以胰腺为轴心的相关筋膜及安全外科平面解剖研究

目的研究胰十二指肠区域血管的应用解剖、相关系膜及系膜间隙的解剖学特点,观察胰十二指肠区域解剖标志及安全外科平面,为临床上开展胰头及十二指肠、胆总管末端手术提供解剖学基础。方法对7具甲醛固定的成人尸体的十二指肠、胰腺周围供血血管及胆总管下段作了解剖学观察,对横结肠系膜构成的网膜囊及胰腺周围胚胎时期形成的潜在的筋膜间隙和解剖层次标志进行观察描述。结果准确定位胃左动脉和肝总动脉,由胰腺前筋膜形成的肝胰襞及胃胰襞是一个很好的标志。当进行胰腺游离及后方淋巴结清扫时,在胰腺后筋膜及肾前筋膜间有一无血管平面可以应用。肾前筋膜是避免损伤腹膜后血管、肾上腺的安全界面,为避免腹膜后血管及肾上腺的损伤,肾前筋膜应作为安全分离平面的后界。胰十二指肠前后动脉弓及分支主要供应十二指肠降部和水平部的血运,行保留十二指肠的胰头切除术时应注意保护胰十二指肠前后动脉弓。结论充分理解胚胎发育过程胰腺周围筋膜及筋膜间隙的形成,对于手术中正确理解、辨识解剖平面非常重要,沿着筋膜间隙的操作可避免出血及副损伤,也是肿瘤外科根治性切除的基本要求。     

保留十二指肠的胰头切除术实用外科血管解剖学研究

目的研究胰头和十二指肠之间的血管解剖 ,为临床上开展关于十二指肠、胰头以及胆总管末端手术提供解剖学基础。方法对 30例甲醛固定的成人尸体和 10例新鲜尸体的十二指肠、胆总管下段及Vater壶腹的血液供应进行解剖研究。结果十二指肠降部和水平部血运由胰十二指肠前、后动脉弓及分支供应 ;胆总管下段血运主要是由胰十二指肠上后动脉供应 ;Vater壶腹血运主要是由胰十二指肠上后动脉发出的乳头动脉供应。结论胰十二指肠前、后动脉弓是供应十二指肠降部和水平部、胆总管下段和Vater壶腹的主要动脉。在行保留十二指肠的胰头切除术时应注意保护前、后动脉弓。     

Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas.

OBJECTIVE: The authors precisely examined the topography of the duodenum, pancreas, bile duct, and supplying vessels from the perspective of performing duodenum-preserving resection of the pancreatic head. SUMMARY BACKGROUND DATA: Little has been reported regarding the detailed surgical anatomy that is crucial in this procedure. METHODS: The authors precisely examined the local anatomy of the pancreas head and duodenum, using materials from 40 autopsy cases. RESULTS: Arcade formation between the anterior superior pancreaticoduodenal (ASPD) artery and the anterior inferior pancreaticoduodenal (AIPD) artery was found in all of the cases. After departing from the gastroduodenal artery, the ASPD ran toward a point 1.5 cm below the papilla of Vater, then turned to the posterior aspect of the pancreas to joint the AIPD. In 88% of the cases, an arcade was found between the posterior superior pancreaticoduodenal (PSPD) artery and the posterior inferior pancreaticoduodenal (PIPD) artery. The ASPD, AIPD, PSPD, PIPD, or their branches to the duodenum, the bile duct, and the papilla of Vater were not completely buried in the pancreatic parenchyma in any of these cases. Generally, it was easy to dissect the pancreas from the duodenum because of the loose connection. Near the accessory papilla, however, dissection of the vessels was difficult, and the pancreatic parenchyma sometimes was found in the wall of the duodenum. Dissection of the pancreas from the common bile duct and identification of the main pancreatic duct at the junction with the terminal portion of the bile duct were straightforward in all cases. CONCLUSIONS: It may be possible to remove the head of the pancreas while preserving of the vascular arcades and their branches to the duodenum, the bile duct, and the papilla of Vater.     

