多层螺旋CT门静脉血管成像在胰源性门脉高压症诊断中的应用

目的 研究多层螺旋CT门静脉血管成像在胰源性门静脉高压患者诊断中的应用.方法 应用16排多层螺旋CT门静脉血管成像,对47例临床怀疑胰腺体尾部病变的患者的门静脉系统形态改变与126例肝源性门脉高压患者和47例正常对照组进行形态学对比观察,并测量胃冠状静脉、门静脉、脾静脉、肠系膜上静脉内径、门静脉期肝实质和门静脉主干CT值,对比肝脏、脾脏体积.结果 在47例胰腺体尾部病变中发现有脾静脉狭窄、闭塞者38例,其中胰腺肿瘤患者27例(71.1%),急慢性胰腺炎患者11例(28.9%).38例胰源性门脉高压患者中,发现食管静脉曲张5例(13.2%),胃底静脉曲张25例(65.8%),胃体静脉曲张22例(57.9%),胃短-胃后静脉显示26例(68.4%),胃冠状静脉显示26例(68.4%),发现胃网膜静脉曲张24例(63.2%),肠系膜静脉曲张1例.脾静脉闭塞14例(36.8%),脾静脉狭窄23例(63.2%).结论 胰源性门脉高压在影像学上表现为脾静脉栓塞,脾脏增大,脾门处大量曲张静脉,胃后-胃短静脉及胃网膜静脉增粗迂曲,胃底和胃体静脉曲张,较少合并食管静脉曲张,肝脏形态大小亦无异常.多层螺旋CT门静脉血管成像检查可为胰源性门脉高压患者提供血管形态、病因诊断等多方面有价值信息,为临床诊断和治疗提供客观的影像学依据.     

多层螺旋CT门静脉成像评估肝硬化食管静脉曲张出血风险

目的 本文旨在评估多层螺旋CT（MSCT）门静脉重建对肝硬化门脉高压患者食管静脉曲张破裂出血风险的预测价值.方法 选取94例肝硬化可疑食管静脉曲张患者,1周内行MSCT和上消化道内镜检查.内镜排除合并胃底静脉曲张患者,共80例单纯食管静脉曲张患者入选本实验,对比分析MSCT及内镜资料.结果 食管曲张静脉评分、曲张静脉最大直径以及栅栏状静脉扩张均与内镜下曲张静脉形态、有无红色征及其严重程度明显相关.MSCT门静脉成像在判断红色征方面（≥4 mm）的灵敏度、特异度分别为71.3%、89.1%.结论 MSCT门静脉成像与内镜对食管静脉曲张程度的显示具有很好的一致性,可以作为预测曲张静脉出血的有效指标.     

多层螺旋CT门静脉成像对肝硬化门脉高压侧支循环的诊断价值

目的探讨多层螺旋CT(MSCT)门静脉成像对肝硬化门脉高压侧支循环的诊断价值。方法对109例经临床、肝功能和影像学检查诊断为肝硬化门脉高压患者行腹部三期增强扫描,经图像后处理,获得门静脉系统及侧支血管三维重建图像。结果 CTPV可以直观地显示门静脉系统及侧支循环。109例中,胃左静脉曲张67例(61.5%),食管下段静脉曲张87例(80.0%),胃后/短静脉曲张10例(9.2%),食管旁静脉曲张21例(19.3%),胃/脾-肾静脉分流14例(12.8%),门静脉海绵样变18例(16.5%),附脐静脉、腹壁静脉曲张15例(13.8%),椎旁静脉分流6例(5.5%)。结论 MSCT门静脉成像可精确显示各类侧支循环的部位、程度及走行,可为临床治疗前评估提供可靠的影像依据。     

