64层螺旋CT三维重建活体肝静脉的研究及临床意义

目的:探讨64层螺旋CT应用于正常人活体体肝静脉研究的可行性,观察三维重建肝静脉的一般形态及走行规律.方法:153例正常受试者经肘正中静脉注射造影剂后,使用64层螺旋CT进行上腹部扫描,图像采集后经容积再现(volume rendering,VR)技术重建肝静脉.结果:重建图像清晰,可显示出6～8级血管及与周围组织间的关系.其中153例肝静脉的分型结果如下:①3分支型,占35.3%(54例);②中左共干型,占41.8%(64例);③中左合干型,占20.9%(32例);④中右共干型,占2.0%(3例).结论:64层螺旋CT可以作为研究活体肝静脉形态的有效手段,三维重建能更准确、全方位地显示肝静脉的正常解剖类型和发现变异,而且图像清晰,对于活体肝静脉的研究有较好的临床应用价值.     

The hepatic veins: Anatomy and classification on single slice spiral CT in North Indian population

AimsTo find out the normal pattern of hepatic veins in the North Indian population and to categorize them.MethodsThe present study was conducted on 100 patients whose spiral CT abdomen was performed for various medical conditions in the department of radiodiagnosis.ResultsFour categories were recognized. Category-1, when right hepatic vein drains independently into the inferior vena cava whereas middle and left hepatic veins join together to form a common trunk before draining into the inferior vena cava. It was observed in 74% patients. Category-2 was observed in 2% patients, where right & middle hepatic veins join to form a common trunk and left hepatic vein drain independently into the inferior vena cava. Category-3 was observed in 21% patients, where all the three major hepatic veins drain independently into the inferior vena cava. Category-4 was observed in 3% patients, where all the three major hepatic veins join together to form a common trunk before draining into the inferior vena cava.ConclusionsCategory-1 is the most common pattern of major hepatic vein drainage found in the North Indian population. The present study also concluded that single right, middle and left hepatic vein is the most common pattern of hepatic veins present in the North Indian population. Caudate lobe is drained by more than one vein in majority of North Indians. Also superomedial vein, right accessory vein and inferior right hepatic vein are the most common accessory veins present in the North Indian population.     

右叶部分肝移植肝静脉的临床应用解剖

目的：为右叶部分肝移植提供肝静脉的解剖学基础。方法：观测52个铸型标本中肝静脉的走行、分布、分型，肝中静脉肝左静脉合干比率，肝短静脉的数量，大小，及其在肝静脉的各类型中的出现率。结果：肝静脉的分型中A型、B型、C型分别为65．4％、26．9％、7．7％。肝中静脉肝左静脉合干机率67．3％。肝短静脉出现率为32．6％，肝右静脉汇入下腔静脉处与肝中静脉汇入肝左静脉或下腔静脉处的距离2．Ocm以内者占80．7％。结论：本文结果为右叶部分肝移植提供了肝静脉的解剖学基础，提示中国人肝静脉的结构似乎较适合右叶部分肝移植。     

妊娠后期胎儿肝静脉发育的多普勒超声研究

目的:利用彩色多普勒超声观察妊娠后期胎儿肝静脉的发育状况,从而为肝发育异常性疾病的诊断及治疗提供依据.方法:选择临床及常规超声检查排除各种病变的正常单胎妊娠胎儿118例,孕龄26～40周;采用多功能彩色多普勒超声显像仪进行扫查,观察胎儿肝左、中、右静脉汇入下腔静脉的类型,肝静脉的内径与属支、相互夹角以及血流动力学的状态.记录相关数值并进行分析.结果:肝中静脉与肝左静脉合干后汇入下腔静脉(Ⅰ型)者57例(48.3%),肝左、中、右静脉分别汇入下腔静脉(Ⅱ型)者53例(44.9%),肝中、右静脉合干或出现肝右后静脉等(Ⅲ型)者8例(6.8%).随孕周增加,肝静脉内径增加,肝左、中、右静脉内径分别为(0.34±0.04)cm、(0.35±0.04)cm、(0.36±0.05)cm,与孕周有较高的相关性.可观察到的肝静脉属支1～4支不等.肝右静脉与肝中静脉之间的夹角为(56.8±14.2)°,肝中静脉与肝左静脉之间的夹角为(50.7±19.4)°,肝左静脉与肝右静脉之间的夹角为(98.4±20.3)°.肝静脉和下腔静脉血流频谱为三相,随孕周增加a/s值逐渐减小.以上各数值未见明显性别差异.结论:胎儿肝静脉发育状况与成人不同,胎儿肝静脉属支变异较大.本研究可以丰富与完善肝静脉发育影像学知识,提高肝静脉发育异常胎儿临床诊断水平.     