Embryologic and anatomic basis of duodenal surgery

The following points should be remembered by surgeons (Table 1). In writing about the head of the pancreas, the common bile duct, and the duodenum in 1979, the authors stated that Embryologically, anatomically and surgically these three entities form an inseparable unit. Their relations and blood supply make it impossible for the surgeon to remove completely the head of the pancreas without removing the duodenum and the distal part of the common bile duct. Here embryology and anatomy conspire to produce some of the most difficult surgery of the abdominal cavity. The only alternative procedure, the so-called 95% pancreatectomy, leaves a rim of pancreas along the medial border of the duodenum to preserve the duodenal blood supply. The authors had several conversations with Child, one of the pioneers of this procedure, whose constant message was to always be careful with the blood supply of the duodenum (personal communication, 1970). Beger et al popularized duodenum-preserving resection of the pancreatic head, emphasizing preservation of endocrine pancreatic function. They reported that ampullectomy (removal of the papilla and ampulla of Vater) carries a mortality rate of less than 0.4% and a morbidity rate of less than 10.0%. Surgeons should not ligate the superior and inferior pancreaticoduodenal arteries because such ligation may cause necrosis of the head of the pancreas and of much of the duodenum. The accessory pancreatic duct of Santorini passes under the gastrointestinal artery. For safety, surgeons should ligate the artery away from the anterior medial duodenal wall, where the papilla is located, thereby avoiding injury to or ligation of the duct. "Water under the bridge" applies not only to the relationship of the uterine artery and ureter but also to the gastroduodenal artery and the accessory pancreatic duct. In 10% of cases, the duct of Santorini is the only duct draining the pancreas, so ligation of the gastroduodenal artery with accidental inclusion of the duct is catastrophic. With the Kocher maneuver, surgeons reconstruct the primitive mesoduodenum and achieve mobilization of the duodenum, which is useful for some surgical procedures. Surgeons should not skeletonize more than 2 cm of the first part of the duodenum. If more than 2 cm of skeletonization is done, a duodenostomy using a Foley catheter may be necessary to avoid blow-up of the stump secondary to poor blood supply. Proximal duodenojejunostomy is advised for the safe management of patients with difficult duodenal stumps. Roux-en-Y choledochojejunostomy and duodenojejunostomy divert bile and food in the treatment of the complicated duodenal diverticulum. The suspensory ligament may be transected with impunity. It should be ligated before being sectioned so that bleeding from small vessels contained within can be avoided. Failure to sever the suspensory muscle completely, which is possible if the insertion is multiple, fails to relieve the symptoms of vascular compression of the duodenum (Fig. 18). Mobilization, resection, and end-to-end anastomosis of the duodenal flexure have been performed as a uniform surgical procedure, avoiding the conventional gastrojejunostomy. With a large, penetrating posterior duodenal or pyloric ulcer, surgeons should remember that The proximal duodenum shortens because of the inflammatory process (duodenal shortening) The anatomic topography of the distal common bile duct and the opening of the duct of Santorini and the ampulla of Vater is distorted Leaving the ulcer in situ is wise Careful palpation for or visualization of the location of the ampulla of Vater or common bile duct exploration with a catheter insertion into the common bile duct and the duodenum are useful procedures In most cases, the common bile duct is located to the right of the gastroduodenal artery at the posterior wall of the first part of the duodenum. (ABSTRACT TRUNCATED)     

Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries

BACKGROUND: Pancreaticoduodenectomy (Whipple's procedure) is a formidable procedure when undertaken for severe pancreaticoduodenal injury. The purposes of this study were to review our experience with this procedure for trauma; to classify injury grades for both pancreatic and duodenal injuries in patients undergoing pancreaticoduodenectomy according to the American Association for the Surgery of Trauma-Organ Injury Scale for pancreatic and duodenal injury; and to validate existing indications for performance of this procedure. STUDY DESIGN: We performed a retrospective 126-month study (May 1992 to December 2002) of all patients admitted with proven complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy. RESULTS: Eighteen patients were included; mean age was 32 +/- 12 years (SD), mean Revised Trauma Score was 6.84 +/- 2.13 (SD), and mean Injury Severity Score was 27 +/- 8 (SD). There were 17 penetrating injuries (94%) and 1 blunt injury (6%). One of 18 patients had an emergency department thoracotomy and died (100% mortality); 5 of the remaining 17 patients required operating room thoracotomies, and only 1 survived (80% mortality). There was 1 AAST-OIS pancreas grade IV injury, and there were 17 pancreas grade V injuries and 18 AAST-OIS duodenum grade V injuries. Indications for pancreaticoduodenectomy were: massive uncontrollable retropancreatic hemorrhage, 13 patients (72%); massive unreconstructable injury to the head of the pancreas/main pancreatic duct and intrapancreatic portion/distal common bile duct, 18 patients (100%); and massive unreconstructable injury, 18 patients (100%). Mean estimated blood loss was 6,888 +/- 7,866 mL, and overall survival was 67% (12 of 18 patients). CONCLUSIONS: Complex pancreaticoduodenal injuries requiring pancreaticoduodenectomy (Whipple's procedure) are uncommon but highly lethal; virtually all are classified as AAST-OIS grade V for both pancreas and duodenum. Current indications for performance of pancreaticoduodenectomy are valid and should be strictly applied during procedure selection.     

保留十二指肠的胰头全切术治疗慢性胰腺炎35例报告

目的 总结保留十二指肠的胰头全切术治疗慢性胰腺炎的经验.方法 回顾分析自1999年1月至2006年12月采用保留十二指肠的胰头全切术治疗慢性胰腺炎35例的临床资料,并对患者疼痛改善情况及内分泌功能变化进行随访.结果 平均手术时间为286±55min,平均手术输血量为1.4±1.3单位压积红细胞.无手术死亡.术后并发症发生率为17%,其中1例胰瘘,3例胆漏,1例腹腔出血,1例切口裂开,无十二指肠瘘.术后患者疼痛得到缓解,QLQ-C30疼痛评分由术前的59±27降至术后的13±21.术后患者内分泌功能未继续恶化,随访过程中无新增糖尿病病例出现.结论 保留十二指肠的胰头全切术是一种安全、有效的治疗慢性胰腺炎的手术方式.较之保留十二指肠的胰头次全切除术,本手术能更彻底的切除胰头和钩突的炎性病变.     

胆肠胰结合部及其邻近区域外科手术的改进

目的: 总结几种胆肠胰部新型手术及其疗效 。方法及结果: 分析9例行胆肠胰部手术的特点及疗效。其中胰头部胰管及近邻手术3例;胆总管下端及壶腹部手术3例;十二指肠及近邻手术3例。根据各病例的病理及临床特点,设计并实施相应的新型手术方法,如胰头后侧径路主胰管切开取石术,胰头下部切除、钩突胰管空肠Roux-Y吻合术、经壶腹胆总管末端穿透伤直视下修补术、十二指肠节段切除术等,均获良好疗效 。结论: 本文介绍的新手术方法适合胆肠胰部的特殊病症,可有效预防胰、胆、十二指肠瘘等并发症。     

Pancreatic head resection with second-portion duodenectomy for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head region.