64层螺旋CT门静脉造影及三维重建技术的临床应用

目的 探讨64层螺旋CT门静脉造影(MSCTP)及三维重建技术的临床应用价值.方法 对72例正常者(正常组)及30例门静脉病变者(病变组)以小剂量预注射法行MSCTP,采用三维(MIP、VR及MPR)重建技术观察门静脉分支、分级情况以及门静脉病变的影像学特征.结果 正常组均获得良好原始图像和三维重建图像,重建图像均可观察到门静脉5级以上分支,共5种解剖类型.病变组依据病史和三维重建图像诊断为门静脉高压症伴静脉曲张21例,其中海绵样变性2例,曲张静脉主要分布于食管下段及胃底静脉、前腹壁静脉、直肠上静脉曲张、自发性脾/胃-肾静脉分流、左性腺静脉、腹膜后交通支、胆囊周围静脉曲张、脾-左卵巢静脉;门静脉栓子6例,肝动脉-门静脉瘘3例.结论 MSCTP能清晰显示门静脉肝内分支、属支及侧支循环,对门静脉病变的病因诊断及外科手术方案的制定具有重要指导意义.     

胰源性门静脉高压症合并上消化道出血的治疗策略

胰源性门静脉高压症(PSPH)的发病机制和肝硬化性门静脉高压症完全不同,是唯一可被治愈的门静脉高压症。PSPH合并胃曲张静脉出血是相对少见的临床表现,但起病凶险,病情复杂,不恰当的治疗决策会延误病情,造成患者死亡。因此探索最优化的PSPH合并上消化道出血救治策略很有必要。脾切除是治疗PSPH继发消化道出血的确定性术式,同时实施针对胰腺原发疾病的术式。对于不适合手术的晚期肿瘤或手术高风险患者,优先选择疗效确切的脾动脉钢圈栓塞止血后再评估是否二期手术。PSPH出血的治疗须个体化决策,有必要开展多中心研究以获得最优化的PSPH出血治疗策略。     

孤立性胃静脉曲张的病因和临床特征

目的 分析孤立性胃静脉曲张的病因和临床特征.方法 选择2003年1月至2008年1月收治的31例孤立性胃静脉曲张患者,回顾性分析其病因、临床表现、影像学检查及治疗情况.结果 31例占同期胃食管静脉曲张患者的7.38%(31/420).病因依次为左侧门脉高压(14例,45.2%)、肝硬化(8例,25.8%)、不明原因(6例,19.4%)、原发性肝癌(2例,6.5%)、门静脉海绵样变性(1例,3.2%).曲张静脉破裂出血21例(67.7%).脾肿大21例(67.7%),其中脾功能亢进10例(32.3%).18例患者有明确的受侵静脉,其中脾静脉阻塞9例(50%),门静脉受侵9例(50%).外科手术8例,硬化剂治疗3例,其余20例内科保守治疗.结论 孤立性胃静脉曲张大部分由左侧门脉高压引起,部分病因是肝硬化.手术是治疗出血和预防再出血的有效措施.     

内镜治疗门静脉海绵样变食管胃底静脉曲张出血13例

门静脉海绵样变(cavernous transformation of the portal vein,CTPV)是指肝门部或肝内门静脉分支慢性部分性或完全性阻塞后,导致门静脉血流受阻,引起门静脉压力增高,为减轻门静脉高压,机体代偿性在门静脉周围形成侧枝循环或阻塞后的再通.CTPV患者可反复呕血和解柏油样便,伴有轻到中度的脾肿大和脾功能亢进.我院2003年至2011年采用内镜套扎(endoscopic variceal ligation,EVL)、内镜下硬化(endoscopic variceal sclerotherapy,EVS)及胃底曲张静脉粘合剂注射对13例CTPV食管胃底静脉曲张出血患者进行了治疗,现总结报道如下.     

