联合血管切除的胰十二指肠切除术的探讨

目的探讨联合血管切除的胰十二指肠切除术的必要性、手术适应证和手术操作中必须注意的问题。方法回顾性分析我院2002年1月至2005年1月行联合血管切除的胰十二指肠病人43例（A组），并与同期未行联合血管切除的96例病人（B组）在术中、术后各方面进行比较。结果A组中单独PV或SMV节段切除者为8和16例，楔形切除分别为3和4例，同时切除PV／SMV者9例，联合PV／SMV／SMA／HA切除者3例；A组病理示肿瘤侵犯血管全层共6例（13．95％）；A、B两组在术时、术中输血量及术后并发症、淋巴结阳性率方面差异均无显著性。结论对术前检查未发现PV／SMV内有癌栓或闭塞、肿瘤未包埋SMA或腹腔干根部的病人，行联合血管切除的胰十二指肠切除术是必要的，但须严格掌握手术适应证且术中解剖仔细、操作细致，以期提高手术的安全性和成功率。     

肠系膜上动脉路径在胰十二指肠切除及合并血管切除术中的应用

目的：探讨经肠系膜上动脉途径行胰头十二指肠切除及合并血管切除的可行性及优劣。 方法：2012年9月—2014年2月采用肠系膜上动脉旁路径的方法实施胰头十二指肠切除术治疗胰头癌及壶腹周围癌16例,其中实施门静脉、肠系膜上静脉切除重建手术5例。患者均首先显露、游离肠系膜上动、静脉并清除其周围的神经淋巴组织,再打通胰后隧道并切断胰腺颈部,最后切除胰腺钩突或被侵犯的门静脉、肠系膜上静脉。 结果：15例术后顺利恢复后出院,1例术后出现肾功能衰竭、肺部感染,放弃治疗自动出院。术中平均出血量为470 mL,平均手术时间4.5 h,无手术中及术后死亡。5例术后出现胰瘘等并发症,均经保守治疗后痊愈。切缘病理检查均阴性,淋巴结及后腹膜神经、淋巴组织阳性检出率较高。 结论：经肠系膜上动脉途径行胰头十二指肠切除术治疗胰头癌及壶腹周围癌安全可行,并可增加R0切除率。     

Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy

BACKGROUND: Resection of the portal/superior mesenteric vein (PV/SMV) during pancreatoduodenectomy (PD) is disputed. Although morbidity and mortality are acceptable, survival is limited after PV/SMV resection. In this study, we evaluate the effect of PV/SMV resection. METHODS: Between 1992 and 1998, there were 215 consecutive patients who underwent PD for malignant disease. Thirty-four patients underwent a PV/SMV resection. Resection was only performed when minimal venous ingrowth was found perioperatively. Surgical techniques, perioperative parameters, and survival were analyzed. RESULTS: The percentage of PV/SMV resections was 16%. Extensive (segment) resections were performed in 6 patients. The median blood loss was 1.8 L and resection margins were microscopically tumor free in 41% of the patients. The median hospital stay was 15 days, and mortality was 0%. Median survival after PV/SMV resection for pancreatic adenocarcinoma was 14 months. CONCLUSIONS: Limited PV/SMV resection for perioperatively encountered minimal venous ingrowth during PD can be performed safely without increased morbidity and mortality but also results in a high frequency of tumor-positive resection margins.     

An experimental evaluation of the lactate concentration following mesenteric ischemia

PURPOSE: Although a diagnosis of mesenteric necrosis can easily be made, mesenteric ischemia is sometimes overlooked, especially in the acute phase. We experimentally evaluated the time course of the lactate concentration, which may be a possibly useful variable in making a diagnosis of mesenteric ischemia, and determined how an early diagnosis can be made. METHODS: The superior mesenteric artery (SMA) was surgically ligated in an anesthetized pig. Blood tests, including a blood gas analysis, were done using samples from the superior mesenteric vein (SMV), hepatic vein, femoral vein, and artery until 6 h after SMA ligation. RESULTS: There were no variables in any samples that showed a significant change within 4 h after SMA ligation except for samples taken from the SMV. All acidosis-related variables had changed significantly within 6 h after ischemia. Among them, the lactate concentration only in the SMV was observed to have increased significantly within one hour after SMA ligation. CONCLUSIONS: Currently available peripheral blood tests, including tests using blood obtained from the hepatic vein, do not enable the detection of mesenteric ischemia within 4 h after onset. In a case in which an exploratory laparotomy is performed, the measurement of the lactate concentration in SMV is thus considered to be a useful supplementary test for making a prompt diagnosis of mesenteric ischemia in an early phase.     

Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes

Purpose  

During pancreatoduodenectomy (PD), two techniques have been described to dissect the head of pancreas, viz. the superior mesenteric artery (SMA) approach by dissecting the uncinate process and the uncinate process first approach.     

Percutaneous treatment of a large superior mesenteric artery pseudoaneurysm and arteriovenous fistula: a case report

The combination of superior mesenteric artery (SMA) pseudoaneurysm and arteriovenous (AV) fistula is a rare complication following penetrating abdominal trauma. We report a case of a post-traumatic SMA pseudoaneurysm and large fistula between the SMA and superior mesenteric vein (SMV), which was successfully treated with an endovascular stent graft.     

Treatment of superior mesenteric and portal vein thrombosis with direct thrombolytic infusion via an operatively placed mesenteric catheter

Acute superior mesenteric vein (SMV) and portal vein (PV) thrombosis can be a complication of hypercoagulable, inflammatory, or infectious states. It can also occur as a complication of medical or surgical intervention. Management of mesenteric and portal vein thrombosis includes both operative and nonoperative approaches. Operative interventions include thrombectomy with thrombolysis; this is often employed for patients who present with signs of peritoneal irritation. Nonoperative approaches can be either noninvasive or invasive. Treatment with anticoagulation has been shown to be efficacious, though its rate of recanalization is not as high as with intravascular infusion of thrombolytics. Intravenous catheterization and thrombolytic infusion has the advantage of direct pharmacologic thrombolysis of clot, with decreased infusion required and the possibility to carry out dilation or thrombectomy concurrently. We report the use of recombinant tissue-plasminogen activator (rt-PA) infusion via an operatively placed multi side-hole catheter/5-Fr introducer sheath into the right portal and superior mesenteric vein clot, inserted through a small jejunal vein, in a patient who presented with acute gangrenous appendicitis and thrombosis of the main portal trunk and superior mesenteric vein. A temporary abdominal closure was maintained until 36 hours after the start of infusion of the rt-PA. At this time venous system had normal flow, with complete recanalization of the right portal and superior mesenteric veins.     

联合门静脉/肠系膜上静脉切除的胰十二指肠术治疗胰头癌的疗效

目的:分析联合门静脉(PV)/肠系膜上静脉(SMV)切除的胰十二指肠切除术(PD)治疗胰头癌的临床疗效。方法:回顾性分析2010年1月—2013年7月手术治疗的72例胰头癌患者的临床及术后随访资料,其中40例肿瘤未累及肝总动脉、SMV、PV也无转移的患者行单纯PD术(PD组),32例单纯性累及PV/SVM的患者行联合PV/SMV切除的PD术(PV/SMV组),比较两组患者的围手术期指标及术后情况。结果:与PD组比较,PV/SMV组的手术时间(357.4min vs.289.3min)、术中出血量(851.2m L vs.641.5m L)均明显增加(均P0.05),但输血量(700.0m L vs.650.5m L),手术并发症发生率(18.75%vs.20.00%),1、2、3年生存率(50.00%vs.57.50%、31.25%vs.37.50%、21.86%vs.25.00%)以及中位生存时间(15个月vs.18个月)差异均无统计学意义(均P0.05)。结论:对于胰头癌患者应根据患者的实际情况选择适宜的手术方式,联合PV/SMV切除的PD治疗单纯性累及PV/SVM的胰头癌临床效果可靠,术后远期预后与PD手术适应证者相当。     

