胞瘤或卓艾综合征（ZES）。共对4例胰岛细胞瘤和8冽ZES进行了传统的影像学检查和激发性血管造影，在ZES病例中4例为I型多发性内分泌肿瘤。传统的影像学检查有CT、MRI、内镜超声或奥曲肽扫描。刺激胰岛细胞瘤的方法系自右股动脉插管至腹主动脉以显示肠系膜上动脉、肝固有动脉、近端牌动脉和胃十二指肠动脉，上述动脉分别供血至胰头下半（通过下胰十二指肠动脉）、肝、胶体尾和胶头上半，另自右股总静脉插管至右肝静脉。在ZES…     

胰头部动脉优先离断在根治性胰十二指肠切除术中的运用

目的探讨胰头部动脉优先离断在肠系膜上静脉或门静脉受侵犯的胰头部恶性肿瘤行根治性胰十二指肠切除术中的运用价值。方法回顾性分析2012年1月至2013年5月华中科技大学同济医学院附属同济医院完成的58例胰头部恶性肿瘤行根治性胰十二指肠切除术患者的临床资料。58例患者术前薄层CT检查均显示肠系膜上静脉或门静脉受侵犯或受压,均行胰头部动脉优先离断的根治性胰十二指肠切除术,即在处理胰头部静脉血管之前优先离断胰头部的所有动脉供血,即三大动脉血管的分支,主要步骤包括：在十二指肠水平部或横结肠系膜根部暴露和悬吊肠系膜上动、静脉;解剖肝总动脉从而离断胃十二指肠动脉和胃右动脉,同时沿肝总动脉根部解剖腹腔动脉干上方;离断胰腺和脾动脉的胰头分支;沿暴露的肠系膜上动脉前方、右侧和后方解剖,完全离断胰头钩突部与肠系膜上动脉和腹腔动脉干间的神经结缔组织,与腹腔动脉干的上方贯通,此时可清楚地显示腹主动脉前方;最后通过预置的静脉血管阻断带安全剥离、切除或重建肠系膜上静脉或门静脉,完整切除肿瘤。结果术前影像学检查判断局部肿瘤可切除患者37例,可能切除患者21例。58例患者均顺利施行胰头部动脉优先离断的根治性胰十二指肠切除术,手术时间为4．5～8．1h,术中出血量为200—900mL,术中及术后胰腺钩突部无出血。行肠系膜上静脉侧壁部分切除修补术21例,肠系膜上静脉受累段切除端端吻合术10例,血管受压迫成功将肿瘤从血管上剥离行标准的胰十二指肠切除术27例。术后患者出血、胰液漏和胆汁漏的发生率分别为5．2％（3／58）、6．9％（4／58）和1．7％（1／58）。围手术期无患者死亡。结论胰头部动脉优先离断方式能保障肠系膜上静脉或门静脉受侵犯或受压的胰头部恶性肿瘤行根治性胰十二指肠切除术的安全性,减少术中出血。     

CT血管成像对胰十二指肠切除术前肝动脉变异的检出价值

目的 评价多层螺旋CT血管成像(MSCTA)对胰十二指肠切除术前肝动脉的检出价值.方法 胰腺癌和壶腹周围肿瘤患者术前均行腹部CT血管成像(CTA),以数字减影血管造影(DSA)和术中所见的肝动脉解剖为金标准进行比较.结果 81例患者纳入本研究,其中29例行DSA评估肿瘤可切除性和动脉灌注化疗,66接受了手术治疗.CTA检测到17例(21％)患者有变异的肝动脉,13例(16.0％)为一根动脉变异,4例(4.9％)为两根动脉变异.按Michels分型,Ⅳ型、Ⅶ和Ⅷ型各1例,MichelsⅢ型和Ⅴ型各2例,5例为MichelsⅥ型,4例为MichelsⅪ型,1例为罕见变异,未包括在Michels分型里.MSCTA的准确率、灵敏度和特异度均为100％.对于每根肝动脉的清晰度评分,MSCTA与DSA的差异无统计学意义.结论 MSCTA可有效评估胰头周围动脉的解剖变异,为胰十二指肠切除术前了解胰周血管结构提供有价值的信息.     

