直肠系膜的形态学特点及其临床意义

目的：以直肠系膜为中心，探讨直肠癌手术切除术的最佳的解剖层次。方法：应用尸体标本27例、新鲜尸体标本10例、临床取材标本10例，分别进行解剖、测量及灌注。结果：直肠系膜是由直肠周围包裹在盆脏筋膜周围之内的脂肪组织、神经、血管、淋巴管等组成。直肠系膜上端与乙状结肠系膜相连续，下端与直肠肛管相连接，盆腔内的生殖管道，髂内血管，盆自主神经及盆腔侧壁的肌肉均为壁层筋膜覆盖，外面是一层光滑的盆脏筋膜，长8～10cm，宽6～8cm，直视下清晰可见脂肪、毛细血管等。结论：直肠系膜是被盆筋膜脏层完整地包裹着的脂肪、血管和淋巴即称为直肠系膜，是一独立的解剖单位；从常规病理可见直肠系膜是由脂肪、血管和淋巴组织组成；MRI及VCH上直肠系膜清晰可见。     

直肠系膜的形态结构特点及临床意义

目的：明确直肠系膜的内容、形态学特点及毗邻关系。方法：对35具尸体材料进行解剖，运用大体解剖、组织学、透射电镜和核磁共振等方式进行观察、记录。结果：直肠系膜是包绕在直肠周围的血管、淋巴管、神经及脂胁组织，其上端与乙状结肠系膜相延续，下端在直肠肛管连接处明显变薄后止于该处；在直肠的前腹膜反折以上由腹膜覆盖存盆脏筋膜的外面，反折以下盆脏筋膜的前面有Denonvilliers’筋膜，结论：直肠系膜是包绕在袖套样盆脏筋膜之内(包括盆脏筋膜在内)的直肠周围所有血管、淋巴管和淋巴结、神经及脂肪组织等共同构成的独立解剖结构。     

肠系膜巨大淋巴结增生症1例

患者女 ,33岁 ,右上腹隐痛不适 3年 ,1个月前自己扪及中上腹肿块。全身情况好 ,无发热 ,浅表淋巴结及肝、脾无肿大。常规实验室检查均未见异常。Ｂ超示中上腹 5ｃｍ× 7ｃｍ肿块。ＣＴ示肠系膜淋巴源性肿瘤。剖腹探查 ,见肠系膜根部肿块。病理检查　肿块 7ｃｍ× 5ｃｍ× 6ｃｍ、3ｃｍ× 2ｃｍ× 2ｃｍ及 2ｃｍ× 1 5ｃｍ× 1 5ｃｍ 3个 ,包膜完整 ,实性 ,切面均一灰黄色 ,质中。镜检 :大淋巴结内为弥散分布的滤泡样结构 ,滤泡生发中心变小或消失 ,中央由透明变性的小血管穿入 ,外套层明显增厚 ,小淋巴细胞绕中央呈同心圆层状排列 ,形似葱皮…     

多排螺旋CT在检测肠系膜淋巴结中的应用及其意义

目的以健康人群为研究对象,探讨肠系膜淋巴结在薄层螺旋CT图像上的分布特点及其临床意义。方法选择60例健康体检者,其中男性35例,女性25例;年龄26～67岁,平均年龄55岁。用Siemens Definition AS 128层螺旋CT进行腹部扫描,成像参数:120 kV,280 mA,128 i×0.6 mm,0.5 s/r,螺距0.6,扫描层厚、层间距均为8 mm。由3名放射学工作者应用同一图像贮存和传输系统(PACS)工作站阅读所有CT图像,记录所有短轴大于3 mm的肠系膜淋巴结的大小、数目及位置(肠系膜根部、周边肠系膜或右下腹肠系膜区)。结果有54例检测到短轴直径大于3 mm肠系膜淋巴结,其中12例(22.2%)检测到10个以上淋巴结,31例(57.4%)检测到5个以上淋巴结,其余11例(20.4%)检测到5个以下淋巴结。同时所有体检者都检测到多个短轴直径小于3 mm的肠系膜淋巴结,短轴直径多为2 mm左右。在所有检测到的淋巴结中,最大淋巴结直径范围为5.4～9.2 mm,平均直径范围为3.5～6.5 mm。54例中,肠系膜根部发现较多淋巴结者25例(46.3%),右下腹肠系膜区22例(40.7%),肠系膜周边部7例(13.0%)。结论128层螺旋CT能检出更多、更小的肠系膜淋巴结。这些淋巴结直径可小于3 mm。在健康人群中发现这些淋巴结,无临床意义,不需要进一步的影像学检查及临床治疗。     