BACKGROUND: Preservation of arterial blood supply to the duodenum and common bile duct during duodenum-preserving total resection of the pancreatic head is a major problem. We describe here a new procedure comprising pancreatic head resection with second-portion duodenectomy to overcome it. METHODS: The procedure was performed in 18 patients with benign lesions, low-grade malignancies, or early stage carcinomas involving the pancreatic head and with carcinoma of the middle bile duct or the gallbladder. The technique preserves the third portion of the duodenum by conserving the anterior inferior pancreaticoduodenal artery. The second portion of the duodenum is divided, followed by division of the lower bile duct and pancreatic neck. After resection followed by duodenoduodenostomy, there is a choice of two procedures: type A, pancreaticoduodenostomy and choledochoduodenostomy; or type B, pancreaticojejunostomy and hepatodochojejunostomy. RESULTS: There were no operative or hospital deaths (type A, 6; type B, 12). Postoperative complications occurred in 2 patients, but the others had an uneventful postoperative course. The quality of life of all patients has been satisfactory up to 36 months postoperatively. CONCLUSION: This procedure is a reliable option as an organ-preserving procedure for benign lesions, low-grade malignancies, and early stage carcinomas involving the pancreatic head.     

保留十二指肠胰头全切除术

保留十二指肠胰头全切除术要点：采用柯克手法将胰头从后腹膜分离,直至见到肠系膜下静脉。沿着肠系膜上静脉解剖直至胰颈。结扎切断Henle静脉干。游离、悬吊胃十二指肠动脉,暴露门静脉。缝扎胰腺上下缘、结扎胰头以减少横断胰颈时的出血。切断胰腺勾突,残端缝扎止血。沿着胰头部实质与十二指肠之间的疏松结缔组织解剖,结扎从胰十二指肠动脉弓到胰头的分支。沿着胰头与胆总管之间解剖。切断主胰管,残端用5/0普理灵线缝扎。胰管空肠吻合采用胰管对粘膜吻合法。     

Pancreatic head resection with segmental duodenectomy for intraductal papillary mucinous tumors of the pancreas

Various modifications of organ-preserving pancreatic resections have been performed for intraductal papillary mucinous tumor (IPMT) of the pancreas. The aim of this study was to evaluate usefulness of pancreatic head resection with duodenal segmentectomy (PHRSD), which is one of the organpreserving pancreatic resections for IPMT. Pancreatic head resection with duodenal segmentectomy was indicated for the branch duct type of IPMT. Eight patients underwent PHRSD. The mean operative time was 390 minutes, and the mean blood loss was 1270 ml. Duodenal ischemia was prevented by preserving the duodenal branches of the gastroduodenal artery and the anterior inferior pancreaticoduodenal artery. Complications occurred in four patients: one with pancreatic leak, one with choledochoduodenal anastomotic stenosis, and two with delayed gastric emptying. However, no deaths occurred. The final pathologic diagnosis was adenoma in seven patients and carcinoma in situ in one patient. Six of eight patients had an adenoma with papillary growth in the main pancreatic duct. Postoperative pancreatic endocrine and exocrine functions were satisfactory. All patients were alive without recurrent disease at a median follow-up of 30 months. Pancreatic head resection with duodenal segmentectomy appears to be a useful procedure as an organ-preserving pancreatic resection for the branch duct type of IPMT, because this procedure allows a safe and complete resection of the pancreatic head without ischemia of the common bile duct and the duodenum.     

Anatomical segmentectomy of the head of the pancreas along the embryological fusion plane: a feasible procedure?

