十二指肠大乳头血供的临床解剖学研究

目的　为内窥镜下十二指肠乳头括约肌切开术( EST) 与内镜乳头气囊扩张术 (EPBD)取结石术提供形态学依据。 方法　(1)20例乳胶动脉血管灌注胰腺十二指肠标本,解剖观测十二指肠大乳头血供的来源、数量,营养血管起始处直径、至Vater壶腹和十二指肠大乳头开口的距离。前、后弓最凸处与十二指肠内缘、肝胰壶腹、十二指肠大乳头的距离。(2)按胰十二指肠正常解剖学位置摆放,以十二指肠大乳头的开口为圆心,十二指肠大乳头背面纵轴为12~6点轴,横轴为9~3点轴,顺时针依次定点,观察动脉分布特点。 结果　(1) 胰十二指肠前、后动脉弓各发出2支营养血管至十二指肠大乳头。前弓2支血管起始处直径分别为（1.3±0.1、1.0±0.2）mm,至Vater壶腹和十二指肠大乳头开口的距离分别为（5.7±0.6、6.0±0.4）mm、（16±0.9、16±1.5）mm。后弓2支血管起始处直径分别为（0.62±0.02、0.98±0.06）mm,至Vater壶腹和十二指肠大乳头开口的距离分别为（20±1.5、16.4±0.4）mm、（25±1.2、19.2±0.6）mm。前、后弓最凸处与十二指肠内缘、肝胰壶腹的距离分别为（4.05±0.1、3.1±0.15）mm、（10.5±1.5、13.2±1.6）mm。(2)十二指肠大乳头前壁第1支血管位于9~10点钟方位,第2支位于2~3点钟方位;后壁第1支动脉血管位于8~9点钟方位,第2支位于4~5点钟方位;8~10点钟方位血管最集中,2~5点钟方位血管次之,11~1、6~7点钟方位血管供应最少。 结论　临床EST Oddi括约肌切开和EPBD取结石时,易损伤十二指肠大乳头血管,需小心保护。EST可在11~1或6~7点钟方位行乳头切开。     

对十二指肠乳头旁憩室形成原因的探讨

目的:探讨十二指肠乳头旁憩室形成的原因.方法:随机选择100例十二指肠-胰标本,发现有乳头旁憩室的标本26例,无乳头旁憩室的标本74例,将26例有乳头旁憩室标本和随机选择的26例无乳头旁憩室标本作为观测对象,对其十二指肠降部、胆总管-胰管汇合部及汇合部穿肠处左侧的胰腺组织进行观测.结果:有乳头旁憩窜标本与无乳头旁憩室标本,在十二指肠大乳头处的肠管周经分别是(110±13.4)、(88.4±8.61)mm,在下曲处的肠管周经分别是(73.3±5.52)、(83.2±6.01)mm;在胆总管-胰管汇合部穿肠处胆总管-胰管汇合部的周经分别是(22.4+1.72)、(16.8±1.32)mm;在胆总管-胰管汇合部的前面,胰腺组织的厚度分别是(4.33±0.82)、(9.13±2.24)mm.结论:十二指肠乳头旁憩室形成的主要原因是十二指肠下曲较细、胆总管-胰管汇合部较粗大及在憩室发生处的左侧胰腺组织较少.     

先天性空肠间隔症二例

经手术证实先天性空肠间隔症2例.1 女性,距Treitz韧带(十二指肠悬肌)10cm处空肠有一狭窄环,小指尖不能通过且有紧砸感,近端胃肠扩张.远端肠管空虚.于狭窄处纵剖肠壁,见腔内系膜侧有瓣膜状物堵塞肠腔4/5.2 男性,距Treitz韧带(十二指肠悬肌)10cm处空肠有一缩窄环,纵形剖开,见腔内一环形隔膜,厚2mm,中央孔径5mm.     