孤立性胃静脉曲张的临床特点及内镜形态分析

目的:分析孤立性胃静脉曲张的临床和内镜形态特征。方法 :收集2007年1月至2015年5月期间我科经胃镜检查确诊为胃食管静脉曲张破裂出血的住院患者340例,其中孤立性胃静脉曲张38例(11.2%)。分析其病史资料、内镜所见、治疗情况及随访结果。结果:38例患者中常见病因分别为乙型肝炎后肝硬化(8例)、胰源性门静脉高压症(8例)及隐源性肝硬化(7例)。胃曲张静脉最常累及的区域分别为胃底大弯侧(84%)及胃底后壁侧(29%);形态上以多发结节状最常见(53%),其次为巨瘤状(37%);色泽上大多与周围正常黏膜相同(87%),且表面红色征少见(21%)。29例患者接受了内镜下硬化剂及组织黏合剂联合注射治疗术,所有患者对操作耐受良好,围手术期内未发生严重并发症。结论:孤立性胃静脉曲张为一少见疾病,其内镜形态复杂,缺乏明显色泽改变。胰源性门静脉高压症为其重要病因之一。内镜治疗可有效消退此类曲张静脉。     

左侧门静脉高压的超声诊断价值

超声在诊断各种肝脏疾病、布一加综合征等肝源性及肝后性引起的门静脉高压症方面已有广泛的应用和总结.门静脉由脾静脉和肠系膜上静脉两个主要属支汇合形成,分别接受同名伴行动脉的血流.当各种原因引起脾静脉阻塞时,大量的脾血将取道胃网膜左静脉、胃短静脉经胃壁静脉网从胃左静脉回流至门静脉.     

胃静脉曲张的病因及临床特点

目的探讨胃静脉曲张的病因及临床特点。方法回顾性分析北京协和医院2000年1月至2005年4月胃静脉曲张患者的病因及并发出血的情况,胃静脉曲张出血与红色征、曲张静脉类型、程度的关系,以及各型曲张静脉发生门脉高压性胃病的情况。结果我院5年间共诊治胃静脉曲张407例,占同期全部食管、胃静脉曲张的47.1%。胃静脉曲张的病因中,肝硬化占74.4%。孤立性胃静脉曲张的病因中脾静脉阻塞占37.2%,肝硬化占33%。407例胃静脉曲张患者中出血121例(29.7%)。在1型和2型胃静脉曲张、1型孤立性胃静脉曲张患者中,出血组红色征的阳性率、静脉曲张的程度均显著高于未出血组(P<0.01)。门脉高压所致的304例胃静脉曲张患者中发生门脉高压性胃病60例(19.7%),与食管静脉曲张发生门脉高压性胃病(22.3%)无差异,但孤立性胃静脉曲张很少出现门脉高压性胃病(9.6%,P<0.05)。结论胃静脉曲张最常见的病因是各种原因引起的肝硬化,而孤立性胃静脉曲张最常见的病因是脾静脉阻塞。红色征、静脉曲张程度是胃静脉曲张出血的危险因素。胃静脉曲张对门脉高压性胃病无影响。     

Venous anatomy of the right colon: precise structure of the major veins and gastrocolic trunk in 58 cadavers

PURPOSE: This study was designed to describe the precise venous anatomy of the right colon, which is especially important for laparoscopic right hemicolectomy. METHODS: Fifty-eight adult cadavers were dissected to define the three major venous tributaries of the right colon: the ileocolic vein, right colic vein, and middle colic vein. Two or three middle colic veins were often present, and the biggest one was designated as the main middle colic vein. The middle colic vein and the right colic vein occasionally formed a common trunk with the right gastroepiploic vein and/or the pancreaticoduodenal vein. This common trunk was defined as the gastrocolic trunk. RESULTS: All 58 cadavers had a single ileocolic vein. All of the ileocolic veins drained into the superior mesenteric vein. The right colic vein was absent in 56.9 percent (33/58), and the other 43.1 percent had a single right colic vein. The right colic vein joined the superior mesenteric vein directly in 56 percent (14/25) and the gastrocolic trunk in 44 percent (11/25). The middle colic vein was the most variable. A single middle colic vein was present in 37.9 percent (22/58), 2 middle colic veins were present in 50 percent (29/58), and 3 middle colic veins were present in 12.1 percent (7/58). The main middle colic vein drained into the superior mesenteric vein directly in 84.5 percent (49/58), whereas 12.1 percent (7/58) drained into the gastrocolic trunk. In two cadavers, there was anomalous drainage of the main middle colic vein to the splenic vein and the inferior mesenteric vein. Forty-three accessory middle colic veins were present in total. These drained into the superior mesenteric vein in 17 cadavers and into the gastrocolic trunk in 23. The gastrocolic trunk was present in 69 percent (40/58), being formed with the right colic vein in 27.5 percent (11/40; 1 was together with an accessory middle colic vein) and with the middle colic vein in 75 percent (30/40; 7 with the main middle colic vein, 23 with the accessory middle colic vein). CONCLUSION: Venous anatomy of the right colon is highly variable. It is especially important to recognize the lack of direct drainage of the right colic vein to the superior mesenteric vein and the high frequency of the presence of plural middle colic veins and the gastrocolic trunk.     