BACKGROUND: Less extensive resection of the head of the pancreas has been the procedure of choice recently for low-grade malignant neoplasms. The anatomical detail of the head of the pancreas is currently insufficient for segmental resection along the embryological fusion plane. METHODS: The anatomy of the head of the pancreas was analyzed in 31 consecutive autopsy specimens. An anterior (n = 10) or posterior (n = 10) segmentectomy of the head of each pancreas was performed along the macroscopically found fusion plane. The pancreatic arteries, the portal vein, the bile duct, and the pancreatic duct were visualized by injecting 3 silicon dyes of different colors. Another 11 specimens were examined by pancreatography before and after anterior (n = 5) or posterior (n = 6) segmentectomy. Eight of these 11 specimens were stained immunohistochemically to reveal the distribution of pancreatic polypeptide cells after segmentectomy. RESULTS: The cleavage between the anterior and posterior segments was discovered at the anterior inferior edge or at the posterior superior edge of the head of the pancreas. Anterior segmentectomy was accomplished while preserving the anterior and posterior pancreaticoduodenal arcades and the lower bile duct in the posterior segment. Posterior segmentectomy involved the removal of the lower bile duct and the posterior pancreaticoduodenal arcades. Pancreatography after segmentectomy showed the division of the ducts of Wirsung and Santorini with the peripheral branches. The immunohistochemical boundary of pancreatic polypeptide cells coincided with the surgical plane. These results showed the anterior and posterior segments were originated from the embryologically dorsal and ventral primordia, respectively. CONCLUSIONS: The current anterior or posterior segmentectomy of the head of the pancreas corresponded to the resection of the embryologically dorsal or ventral primordium, respectively. Anterior segmentectomy of the head of the pancreas might be a clinically applicable procedure; however, posterior segmentectomy involving the resection of the lower bile duct may be impractical.     

Benign extrinsic compression of the common bile duct: a case report

Painless obstructive jaundice is usually the result of malignant compression of the distal common bile duct. Infrequently extrinsic benign lesions may also cause ductal obstruction and be mistaken for a malignant process. A case of compression of the distal common bile duct is described. Preoperative evaluation was most consistent with a cystadenocarcinoma of the head of the pancreas. At operation we found an enlarged and calcified periductal lymph node with associated fibrosis and compression and obstruction of the distal common duct. Massive dilatation of the distal common duct and the cystic duct remnant gave it the appearance of a cystic mass in the superior border of the head of the pancreas. Resection and choledochoduodenostomy were curative.     

Subtotal resection of the head of the pancreas combined with ductal obliteration of the distal pancreas in chronic pancreatitis.

Subtotal resection of the head of the pancreas combined with duct obliteration of the distal pancreas by prolamine was performed in 12 selected patients who had chronic alcohol-induced pancreatitis with most destruction in the proximal pancreas. The main indication for operation was intractable pain. There was no postoperative mortality but morbidity was high when no pancreaticojejunostomy was constructed. After a follow-up period of 32 months, lasting pain relief was obtained in 10 patients; pseudocyst formation occurred in three patients; calcification of the distal pancreas, absent before operation, was demonstrated in four of six patients; six of 11 nondiabetic patients became hyperglycemic either abruptly (1 patient) or progressively (5 patients); quality of life improved in most patients. This procedure preserves the stomach, duodenum, spleen, distal pancreas and common bile duct if possible. However, pancreatic ductal obliteration with prolamine does not prevent relapses of chronic pancreatitis.     

Duodenum-preserving head resection in chronic pancreatitis

A duodenum-preserving head resection was performed in 295 patients with chronic pancreatitis and an inflammatory mass in the head of the pancreas. Ninety-four percent of patients suffered severe pain syndrome, 48% had a common bile duct stenosis, 17% a vascular obstruction in the portal vein and splenic vein branches, and 6% had a severe stenosis of the duodenum. Surgical resection of the inflammatory mass in the head of the pancreas was indicated after a medical treatment of 4.1 years (median). Subtotal resection of the head of the pancreas, including the inflammatory mass, resulted in decompression of the narrowed common bile duct segment, decompression of the pancreatic main duct, and the relief of duodenum stenosis, as well as a relief of portal hypertension. The mean hospitalization time was 13 days, frequency of re-operation 5.8%, and hospital mortality 1.02%. Seventy-nine percent of patients experienced long-lasting pain relief and 11% reported a significant and long-lasting reduction of pain; late morbidity proved to be low. In comparison to the Whipple procedure the duodenum-preserving head resection has the advantage of preserving the stomach, duodenum and biliary tract.     