肝静脉,肝短静脉注入下腔静脉壁处在肝移植术中的应用

目的 探讨采用膈下肝段下腔静脉壁前半部钳夹,解决肝移植术中无肝期下肢静脉回流障碍。方法 对17例成人尸肝进行解剖,以时钟刻度方法描述肝静脉、肝短静脉注入下腔静脉壁的位置。结果 肝左静脉、肝右静脉、肝中静脉均注入下腔静脉前半壁(即3～9点),肝短静脉多为针眼大小,注入部位多在5～9点之间(154支),少数注入9～11点(9支)。结论 肝移植术中可以采用下腔静脉壁前半钳夹,解决无肝期下肢静脉回流障碍。     

Can the left hepatic vein always be safely selectively clamped during hepatectomy? The contribution of anatomy

The minimization of blood loss is the main objective during hepatic resection to minimize perioperative mortality and morbidity. Selective clamping of the hepatic veins, combined with pedicle clamping, may make it possible to spare the non-resected territories from ischemia. These clamping procedures are particularly useful in the treatment of hepatic metastases of colorectal cancers, because preoperative chemotherapy may temporarily alter the hepatic parenchyma, increasing its susceptibility to ischemia. During left lobectomy or left hepatectomy, extraparenchymatous control of the left and median hepatic veins (the LHV and MHV, respectively) and of the common trunk (CT) requires exact knowledge of this anatomical region. Biometric analyses were carried out on extraparenchymatous portions of the LHV, MHV and CT of 20 fresh cadavers and 10 living subjects, to assess the feasibility of selective clamping without liver mobilization. Fourteen of the 20 cadaveric subjects (70%) had a common trunk between the LHV and the MHV. The extraparenchymatous portion of the LHV was between 4 and 13 mm long, depending on the presence or absence of a CT. The angle between the sagittal plane of the inferior vena cava and the LHV was about 18.3° on average, in the absence of liver mobilization. Selective clamping of the left hepatic vein was possible only when the extraparenchymatous portion of this vein was at least 6 mm long. The selective clamping of this vein is, therefore, less straightforward than that of the right hepatic vein, given the high frequency of a common trunk shared with the median hepatic vein and of a short extraparenchymatous segment.     

Primary liver carcinoma complicating membranous obstruction of the inferior vena cava

A rare autopsy case of primary liver carcinoma complicating a pre-existing, incomplete membranous obstruction of the inferior vena cava (MOVC) is reported. The patient, a 67-year-old Japanese male, was admitted to hospital following a 2 year illness of a left chest wall tumor and a 3 month illness with progressive abdominal pain. Computed tomography scans of the abdomen displayed space-occupying lesions in the third and seventh hepatic segments, respectively. One month later, the patient developed edema of the lower extremities and marked venous dilatation of the abdominal trunk. At that time, Doppler examination revealed the presence of intrahepatic large venovenous collaterals. The patient subsequently succumbed 82 days after hospitalization. At subsequent autopsy, the inferior vena cava was completely obstructed by tumor thrombus, which was formed caudally and cranially to a thin membrane and mimicked the valve, with calcification and elastic lamina, at the phrenic portion. Intrahepatic large collateral pathways were found between submembranous and supramembranous hepatic veins. Anomalous absence of the ostia of the middle hepatic vein was found. In addition, the portal venous trunk was occluded by tumor thrombus. Histology of hepatic tumors revealed a combined hepatocellular and cholangiocellular carcinoma in the non-cirrhotic liver with severe acute centrilobular congestion. In MOVC patients such as the case presented, malignancy-induced thrombosis was deemed to be an important factor in prognosis.     