256层螺旋CT对腹腔镜结直肠癌手术前肠系膜血管解剖结构评估的价值

目的探讨CT三维血管重建技术对结直肠癌患者术前进行肿瘤血管评估的临床价值．为腹腔镜结直肠癌手术提供参考。方法2010年2月至2010年12月间,对11例准备行腹腔镜结直肠癌根治术的患者术前进行256层螺旋CT扫描．通过三维血管重建技术观察其肠系膜血管解剖及变异情况．并将结果与腹腔镜术中所见进行对照。结果256层螺旋CT三维血管重建均清晰地显示出肠系膜血管解剖及变异情况．并与腹腔镜手术中所见吻合。3例右半结肠切除术患者中,1例回结肠动脉走行于肠系膜上静脉的腹侧．2例回结肠动脉走行于肠系膜上静脉的背侧：2例右结肠动脉和回结肠动脉分别直接起源于肠系膜上动脉．另1例未见右结肠动脉而由结肠中动脉右支参与供血。1例横结肠切除患者的结肠中动脉发自肠系膜上动脉。3例乙状结肠切除患者中,2例乙状结肠动脉与左结肠动脉共干起源于肠系膜下动脉．另1例乙状结肠动脉直接起源于肠系膜下动脉。4例直肠癌患者均由肠系膜下动脉延续的直肠上动脉供血。结论256层螺旋CT血管重建技术可以满足腹腔镜结直肠癌根治术前对肠系膜血管解剖及变异情况的观察．为手术提供重要参考。     

A simple but useful method of screening for mesenteric ischemia secondary to acute aortic dissection

BACKGROUND: In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection. METHODS: From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared. RESULTS: The SMV/SMA ratios in groups M and C were 1.16 +/- 0.33 and 1.78 +/- 0.29, respectively (P=.003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful (P=.002). CONCLUSIONS: The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.     

Surgical Anatomy of the Superior Mesenteric Vessels Related to Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis

Background and Purpose

Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery.

Methods

We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017.

Results

Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases.

Conclusions

Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.

     

Outcomes and complications for portal vein or superior mesenteric vein injury: No improvement in the era of damage control resuscitation

IntroductionPortal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care.MethodsWe reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes.ResultsTwenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting.ConclusionDespite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality.     

Posterior ‘Superior Mesenteric Artery First’ Approach for Resection of Locally Advanced Pancreatic Cancer

Background

En bloc resection of the superior mesenteric vein (SMV), portal vein (PV), and/or splenic vein (SV) with concomitant venous reconstruction is required in 11–65 % of cases of locally advanced pancreatic cancer.1 Early retropancreatic dissection of the superior mesenteric artery (SMA) from behind the pancreatic head utilizing an ‘artery first’ approach has been reported to be an efficient and safe approach to pancreaticoduodenectomy when SMA involvement is suspected.2 Additionally, this technique has been shown to reduce blood loss and result in shorter PV clamp times.3 While there are multiple variations to ‘artery first’ resection,4 this video will illustrate the critical steps of using the ‘posterior approach’ in patients with locally advanced pancreatic cancer. This approach has the benefit of early identification of a replaced right hepatic artery, but may be difficult in obese patients or those with extensive peripancreatic inflammation. These difficulties may be overcome by utilizing an ‘inferior supracolic (anterior) approach’, but this necessitates early division of the pancreatic neck and stomach.5

Methods

Select video clips were compiled from several pancreatoduodenectomies to demonstrate this technique. A variety of bipolar devices were utilized for dissection depending on surgeon preference. All patients were diagnosed with locally advanced pancreatic cancer by Americas Hepato-Pancreato-Biliary Association/Society of Surgical Oncology (AHPBA/SSO) consensus criteria, confirmed by biopsy, and completed neoadjuvant chemotherapy. Patients were restaged by pancreas protocol computed tomography scan at the end of chemotherapy and offered local resection if the tumor did not progress and they were medically fit. No Institutional Review Board approval was required.

Results

The operation begins by dividing the attachment of the transverse mesocolon to the right perinephric area and extending this down to the white line of Toldt, followed by a wide Kocher maneuver. The lateral attachments to the pancreatic head are then divided, thereby exposing the left renal vein. The lesser sac is entered directly over the uncinate, allowing for a full visceral rotation of the pancreatic head, and further facilitating exposure of the left renal vein. In the setting of malignancy, the SMA may now be palpated posterior to the pancreatic head and/or neck to confirm it is free of tumor. If tumor is invading the SMA, the pancreaticoduodenectomy is aborted prior to performing any gastrointestinal or pancreatic transections. If the SMA is free, the dissection is then carried on to the inferior aspect of the pancreatic neck. Here the SMV (jejunal and ileal branches), middle colic vein, and the gastroepiploic vein are identified and the latter is ligated and transected. Following this, dissection of the portal structures (hepatic arteries, gastroduodenal artery, common bile duct, and PV) is performed. The jejunum is then divided, the ligament of Treitz is taken down, and the jejunum is then mobilized to the patient’s right side. This allows for clear visualization of the pancreatic head/uncinate/SMV relationship. At this point, proximal and distal control of the PV, SMV, and SV should be obtained using vessel loops or umbilical tape. The dissection then proceeds laterally along the SMA border (posterior to the pancreatic head). This is often facilitated by use of a bipolar sealing device due to a rich lymphovascular network. Once the lateral border of the SMA is clearly exposed, dissection along its longitudinal axis is performed utilizing the jejunum for traction. Following this dissection, larger vessels such as the inferior pancreaticoduodenal artery can be more readily identified and ligated to fully mobilize the pancreatic head. After the head is completely separated from the SMA, the neck is divided. This leaves the specimen attached solely by the PV and SMV, which greatly facilitates venous resection and reconstruction when necessary.