Effects of vasopressin on left gastric venous flow in cirrhotic patients with esophageal varices

To assess vasopressin control of esophageal variceal bleeding, we investigated the effect of vasopressin on the left gastric venous flow, portal venous flow, superior mesenteric venous flow, and splenic venous flow in seven cirrhotic patients with esophageal varices, using a duplex system consisting of a real-time ultrasonograph and an echo-Doppler flowmeter. Infusion of vasopressin (0.3 U/min) significantly decreased the blood flow in the left gastric vein (-56%), portal trunk (-54%), superior mesenteric vein (-54%), and splenic vein (-56%) as a result of decrease of blood velocity in these vessels. Thus, vasopressin seems to control esophageal variceal bleeding, in part, by reducing blood velocity and blood flow in the left gastric vein following reduction of blood velocity and blood flow in the superior mesenteric vein and splenic vein.     

Laparoscopic splenectomy for variceal bleeding with non-cirrhotic portal vein thrombosis: a case report

A 57-year-old man was referred to our hospital for treatment of refractory gastric bleeding from gastric varices secondary to portal vein thrombosis. The patient's liver function tests and coagulation profile were normal. The venous phase of the superior mesenteric arteriogram, on the other hand, showed superior mesenteric vein-portal vein occlusion with surrounding hepatopetal variceal collaterals. The venous phase of the splenic arteriogram additionally showed splenic vein occlusion and collateral vessels from the gastric and retroperitoneal regions flowing into a portal cavernous transformation. Gastroscopy confirmed that the patient had gastric varices in the cardia. We performed laparoscopic splenectomy to treat refractory gastric bleeding from varices and symptomatic hypersplenism. The postoperative course was uneventful; the patient's gastric varices were less prominent on follow-up gastroscopy and the hematologic profile returned to normal. Extrahepatic portal vein thrombosis is the leading cause of variceal hemorrhage in patients with healthy livers. There is a consensus in the literature that splenectomy alone is of minimal value in preventing variceal bleeding in portal vein thrombosis. Splenectomy is, however, indicated in cases in which the patient has hepatopetal collaterals from the mesenteric vein system and whose hemorrhagic gastric varices are related to splenic vein thrombosis as in our case.     

64层螺旋CT对门静脉海绵样变性的诊断价值

目的探讨64层螺旋CT在门静脉海绵样变性（CTPV）诊断中的价值。方法对CT检查发现的CTPV患者22例,采用MPR、MIP、VR等图像后处理技术显示异常的门静脉及侧支血管情况。结果 22例CTPV在CT平扫上显示门静脉结构不清,肝门区可见多发的结节状、条状软组织影。增强扫描显示6例动脉期肝实质灌注异常;门静脉期11例患者门静脉主干和（或）左右分支增粗,内可见充盈缺损,4例门静脉显示不清;2例门静脉主干和（或）左右分支在正常范围内;4例门静脉主干变细;1例门静脉主干受侵致管腔狭窄。胆管周围静脉丛（86.36%）、胆囊静脉（77.27%）及食管胃底静脉（77.27%）呈点状、细网状、簇状扩张。结论 64层螺旋CT能准确显示CTPV的部位、范围,立体地显示各曲张血管的走行及曲张程度,是检查CTPV的有效手段。     

