活体造影法肝内胆管的解剖学研究及临床意义

目的　通过经皮胆道直接造影,研究肝内胆管的解剖与变异的类型与分布。 方法　经皮胆道造影50例, 用20 ml注射器接体外引流管进行造影,胆管充分显影的状态下,旋转拍摄胆管,观察胆管解剖与变异。 结果　50例成像中胆管变异42.0％（21例）。12.0% (6例)显示右前叶肝管、右后叶肝管及肝左管呈三分叉状汇合形成肝总管。8.0% (4例) 肝左管先和右前叶肝管汇合,在肝门处与右后叶肝管汇合。20.0% (10例) 肝左管先和右后叶肝管汇合,在肝门处与右前叶肝管汇合。2.0% (1例)多个肝管在肝门处汇合。 结论　胆管解剖与变异的分析对术前手术方式的确定有一定的临床意义。     

肝右叶肝管表面定位及临床意义

为探讨肝右叶胆管手术的入肝途径和新的手术方法，解剖了４０例成人肝剥制标体和３例肝铸型标本的Ｇｌｉｓｓｏｎ系统。观测肝右管汇合类型及变民；肝右叶Ⅰ－Ⅲ级胆管端作了肝的脏面、膈面三维投影定位。结果表明：行肝右叶胆管手术经脏面入路优于膈面经投影点定位、穿刺、剖肝、找管的手术方法，具有定位准确、直视到达、操作简便、肝组织损伤小等优点。同时还讨论他其它临床问题。     

肝叶切除术在肝内胆管结石治疗中的应用

目的：探讨肝叶切除治疗肝内胆管结石的效果。方法：对1997年1月-2008年6月收治的55例肝内胆管结石患者采取肝叶切除术治疗,其中肝左外叶切除45例,左半肝切除6例,右后叶切除3例,右前叶切除1例。结果：本组50例获随访,随访时间6个月-10a,其中疗效优34例,良11例,差5例,优良率为90％。术后并发切口感染3例、胆漏2例、肺部感染2例、胸腔积液2例、膈下感染1例、肝衰1例、上消化道出血1例,均经对症处理、抗感染、支持疗法治疗,于术后21～36d治愈。无死亡病例。结论：肝叶切除是治疗肝内胆管结石的的有效措施之一。     

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。     

肝内胆管结石并发胆管狭窄的治疗

原发性肝胆管结石常合并有肝内胆管狭窄，由于其复杂的病因及病理改变，治疗上仍为当前肝胆外科未能很好解决的问题，主要表现为手术治疗困难，复发和残石率高，疗效差。我院2003年1月至2007年8月共收治肝内胆管结石并发胆管狭窄患者58例，采用肝叶、肝段切除，狭窄胆管切开整形，肝胆管空肠吻合术，效果满意，现报告如下。     

右半肝内门静脉的断层影像解剖学研究

目的 探讨右半肝内门静脉的走行、分布规律及门静脉肝裂和肝静脉的关系,进而为肝段的划分提供断层解剖学依据. 方法使用30例上腹部连续断层标本(10例横断面、20例冠状面)以及20例多层螺旋CT图像和三维图像,探讨右半肝内门静脉的分支类型和常见变异以及肝内门静脉和肝静脉之间的关系. 结果 50例标本和图像中,右半肝内门静脉均可分为前上和后下两组分支.76%(38150)的门静脉右前支的分支向后分布至肝右静脉后方的部分区域.40%(20/50)的门静脉右后支的起始部向尾侧发出的第一分支分布至肝右静脉前的部分区域.门静脉右前支的分布区域,越过肝中静脉偏向左侧,在15例无门静脉右支主干的标本和图像中尤其明显.肝右前叶无明显横裂存在.门静脉的亚段分型有显著的个体差异,且无优势分支类型. 结论右半肝可分为右前上叶和右后下叶,两叶之间为一弯曲的"裂隙".肝右前上叶有一恒定的纵裂存在.肝右静脉不是右叶间裂的准确定位标志,尤其在其上份和下份.肝中静脉不是正中裂的准确识别标志,尤其在门静脉右支主干缺如的人群中.     