人胎儿期肠系膜淋巴结内T,B淋巴细胞分布的免疫组织化学研究

收集１８例第１２－４０周人胎儿肠系膜淋巴结，用免疫组织化学技术，观察了Ｔ、Ｂ淋巴细胞的分布。结果显示：ｓＩｇＭ和Ｋａｐｐａ轻链阳性Ｂ细胞主要分布在淋巴结的皮质部。Ｔ细胞分布较广泛，除融皮质区和皮质浅层外，还大量集中在髓质部。第２９周后，洒巴结、Ｂ细胞在皮质部已形成初级淋巴小结，但无生发中心和浆细胞。淋巴结内的毛细血管后微静脉随胎龄的增长而增多，其意义可能与介导淋巴细胞进入淋巴结内Ｔ、Ｂ细胞的分布区     

大鼠肠系膜淋巴结高内皮微静脉内蛋白多糖的分布

目的　研究蛋白多糖在大鼠肠系膜淋巴结高内皮微静脉(HEVs)中的分布,探讨蛋白多糖在淋 巴细胞归巢过程中的调节作用。方法　阳性胶体铁染色—酶连续阻断法,光镜和电镜观察蛋白多糖于HEVs 内的淋巴细胞、内皮细胞、基膜上的分布。结果　HEVs的基膜和邻接基膜的淋巴细胞胞膜呈强阳性染色,能 被透明质酸酶、肝素酶、软骨素酶ABC阻断;电镜显示,胶体颗粒主要排列于基膜的内、外侧及穿越基膜的淋 巴细胞胞膜上,内皮细胞、穿内皮细胞的淋巴细胞和腔内的淋巴细胞不着色。结论　蛋白多糖于大鼠肠系膜 淋巴结HEVs内主要分布于基膜和穿基膜的淋巴细胞胞膜上,可能对归巢淋巴细胞穿越HEVs管壁有调节作 用。     

直肠系膜临床解剖学的研究与进展

BACKGROUND: Currently, it is still controversial about the border, surrounding fascia, space of pelvic cavity, distribution of nerves and lymph nodes of the mesorectum, and the development of new technologies makes a progress in related anatomic research. OBJECTIVE: To summarize the previous studies so as to describe clearly the progress of mesorectal anatomy and to discuss its clinical value. METHODS: Using “rectum; mesentery; fascia; space; nerve; lymph node; total mesorectal excision (TME); clinical anatomy” as key words, a computer-based search of PubMed was done for articles related to the mesorectum and surrounding fasciae, space of pelvic cavity, distribution of nerves and lymph nodes. RESULTS AND CONCLUSION: Fresh or frozen specimens are often used for studying the mesenterium, fascia, nerves and lymph nodes by using traditional pelvic and perineum anatomical methods. Computer-assisted anatomical dissection can combine immunostaining with computer imaging. A three-dimensional model can well reflect the relationship among the different anatomical structures, as well as nerve traveling and spatial location. Mesorectum is located behind the denonvilliers and in the front of the sacral fascia of the rectum. Pelvic splanchnic nerve of the mesorectum is derived from the anterior sacral nerve root, runs through the presacral fascia, and enters into the neuro-fascial layer via the pesacral space, which is divided into the upper and lower parts according to the peritoneum. There are more folds in the rear of lymph nodes within the mesorectum within and near the peritoneum. There are still a lot of controversies about anatomical relationship between the mesorectum and surrounding structures, and to elaborate these issues can provide an objective basis for guiding clinical work.      