成年中国人第5腰椎峡部Micro CT扫描的显微影像特点

背景：目前国内外学者对成年中国人第5腰椎峡部作了大量的应用解剖学研究,但研究结果各不相同,并且观测参数不系统、不完整,而对成年中国人第5腰椎峡部进行较系统的临床应用解剖与Micro CT扫描显微影像解剖对照研究国内外文献未见报道。 目的：观测成年中国人第5腰椎峡部Micro CT扫描显微影像解剖学及应用解剖学特点,以期为成年中国人第5腰椎峡部易患病性提供形态学依据。 方法：实验从成都医学院局解实验室随机选取60例成年中国人干燥、无破损第5腰椎标本,应用游标卡尺测量第5腰椎峡部的相关数据,并应用Micro CT的三维重建系统分析第5腰椎标本三维骨结构,并逐一测量与第5腰椎左、右侧峡部临床应用解剖观测的指标相对应的Micro CT扫描显微影像解剖参数。 结果与结论：在成年中国人第5腰椎标本观测： ①左、右侧峡部上缘厚度分别为(4.27±0.99) mm,(4.25± 0.98) mm。②左、右侧峡部下缘厚度分别为(7.31±1.23) mm,(7.29±1.25) mm。③左、右侧峡部内缘厚度分别为(6.61±0.33) mm,(6.59±0.36) mm。④左、右侧峡部外缘厚度分别为(8.65±0.27) mm,(8.59±0.33) mm。⑤左、右侧峡部上下缘距离分别为(11.10±3.14) mm,(11.07±3.11) mm。⑥左、右侧峡部上缘长度分别为(8.37±0.99) mm,(8.40±0.96) mm。⑦左、右侧峡部下缘长度分别为(4.71±0.71) mm,(4.73±0.62) mm。⑧左、右侧峡部内缘长度分别为(13.01±1.38) mm,(13.04±1.36) mm。⑨左、右侧峡部外缘长度分别为(10.75±1.11) mm,(10.78±1.06) mm。游标卡尺与Micro CT所测的第5腰椎峡部左右侧的三维数值之间均差异无显著性意义。结果证实,对成年中国人第5腰椎峡部临床应用解剖测量值与Micro CT测量值之间具有统一性,左右侧腰椎峡部解剖值没有差异,Micro CT能为临床上第5腰椎的易患病性提供更为详尽准确的参考数据。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程全文链接：     

十二指肠乳头肿瘤局部切除术应用解剖

目的：为十二指肠乳头部肿瘤局部切除术提供解剖学资料。方法：50例正常成人腹部标本，解剖观测胆总管、胰管、肝胰壶腹和乳头区长度、宽度，胆总管与胰管的夹角，肝胰壶腹区的血管分布，十二指肠大乳头位置、乳头小孔开口位置、胆胰管开口形式等。结果：肝胰壶腹和十二指肠乳头区的营养动脉平均为2．2支，均来源于胰十二指肠上动脉、下动脉，其中肝胰壶腹和十二指肠乳头区9—12点钟处的营养动脉出现率为45．9％（50支）。胆总管、胰管、壶腹末端的长度分别为（32．1±8．7）mm、（9．9±4．1）mm、（12．6±2．8）mm；宽度分别为（7．3±2．1）mm、（3．2±0．7mm）、（7．3±1．2）mm。胆总管和胰管之间的夹角平均为35．6°。十二指肠大乳头位于十二指肠降部上1／3段占8．45％±4．39％，中1／3段占72．33％±6．72％，下1／3段占19．22％±4．12％；乳头小孔开口于十二指肠纵襞占74．3％±6．68％。有十二指肠小乳头占41．43％±3．65％。胆胰管开口呈V型占37．1％±7．43％，Y型占62．9％±6．32％。结论：本实验结果为临床在十二指肠乳头部肿瘤切除过程中选择切开部位和切开深度等提供了解剖学依据，对防止术后并发症具有重要意义。     

十二指肠小乳头的应用解剖

目的：为内镜下副胰管插管、十二指肠小乳头切开等提供解剖学基础。方法：在30例成人尸体上对十二指肠小乳头的形态、位置、开口以及与大乳头之间的关系进行解剖观察。结果：十二指肠小乳头的出现率为70%。可见明显开口的占55%。小乳头形态有半球形、圆锥形、半颗粒形、扁平形和不规则形。小乳头距离幽门、十二指肠第一环、大乳头的距离分别为(58．69±15．74)mm,(23．21±8．82)mm和(22．75±6．81)mm;大、小乳头开口连线与十二指肠纵襞纵轴线的夹角为(20．80±9．40)°。结论：十二指肠小乳头的出现率与副胰管的发育程度相关,本文结果为内镜下行十二指肠小乳头插管和小乳头切开术提供了参考。     