肝左外叶切除治疗肝内胆管结石

目的 总结用肝左外叶切除术治疗肝内胆管结石的经验及疗效.方法 回顾性分析我院近10年来采用肝左外叶切除术治疗原发性肝内胆管结石48例的临床资料、手术方法及术后恢复情况.结果 全组随访6月至8年,其中再发胆管结石2例(占4.17%)胆管炎1例(占2.08%),其余病人无明显胆道症状(占93.7%).结论 肝左外叶切除治疗肝内胆管结石疗效确切.     

肝内胆管结石的手术方法选择

肝内胆管结石的手术方法选择自１９８０～１９９３年手术治疗肝内胆管结石５５９例。结石位于左肝２３０例（４１．１４％），右肝１１０例（１９．６８％），左右肝内均有结石２１０例（３９．１８％），合并胆管狭窄２４５例（４３．８％）２９２处。根据肝内胆管结石状...     

左肝管行程定位与临床应用

<正> 胆肠内引流是解决肝内胆管狭窄的主要措施,为手术经多种途径显露肝管及肝方叶的切除提供应用解剖学基础.本文对64例成人肝标本中左肝管的长度及毗邻关系进行测量.左肝管位于肝方叶后1/3范围,相当于在肝门左半内横行或斜行.其起始部大多贴近肝圆韧带裂,占84.37%;其余向右偏离该裂一段距离,距肝方叶脏面(0.83±0.52)cm(0-1.6cm),距肝方叶后面(0.39±0.29)     

肝叶部分切除治疗肝内胆管结石

肝内胆管结石的发生率约占胆道结石的13％～20％,因其在肝内胆管,位置较深,易发生感染形成脓肿及狭窄,而且有相当一部分病人是手术后复发,所以治疗难度较大,对于这一类病人最有效的治疗方法就是行手术治疗。1996～1999年我院对17例肝内胆管结石的病人成功地实施了肝叶部分切除,肝内胆管取石Roux-Y胆肠吻合,胆道重建手术,取得了理想的效果,报道如下。     

Intraductal oncocytic papillary neoplasm of the liver

A very rare case of intraductal oncocytic papillary carcinoma of the liver is reported. A 63-year-old Japanese man was admitted to our clinic because of abdominal pain and jaundice. Imaging techniques revealed a unilocular cystic neoplasm of 14 cm diameter in the medial segment of the left hepatic lobe. Combined percutaneous and endoscopic retrograde cholangiographies revealed the unilocular cystic neoplasm contained a lot of mucus and communicated with the left segmental intrahepatic bile duct, and that mucus filled the left segmental and hepatic ducts. Left lobectomy was performed. The postoperative course was good, and the patient is free of disease 30 months after operation. Pathological examination revealed that the cavity of the neoplasm was continuous with the left segmental intrahepatic bile duct, and that a lot of mucus was present in the neoplasm, as well as in the left segmental and hepatic ducts. The neoplasm consisted of papillary growth of atypical epithelial cells with oncocytic changes. Atypical goblet cells were also recognized. No invasion into the surrounding liver was noted. Non-tumorous intrahepatic bile ducts near the lesion occasionally showed epithelial dysplasia and contained a lot of mucus. Immunohistochemically, the tumor cells were rich in mitochondria and were immunoreactive for cytokeratins 7, 18 and 19, carbohydrate antigen 19-9, and hepatocyte-specific antigen. Some tumor cells were immunoreactive for pancreatic alpha-amylase and lipase. Ultrastructurally, the tumor cells showed numerous mitochondria and mucus droplets. Intraductal neoplasm communicating with the intrahepatic bile ducts has rarely been reported. The present case suggests that intraductal oncocytic papillary neoplasm, as described in the pancreas, may also occur in the intrahepatic bile ducts, and that such hepatic intraductal neoplasm may express hepatocellular and pancreatic acinar phenotypes.     

