胰头与十二指肠的血供关系及其临床意义

中国临床解剖学杂志 ›› 2013, Vol. 31 ›› Issue (6): 655-658.

胰头与十二指肠的血供关系及其临床意义

殷永芳¹,　许继凡¹,　郭涛¹,　戴珏¹,　罗诗樵¹,　孙善全²

1.重庆医科大学附属第一医院肝胆外科；　2.重庆医科大学基础医学国家级示范中心大体解剖实验室，重庆 400016

收稿日期:2013-03-03 出版日期:2013-11-25 发布日期:2013-12-16
通讯作者: 罗诗樵，副教授，Tel：15002355050, E-mail：luoshiqiao@　hotmail.com E-mail:yin_yongfang@163.com afanti52987143@163.com
作者简介:并列第一作者:殷永芳（1987-），男，浙江宁波人，在读硕士，Tel：15826120725 许继凡（1987-），男，山东临沂人，在读硕士，Tel：15223066062
基金资助:
国家自然科学基金（30972789）

Blood supply to the head of the pancreas and the duodenum and its clinical application

YIN Yong-fang¹, Xu Ji-fan¹, GUO Tao¹, DAI Jue¹, LUO Shi qiao², SUN Shan-quan³

Department of Hepatobiliary surgery of the 1st affiliated hospital of Chongqing Medical University, Chongqing 400016, China

Received:2013-03-03 Online:2013-11-25 Published:2013-12-16

摘要/Abstract

摘要：

目的　了解胰头及十二指肠的血管走行，为在DPPHR术中如何保护十二指肠的血供及是否行Kocher操作提供更多的形态学资料。方法　随机选取40具尸体，充分解剖暴露肠系膜上动脉、胃十二指肠动脉及胰十二指肠前后动脉弓，对供应十二指肠的动脉及伴行的静脉行径进行仔细观察和记录。结果　在97.5%的标本中（n=39）, 胰十二指肠后动脉弓及伴行的静脉均位于胰后筋膜内；在90%的标本中（n=36）, 胰十二指肠下前动脉及伴行的静脉走行于胰十二指肠沟内，易于保留；在个别标本中（10%, n=4）, 没有完整的胰十二指肠前动脉弓；其中1例标本（2.5%,n=1），没有完整的胰十二指肠后动脉弓，但供应十二指肠的动脉及其伴行静脉仍位于胰后筋膜内。结论　DPPHR手术的关键在于保留胰十二指肠后动脉弓，同时尽可能地保留部分胰十二指肠前动脉弓，而Kocher操作有利于保护胰十二指肠后动脉弓；在个别标本中，没有完整的胰十二指肠前动脉弓，此时施行DPPHR可能伤及十二指肠血供，导致手术失败。

关键词: 保留十二指肠的胰头切除术, 胰十二指肠前动脉弓, 胰十二指肠后动脉弓, Kocher操作

Abstract:

Objective　 To study blood supply to the head of the pancreas and the duodenum, and provide anatomical basis for Kocher maneuver and protecting vessels of the duodenum during duodenum preserving pancreatic head resection (DPPHR).　Methods　A total of 40 cadavers were collected for the study. The superior mesenteric artery, the gastroduodenal artery, the anterior pancreaticoduodenal arterial arcade, the posterior pancreaticoduodenal arterial arcade，their branches and accompanying veins were completely exposed. The arterial branches between the head of the pancreas and the duodenum were observed.　Results　For 97.5% cases (n=39), the posterior pancreaticoduodenal arterial arcade and accompanying veins were found in pancreatic fascia. For 90% cases (n=36), it was easy to preserve the anterior inferior pancreaticoduodenal artery and accompanying veins lied in the pancreaticoduodenal groove. For 10% cases (n=4), the anterior pancreaticoduodenal arterial arcade was absent, and 2.5% (n=1) was absent for the posterior pancreaticoduodenal arterial arcade, but the arteries to the duodenum and their accompanying veins were found in pancreatic fascia.　Conclusions　Protecting the posterior pancreaticoduodenal arterial arcade and the part of the anterior pancreaticoduodenal arterial arcade are the key process for successful DPPHR. Kocher maneuver helps to expose and identify the posterior pancreaticoduodenal arterial arcade and drainage veins. The failure of DPPHR maybe caused by the absence of the anterior pancreaticoduodenal arterial arcade.