卵巢癌腹膜后淋巴结转移的特点及其临床意义

目的：研究卵巢上皮性癌淋巴结转移的解剖学和生物学特点及临床合理治疗。方法：40例Ⅰ期卵巢癌根据清除淋巴结与否分成A、B两组；40例Ⅲ-Ⅳ卵巢癌清除淋巴结20例为C组、不清除淋巴结20例为D组，C、D两组减瘤术后残余癌灶均2cm。化疗方法，药物及其剂量基本相同。结果：A组3例腹主动脉旁淋巴结转移者合并盆腔淋巴结转移2例，单纯盆腔淋巴结转移1者，共4例淋巴结转移，转移率20％。A、B两组5年生存率各为95％与80％。C组腹主动脉旁淋巴结转移10例中合并盆腔淋巴结转移9例，单独盆腔淋巴结转移2例，转移率为60％（12／20）。C、D两组5年生存率各为55％与15％。5年生存率A、B两组差异有显著意义（P〈0．05），C、D两组差异有极显著意义（P〈0．001）。结论：卵巢癌淋巴结转移率，随期别而升高，腹主动脉旁与盆腔淋巴结转移率几乎相等，但腹主动脉旁淋巴结转移是主要路线。恰当清除淋巴结可以提高生存率。     

晚期结肠癌病人肠系膜淋巴结高内皮微静脉超微结构观察

目的：探讨晚期结肠癌病人肠系膜淋巴结内高内皮微静脉超微结构的变化及其对淋巴细胞进入肠系膜淋巴结的影响。方法：采用透射电镜观察晚期结肠癌病人肠系膜淋巴结内高内皮微静脉的超微结构。结果：晚期结肠癌病人的肠系膜淋巴结内，高内皮微静脉管壁内皮细胞的细胞核出现大量齿状切迹，细胞膜出现大量脂状突起。质膜小泡，AWeibel-Palade小体，高尔基复合体减少，线粒体多出现肿胀，扩张，部分基膜不完整。高内皮微静脉管壁内少见淋巴细胞穿越。结论：晚期结肠癌病人肠系膜淋巴结内，高内皮微静脉的超微结构受到不同程度的影响和破坏，导致淋巴细胞进入肠系膜淋巴结的能力减弱。     

直窦的形态及其临床意义

解剖观测了１００例（男５７、女４３）成人硬脑膜标本。结果如下：１．按直窦前后走行方向，将其分为４种类型：①前后水平型，占６２％；②前高后低型，占１９％；③前低后高型，占１２％；④弯曲型，占７％。２．直窦平均长度３．８０±０．４６ｃｍ，宽平均０．３６±０．１１ｃｍ。３．单直窦占９３％；双直窦占７％。４．本文还对直窦属支与侧支循环径路以及直窦和硬脑膜动静脉瘘等与临床有关的内容进行了讨论。     

全直肠系膜切除相关盆自主神经的解剖学观察

目的：阐述全直肠系膜切除术相关盆自主神经的局部解剖学特点，探讨盆自主神经保留的部位和对策。方法：对20具男性盆腔固定标本进行解剖观察。结果：腹主动脉丛远离肠系膜下动脉起点；上腹下丛贴近骶岬表面；腹下神经部分毗邻输尿管；盆内脏神经伴行直肠中动脉外侧部；下腹下丛位于直肠系膜后外侧；其直肠侧支走行于直肠侧韧带内，直肠前支向前穿过Denonvilliers筋膜后叶；勃起神经位于Denonvilliers筋膜前叶外侧部。结论：盆自主神经保留的部位是：离断肠系膜下血管时的腹主动脉丛左干，直肠后分离时的上腹下丛和腹下神经，直肠侧面分离时的下腹下丛和盆内脏神经，直肠前分离时的勃起神经。共同原则是：在直肠后间隙中贴近直肠系膜操作；直视下操作；避免过度牵引直肠系膜。     