腹腔镜下肝门血流阻断肝切除术的解剖学基础

目的　探讨腹腔镜下肝门血流阻断在肝切除术（LH）的解剖基础及手术路径。 方法　解剖尸体肝脏,分离血流阻断所涉及各肝门结构,观察在二维平面中毗邻,测量在肝外长度及夹角;观察LH视频中肝门结构,总结镜下的位置及特征。 结果　肝动脉平面低于肝管（90%）,肝门静脉分叉位置固定于后方;肝左和肝中静脉在肝外大多共干（90%）,肝右静脉与共干间存在间隙,与肝后下腔静脉(IVC)前方相通;肝短静脉位于IVC两侧,有（7±3）支;IVC韧带在尸体中易忽略,活体中较明显,为包绕IVC的膜性结构,厚度个体差异大;各结构在肝外长度及夹角为肝门血流阻断提供足够空间;镜下各结构位置及特征与实体比较有特殊性。 结论　LH中应用肝门血流阻断有解剖依据及路径遵循。     

Duplication of the inferior vena cava associated with other variations

Multiple vascular variations, including duplication of the inferior vena cava, double renal arteries and anomalies of the testicular blood vessels, were observed during dissection of the retroperitoneal region of a cadaver of an 87-year-old Japanese man. The right inferior vena cava arose from the union of right common iliac veins and a thinner interiliac vein. This interiliac vein ascended obliquely from right to left and joined the left common iliac veins to form the left inferior vena cava. The right and left inferior venae cavae were of approximately equal width. The right testicular vein consisted of medial and lateral venous trunks. The two venous trunks coalesced to form a single vein, which drained into the confluence of the right inferior vena cava and right renal vein. The left testicular vein was composed of the medial and lateral testicular veins, which drained into the left renal vein. Double renal arteries were seen bilaterally, which originated from the lateral aspects of the abdominal aorta. The right testicular artery arose from the right inferior renal artery and accompanied the lateral trunk of the right testicular vein running downwards. The left testicular artery arose from the ipsilateral inferior renal artery and ran downwards accompanied by the left lateral testicular vein. In addition, the bilateral kidneys showed multicystic changes.     

A morphological and functional study of the cavo-hepatic junction in the human

Summary The authors studied the morphological and structural aspects of the junctions between the hepatic veins and the inferior vena cava. The study was carried out on 20 specimens obtained from adult cadavers of both sexes, fixed in 10% formaldehyde solution. The hepatic veins with their junctions on the inferior vena cava were isolated. Then a macroscopic analysis of the openings of the hepatic veins into the inferior vena cava was performed. Part of this material was embedded in paraffin, submitted to serial sectioning and stained with Azan's trichrome and resorcin-fuchsin. Three hepatic veins were observed in all cases: right, left and the middle. In 20% of the cases the middle hepatic vein opens directly into the inferior vena cava. The hepatic vein openings are supported by two pillars inferiorly united through a semilunar fold. The hepatic vein wall is greatly thickened at the level of its junction with the inferior vena cava, showing a large ammont of muscular and collagenous fibers. These bundles constitute a sphincter-like formation which may play a physiological role in the control of the hepatic circulation.Les auteurs étudient les aspects morphologiques et structuraux du carrefour hépatico-cave. Cette étude porte sur 20 sujets adultes des deux sexes après formolisation. Les veines hépatiques et leurs terminaisons dans la veine cave inférieure sont prélevées, étudiées sur le plan macroscopique et incluses dans la paraffine. Les coupes sériées sont fixées selon la technique d'Azan. Trois veines hépatiques sont retrouvées dans tous les cas : les veines hépatiques droite, moyenne et gauche. Dans 20% des cas, la veine moyenne s'ouvre directement dans la veine cave inférieure. L'ostium des veines hépatiques s'appuie sur deux piliers réunis à leur partie inférieure par un repli semilunaire. La paroi des veines hépatiques au niveau de leur ostium est très épaisse avec un fort contingent de fibres musculaires et collagènes. Les fibres musculaires réalisent un véritable sphincter qui peut jouer un rôle physiologique dans le contrôle de la circulation hépatique.This report was made at the Anatomy Department of the Biological Sciences Center of UFPE     

Three patterns of extra-testicular venous drainage in the rabbit. Divergence from a traditional concept

Summary Seventy-eight male New Zealand white rabbits were autopsied and found to have variable left extra-testicular venous anatomy. Our observations reveal that in the rabbit the left testis is drained in one of three ways, identified as either A (18%), B (30%) or C (52%) —type drainage. The right testicular vein in all cases drained directly into the inferior vena cava immediately superior to the right iliolumbar vein.In type A drainage, the left testicular vein drained directly into the inferior vena cava at the level of the left iliolumbar vein. In type B drainage, the left testicular vein emptied into the left iliolumbar vein, which in turn drained into the inferior vena cava. In type C drainage both the left testicular and iliolumbar veins anastomosed to form a lumbotesticular trunk which emptied directly into the left renal vein.These three patterns of left venous vascular anatomy in the rabbit can be explained on the basis of their embryologic development. Our observations suggest that it is the caudal segment of the left pelvic subcardinal vein and its anastomosis with the caudal cardinal complex which persist as the left testicular vein and that the more cranial segment of this vein, heretofore presumed to remain patent, atrophies to the level of the developing left renal vein.     