Key words: Duodenum preserving pancreatic head resection, The anterior pancreaticoduodenal arterial arcade, The posterior pancreaticoduodenal arterial arcade, Kocher maneuver

中图分类号:

R323.3

殷永芳, 许继凡, 郭涛, 戴珏, 罗诗樵, 孙善全. 胰头与十二指肠的血供关系及其临床意义[J]. 中国临床解剖学杂志, 2013, 31(6): 655-658.

YAN Yong-Fang, HU Ji-Fan, GUO Chao, DAI Jue, LUO Shi-Qiao, SUN Shan-Quan. Blood supply to the head of the pancreas and the duodenum and its clinical application[J]. Chinese Journal Of Clinical Anatomy, 2013, 31(6): 655-658.

参考文献

[1] Whipple AO, Parsons WB, Mullins CR. TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER
[J]. Ann Surg,1935,102(4):763-779.

[2] 王春友. 保留十二指肠的胰头切除术
[J]. 临床外科杂志, 2009,17(6):370-372.

[3] Beger HG, Krautzberger W, Bittner R, et al. Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis
[J]. Surgery,1985,97(4):467-473.

[4] 木村理. 要点与盲点：胰脾外科
[M]. 人民卫生出版社, 2010.

[5] Beger H G, Kunz R, Poch B. The Beger procedure--duodenum-preserving pancreatic head resection
[J]. J Gastrointest Surg,2004,8(8):1090-1097.

[6] Koninger J, Seiler C M, Sauerland S, et al. Duodenum-preserving pancreatic head resection--a randomized controlled trial comparing the original Beger procedure with the Berne modification (ISRCTN No. 50638764)
[J]. Surgery,2008,143(4):490-498.

[7] Wang C, Liu T, Wu H, et al. Duodenum-preserving total pancreatic head resection without segment resection of the duodenum for chronic pancreatitis
[J]. Langenbecks Arch Surg,2009,394(3):563-568.

[8] Kimura W, Nagai H. Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas
[J]. Ann Surg,1995,221(4):359-363.

[9] 熊炯圻，王春友，陶京，等. 保留十二指肠胰头切除术的适应证及术式选择：附22例报告
[J]. 中华外科杂志,2007,45(1):24-26.

[10] 傅群武，丁自海，吴涛. 胰头的动脉分布及其临床意义
[J]. 中国临床解剖学杂志,2005,23(6):631-634.

[11]Kimura W. Surgical anatomy of the pancreas for limited resection
[J]. J Hepatobiliary Pancreat Surg,2000,7(5):473-479.

[12]Yamaguchi H, Wakiguchi S, Murakami G, et al. Blood supply to the duodenal papilla and the communicating artery between the anterior and posterior pancreaticoduodenal arterial arcades
[J]. J Hepatobiliary Pancreat Surg,2001,8(3):238-244.

[13]Kimura W, Morikane K, Futakawa N, et al. A new method of duodenum-preserving subtotal resection of the head of the pancreas based on the surgical anatomy
[J]. Hepatogastroenterology,1996,43(8):463-472.

[14] 韩德恩，孙庆峰，胡占良，等. 保留十二指肠的胰头切除术实用外科血管解剖学研究
[J]. 中华普通外科杂志,2004,19(3):150-152.

[15]Hong K C, Freeny P C. Pancreaticoduodenal arcades and dorsal pancreatic artery: comparison of CT angiography with three-dimensional volume rendering, maximum intensity projection, and shaded-surface display
[J]. AJR Am J Roentgenol,1999,172(4):925-931.

[16]Kim S W, Kim K H, Jang J Y, et al. Practical guidelines for the preservation of the pancreaticoduodenal arteries during duodenum-preserving resection of the head of the pancreas: clinical experience and a study using resected specimens from pancreaticoduodenectomy
[J]. Hepatogastroenterology,2001,48(37):264-269.