左外叶活体肝移植的解剖学研究

目的：模拟左外叶活体肝移植门静脉、肝动脉和胆管的切取方法。方法：解剖正常人肝脏标本30具，观察肝脏铸型标本30具，测量门静脉、肝动脉及胆管长度、管径及属支或分支分布情况。结果：左外叶门静脉的血供来自门静脉左支，主要为左外叶上段门静脉支、左外叶下段门静脉支；动脉主要来源于肝固有动脉、肝左动脉、肝中动脉，偶有迷走动脉支；胆道引流属支有左外叶上段胆管支、左外叶下段胆管支。结论：左外叶解剖变异较多，活体取肝前应仔细研究其结构特点，设计合理的切取模式；对门静脉、肝动脉和胆管支需行必要的整形，以便与受体相应的管道进行吻合。     

Secondary joining of the bile ducts during the hepatogenesis of the mouse embryo

Summary Development of the bile duct system of the mouse embryo was studied histologically and by an immunofluorescent technique. The hepatic primordium consisted of cranial and caudal portions. In the liver of young embryos, the hepatic cords were present in the presumptive cysticduct epithelium, and the histology of the presumptive cystic duct epithelium near the hilus was similar to that of the hilus epithelium. The results suggest that at least a part of the cystic duct epithelium develops from the cranial diverticulum of the hepatic primordium. Lumen structures were precursors of intrahepatic bile ducts and originated from type I (immature) hepatocytes. The lumina of the lumen structures appeared near the hilus area first, but most were discontinuous with those of the hepatic ducts. With the progress of development, the discontinuous lumen structures became distributed around the portal vein branches in the central part of the liver parenchyma, and gradually connected with each other and also with hepatic ducts. the discontinuous laminin immunofluorescence also appeared in the endodermal cells around the portal vein branches at the younger stages. Therefore, it is conceivable that the intrahepatic bile ducts originate from discrete cell populations of type I hepatocytes around the portal vein branches and subsequently become confluent, but not from the cells of hepatic ducts.     

Embryology of Extra‐ and Intrahepatic Bile Ducts,the Ductal plate

In the human embryo, the first anlage of the bile ducts and the liver is the hepatic diverticulum or liver bud. For up to 8 weeks of gestation, the extrahepatic biliary tree develops through lengthening of the caudal part of the hepatic diverticulum. This structure is patent from the beginning and remains patent and in continuity with the developing liver at all stages. The hepatic duct (ductus hepaticus) develops from the cranial part (pars hepatica) of the hepatic diverticulum. The distal portions of the right and left hepatic ducts develop from the extrahepatic ducts and are clearly defined tubular structures by 12 weeks of gestation. The proximal portions of the main hilar ducts derive from the first intrahepatic ductal plates. The extrahepatic bile ducts and the developing intrahepatic biliary tree maintain luminal continuity from the very start of organogenesis throughout further development, contradicting a previous study in the mouse suggesting that the extrahepatic bile duct system develops independently from the intrahepatic biliary tree and that the systems are initially discontinuous but join up later. The normal development of intrahepatic bile ducts requires finely timed and precisely tuned epithelial–mesenchymal interactions, which proceed from the hilum of the liver toward its periphery along the branches of the developing portal vein. Lack of remodeling of the ductal plate results in the persistence of an excess of embryonic bile duct structures remaining in their primitive ductal plate configuration. This abnormality has been termed the ductal plate malformation. Anat Rec, 291:628–635, 2008. © 2008 Wiley‐Liss, Inc.     

A tongue-like projection of the left lobe in human liver, accompanied with lienorenal venous shunt and intrahepatic arterial anastomosis.

The characteristic features of a tongue-like projection of the left lobe of the liver in a female adult, accompanied with a large lienorenal venous shunt and an intrahepatic anastomosis of the hepatic arteries, are described. By dissecting the liver parenchyma, this projection is supplied by a set of the lateral segmental branches of the portal vein, hepatic artery and hepatic ducts and by the branch of the left hepatic vein. The boundary between the abnormal and the proper left lobes can not be confirmed accurately, because the tongue-like projection is overlapped with the paraumbilical lobe on the visceral surface. However, the position is estimated a transverse line superior to the attachment to the proper left lobe. The anomaly is derived from a medial and inferior portion of the left lobe of the liver and may be regarded as a left half of the central lobe in the ape etiologically. No evidences to justify the co-existence of the tongue-like projection with the lienorenal shunt are confirmed.     

