源自肠系膜上动脉的变异肝动脉在胃癌D2根治术中的应用

The application of the abnormal hepatic artery derived from superior mesenteric artery in D2 radical gastrectomy

目的对源自肠系膜上动脉的变异肝动脉走行情况进行分型，并检测变异肝动脉旁淋巴组织是否有转移，从而指导胃癌D2根治术。方法对2008年1月至2010年6月间由同一术者进行胃癌D2根治术的86例胃癌患者的临床资料进行研究。患者术前均通过多层螺旋CT血管造影（MSCTA）对存在源自肠系膜上动脉变异肝动脉的走行情况进行分型，并经术中验证，术后将变异肝动脉旁淋巴组织行重组人细胞角蛋白20（CK20）、癌胚抗原（CEA）免疫组化作对照，从而判断异常动脉旁是否有淋巴结转移的发生。结果本组源自肠系膜上动脉变异肝动脉14例，其中男12例、女2例，平均62岁，其中变异肝总动脉3例，变异肝右动脉11例，总变异率为16．3％，其中走行于胰腺前方的1例、胰腺后方的13例，术中清扫此变异肝动脉，尤其胰后型其难度较大，易损伤异常血管及胰腺，并且手术时间较正常肝动脉者明显延长[（218．8±23．9）min比（179．64±18．5）min]，术前可通过MSCTA了解变异肝动脉的走行情况，从而指导术中的操作；胰前、后型异常血管旁淋巴组织的CK20、CEA免疫组化未发现淋巴结转移。结论源自肠系膜上动脉的变异肝动脉走行分为胰前型和胰后型；建议在D2胃癌根治术中若发现此变异肝动脉存在时，可不做此血管周围组织清扫。

Objectives To classify the courses of the abnormal hepatic arteries originated from superior mesenteric artery in patients with gastric cancer, and to define its application in the D2 radical gastrectomy in those patients. Methods Eighty-six patients with gastric cancer who had received D2 radical gastreetomy by the same surgeon between January 2008 and June 2010 were included in this study. All patients received the preoperative muhislice spiral computed tomoangiography （MSCTA） to classify the abnormal hepatic artery originated from the superior mesenteric artery, which was verified during the surgery. Postoperative immunohistochemistry of the lymphoid tissues around the abnormal hepatic artery was performed by recombinant human cytokeratin 20 （ CK20 ） and carcino-embryonic antigen （CEA） to verify the micrometastasis. Results In this group, the abnormal hepatic artery originated from the superior mesenteric artery were found with MSCTA and verified by operation in 14 patients, including 12 men and 2 women. The mean age was 62 years. Of the 14 cases with abnormal hepatic artery, 3 cases were found with abnormal common hepatic artery and 11 cases with abnormal right hepatic artery. The total mutation rate is 16. 3%. In those patients, the hepatic artery ran in front of the pancreas in 1 case and behind the pancreas in 13 cases. It was difficult to dissect the abnormal hepatic artery, especially for the post-pancreas type in D2 lymphadenectomy, for fear of damaging the abnormal blood vessel and pancreas. The operation time in cases with abnormal hepatic artery was significantly longer than that in patients with normal hepatic artery [ （218.8 ±23.9） min vs. （ 179. 6 ±18.5 ） rain ] . Immunohistochemica] analysis revealed no metastasis in the lymphoid tissues surrounding the abnormal artery. Condusions Abnormal hepatic arteries originated from the superior mesenteric artery can be classified into pre-pancreas type and post-pancreas type. The dissection of the abnormal hepatic artery is not advocated in D2 radical gastrectomy for no lymph node metastasis is found around the abnornal hepatic artery in this study.