Conclusion

The ‘artery first’ approach has been shown to be safe and feasible in pancreatic resections. This technique should be considered whenever tumor is thought to involve the SMV and/or PVs as a means to facilitate safe venous resection and reconstruction while preserving sound oncologic principles.     

Mesenteric fibromatosis of the transverse colon with the reconstruction of the superior mesenteric arteries: report of a case

In general, with large mesenteric tumors it may be rather difficult to determine whether infiltration into adjacent large vessels occurred. We wish to stress the importance of preparation for microsurgery when a huge lesion appears close to a large artery in preoperative images, based on our experience of successful microscopical reconstruction of a superior mesenteric artery (SMA) and marked improvement of blocked vascular flow to the small intestine during the surgery. We have experienced a case of mesenteric fibromatosis (MF) invading the SMA and vein, contrary to preoperative expectation. The patient underwent extirpation of a MF, 21 cm in size, with reconstruction of the SMA by microsurgery. The sacrificed small intestine was only 80 cm of the distal ileum with the benefit of microscopic anastomosis between the SMA and a major jejunal artery. Preparations for microscopic surgery must be made with resection of large lesions, because involvement of mesenteric large vessels may be expected. It is possible for microsurgery to extend indications for surgical resection of huge mesenteric tumors.     

Technique of hybrid retrograde superior mesenteric artery stent placement for acute-on-chronic mesenteric ischemia

Revascularization for acute mesenteric ischemia can be challenging in patients with bowel gangrene, peritoneal contamination, and no good source of inflow for a bypass graft. A 70-year-old female patient presented with acute-on-chronic mesenteric ischemia, flush superior mesenteric artery (SMA) occlusion, and diffuse aorto-iliac occlusive disease. This study describes the technique of hybrid retrograde SMA recanalization and stent placement using a midline laparotomy is described. The mid-portion of the SMA was exposed and jejunal branches were controlled with silastic vessel loop. Retrograde access was established under direct vision and the occluded SMA segment was crossed, pre-dilated, and stented using a balloon-expandable stent. The SMA was flushed through a longitudinal arteriotomy, which was closed using a saphenous vein patch. Retrograde hybrid SMA stenting is an expeditious option to revascularize patients with acute on chronic mesenteric ischemia who have peritoneal contamination and no other good source of inflow to the mesenteric arteries.     

腹腔镜右半结肠切除术中血管解剖辨识及意义研究

目的 探讨腹腔镜右半结肠切除术中肠系膜上血管主干及对应分支与属支的解剖规律、变异类型及临床意义。方法 回顾性分析2017年3月至2021年1月中国医科大学附属盛京医院结直肠肿瘤外科200例腹腔镜右半结肠切除术病人资料,通过影像学读片、手术记录查阅、术后视频回放方式观察肠系膜上血管主干、回结肠血管、右结肠血管、结肠中血管、Henle干的出现概率、走行特点、毗邻关系以及变异情况。结果 肠系膜上血管主干变异按肠系膜上静脉（SMV）数量分为单支型与双支型,按SMV与肠系膜上动脉（SMA）的空间位置关系分为右位、左位、交叉3种类型。回结肠动脉（ICA）与回结肠静脉（ICV）出现率均为100.0%,2例ICV直接汇入Henle干,62.0%病人ICA走行于SMV背侧。术中解剖出右结肠动脉（RCA）73例（36.5%）,右结肠静脉（RCV）195例（97.5%）,单支型、双支型、三支型RCV分别占48.2%、43.6%和8.2%,RCA走行于SMV腹侧者62例（84.9%）,RCA走行与SMV背侧者11例（15.1%）。解剖出结肠中动脉（MCA）192例（96.0%）,结肠中静脉（MCV）196例（98.0%）,单支型、双支型与三支型MCV分别占63.8%、33.2%与3.0%,MCV有4种汇入情况：汇入SMV、Henle干、脾静脉（SV）和第一支空肠静脉（FJV）,其中汇入到SMV最常见占95.4%,当MCV汇入FJV时,FJV均走行于SMA前方,当MCV为多支型时,RCV多支型占比更高。按胰十二指肠上前静脉（ASPDV）与胃网膜右静脉（RGEV）是否共干以及结肠支的数量将Henle干分为基本型（0~Ⅲ型）和特殊型,其中基本Ⅰ型最为常见（43.6%）。结论 肠系膜上血管主干变异情况较少,分支与属支变异常见。术中操作应始终遵循精细解剖的原则,避免辨识不清晰的情况下导致出血及副损伤。     