供体动脉变异对肝移植的影响:附连续527例肝移植的处理和转归(英)

肝动脉变异的发生率为12％～49％.作者对连续527例肝移植手术中供肝动脉变异的情况进行回顾.其中366例解剖正常,161例(30.6%)有解剖变异.将其分为以下5种情况:肝总动脉均来自腹腔动脉,副肝左动脉起自胃左动脉75例(14.2%);副肝右动脉起自肠系膜上动脉44例(8.3%);以上两种情况同时存在9例(1.7%);肝总动脉发自肠系膜上动脉12例(2.3%);罕见肝动脉变异21例,如肝左、右动脉分别来自胃左、肠系膜上动脉而肝总动脉缺如,肝动脉直接发自腹主动脉等等.     

Surgical anatomy of the hepatic arteries in 1000 cases.

OBJECTIVE: Anatomic variations in the hepatic arteries were studied in donor livers that were used for orthotopic transplantation. SUMMARY BACKGROUND DATA: Variations have occurred in 25% to 75% of cases. Donor livers represent an appropriate model for study because extrahepatic arterial anatomy must be defined precisely to ensure complete arterialization of the graft at time of transplantation. METHODS: Records of 1000 patients who underwent liver harvesting for orthotopic transplantation between 1984 and 1993 were reviewed. RESULTS: Arterial patterns in order of frequency included the normal Type 1 anatomy (n = 757), with the common hepatic artery arising from the celiac axis to form the gastroduodenal and proper hepatic arteries and the proper hepatic dividing distally into right and left branches; Type 3 (n = 106), with a replaced or accessory right hepatic artery originating from the superior mesenteric artery; Type 2 (n = 97), with a replaced or accessory left hepatic artery arising from the left gastric artery; Type 4 (n = 23), with both right and left hepatic arteries arising from the superior mesenteric and left gastric arteries, respectively; Type 5 (n = 15), with the entire common hepatic artery arising as a branch of the superior mesenteric; and Type 6 (n = 2), with the common hepatic artery originating directly from the aorta. CONCLUSIONS: These data are useful for the planning and conduct of surgical and radiological procedures of the upper abdomen, including laparoscopic operations of the biliary tract.     

Assessment of Hepatic Arterial Anatomy in Keeping with Preservation of the Vasculature While Performing Pancreatoduodenectomy: An Opinion

Background Pancreatic surgeons often must make decisions regarding hepatic artery (HA) resection while performing a pancreatoduodenectomy (PD). The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during PD and to develop a useful guideline for pancreatic surgeons in dealing with these needs. Methods We reviewed 1324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in PD. In reviewing our PD series (n = 254), we have created a set of guidelines that enable a pragmatic approach to the unique variations in HA and the risks of cancer invasion. Results Challenging HA variations during PD were found in 20.1% of the cases and included the common HA arising from the superior mesenteric artery (SMA) (2.34%), a replaced right HA (RHA) from the SMA (9.82%), an RHA or left HA from the gastroduodenal artery (0.97%), and the right anterior or right posterior HA from the SMA (1.06%), among others. In our PD series, the problematic HAs (15.8%) were preserved, except for a single case (0.4%) in which PD involved en bloc resection of the RHA from the SMA due to a cancerous invasion and without right hemihepatectomy. Conclusions Surgeons should have knowledge of the anatomically variable vasculature of the HA when planning for PD. Preoperative imaging studies can aid and should be performed in anticipation of the potential HA variations during PD.     

Anatomical alteration of the vascular tree observed during living related liver transplantation

INTRODUCTION: The number of available cadaveric donor organs has reached a plateau. One current solution has been to increase number of living related liver transplantations. MATERIAL AND METHODS: Since October 1999 in the Department of General, Transplant and Liver Surgery, Medical University of Warsaw, 40 living related liver transplantation have been carried out. RESULTS: In 31 (77.5%) cases, a normal arterial supply was observed: the common hepatic artery arose from a celiac trunk. In two cases (5.0%), there was a partial arterial blood supply by the right accessory hepatic artery originating from the superior mesenteric artery. In two cases (5.0%), a right hepatic artery arose completely from the superior mesenteric artery (replaced artery). In one case (2.5%), a common hepatic artery originated from the superior mesenteric artery. In two cases (5.0%), an accessory left segmental artery originated from the left gastric artery. In two cases (5.0%), the function of an absent left hepatic artery was assumed by a replaced left hepatic artery originating from the left gastric artery. In two (5.0%) cases, there were two separate ducts draining the right hemiliver. There were two (5.0%) cases of an accessory duct draining segment IV, originating within the confluence of the right and left hepatic ducts. In one (2.5%) case, the common hepatic duct showed a trifurcation. CONCLUSION: During harvesting from a living donor knowledge of anatomical variants must be used to optomize the liver graft.     