膝降血管髌下支蒂股骨内侧髁骨膜瓣逆行转位术的应用解剖

目的　为膝降血管髌下支蒂股骨内侧髁骨膜瓣修复膝关节面缺损提供解剖学基础。 方法　在30侧动脉内灌注红色乳胶的成人下肢标本上,以收肌结节、股骨内侧髁为观测点解剖观测膝降动脉关节支的走行、分支与分布。另在1侧新鲜标本上进行摹拟手术。 结果　膝降血管关节支在距股骨内侧髁下缘上(5.9±1.2) cm处发出两大分支：①骨膜支起始外径（1.3±0.2）mm,在股骨内侧髁面上走行距离为(4.8±1.1) cm;②髌下支起始外径为(1.3±0.2) mm,向下走行距离为(6.6±1.5)cm。 结论　可形成膝降血管髌下支-骨膜支蒂股骨内侧髁骨膜瓣逆行转位修复膝关节面缺损。     

腰椎峡部四边长度厚度的测量及临床意义

目的　测量腰椎峡部四边长度及厚度，为椎板截取回植固定及“工”型钛板的设计提供解剖学依据。 方法　选取成人男性腰椎干燥骨32例，排除外观畸形和破损，游标卡尺及分规分别测量L1～L5峡部四边长度及厚度，并对其进行分析。 结果 （1）腰椎峡部上缘A长度范围L2:（6.47±0.90）mm~L5:（8.38±0.98）mm，L2~L5逐渐增加；腰椎峡部下缘C长度范围L1: （7.86±0.93）mm~L5:（4.77±0.64）mm，L1~L5逐渐减小;腰椎峡部内缘D长度范围L1:（19.07±0.86）mm~L5:（12.92±1.40）mm，L1最长，L5最短；腰椎峡部外缘B长度范围L3:（11.24±0.80）mm~L4:（9.87±0.65）mm，L3最长，L4最短。(2)外缘与上缘交点E厚度范围L1:（6.10±0.23）mm~L3:（7.53±0.35）mm，L3最厚，L1最薄；上缘与内缘交点F厚度范围L1:（5.10±0.25）　mm~L3: （6.41±0.27）mm，L3最厚，L1最薄;下缘与内缘交点G厚度范围L1:（7.51±0.42）mm~L5:（6.25±0.27）　mm，L1~L5逐渐变薄；外缘与下缘交点H厚度范围L1:（8.59±0.30）mm~L5:（10.11±0.35）mm，L1~L5逐渐增厚。 结论 为腰椎间盘突出症等椎板截骨回植术确定了最佳截骨部位：距腰椎峡部外缘3~4 mm，与内外缘平行；设计的“工”型钛板厚度1.2 mm，上边长9 mm，下边长10 mm，高度10 mm；微型螺钉长度为6、8、10、12 mm四种规格，直径2 mm。     

基于CT三维重建的中国人喙突形态学测量及临床意义

目的 通过对肩胛骨CT扫描三维重建,了解喙突的解剖形态学特点,为临床上相关疾病诊断和治疗提供解剖学依据。 方法 选取西南医科大学附属中医医院,因病情需要对肩胛骨行CT三维重建的256例患者影像学资料,并测量喙突相关解剖学数据,并进行对比和分析。 结果 统计了256例喙突三维重建模型的解剖学数据,测得喙突尖部的宽度为（14.31±2.71）mm,尖部的厚度为（8.79±1.44）mm,折返部的宽度为（22.87±2.82）mm,折返部的厚度为（14.68±2.39）mm,基底部的宽度为（26.29±3.05）mm,基底部的厚度为（10.71±3.01）mm,尖部到折返部的长度为（40.49±4.10）mm,折返部到基底部的长度为（19.36±2.35）mm。且在左右对比中发现,喙突尖厚度、折返部宽度、折返部到基底部长度差异存在显著性（P<0.05）,而喙突的其他解剖形态差异无统计学意义（P> 0.05）。 结论 CT三维重建能够全面准确地观察到喙突的解剖学结构,提供喙突解剖学参数。     