Outcome from traumatic injury of the portal and superior mesenteric veins

Traumatic injuries to the portal vein (PV) and superior mesenteric vein (SMV) are rare and carry a high mortality rate, and the best approach and method of repair is still subject to debate. The objective of the present study was to analyze risk factors for mortality in portal and superior mesenteric venous injuries. A retrospective analysis of 18 patients during a 5-year period was performed. Mechanism of injury, shock upon admission, Revised Trauma Score (RTS), Injury Severity Score (ISS), intraoperative fluid requirements, classification of venous injury severity, and associated injuries were analyzed as potential predictors of outcome. All patients were male, 9 were victims of gunshot wounds, and 11 were in shock at the time of admission. Eight patients sustained PV, and 12 sustained SMV injuries. The great majority of patients had more than 1 associated injury and 61% had an associated vascular injury. Mortality rate correlated with injury severity. Overall mortality rate was 72%. Nonsurvivors had higher ISS than survivors (24 +/-0.4 and 20 +/-1.7, respectively; p = 0.006). Uncontrollable intraoperative hemorrhage was the cause of death in 5 of 13 patients (38.4%). Six patients died during the postoperative period from complications of prolonged shock and multiple organ failure, and 2 died of sepsis. The physiologic status upon admission, the number of associated injuries, and the severity of the vascular injury are the most important factors related to mortality in PV and SMV injuries.     

Arteroportal fistulas between the accessory right hepatic, gastroduodenal and superior mesenteric arteries and portal vein: a difficult technical problem to overcome in liver transplantation

BACKGROUND: Fistulous communications between the accessory right hepatic (ARHA), gastroduodenal (GD), and superior mesenteric (SMA) arteries and the portal vein (PV) may represent a contraindication for liver transplantation (LT). MATERIAL: A patient with HCV-related liver cirrhosis and progressive liver decompensation underwent preoperative LT work-up. Doppler ultrasound (DU), Angiography and MRI revealed arteroportal fistulas (APF) and diversion of mesenteric-splenoportal flow through spontaneous splenorenal shunts (SSRS) in the systemic circulation. The patient was transplanted and the ARHA and GDA were distally sectioned; the HA was anastomosed to the donor HA; the superior mesenteric vein (SMV) was detached from the splenopancreatic venous bed by sectioning and ligating the Henle trunk, by ligating an posterior-inferior pancreatic vein and, finally, by positioning an iliac vein interposition graft between the SMV and the donor PV. The postanastomotic SMV trunk and recipient PV were ligated below and above the pancreatic head, respectively. RESULTS: Reperfusion and late liver function were good. DU and MRI studies showed an effective portal flow and the maintenance of a normal splenopancreatic vein outflow through the SSRS. DISCUSSION: APF represent a serious clinical problem, particularly in patients who need LT. The persistence of arterial flow into the PV is dangerous for the long-term liver function. A particular surgical strategy, strictly tailored to the hemodynamic conditions, has to be planned. CONCLUSIONS: Extrahepatic multiple APF would no longer to represent a contraindication to LT, although this claim needs to be confirmed in the light of further experience and a longer-term follow-up.     