A case of a persistent left vena cava superior with atresia of the right atrial ostium of the coronary sinus

A persistent left vena cava superior with an atretic ostium of the coronary sinus was found during the routine dissecting course in the embalmed cadaver of an 83-year-old woman who had died from cardiac infarction. The left vena cava superior was very narrow in diameter (4 mm), originated at the lateral part of the left vena brachiocephalica and ran down between the venae pulmonales sinistrae and the auricula sinistra. The vena cava opened into the sinus coronarius of the heart, which terminated as a blind sac due to an atretic ostium. The vena coronaria sinistra as well as the vena interventricularis posterior drained into the sinus coronarius. Congenital atresia of the coronary opening is a rare malformation and is usually associated with other anomalies. The congenital ostial atresia could be the cause of a persistent left vena cava superior, which then takes over the drainage of the cardiac veins.     

国人肝段在冠状断层上的划分

目的：为肝内微小病变精确定位诊断和外科治疗提供冠状断层解剖学依据。方法：采用30例上腹部连续冠状断层标本、20例肝内门静脉和肝静脉解剖正常的薄层MSCT断层图像及其三维重建图像,在冠状断层上对其门静脉肝段进行精确划分。结果：经胆囊、门静脉左支及肝左静脉的冠状断面上,肝中静脉主干是划分右前上叶和左前下叶的识别标志,门静脉左支角部是左前下叶的段间裂识别标志,亦是右前上叶和左前下叶的亚段间裂识别标志。经肝门静脉主干的冠状断面上,门静脉右前支主干是右前上叶的段间裂识别标志,该层面以前为右前上叶的腹侧段,该层面以后则为右前上叶的背侧段。经网膜孔的冠状断面上、下腔静脉的右缘是划分尾状叶和右半肝的识别标志,门静脉右后支主干是划分右前上叶背侧段和右后下叶下段的标志,经下腔静脉和肝右静脉的冠状面上,肝右静脉主干是划分右前上叶的背侧段和右后下叶上段的标志;门静脉右后支主干是右后下叶的段间裂识别标志。结论：国人门静脉肝段在冠状断面上的精确划分,不仅有利于肝内微小病变的精确定位,且有利于探索新的和更加安全的外科术式。     

Preureteric inferior vena cava with possible rudiment of the proper inferior vena cava

A right single preureteric inferior vena cava (IVC) was found in the cadaver of a 77-year-old Japanese male during a student dissection course at Kumamoto University School of Medicine in 2003. The ureter emerged from the lower end of the hilum of the right kidney at the second lumbar vertebral level. It ran inferomedially to pass behind the IVC, and turned inferolaterally to cross the vein superficially at the level of the third to the fourth lumbar vertebrae. Then, the ureter was situated to the right of the IVC, and descended ordinarily. The second lumbar vein of each side united bilaterally, as did the third lumbar veins. The common stem of the second lumbar veins drained into the left side of the IVC posterolaterally at the level of the second intervertebral disc, and the third common stem opened into the left border of the IVC at the fourth lumbar vertebral level. The ureter hooked around the IVC between the openings of those common stems. There was a small continuation (0.2 mm in diameter) between the left second lumbar and the right third lumbar veins along the vertebral column slightly right of the midline. It passed superficial to the right third lumbar artery, as did the IVC. The right testicular vein opened into the IVC at the level of the lower end of the third lumbar vertebral body. Generally, the level of the opening of the gonadal vein corresponds to the level of the caudal end of the remaining subcardinal vein, but it is lower than usual in this case. Furthermore, the segment from the confluence of the common iliac veins to the common trunk of the third lumbar veins, and to the small continuation can be regarded as the proper IVC, and the part where the ureter hooks around it may have derived from the anastomosis between the common trunk of the third lumbar veins and the subcardinal vein.     

Anomalous veins of the retroperitoneum: clinical considerations

A case of complex anomalies (variations) of the veins of the retroperitoneum in a 57 year old male cadaver is presented. The anomaly involved a double inferior vena cava, with the left suprarenal v. draining into the left vena cava and the right testicular v. drained into the right renal v.. There was also no left common iliac v., with the left external iliac v. draining into the left vena cava and the left internal iliac v. into the right common iliac v.. Although duplication of the inferior vena cava has previously been reported the present case is interesting because of the complexity of the associated anomalies.     