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。     

机器人胰十二指肠切除术

解剖胰颈下缘肠系膜上静脉，离断胃结肠干，游离十二指肠及胰头，解剖下腔静脉、左肾静脉、肠系膜上动脉并清扫淋巴结。离断空肠、胰十二指肠下动静脉及钩突；解剖变异肝总动脉(起源于肠系膜上动脉)。解剖胰颈上缘门静脉及胆管、离断胃右和胃十二指肠动脉并清扫淋巴结；离断远端胃、胰颈、胆管、切除胆囊。消化道重建：胰管内置硅胶管行内引流；4－0普理灵缝扎胰腺断端，4－0普理灵连续缝合胰腺断端与空肠浆肌层。4－0普理灵行胆肠吻合。胃后壁与空肠用3－0普理灵行连续侧侧吻合。文氏孔及胰肠吻合前置引流管。病理：中分化腺癌，T₂N₁M₀。     

Surgical therapy of inflammatory and malignant strictures of the common bile duct

Although there are growing possibilities of interventional endoscopic treatment of benign and malignant stenosis of the distal common bile duct the definitive operative drainage by terminolateral hepaticojejunostomy is in many cases the therapy of choice. In patients with chronic pancreatitis and bile duct stricture the modified duodenum preserving pancreatic head resection ("Beger operation") enables a resection of the inflammatory mass together with a drainage of the bile. Of 391 patients from our clinic being operated due to a bile duct stricture 337 underwent a biliary drainage together with a pancreatic head resection. Early postoperative biliary complications were in 0.3 % strictures of the duct and 1.5 % bile fistulas. Half of those complications could be managed conservatively. In high volume centers the operative therapy of distal common bile duct stenosis is a safe procedure with high patency rate.     

Resection of the inferior head of the pancreas: Report of a case

We developed a new technique for partial resection of the head of the pancreas with an end-to-side pancreaticoduodenostomy, while preserving the duodenum, the common bile duct, and the upper part of the head of the pancreas around the duct of Santorini. A resection of the inferior head of the pancreas was performed in a patient with an intraductal mucin-producing tumor of the pancreas. This procedure is considered to be appropriate for treating both benign disease and noninvasive malignant disease involving either the uncinate process or the duct of Wirsung, because it removes both the uncinate process and the pancreatic tissue around the duct of Wirsung. We thus believe that a resection of the inferior head of the pancreas with an end-to-side pancreaticoduodenostomy can help play a significant role in the management of patients with benign diseases and localized malignant tumors of the pancreas.     

Recurrence of mucosal carcinoma of the bile duct, with superficial flat spread, 12 years after operation

We report herein a case of recurrent mucosal cancer of the extrahepatic bile duct, with superficial flat spread, 12 years after operation. A 67-year-old woman had undergone common bile duct (CBD) resection and Roux-en-Y reconstruction. Histologically, the tumor was papillary adenocarcinoma, with superficial flat spread, with no invasive component. The epithelium at the distal margin had been exfoliated, so the absence or presence of any remnant cancerous lesion was unclear. But the superficial flat spread had expanded to within at least 3 mm from the distal margin. About 12 years postoperatively, she was hospitalized with upper abdominal pain, and duodenoscopy demonstrated a tumor in the second portion of the duodenum. Biopsy identified adenocarcinoma. Computed tomography showed a low-density mass between the duodenum and pancreatic head. Pancreatoduodenectomy was performed. Histologically, papillary adenocarcinoma was found within the whole of the intrapancreatic bile duct, and its histological appearance resembled that of the original tumor. Moderately differentiated tubular adenocarcinoma had invaded around the tissue of the intrapancreatic CBD. These findings suggest that remnant intramucosal flat carcinoma within the intrapancreatic bile duct had developed into invasive carcinoma over the course of 12 years. This case suggests that remnant intraepithelial flat carcinoma within the CBD may develop a late local recurrence.