“Top down no-touch” technique in robotic complete mesocolic excision for extended right hemicolectomy with intracorporeal anastomosis

Background

Proper identification of the mesocolic vessels is essential for achieving complete mesocolic excision (CME) in cases of colon cancer requiring an extended right hemicolectomy. In robotic procedures, we employed a “top down technique” to allow early identification of the gastrocolic trunk and middle colic vessels. The aim of our study was to illustrate the details of this technique in a series of 12 patients.

Methods

The top down technique consists of two steps. First, the omental bursa was entered to identify the right gastroepiploic vein. Tracing down this vein as a landmark, the gastrocolic trunk was exposed, branches of this trunk and the middle colic vessels were divided. Second, dissection was directed to the ileocolic region and proceeded in an inferior-to-superior direction along the superior mesenteric vein to divide the ileocolic and right colic vessels consecutively. The ileotranverse anastomosis was created intracorporeally.

Results

There were 8 males and 4 females with a mean age of 64.8?±?16.9 years and a mean body mass index of 25.6?±?3.7 kg/m². All the procedures were completed successfully. No conversions occurred. The mean operative time and blood loss were 312.1?±?93.9 min and 110.0?±?89.9 ml, respectively. The mean number of harvested lymph nodes was 45.2?±?11.1. The mean length of hospital stay was 7.6?±?4.7 days. Two patients had intraoperative complications and two had postoperative complications. There was no disease recurrence at a mean follow-up period of 10.4?±?7.1 months.

Conclusions

The top down technique appears to be useful in robotic CME for an extended right hemicolectomy. Early identification of the gastrocolic trunk and middle colic vessels via this technique may prevent inadvertent vascular injury at the mesenteric root of the transverse colon.

     

螺旋CT门静脉造影对门脉高压侧支循环的研究

目的探讨多排螺旋CT门静脉造影(CT portal venography,CTPV)显示肝硬化门脉高压侧支循环血管的临床应用价值。方法对92例肝硬化门脉高压的患者分别进行CT门脉造影,获得门脉侧支循环血管的清晰图像,测量门静脉主干和胃左静脉直径,将胃镜与CT门静脉造影两种技术进行比较。结果应用CT门静脉造影能清晰显示和测量门脉侧支循环的血管。CT门静脉造影与胃镜两种方法对食管和胃底曲张静脉的显示能力具有一致性,Kappa值分别为0.502和0.478。结论应用多排螺旋CT门静脉造影能很好显示和测量门体间侧支循环血管。联合应用多排螺旋CT门静脉造影与胃镜两种方法,对于肝硬化门静脉高压患者的诊断、病情判断和估计预后有帮助。     

Portal vein resection without reconstruction during Appleby operation in a patient with pancreatic body carcinoma with cavernous transformation.

The prognosis of pancreatic body carcinoma has been poor due to cancerous invasion of major vessels. Resection of the involved vessels may improve resectability and prognosis. We report a patient who had a pancreatic body carcinoma with cavernous transformation of the portal vein, in whom the portal vein was resected without reconstruction during an Appleby operation. A 67 year-old man was admitted for evaluation of back pain. Enhanced computed tomography showed no main trunk of the portal vein but a developed collateral circulation. Celiac angiography revealed encasement of the common hepatic, splenic and celiac artery. Venous angiography revealed obstruction of the portal and splenic veins with cavernous transformation surrounding these veins. Pre-operative diagnosis was carcinoma in the pancreatic body, which invaded the portal vein, the celiac and common hepatic arteries. The Appleby operation combined with resection of the portal vein without reconstruction could be performed, by preserving collateral vessels and monitoring hepatic venous oxygen saturation (ShvO2) to prevent hepatic ischemia caused by occlusion of the portal vein. The post-operative course was uneventful.     