肩峰及喙肩韧带的测量及其临床意义

目的 　通过测量成人肩峰的长度、宽度和厚度以及喙肩韧带在肩峰止点处的宽度和厚度,为临床应用提供形态学基础。 方法　选取36个新鲜成人冷冻肩关节标本,分别进行CT扫描,并将扫描数据导入Mimics15.0软件中,重建肩胛骨,使用软件自带工具测量肩峰的长度、宽度和厚度。然后解剖喙肩韧带,用游标卡尺测量其在肩峰止点处的宽度和厚度。 结果　肩峰的长度为(46.27±2.88)mm,宽度为(25.71±1.52)mm,厚度为(8.10±1.14 )mm ;喙肩韧带在肩峰止点处的宽度为(14.27±1.19)mm,厚度为(4.05±0.38)mm。 结论　喙肩韧带和肩峰的解剖学数据,可以为肩关节疾病的临床诊疗提供帮助。     

原发性十二指肠癌 46 例内镜诊断及病理组织分析简

目的提高原发性十二指肠癌的诊断水平。方法选择46例原发性十二指肠癌患者,其中男性26例．女性20例：年龄31-71岁,平均年龄62_3岁。行内镜诊断和病理活组织检查或术后病理组织检查。回顾性分析其临床、内镜及病理学关系。结果46例十二指肠癌发生于十二指肠球部9例,水平部5例．乳头部30例．乳头下段2例。病理活组织检查或术后病理学诊断示中分化腺癌8例,低分化腺癌26例．印戒细胞癌10例．未分型2例。结论临床应提高对原发性十二指肠癌的警惕性;原发性十二指肠癌以十二指肠乳头部好发,病理分型以腺癌为主,诊断首选上消化道内镜及活组织检查,内镜操作时应尽可能观察到十二指肠降部以下,特别应注意观察乳头部。对十二指肠球部溃疡反复治疗效果不佳者,应提高警惕,及时进行活组织检查。手术切除尤其是胰十二指肠切除术是最常用、最可靠的治疗方法。     

Primary adenocarcinoma of the minor duodenal papilla

A 70-year-old man was admitted to our institution due to aggravation of blood-sugar level control and because an abdominal CT showed dilatation of the main pancreatic duct. Upper gastrointestinal endoscopy revealed a flat elevated tumor with central ulceration in the second portion of the duodenum. Subsequent duodenoscopy for a more detailed examination showed that the tumor had originated in the minor duodenal papilla. A biopsy specimen showed moderately differentiated adenocarcinoma. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a slightly dilated main pancreatic duct and obstruction of the accessory pancreatic duct. Endoscopic ultrasonography showed a hypoechoic mass in the minor duodenal papilla with retention of the muscularis propria of the duodenum. These findings suggest that the tumor existed only to a limited extent in the minor duodenal papilla, and that the tumor did not infiltrate into the pancreas. For treatment, pylorus-preserving pancreatoduodenectomy was performed, and histological findings revealed a well-differentiated adenocarcinoma that originated in the minor duodenal papilla. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. Our case is the first report of primary adenocarcinoma of the minor duodenal papilla at an early stage with no infiltration into muscularis propria of the duodenum and pancreas.     

Influence of bile and pancreatic secretions on the size of the intestinal villi in the rat

Along the rat small intestine, the size of the villi gradually decreases from a maximum in the duodenum to less than half of this size in the terminal ileum. In previous work, various villus enlarging and reducing factors present in the intestinal chyme were found to control villus size. A villus enlarging factor which appeared to reach the intestine through the duodenal papilla was presently investigated. Transplants of duodenal papilla, together with a small segment of the duodenum, were made to isolated ileal segments and to the lower ileum. At both sites, the transplants elicited a marked villus enlargement within a month. A previous finding was that villus size decreased in isolated duodenal segments unless the duodenal papilla was present. In the next experiments, the bile-drainage was diverted from the duodenal papilla by implanting the bile duct into an isolated ileal segment which in turn was joined to the colon. The duodenal papilla which now transmitted only pancreatic secretions was then transplanted to the ileum. The bile caused only moderate villus enlargement in the ileal segments whereas marked villus enlargement took place in the ileum receiving the pancreatic secretions. It was concluded that a villus enlarging influence reached the intestine through the duodenal papilla. The pancreatic secretions appeared to play a major role in this influence.     

