选择性脾动脉栓塞术对急诊外伤性脾破裂救治的效果探讨

目的探讨在急诊外伤性脾破裂的救治中实施选择性脾动脉栓塞术(PSAE)的效果。方法选择2015年3月至2019年8月收治的86例外伤性脾破裂患者,根据患者的意愿分为修补组(n=43)和栓塞组(n=43),修补组实施脾修补术,栓塞组实施PSAE。比较2组患者手术时间、术中出血量、下床时间、住院时间、T淋巴细胞水平及并发症发生情况。结果栓塞组患者手术时间、下床时间及住院时间均短于修补组(P=0.002、0.012、0.007),术中出血量少于修补组(P=0.000);治疗14 d后栓塞组CD3+、CD4+、CD4/CD8+水平高于修补组(P=0.023、0.018、0.011),CD8+水平低于修补组(P=0.015)。栓塞组共有3例患者(6.98%)发生并发症,而修补组有10例(23.26%)发生并发症,2组比较差异有统计学意义(P<0.05)。结论PSAE应用于急诊外伤性脾破裂效果良好,可缩短手术至康复所需时间,同时起到改善免疫功能的作用。     

Tortuosity of the human splenic artery

Arantius (1571) was the first to describe tortuosity of the splenic artery. The present study investigated the variations in its tortuosity in man, and possible relationships with age, sex, and presence of atheroma. Twenty-nine cadaveric specimens and forty-four celiac angiograms were studied. The straight distance from the origin of the splenic artery, from the celiac trunk, to the point of commencement of the hilar branches was measured, as was the total length of the artery between these two points. The ratio of these two measurements is called the “index of tortuosity.” The cadaveric arteries were then opened and graded for the presence of atheroma on a scale of 0 to 3. Marked variation in the index was found in both the cadavers and the angiograms. No definite relationship was found with sex. However, there was a suggestion of increasing tortuosity with age, although in one 10-year-old girl, marked tortuosity was demonstrated on angiography. No significant correlation was shown between increased tortuosity and the extent of atheroma. At present, there is apparently no satisfactory explanation for tortuosity of the splenic artery. © 1995 WiIey-Liss, Inc.     

Coexistence of multiple anomalies in the celiac-mesenteric arterial system

The origins and distribution of arteries of the celiac-mesenteric system were examined by dissection of 52 formalin-fixed human cadavers. Seventy-five percent of the cadavers exhibited the classic Michels' Type I hepatolienogastric pattern; 25% had different branching patterns. Multiple anomalies of the celiac-mesenteric arterial system were observed in one Caucasian female cadaver: a short lienogastric trunk; a common hepatic artery arising directly from the abdominal aorta; an anomalous course of the hepatic arteries; an accessory left hepatic artery arising from the left and right gastric arterial anastomosis along the lesser curvature of the stomach; a double cystic artery; a common inferior phrenic trunk arising from the celiac trunk; and an aberrant arterial channel connecting the proximal segments of the splenic and gastroduodenal arteries. A patent ductus venosus and an anomalous formation of the portal vein by the confluence of the splenic and superior and inferior mesenteric veins was also observed. Although single anomalies of the celiac-mesenteric arterial system are common, complex combinations, such as were observed in the present case, represent a significant deviation from the normal developmental pattern. There seems to be no report in the literature of such a combination of anomalies coexisting in one individual. The developmental and clinical significance of these anomalous vessels is discussed.     

Neuropeptide Y and differential sympathetic control of splenic blood flow and capacitance function in the pig and dog

The roles of different mediators in the sympathetic regulation of the pig and dog spleens were investigated using a preparation with intact vascular perfusion in vivo. Sympathetic nerve stimulation caused overflow of neuropeptide Y-like immunoreactivity (NPY-LI) and noradrenaline (NA), arterial vasoconstriction, increase in venous blood flow and haematocrit. The dog spleen responded to single impulse stimulation, whereas more prolonged stimulation was required to elicit vascular responses in the pig spleen. Furthermore, the maximal splenic capacitance response was about 10 times larger in the dog than in the pig. After depletion of neuronal NA content by reserpine combined with preganglionic denervation, about 70% of the splenic arterial vasoconstrictor responses in the dog and pig still remained at 5 Hz stimulation. Fifty per cent of the capacitance response evoked by nerve stimulation still remained in the pig while in the dog spleen the capacitance response was virtually abolished after reserpine. The stimulation-evoked overflow of NPY-LI in pig spleen was increased several fold after reserpine treatment as compared to controls reaching levels in the venous effluent where exogenous NPY evokes vasoconstriction. In the dog spleen, overflow of NPY-LI was only observed after reserpine. Administration of NA caused arterial vasoconstriction with an initial increase in venous blood flow while NPY mainly reduced arterial blood flow. It is concluded that NA is involved in both the splenic arterial vasoconstriction and the capacitance responses while a non-adrenergic splenic vasoconstriction at least in the pig may be mediated by NPY.     