Intrahepatic bile duct development in the rat: a cytokeratin-immunohistochemical study

The development of the intrahepatic bile ducts was studied in rats from day 12 of gestation until 10 days of age using three antibodies directed against cytokeratins in an immunohistochemical procedure on paraffin-embedded liver tissue. In adult rat liver, both hepatocytes and bile ducts were stained by the monoclonal anti-cytokeratin no. 8, whereas two polyclonal antibodies stained bile ducts only. Hepatocytes in developing rat liver were stained by monoclonal anti-cytokeratin no. 8 from day 12 of gestation on. On day 16, cells strongly immunoreactive for cytokeratin no. 8 were observed in a string of pearl-like arrangement around large vascular branches close to the liver hilum. Over the following days, similar structures appeared throughout the liver. Gradually, lumina were formed in these structures, again starting at the liver hilum and resulting in the formation of individual bile ducts. Immunoreactivity with the polyclonal antibodies was first detected in some of the string of pearl-like structures on day 19 and gradually increased until the intensity observed in adult rat liver was reached on day 1 after birth. Even on day 10, portal spaces still revealed more bile duct branches, rings of cells strongly positive for cytokeratin no. 8 and weakly positive with the polyclonal antibodies were present. It is concluded that the intrahepatic bile ducts develop from hepatocytes. The cells closest to large vascular spaces first become strongly positive for cytokeratin no. 8 and only later on acquire additional ("bile duct type") cytokeratins. This process starts at the liver hilum and spreads through the liver. Even at 10 days of age the bile duct system is still immature: around the smaller portal vein branches, rings of cells are still undergoing transformation into bile duct type cells. These data might be useful for reevaluation of pathologic phenomena.     

Arterial supply and biliary drainage of the dorsal liver: A dissection study using controlled specimens

Liver surgeons favor using the entity called the 'dorsal liver' (i.e. the caudate lobe and other paracavally located liver parenchyme of segments 7 and 8). According to minute dissection of 48 livers, we describe the territories of the left/right portal veins, hepatic ducts and hepatic arteries in the dorsal liver. In the caudate lobe, the right hepatic artery, rather than the left hepatic artery (23/48 vs 19/48 for right vs left, respectively), tended to supply the 'left' portal vein territory. Similarly, paradoxical drainage patterns, such as the right hepatic duct draining the left portal vein territory, were found in seven of 48 livers. In the territory of the hilar bifurcation, right hepatic artery dominance was also evident and various bile drainage patterns were found. These included double drainage by the bilateral hepatic ducts (3/48) and drainage into the confluence of bilateral ducts (6/48). In contrast, the arterial supply and biliary drainage of the paracavally located parenchyme of segments 7 and 8 usually depended on the proper segmental arteries and ducts and their variations were within the range of those found in other parts of the right lobe. Therefore, the dorsal liver concept may not be anatomical but, rather, simply aimed at usefulness in surgery. Nevertheless, clear subdivision of the caudate lobe according to biliary drainage and/or arterial supply seemed difficult because of the paradoxical relatioships among the portal vein, hepatic artery and bile duct. Consequently, the present results support extended surgery based on the dorsal liver concept for carcinomas involving the caudate lobe.     

Morphogenesis of intrahepatic bile ducts of the human fetus

Summary The development of the intrahepatic bile ducts of the human fetus was investigated by light and electron microscopy. Bile canaliculi with microvilli and junctional complexes are already found in the embryo of 7 mm. Some of them are of the intracellular type. At six to seven weeks, large bile canaliculi bounded by four to seven liver cells appear. Subsequently, bile canaliculi are formed predominantly between three to four adjoining liver cells and this arrangement persists throughout later fetal life.The early intrahepatic bile ducts develop around the portal vein as epithelial cell plates derived from the hepatic duct and the branches sprout from the epithelial cell plates in several different places. The epithelial cell plates are separated from each other by primitive connective tissue and they change into a complex network of bile ducts. Formation of the intrahepatic bile ducts is completed by three months.Biliary duct cells at the end of the developing bile ducts are thought to transform into liver cells. Therefore, at the ducts of Hering various transitional cells appear between biliary duct cells and liver cells.The fine structure of the developing liver cells and biliaryduct cells is also described.     

肝门静脉右支的临床解剖

目的 探讨肝门静脉右支的形态特征和分支分布规律.方法 50例肉眼观察无病变的成人尸肝进行剥离解剖,对肝门静脉右支的形态结构进行观察,测量主干及主要分支的相关数据并进行统计学分析.结果 82.0%肝门静脉分为左﹑右两支,其成角(105.59±13.82)°,依据右支主干分支将其分为5型,其中65.8%右支主干分为右后叶支...