Anomalous veins of the retroperitoneum: clinical considerations

Abstract: A case of complex anomalies (variations) of the veins of the retroperitoneum in a 57 year old male cadaver is presented. The anomaly involved a double inferior vena cava, with the left suprarenal v. draining into the left vena cava and the right testicular v. drained into the right renal v., There was also no left common iliac v., with the left external iliac v. draining into the left vena cava and the left internal iliac v. into the right common iliac v.. Although duplication of the inferior vena cava has previously been reported the present case is interesting because of the complexity of the associated anomalies.     

Duplicate testicular veins accompanied by anomalies of the testicular arteries.

Duplicate testicular veins associated with other anomalies of the testicular arteries were observed during dissection of the posterior abdominal wall in a 90-year-old Japanese male cadaver. The right testicular vein was composed of the medial and lateral testicular veins. The medial testicular vein drained into the inferior vena cava, whereas the lateral testicular vein drained into the confluence of the inferior vena cava and right renal vein. Several anastomosing branches were seen between the medial and lateral testicular veins. The left testicular vein was formed after the medial and lateral venous trunks joined and drained into the ipsilateral renal vein. The right testicular artery originated from the anterior surface of the abdominal aorta at the level of the left renal artery, passed posterior to the inferior vena cava, and accompanied the right lateral testicular vein running downwards. The left testicular artery arose from the abdominal aorta at a level of 5 cm below the origin of the right testicular artery, and then ran downwards accompanied by the medial trunk of the left testicular vein.     

Rhabdomyosarcoma with focal cartilaginous differentiation (malignant mesenchymoma) of the inferior vena cava.

A sarcoma arising from the inferior vena cava occupied the entire lumen of the inferior vena cava, right atrium, hepatic veins and common iliac veins. Its histological appearance was non-specific sarcoma, except for the presence of a few rhabdomyoblasts and some immature cartilaginous tissue. Immunohistochemically, some tumor cells were positive for myoglobin, desmin, HHF-35, and vimentin. Electron microscopy revealed that some tumor cells contained myofilaments and Z bands in the cytoplasm, which are characteristics of rhabdomyosarcoma. The tumor was diagnosed as rhabdomyosarcoma with focal cartilaginous differentiation (malignant mesenchymoma) of the inferior vena cava.     

Left inferior vena cava with regressed right inferior vena cava

A left inferior vena cava was found in the cadaver of an 88-year-old Japanese man during a student dissection course at Kumamoto University School of Medicine. The right common iliac vein ascended obliquely toward the left behind the right common iliac artery and united with the left common iliac vein to form the inferior vena cava in front of the fifth lumbar vertebral body behind the left common iliac artery. The inferior vena cava ascended on the left side to the aorta, and after the left renal vein joined to it at the level of the third lumbar vertebral body, it turned obliquely to the right and crossed superficially to the aorta. At the right side of the aorta, the common stem of the third lumbar vein and the posterior renal vein was joined to the oblique part. The inferior vena cava then ascended, receiving the right renal vein as it would normally. The inferior vena cava is thought to develop symmetrically but this left inferior vena cava shows a persistence of the left channel of the infrarenal part, which normally disappears. Although the common stem of the veins that joined to the oblique part on the right side did not continue to the right common iliac vein, gross anatomical findings suggested it to be the remnant of the right inferior vena cava.     

Pivotal role of the sub-supracardinal anastomosis in the development and course of the left renal vein

A retroaortic left renal vein is encountered frequently in the dissecting room and in radiological investigations. A number of recent reports of this variation led us to review the development of the renal veins and the inferior vena cava to understand its etiology. For further insight, we also examined our collection of serial sections of cat embryos. In human embryos of about 15 mm the "renal collar," a venous ring around the aorta, is formed by anastomoses between subcardinal and supracardinal veins. The ventral part of the "renal collar" is formed from the intersubcardinal anastomosis, the dorsal part from the intersupracardinal anastomosis and the lateral parts from the sub-supracardinal anastomoses. The primitive renal veins drain venous blood from the metanephros into the sub-supracardinal anastomoses. A retroaortic left renal vein would form if the dorsal part of the sub-supracardinal anastomosis and the intersupracardinal anastomosis persist whereas the ventral part of the sub-supracardinal anastomosis and the intersubcardinal anastomosis regress.