Advantage in using living donors with aberrant hepatic artery for partial liver graft arterialization

BACKGROUND: In living-related partial liver transplantation, the feasibility and safety of using left-sided liver grafts from donors with aberrant hepatic arteries remains to be evaluated. METHODS: Between 1996 and 2000, we harvested left-sided liver grafts from 101 living donors. Hepatic arterial variation in the donors was classified into three types: type I (n=69), normal anatomy; type II (n=24), aberrant left hepatic artery arising from the left gastric artery; and type III (n=8), replaced right hepatic artery arising from the superior mesenteric artery. We performed arterial reconstructions using the donor's left hepatic artery in 70 cases (69 in type I, 1 in type II), an aberrant left hepatic artery in 24 cases (23 in type II, 1 in type III), and the common hepatic artery in 7 cases (all in type III). RESULTS: The diameter and length of the anastomosed hepatic artery were larger (2.5+/-0.7 vs. 2.0+/-0.8 mm, P=0.03) and longer (42.0+/-14.7 vs. 9.0+/-7.3 mm, P<0.0001) in cases in which the aberrant left hepatic artery or common hepatic artery was used for the anastomosis (n=31) than in those using the left hepatic artery (n=70). Hepatic arterial occlusion occurred in nine patients, with the incidence of occlusion tending to be lower in the former cases in which aberrant left or common hepatic arteries were used (3.2% vs. 11.4% for the left hepatic artery group, P=0.15). CONCLUSION: Because thicker and longer arterial branches can be obtained in left-sided liver grafts with aberrant hepatic arteries than in grafts with normal left hepatic arteries, their use is advantageous for safe arterialization in partial liver grafts.     

Imaging of hepatic arterial anatomy for depicting vascular variations in living related liver transplant donor candidates with multidetector computed tomography: comparison with conventional angiography

AIMS: The aim of this study was to evaluate liver arteries to depict variations by using multidetector computed tomography (CT) in donor candidates for living related liver transplantation. METHODS: Computed tomographic hepatic angiography was carried out using a multidetector 16-row CT scanner (Sensation 16; Siemens) in 48 candidates between April 2003 and August 2004. Multidetector CT was performed after intravenous injection of 150 mL of contrast material at a rate of 4 mL/s. Arterial phase images were acquired after contrast injection. Afterward, maximum intensity projections and volume-rendered images were produced from the axial image data. Twenty-eight of these patients underwent conventional catheter angiography. RESULTS: Excellent arterial opacification was shown on multidetector CT scans in all patients; arteries up to tertiary branches were identified with CT. Of 28 patients who had both multidetector CT angiography and conventional angiography, only a branch of hepatic artery originating from superior mesenteric artery that supplied the posterior segment of the right lobe was not identified on multidetector CT angiography. In 27 donors, hepatic arterial anatomy depicted at multidetector CT angiography was identical to that at conventional angiography. We identified hepatic vascular variants in 22 of 48 patients with multidetector CT. The most common arterial variant was an accessory hepatic artery arising from the left gastric artery. CONCLUSIONS: Preoperative imaging evaluation of hepatic vascular anatomy is crucial for surgical planning in living related transplant donors. Multidetector CT is useful to depict hepatic arterial anatomy with high accuracy.     