Clinical anatomy of the inferior phrenic artery

The majority of anatomical textbooks of gross anatomy offer very little information concerning the anatomy and distribution of the inferior phrenic artery (IPA). In the last decade, however, increased numbers of reports have appeared with reference to the arterial supply of hepatocellular carcinoma (HCC). The IPA is a major source of collateral or parasitized arterial supply to this type of carcinoma, second only to the hepatic artery. The aim of this study was to identify the origin and distribution of the IPA (right and left), in normal and pathological cases, and to apply such findings to the clinical scenario of treating hepatic cancer. We have examined 300 formalin-fixed adult cadavers lacking abdominal pathology, and 30 cadavers derived from patients with HCC. Dissections in normal cadavers showed that the right IPA originated from the: a) celiac trunk in 40% of the specimens; b) aorta in 38%; c) renal in 17%; d) left gastric in 3%; and e) hepatic artery proper in 2% of the specimens. The left IPA originated from the: a) celiac trunk in 47%; b) aorta in 45%; c) renal in 5%; d) left gastric in 2%; and e) hepatic artery proper in 1% of the specimens. The IPA gave rise to eight notable branches: ascending, descending, inferior vena cava, superior suprarenal, middle suprarenal, esophageal, diaphragmatic hiatal, and accessory splenic. The right IPA was always associated with HCC and served as the major collateral artery adjunct to the hepatic artery. These findings could have major implications in the transcatheter embolization of HCC patients.     

Heterogeneity of stromal cells in the human splenic white pulp. Fibroblastic reticulum cells,follicular dendritic cells and a third superficial stromal cell type

At least three phenotypically and morphologically distinguishable types of branched stromal cells are revealed in the human splenic white pulp by subtractive immunohistological double-staining. CD271 is expressed in fibroblastic reticulum cells of T-cell zones and in follicular dendritic cells of follicles. In addition, there is a third CD271⁻ and CD271^+/− stromal cell population surrounding T-cell zones and follicles. At the surface of follicles the third population consists of individually variable partially overlapping shells of stromal cells exhibiting CD90 (Thy-1), MAdCAM-1, CD105 (endoglin), CD141 (thrombomodulin) and smooth muscle α-actin (SMA) with expression of CD90 characterizing the broadest shell and SMA the smallest. In addition, CXCL12, CXCL13 and CCL21 are also present in third-population stromal cells and/or along fibres. Not only CD27⁺ and switched B lymphocytes, but also scattered IgD⁺⁺ B lymphocytes and variable numbers of CD4⁺ T lymphocytes often occur close to the third stromal cell population or one of its subpopulations at the surface of the follicles. In contrast to human lymph nodes, neither podoplanin nor RANKL (CD254) were detected in adult human splenic white pulp stromal cells. The superficial stromal cells of the human splenic white pulp belong to a widespread cell type, which is also found at the surface of red pulp arterioles surrounded by a mixed T-cell/B-cell population. Superficial white pulp stromal cells differ from fibroblastic reticulum cells and follicular dendritic cells not only in humans, but apparently also in mice and perhaps in rats. However, the phenotype of white pulp stromal cells is species-specific and more heterogeneous than described so far.     

Histometry of splenic microvascular architecture in hairy cell leukaemia

In this study we investigated the splenic microvascular architecture in hairy cell leukaemia, in order to provide a morphological basis for the haemodynamic modifications occurring in the disease. When compared with controls, the four leukaemic spleens examined showed a set of changes involving both the arterial and the venous system. A real increase in the absolute volume, surface and length of pulp arterial vessels was present. This increase was not so great as the enlargement of the spleen, thus resulting in a reduced density of distribution of arterial vessels in the infiltrated pulp. Enlargement of pulp cords and sinuses was also present: the pulp cord enlargement was apparent in the unit volume, which resulted in a disproportionately higher increase of the absolute volume, compared with that of sinuses. The sinus-cordal rearrangement and, particularly, the increase in the volume of pulp cords may cause a slowing down of blood cell circulation with resultant increased phagocytosis and hypersplenism. Moreover, it is suggested that the changes observed in the arterial bed of the spleen in hairy cell leukaemia involve both a reduced blood supply per unit volume of splenic pulp and a more marked conditioning of blood cells prior to their screening by cordal macrophages.     