Anatomical analysis of gastric lymph nodes in cancer–free individuals

Lymphadenectomy is a crucial part of the surgical therapy for gastric cancer. The number of normal lymph nodes could indicate the number of nodes that need to be retrieved during the procedure. The aim of this study is to analyze the number of lymph nodes in cadavers without gastric cancer according to the Japanese Gastric Cancer Association guidelines. Twenty fresh adult cadavers (14 males, mean age 55, range 24–93 years) were used. Abdominal lymph nodes were dissected and classified according to the Japanese Gastric Cancer Association. For total gastrectomy, the median number of lymph nodes that comprised D1 + dissection was 27 (range 15–42). The median and mean number of lymph nodes that comprised D2 dissection was 33, ranging from 18 to 50. For distal gastrectomy, the D1 + level comprised a median of 21 lymph nodes (range 11–38), and the D2 level 22 lymph nodes (range 11–39). In conclusion, considering gastrectomy + D2 lymphadenectomy as the standard treatment for gastric cancer, our results show that adequate lymphadenectomy must encompass around 30 lymph nodes. Clin. Anat., 2018. © 2018 Wiley Periodicals, Inc.     

影响直肠癌全直肠系膜切除术预后因素

目的：探讨影响直肠癌全直肠系膜切除术预后的主要因素.方法：选取2000年7月至2002年6月间的102例行直肠癌全直肠系膜切除术的病人作为研究对象,回顾性分析病人临床资料.结果：102例行直肠癌全直肠系膜切除术的病例,失访4例,失访率为3.9%,现存活96例,10例术后复发和转移,复发率为10.2%,91例术后性生活无显著障碍,99例泌尿功能基本正常.结果表明影响直肠癌全直肠系膜切除术预后存在因素.结论：直肠癌全直肠系膜切除术可以减少术后复发和转移,减少患者术后泌尿和性功能方面的并发症,可提高病人生活质量的保证.     

An enzyme histochemical study of the sinuses of reactive lymph nodes

The enzyme histochemistry of the cells lining and within the marginal and medullary sinuses of twenty human reactive lymph nodes has been studied. The sinuses contain luminal ('reticular') cells which are strongly positive for certain hydrolytic enzymes, including acid-alpha-naphthyl acetate esterase, acid phosphatase and beta-glucuronidase. In addition, the lining ('littoral') cells on both sides of the medullary sinuses are positive for these enzymes. In contrast, enzyme-containing lining ('littoral') cells of the marginal (subcapsular) sinuses are observed only on the inner aspect of the sinuses, the outer aspect being negative. Alkaline phosphatase is not present in the sinusoidal cells but 5'-nucleotidase is seen in varying amounts. These findings are supported by an ultrastructural study of three of the nodes, using a staining method for esterase activity. The different enzyme histochemical properties of the littoral cells in the marginal and medullary sinuses closely mirrors that observed when, for example, these structures are stained immunohistochemically for IgA or J chain.     

Intraoperative blood loss during surgical treatment of low-rectal cancer by abdominosacral resection is higher than during extra-levator abdominosacral amputation of the rectum

Introduction

Abdominosacral resection (ASR) usually required blood transfusions, which are virtually no longer in use in the modified abdominosacral amputation of the rectum (ASAR). The aim of this study was to compare the intra-operative bleeding in low-rectal patients subjected to ASR or ASAR.

Material and methods

The study included low-rectal cancer patients subjected to ASR (n = 114) or ASAR (n = 46) who were retrospectively compared in terms of: 1) the frequency of blood transfusions during surgery and up to 24 h thereafter; 2) the volume of intraoperative blood loss (ml of blood transfused) during surgery and up to 24 h thereafter; 3) hemoglobin concentrations (Hb) 1, 3 and 5 days after surgery; 4) the duration of hospitalization.