Anatomic variations in right liver living donors

BACKGROUND: Anatomic knowledge is crucial in right liver living donor transplantation. STUDY DESIGN: We reviewed radiologic and surgical findings in right liver donors. Arterial and portal anatomy was assessed in 96 donors, biliary anatomy in 77, and hepatic venous anatomy in 65. RESULTS: Portal vein (PV): 86.4% had classic anatomy; 6.3% had a trifurcated PV; 7.3% had a right anterior PV taken off the left PV. Hepatic artery (HA): 70.8% had classic anatomy; 12.5% had a left HA arising from the left gastric artery; 13.5% had a right HA arising from the superior mesenteric artery; 2.1% had a double replaced left HA and right HA; and in 1.0% the common HA arose from the superior mesenteric artery. Biliary tree: 55.8% had normal anatomy; 14.3% had a trifurcated biliary anatomy; in 5.2% the right anterior bile duct and in 15.6% the right posterior bile duct opened into the left bile duct; in 2.6% the right anterior and in 6.5% the right posterior ducts opened into the common bile duct. Hepatic veins: S5 and S8 accessory hepatic veins had incidences of 43% and 49%, respectively. The incidence of S6 or S7 short hepatic vein was 38%. CONCLUSIONS: Anatomic variations are common but do not contraindicate donation; surgeons should be prepared to recognize and manage them.     

Alternative procedure for failed reconstruction of a right replaced hepatic artery in liver transplantation

A right replaced hepatic artery (RRHA) arising from the superior mesenteric artery (SMA) is the most frequent variation of the hepatic arterial supply requiring backtable reconstruction. There are several widely used techniques for backtable reconstruction of the RRHA to a single conduit. If these reconstructions fail, due to technical reasons or size discrepancies, an alternative method of rearterialization is needed. We describe six cases in which an RRHA was anastomosed to the donor's gastroduodenal artery (GDA) stump utilizing a loupe magnification technique. In four cases the reconstruction was performed at the time of the backtable procedure and in two after reperfusion and failure of the original RRHA to splenic artery (SA) reconstruction. In all cases, the anastomoses remained patent. All patients had Doppler sonography and two had subsequent arteriograms that verified anastomotic patency. This method of reconstruction is more demanding technically but obviates the awkward 90-degree twist of the hepatic artery when an RRHA is anastomosed to the SA stump.     

供肝动脉解剖变异之修整

目的: 探讨供肝动脉解剖特点，掌握供肝修整技术尤其动脉解剖变异之供肝修整方法及技巧。方法:对64例人肝（含24例无脑胎肝和40例成人肝脏）动脉实施解剖及修整，其中31例应用于临床肝移植。结果:64例中肝动脉解剖变异者共12例（18.75%）。其中24例胎儿供肝中5例（20.83%）肝动脉解剖变异，起源于肠系膜上动脉（SMA）替代肝右动脉型1例；起源于SMA副肝右动脉型3例；肝动脉起自SMA型1例。成人供肝动脉变异7例 (17.5%)，来源于SMA替代肝右动脉型2例；来自胃左动脉替代肝左动脉型2例；来自SMA副肝右动脉型3例。应用于临床原位肝移植的31例供肝中，4例存在肝右动脉解剖变异。肝移植时对变异之供肝动脉根据不同情况，可选用变异血管结扎、就近与胃十二指肠动脉、脾动脉或肠系膜上动脉吻合、应用供体髂总动脉搭桥与受体腹主动脉吻合等方法进行修整。结论:肝动脉的修整在供肝修整中占重要地位，供肝切取时避免损伤变异之肝动脉是保障修整成功的关键，对过细的副肝动脉修整时，术中观察侧支反流后可考虑是否予以结扎。     

Aberrant peripancreatic arterial anatomy. Considerations in performing pancreatectomy for malignant neoplasms

One-hundred twenty patients with malignant neoplasms of the pancreas referred to the Surgery Branch of the National Cancer Institute over a 5-year period were prospectively examined with selective celiac and superior mesenteric angiography. Forty-one patients (34%) showed various arterial anomalies in the peripancreatic and hepatic areas. The most common anomalies included the right hepatic artery arising from the superior mesenteric artery (16%) and the left hepatic artery arising from the left gastric (11%). Thirty-two of the 120 patients eventually underwent pancreatic resection, and ten of the 32 resected patients (31%) had aberrant arterial anatomy. Recognition of the arterial anomalies permitted resection with no arterial reconstruction in nine of the patients. One patient required sacrifice of an aberrant right hepatic artery that was reconstructed with an anastomosis to the gastroduodenal artery remnant. Selective angiography should be done routinely before any potential radical resection for malignant neoplasms of the pancreas. Recognition of arterial anomalies generally permits satisfactory resection. Even if arterial segments require sacrifice, reconstruction can generally be accomplished with regional vessels, avoiding major arterial grafts.