Reversed portal flow: Clinical influence on the long-term outcomes in cirrhosis

AIM: To elucidate the natural history and the longitudinal outcomes in cirrhotic patients with non-forward portal flow(NFPF).METHODS: The present retrospective study consisted of 222 cirrhotic patients(120 males and 102 females; age, 61.7 ± 11.1 years). The portal hemodynamics were evaluated at baseline and during the observation period using both pulsed and color Doppler ultrasonography. The diameter(mm), flow direction, mean flow velocity(cm/s), and mean flow volume(m L/min) were assessed at the portal trunk, the splenic vein, the superior mesenteric vein, and the collateral vessels. The average values from 2 to 4 measurements were used for the data analysis. The portal flow direction was defined as follows: forward portal flow(FPF) for continuous hepatopetal flow; bidirectional flow for to-and-fro flow; and reversed flow for continuous hepatofugal flow. The bidirectional flow and the reversed flow were classified as NFPF in this study. The clinical findings and prognosis were compared between the patients with FPF and those with NFPF. The median follow-up period was 40.9 mo(range, 0.3-156.5 mo).RESULTS: Twenty-four patients(10.8%) demonstrated NFPF, accompanied by lower albumin level, worse ChildPugh scores, and model for end-stage liver disease scores. The portal hemodynamic features in the patients with NFPF were smaller diameter of the portal trunk;presence of short gastric vein, splenorenal shunt, or inferior mesenteric vein; and advanced collateral vessels(diameter 8.7 mm, flow velocity 10.2 cm/s, and flow volume 310 m L/min). The cumulative incidence rates of NFPF were 6.5% at 1 year, 14.5% at 3 years, and 23.1% at 5 years. The collateral vessels characterized by flow velocity 9.5 cm/s and those located at the splenic hilum were significant predictive factors for developing NFPF. The cumulative survival rate was significantly lower in the patients with NFPF(72.2% at 1 year, 38.5% at 3 years, 38.5% at 5 years) than in those with forward portal flow(84.0% at 1 year, 67.8% at 3 years, 54.3% at 5 years, P = 0.0123) using the Child-Pugh B and C classifications.CONCLUSION: NFPF has a significant negative effect on the prognosis of patients with worse liver function reserve, suggesting the need for careful management.     

Clinical and endoscopic features of gastric varices secondary to splenic vein occlusion

Aim: This study provides a retrospective evaluation of cases with gastric varices secondary to splenic vein occlusion. Methods: Our study group consisted of 14 patients. The clinical manifestations, diagnostic methods and therapeutic modalities were analyzed retrospectively. Results: Eleven patients had co‐existing pancreatic diseases: seven with chronic pancreatitis, three with cancer of the pancreatic body or tail and one with severe acute pancreatitis. Among the three remaining patients, one had advanced left renal cancer, one had myeloproliferative disease and the third had splenic vein occlusion due to an obscure cause. A diagnosis of gastric varices was made following endoscope gastroduodenoscopy or endoscopic color Doppler ultrasonography (ECDUS), and splenic vein occlusions were diagnosed from enhanced computed tomography in all cases. Specific findings of gastric varices secondary to splenic vein occlusion were based on ECDUS color flow images of gastric variceal flow that clearly depicted round cardiac and fundal regions at the center, with varices expanding to the curvatura ventriculi major of the gastric body. For three cases with gastric variceal bleeding, endoscopic injection sclerotherapy using a mixture of histoacryl and lipiodol (70% histoacryl solution) was performed, after which no further bleeding from gastric varices was detected. Due to a high risk of gastric variceal rupture, splenectomy was performed in two cases and splenic arterial embolization in another two cases. Conclusion: ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion. Treatment should take into account the diseases underlying these conditions.