Results

Blood transfusions were necessary in 107 ASR patients but in none of those subjected to ASAR (p < 0.001). Median blood loss in the ASR group was 800 ml (range: 100–4500 ml). The differences between the groups in median Hb determined 1, 3 and 5 days following surgery were insignificant. The proportions of patients with abnormal values of Hb, however, were significantly higher in the ASR group on postoperative days 1 and 3 (day 1: 71.9% vs. 19.6% in the ASAR group, p = 0.025; day 3: 57.% vs. 13.0%, p = 0.009). Average postoperative hospitalization in ASR patients was 13 days compared to 9 days in the ASAR group (p = 0.031).

Conclusions

Abdominosacral amputation of the rectum predominates over ASR in terms of the prevention of intra- and postoperative bleeding due to the properly defined surgical plane in low-rectal cancer patients.     

The routine histological investigation of axillary lymph nodes for metastatic breast cancer

A simple method of preparing axillary nodes from breast cancer patients for routine histology is presented. It is based on appreciation of nodal anatomy and the pathophysiology of tumour growth in them. Current methods assume that the latter is a random process, but this is not so. It has long been known that tumour cells enter via the afferent lymphatics. They may also exit by the efferent. It has not been generally realized that these vessels enter/leave the node in the same plane of section, or that a section in this plane, a hilar section, is theoretically the one of choice for the identification of tumour cells in the node. It is shown here that use of hilar sections alone allows the identification of tumour-free and tumour-bearing nodes, as well as the tumour status of the efferent vessels, with considerable certainty. The use of random sections, in contrast, carries a high risk of false negative reporting.     

Number and size of perigastric lymph nodes in human adults without gastric cancer

Summary For classification of perigastric lymph node metastases in gastric cancer, only topographical aspects are taken into consideration at present. As a numerical classification for lymph node metastases was proposed recently, the current problem is that of determining the number of dissectable perigastric lymph nodes and also assessing the quality of nodal dissection. The perigastric lymph nodes of 10 adults without gastric disease were therefore evaluated microscopically by a serial section technique. On average a total of 36.2±15.2 perigastric lymph nodes were found, e.g. 14.9±14.1 lymph nodes on the greater and 7.4±4.8 on the lesser curvature. These figures are similar to those in fetuses and newborn infants, but they exceed the numbers of perigastric lymph nodes reported in the literature for adults with or without gastric cancer. This difference could be attributable to our use of the serial section technique, because the so-called micro-lymph nodes with a diameter of less than 1.5 mm are consequently included in this study. Our results support the assumption, that pathologic processes do not result in any real increase of regional lymph nodes, but in an activation and enlargement of fetal lymph node reserve.Dedicated to Prof. Hort on the occasion of his 65th birthday     

Tumour regression and mesorectal lymph node changes after intensified neoadjuvant chemoradiation for carcinoma of the rectum

Neoadjuvant radiation or chemoradiation is currently the treatment of choice for patients with locally advanced carcinoma of the rectum. To assess the effects of chemoradiation on tumour regression and on uninvolved mesorectal lymph nodes, a consecutive series of 76 patients receiving neoadjuvant chemoradiation and a stage-adapted control series of 57 patients without pretreatment were studied. Densities of cells positive for CD4 (T-helper cells), CD8 (cytotoxic T-cells), CD83 (mature dendritic cells), and CD57 (natural killer cells) were determined on immunostains. Tumour regression was graded, and presence or absence of extramural tumour was recorded. The densities of CD4+ T-lymphocytes and CD83+ dendritic cells in the paracortex of mesorectal lymph nodes were observed to be significantly reduced, as were the densities of CD57+ cells in the follicles; densities of CD8+ T-lymphocytes did not differ. Strong, moderate and poor tumour regression was observed in 29, 25, and 22 cases, respectively. For 12 patients, absence of extramural vital or regressing tumour was recorded, indicating pretherapeutic overstaging. The results bring to mind that neoadjuvant chemoradiation as a side effect may have a negative impact on anti-tumour immunity. Together with the drawback of overstaging the results argue for a careful selection of patients.