Anatomical variations of the splenic artery and its clinical implications

The variations in orgin, course, and terminal branching pattern of the splenic artery were studied in 320 cadavers. The artery originated from the coeliac trunk in the majority of cadavers (90.6%), followed by abdominal aorta (8.1%), and other sights (1.3%). A suprapancreatic course of the artery was commonly observed (74.1%) followed by enteropancreatic (18.5%), intrapancreatic (4.6%), and retropancreatic (2.8%) courses. In two cases (0.63%) the proximal part of the splenic artery made a loop that was embedded in the substance of the pancreas, which is an interesting and rare finding. In five cases (1.5%) the proximal part of the artery divided into two or more branches that had suprapancreatic and enteropancreatic courses. The splenic artery divided into terminal branches in 311 (97%) cadavers. In nine (2.8%) cadavers it passed through the hilum of spleen without dividing. Two terminal branches were the most common (63.1%) followed by four (18.8%), six (9.7%), and more than six (5.6%) branches. The present study clearly indicates that there is variation in origin, course, and terminal distribution pattern of the splenic artery. The knowledge of these variations are of significant importance during surgical and radiological procedure of upper abdominal region to avoid any catastrophic complications.     

Berry splenic artery aneurysm rupture in association with segmental arterial mediolysis and portal hypertension

A rare case of berry splenic artery aneurysm (SAA) rupture associated with segmental arterial mediolysis (SAM) and portal hypertension is reported. A 66-year-old woman, diagnosed as having liver cirrhosis and portal hypertension 6 years earlier, suddenly developed a lancinating pain in the upper abdomen and lost consciousness. She recovered consciousness while being transferred to hospital by ambulance. During the investigations, her level of consciousness suddenly deteriorated. Ultrasonography showed a massive intraperitoneal hemorrhage, and she died 5(1/2) h after admission. On gross examination at autopsy it was not possible to find the rupture point of the vessel because the pancreas was embedded in a massive hematoma. However, careful dissection of the pancreatic tail after fixation revealed a berry aneurysm measuring 0.8 cm in diameter in a branch adjacent to the bifurcation in the distal third of the main splenic artery. Microscopic examination detected a rupture of the aneurysm. The histology of the arterial wall proximal to the aneurysm showed typical SAM. In general, berry SAA caused by SAM is rare and unlikely to rupture. The SAA in the present case likely occurred and ruptured due to the combination of SAM and portal hypertension.     

A rare case of inferior mesenteric artery arising from the superior mesenteric artery,with a review of the review of the literature

Anatomical variations of the inferior mesenteric artery (IMA) are uncommon. Generally, the IMA is very stable, arises directly from the abdominal aorta at the level of the third lumbar vertebra. We describe here an extremely rare case in which the IMA arose from the superior mesenteric artery. The findings were made during routine dissection of the cadaver of a 79-year-old Japanese man. This present case is the ninth report of this variation and was associated with gastrophrenic trunk, hepatosplenic trunk, hypoplastic spleen and accessory spleen. Clinically, cases like this highlight the importance of knowing the IMA anatomy and the possibility of its numerous variations in surgical procedures such as right hemicolectomy, resection of the transverse colon, left hemicolectomy, sigmoidectomy, and en bloc resection of the head of the pancreas and the superior mesenteric vessels. The developmental significance of this variation is also discussed with a detailed review of the literature.     