扩大胰十二指肠切除术中联合肝动脉、肝固有动脉与髂内静脉切除重建应用的可行性研究

目的探讨在行扩大胰十二指肠切除联合血管切除术中应用肝动脉(HA)或肝固有动脉(PHA)与肠系膜上动脉(SMA)吻合、髂内静脉(IIV)与肠系膜上静脉(SMV)或门静脉(PV)吻合应用的可行性。方法解剖20具成人尸体的HA、PHA、SMA、SMV、PV、左IIV及右IIV,测量各血管长度、血管壁厚度和血管直径;用多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影检测20例胰头癌患者和本组5例患者的上述血管,并进行比对。根据比对结果,对5例已经发生血管浸润的胰头癌行扩大胰十二指肠切除术,行HA或PHA与SMA、IIV与SMV或PV吻合重建。结果尸体的HA-PHA长度为(5.50±1.50)cm,血管壁厚度为(0.20±0.01)mm,血管直径为(5.02±1.32)mm;SMA长度为(4.00±1.00)cm,血管壁厚度为(0.21±0.01)mm,血管直径为(6.05±1.06)mm。左IIV、右IIV及PV主干或SMV血管直径分别为(11.06±0.16)mm、(11.10±0.13)mm及(11.56±0.20)mm;左IIV、右IIV及PV主干或SMV的管壁厚度分别为(0.10±0.01)mm、(0.10±0.02)mm和(0.10±0.02)mm。活体多层螺旋CT扫描、磁共振血管成像、彩色多普勒、选择性动脉造影显示HA或PHA和SMA管壁厚度及血管直径分别稍比尸体解剖大0.1 mm和0.3 mm,差异均无统计学意义(P>0.05),而HA-PHA的长度比SMA长1～2 cm(P<0.05)。5例行扩大胰十二指肠切除术同时联合HA或PHA和SMA、IIV和PV或SMV切除重建患者的生存期均长于同期姑息性或放弃手术者,无一例发生远期并发症。结论有血管侵犯的胰头癌不是根治术的绝对禁忌证;就本组5例扩大胰十二指肠切除联合血管切除重建的患者比同期发生血管浸润的胰头癌仅施行探查或姑息性手术的33例患者生存时间而言,前者生存时间明显延长;HA或PHA和IIV是最好的自体血管代用材料,没有明显增加术后并发症;熟识尸体局部解剖结构对手术医生有一定的指导性意义。     

小肠自体移植式扩大胰腺癌根治术的疗效与安全性分析：附2例报告

背景与目的 局部进展期胰腺癌（LAPC）的治疗方法在不断更新，且随着血管重建技术与自体器官移植技术的进步，血管侵犯的LAPC的手术根治率也极大提高。本文探讨小肠自体移植式扩大胰腺癌根治术的可行性与安全性。方法 回顾性分析中国人民解放军火箭军特色医学中心2022年5月—2023年5月收治的肠系膜根部受侵的2例LAPC患者的临床资料。2例患者均为女性，分别为66岁和58岁，术前影像学检查提示胰腺钩突恶性肿瘤，肿瘤侵犯并包绕肠系膜上动脉（SMA）及空肠动脉分支。2例患者术前一般情况可，均有十二指肠梗阻表现而未实施化疗，术前心、肺、肝、肾功能经评估患者均能耐受手术，实施小肠自体移植式扩大胰腺癌根治术。手术的关键是将小肠连同肿瘤标本一并切除至体外，再迅速移除标本，后遵循“先动脉、后静脉”的顺序进行SMA/肠系膜上静脉（SMV）重建。结果 2例患者的手术均顺利实施，患者1使用脾动脉翻转与SMA进行重建，SMV与门静脉（PV）对端吻合，小肠热缺血时间为24 min，术后病理诊断为胰腺低分化腺癌。患者2使用SMA端端吻合重建，SMV与PV对端吻合，小肠热缺血时间为18 min，术后病理诊断为胰胆管型壶腹癌。2例患者术后恢复均良好，没有出现动静脉血栓，术后住院时间分别为25 d和21 d。截至2023年8月1日，2例患者分别已在门诊随访12个月与2个月，随访期间患者一般情况良好，除患者2血糖控制尚不平稳外，2例均未见复发或转移证据。结论 从对2例病例回顾性分析结果看，对于侵犯肠系膜根部的LAPC患者采用小肠自体移植式的扩大根治术可以安全成功实现，为此类患者提供了一种可以获得解除病痛、增加生存机会的治疗选择。