胎儿胰胆管解剖研究

目的：探讨胎儿胰胆管合流的类型及十二指肠乳头的形状和位置。方法：选取经水囊引产死后6h内的新鲜胎儿36例,胎龄4月～9月。切取包括胆囊、胆总管、十二指肠、胰腺的标本,观察十二指肠乳头的位置、形状。再置于福尔马林中24h,脱水、透明、浸腊、包埋。组织块以乳头为中心,横行连续切片,厚6μm,每隔5张选1张,作HE染色。显微镜下观察胰胆管合流的类型。结果：(1)十二指肠大乳头半球形58.1% (21例),圆柱形25% (9例),扁平形16.9%(6例)3种形态。乳头位于十二指肠降部上1/3部8.3% (3例),中1/3部69.4% (25例),下1/3部19.4% (7例),远部2.9% (1例)。(2)存在U、V、Y和异常合流4种胰胆管合流方式,其中以Y型66.7% (24例),V型19.4%（7例）,U形11.1%（4例）,APBDU2.8%（1例）。结论：乳头形态位置及胰胆管合流的类型变化较多,了解这一解剖在临床有重要的意义。     

The anatomical study on the rat pancreas and its ducts with emphasis on the surgical approach.

It was intended to present information about the anatomy of the pancreas and especially to emphasize the variation of pancreatic ducts in the rat, which may guide researchers in experimental studies. In 27 adult rats, latex dye was introduced into the biliopancreatic duct, portal vein and arteries. The pancreas with the neighboring structures was studied with the aid of the dissection microscope and measurements were by means of micrometric ocular. The pancreas was divided into three parts i.e. the biliary, duodenal and gastrosplenic portions. The biliopancreatic and pancreatic ducts as well as biliary and duodenal portions of the pancreas could be seen ventrally with a minor procedure such as pulling the duodenum caudally, and additionally the entire pancreas and its ducts could also be reached dorsally since the stomach was turned cranially with the duodenum. The biliopancreatic duct diameter and length of the ducts were 1.01+/-0.03 and 28.86+/-0.59 mm, respectively. The anterior pancreatic duct originated from the biliopancreatic duct on different sides, 17.96+/-0.75mm away from the duodenal papilla. The anterior pancreatic duct drained the gastrosplenic portion of the rat pancreas and this duct, via the duodenal duct, partially collected secretion of the duodenal portion at a ratio of 74.07%. The posterior pancreatic duct opened to the biliopancreatic duct and its distance from papilla duodeni was changed from 0 to 8 mm. When the biliopancreatic duct is ligated at the level of the duodenal opening, the posterior pancreatic duct or a small duct from duodenal portion should be taken into consideration because these ducts opened to biliopancreatic duct at the level of papilla duodeni at a ratio of 37.04%. In conclusion, the duct system of pancreas had a great variation and therefore the success rate of the surgery could be increased when surgeons have more knowledge on variations of the duct system in this region.     

Anatomical and neuropeptidergic properties of the duodenal neurons projecting to the gallbladder in the golden hamster

This study investigated the anatomical and neuropeptidergic properties of the duodenal neurons projecting to the gallbladder in the golden hamster. Fast blue (FB) was injected into the subserosa of the gallbladder in order to identify by retrograde tracing the duodenal neurons that project to the gallbladder. Subsequently, immunofluorescence microscopy was employed to see whether these duodenal neurons contained putative peptidergic neurotransmitters such as calcitonin gene-related peptide (CGRP), galanin (GAL) and vasoactive intestinal polypeptide (VIP). The FB-labeled cells were only found in the duodenal region adjacent to the major duodenal papilla where the biliary duct opens. On the other hand, there was no difference within this duodenal region in the numbers of FB-labeled cells between the mesenteric and antimesenteric portions, suggesting that these two portions of the duodenum equally contribute neuronal projections to the gallbladder. Double-immunofluorescence microscopy clearly demonstrated that a small population of FB-positive duodenal neurons contained putative neurotransmitters CGRP, GAL and VIP. Our data suggest that duodenal neurons around the major duodenal papilla in the golden hamster project to the gallbladder and exert their influence on the gallbladder via neuropeptides such as CGRP, GAL and VIP.     