The prevalence of transpancreatic common hepatic artery and coexisting variant anatomy

We studied the prevalence of the transpancreatic common hepatic artery (tp‐CHA) and coexisting variant anatomy. The study group comprised 788 consecutive liver transplant donor candidates who had undergone thin‐section multidetector‐row computed tomography (MDCT) studies to investigate vascular anatomy. Multiplanar reformatted (MPR) images obtained from the arterial phase were retrospectively reviewed to assess the presence/absence of the tp‐CHA. Five cases of tp‐CHA with pancreaticobiliary tumors were also included in an investigation of the presence/absence of variant hepatic arteries, celiac stenosis, and circumportal pancreas. Three of the 788 (0.38%) donor candidates had a tp‐CHA. Overall, eight tp‐CHA cases were assessed for coexisting variant anatomy. Seven of these eight cases had a hepatomesenteric trunk, six had celiac stenosis, and two had a circumportal pancreas. The prevalence of the tp‐CHA was 0.38% (approx. one in 260 in normal populations). A tp‐CHA can commonly be associated with a hepatomesenteric trunk and celiac stenosis. A circumportal pancreas can also coexist with a tp‐CHA. Clin. Anat. 31:598–604, 2018. © 2017 Wiley Periodicals, Inc.     

A comparative study of the tortuosity of the splenic artery

The splenic artery of four mammals-pig, greyhound, rhesus macaque, and olive baboon-was studied to determine its tortuosity and pattern of convolutions. The results were compared to those previously gathered in humans. It was found that the isolated cadaveric arteries showed a noticeable species variation in mean index of tortuosity. In the pig and dog, the artery was nearly straight throughout its length, with a very low index of tortuosity, not significantly different in the two species (P >0.1). The artery was significantly more tortuous in the rhesus macaque and baboon than in both pig and dog, (Ps < 0.001), with a single large convolution present in the proximal one-third. In humans, the artery is commonly tortuous throughout its length and is significantly more tortuous than in the pig and dog (P < 0.001), but not significantly more tortuous than in the baboon (P > 0.1) and only just significantly more so than in the rhesus macaque (0.02 < P > 0.05). The speculation that the tortuosity of the artery may be related to habitual posture, being less in the pronograde pig and dog than in the partly orthograde rhesus macaque and baboon, is not supported by results in the wholly orthograde human. © 1995 WiIey-Liss, Inc.     

The third time is the charm--anastomosis between the celiac trunk and the left colic artery

An atypical case of abdominal vasculature, found in a 58-year-old woman is presented. The multidetector computed tomography angiogram revealed a large tortuous anastomotic vessel between the stem of the celiac trunk and the left colic artery, supplying branches for the left colon and pancreatic body and tail. We propose a simple embryological explanation for the development of this aberrant artery--the longitudinal ventral anastomosis, which connects the precursors of principal visceral arteries in a loop-like manner, loses its direct communication with the superior mesenteric artery but maintains its continuity above and below this level. This variation could pose a problem for radiological interpretation and affect surgical approaches to the aorta, left colon, and the pancreas.     

Branches and arterial supply of the recurrent artery of Heubner

The aim of this study was to describe the branches and arterial supply of the recurrent artery of Heubner (RAH) in order to provide detailed information to neurosurgeons operating in this area of the brain. A total of 70 human brains (39 male and 31 female) obtained from cadavers (aged 31–75 years) during routine autopsies were examined; brains from individuals who died due to neurological disorders were not included in the study. Immediately after dissection the arteries were perfused with acrylic paint emulsion through the circle of Willis or electively through the RAH. Brains were fixed in a 10 % solution of formaldehyde and sectioned; the sections were analyzed under a stereoscopic light microscope (magnification 2–40×). The RAH was present in 138 hemispheres with a mean of 1.99 per hemisphere. Mean RAH length was 25.2 mm and the mean diameter, in its place of origin, was 1 mm. Between two and 30 (mean 9.4) branches originated from the stem of the RAH. Each branch then divided into 2–40 smaller branches (mean 19). Primary branches were divided and named in accordance with their course and arterial supply. Primary RAH branches include the anterior perforating substance, sylvian fissure, olfactory, frontal, hypothalamic, optic tract and connecting branches. Left and right hemispheres were asymmetrically supplied by RAH branches, but none of these discrepancies were of statistical significance.     

Critical mass of splenic autotransplant needed for the development of phagocytic activity in rats

When total splenectomy is inevitable, heterotopic splenic autotransplantation seems to be the only alternative to maintain the functions of the spleen. The present study was carried out to analyse the critical mass of splenic autotransplant (SAT) for the development of phagocytic activity in rats. Wistar rats were submitted to total splenectomy (TS) alone or in combination with slices of SAT ranging from an average rate of 21·9% (one slice) to 100% (five slices) of the total splenic mass implanted into the greater omentum. Sixteen weeks after the beginning of the experiment, the animals were inoculated intravenously with a suspension of Escherichia coli labelled with Tc‐99m. After 20 min, the rats were killed and the liver, lung and spleen or SAT, as well as blood samples were removed to determine the percentage of labelled bacteria uptake in these tissues. As the percentage of the total splenic mass contained in the SAT increased, the bacteria remaining in the blood decreased. From the implant of 26% up to the implant of the total splenic mass (100%) there was no difference in the bacteria remaining in the blood between the healthy animals of the control group and those submitted to TS combined with SAT. This finding shows that the critical mass needed for the development of phagocytic activity of macrophages in splenic autotransplants in adult rats is 26% of the total splenic mass.     

Main trunk of the left coronary artery: anatomic study of the parameters of clinical interest

The objective of this study was to analyze in one single series all the characteristics of the main trunk of the left coronary artery (MT) that may be of use in the diagnosis and treatment of its pathologies. One-hundred human hearts from autopsies were used. The average age of the sample studied was 63.15 years +/- 18.76 (range = 17-94 years). The heart was removed after resection of the costosternum and placed in 10% formaldehyde. With gradual separation and retraction of the myocardial fasciculi the MT was exposed. The length of the MT, the luminal diameter of the MT at its midpoint, and the luminal diameter of the left coronary orifice were measured with a caliper. The angle of division between the anterior interventricular and circumflex branches was also measured, and the number of terminal branches originating from the MT was recorded. In four cases, there was no MT and the anterior interventricular and circumflex branches originated directly from the left aortic sinus. The average length of the MT was 10.8 +/- 5.52 mm (range = 2-23 mm); the average diameter at its midpoint was 4.86 +/- 0.80 mm; and there was no significant difference noted between the midpoint diameter of the MT and the diameter of the left coronary orifice. The most frequent type of division of the MT was bifurcation (62%); in 38% of cases the MT divided into three or more branches. An average value of 86.7 +/- 28.8 degrees was obtained for the angle of division of the terminal branches of the MT (range = 40-165 degrees ). There was a positive correlation between the length of the MT and the angle of division of its terminal branches, with the longest MTs having the largest angle of division.     

Pathology of primary splenic B-cell lymphomas: a review

Splenic B-cell lymphomas comprise a heterogeneous group of entities that either arise in or show a conspicuous involvement of the spleen, usually accompanied by bone marrow and peripheral blood involvement. The lack of lymphoid tissue available for diagnosis due to the decrease in splenectomies is a challenge for the hematopathologist for the correct classification. The current WHO classification recognizes five distinct entities which are systematically reviewed for the practising pathologist.     

Celiac Trunk and Hepatic Arteries: Anatomical Variations of Liver Arterial Supply as Detected with Multidetector Computed Tomography in 1,520 Patients and its Clinical Importance

Hepatic arterial variations are relatively common, but usually overlooked by radiologists, leading to iatrogenic complications or prolonging interventional or surgical procedures. Michels in 1966 classified hepatic arterial variations in 10 categories, based on a cadaveric study. Establishment of multidetector computed tomography (MDCT) provides useful anatomical information. The purpose of our study is to highlight these variations and to propose of a user-friendly algorithm when studying a CT examination. We studied 1,520 contrast-enhanced CTs (16-row MDCT system) during arterial phase and searched for hepatic arteries and celiac trunk (CTr) variations. CT images were postproccessed using multiplanar reconstruction, maximum intensity projection and volume rendering techniques in axial, sagittal, and coronal planes. Our results were organized according to Michels' classification. Normal anatomy was found in 72.89% of the cases and variations classified in Types II–X in 22.24%. However, 4.87% of the cases could not be classified in Michels' types. A single arterial variation was found in 22.89% of the cases and multiple arterial variations were found in 4.21% of the cases. We examined first the aorta for supernumerary branches and then checked the fissure between right and left liver lobe, following porta hepatis, and finally the CTr and superior mesenteric artery. Hepatic arteries and CTr variations are relatively common (27.11%) and should be identified by the radiologists when studying CTs as their recognition provides better surgical planning, preventing iatrogenic complications. Imaging in coronal plane was helpful for end branches, while sagittal plane was better for aortic branches. Clin. Anat., 33:1091-1101, 2020. © 2019 Wiley Periodicals, Inc.