Microangioarchitecture of the guinea pig common bile duct and duodenal papilla: A scanning electron and light microscopic study

Background: The microvascular pattern of the duodenal papilla is unknown. Since the duodenal papilla is located in the transition zone between the stomach and duodenum, and because it regulates bile transfer into the duodenum, a particular microangioarchitecture can be expected. Therefore, we examined the microvasculature of the papilla using guinea pigs as a model. Methods: The microvascularization of the duodenal papilla and common bile duct was studied in 26 adult guinea pigs (Cavia porcellus), using scanning electron microscopy of microvascular corrosion casts and critical point dried specimens, and light microscopy of tissue sections. Results: The duodenal papilla is located in the cranial portion of the duodenum, approximately 5 mm beyond the pyloric valve. At the most luminal aspect of the cast papilla, ring-shaped capillaries, resembling those of the cast gastric mucosa, are present. Deeper parts of the papilla are provided with villi. Subepithelial capillaries of the papilla are 15 μm thick in average. These capillaries have a dual blood supply either via the straight long arterioles arising from the submucosa or by the pericryptal capillaries. The common bile duct comprises numerous mucoid glands with their pits surrounded by ring-shaped capillaries in corresponding casts. Conclusions: The special arrangement of different capillary patterns, together with their luminal size and the dual blood supply, favor their protective role from the gastric chyme. © 1994 Wiley-Liss, Inc.     

十二指肠大乳头的扫描电镜形态特征

对3例成人十二肠大乳头进行扫描电镜观察，结果为大乳头口附近的粘膜皱襞呈纵横交错，并围成大小不等的窦腔，本从胚胎发生及临床应用进行了讨论。     

The fine venous architecture of the major duodenal papilla in human beings

After injecting Indian ink or sulphate of barium backwards into the venous trunks that drain the 2nd portion of the duodenum, the author describes 3 venous networks, continuous to the major papilla and which differ in their topography and morphology of their nets. From the functional point of view, he believes that the traction or compression of the collectors' walls might cause turgidity in the deep network, regulating the bile-pancreatic outlet as well as not allowing the duodenal reflow. The author states that during papillotomies the bleeding is insignificant, because the thick veins lie in the body and at the base of the papilla.     

The shape of the duodenal loop. Radiological, physiological and clinical aspects in patients with X-ray negative dyspepsia

The survey is based on nine previously published papers and is divided into three main sections dealing with the relationship between the duodenal loop and the radiological, the physiological and the clinical examinations in patients with X-ray negative dyspepsia. In the first section the development of the duodenal loop, the various types of development anomalies and their radiological image are discussed. Furthermore the causes of the extensive variation in the indications of the duodenal anomaly incidence and the duodenal anomalies which have been the basis of the examinations, are discussed. Only severe duodenal anomaly is included in these examinations, namely those demonstrable both in the supine and the erect position, which means developmental anomalies corresponding to the superior and transverse parts of the duodenum. Patients with a normal duodenal shape have been used as controls. Patients with duodenal anomaly had reduced food-stimulated gastro-oesophageal sphincter pressure, more frequently a positive acid-reflux-test and increased food-stimulated serum-gastrin and serum-pancreatic polypeptide secretion. The results of the examinations for duodeno-gastric reflux and gastric emptying varied. Patients with anomalies located at the transverse part of the duodenum had prolonged gastric emptying and an increased tendency to duodeno-gastric reflux, whereas patients with anomalies located at the superior part of the duodenum showed quick gastric emptying and the same frequency of duodeno-gastric reflux as patients with a normal duodenal shape. Furthermore, patients with anomalies located at the transverse part of the duodenum had a significantly higher food-stimulated duodenal contraction frequency compared to patients with anomalies located at the superior part of the duodenum and patients with a normal duodenal shape. On the other hand the three groups had a similar food-stimulated antral contraction frequency. The shape of the duodenal loop was related to dyspeptic symptoms. Food-provocation, symptoms of gastrooesophageal reflux, and irritable bowel were found in patients with duodenal anomalies as well as in patients with a normal duodenal shape. However, the symptoms seemed significantly more frequent in patients with duodenal anomalies. At a 5-year follow-up examination this difference could not be demonstrated except for food-provocation, but unchanged or exacerbated dyspeptic inconveniences seemed significantly more frequent in patients with duodenal anomalies.