胰十二指肠下静脉的影像学解剖特征及临床意义

Imaging anatomy and clinical significance of the inferior pancreaticoduodenal veins

目的探讨胰十二指肠下静脉(IPDV)的影像学解剖特征及临床意义。方法采用回顾性描述性研究方法。收集2018年1月至6月北京协和医院收治的42例胰头导管腺癌患者的临床病理资料;男24例,女18例;平均年龄为61岁,年龄范围为41~78岁。患者术前行1 mm层距的CT增强扫描检查,根据术前评估行相应手术治疗。观察指标:(1)术前CT检查结果。(2)手术情况。采用Shapiro-Wilk检验计量资料的正态性假设,偏态分布的计量资料以M(QR)或M(范围)表示,组间比较采用Mann-Whitney U检验。计数资料以绝对数或百分比表示,组间比较采用χ^2检验。结果(1)术前CT检查结果:42例患者术前均行层间距为1 mm的CT增强扫描检查。CT检查结果显示:①42例患者均存在第一空肠静脉干,其中34例第一空肠静脉干走行于肠系膜上动脉(SMA)背侧,8例第一空肠静脉干走行于SMA腹侧。②42例患者中,2例未显示IPDV;40例存在IPDV,其中23例存在1支IPDV,13例存在2支IPDV,3例存在3支IPDV,1例存在4支IPDV。42例患者共检出62支IPDV,人均IPDV为1支(0~4支),其中43支汇入第一空肠静脉干或第二空肠静脉干,19支汇入肠系膜上静脉(SMV)。③42例患者中,32例为Ⅰ型IPDV(1支IPDV汇入SMA背侧空肠静脉干20例、2支IPDV汇入SMA背侧空肠静脉干7例、3支IPDV汇入SMA背侧空肠静脉干2例、1支IPDV汇入SMA腹侧空肠静脉干3例),10例为非Ⅰ型IPDV;18例为Ⅱ型IPDV(1支IPDV汇入SMV 17例、2支IPDV汇入SMV 1例),24例为非Ⅱ型IPDV。患者可同时合并Ⅰ型和Ⅱ型IPDV。(2)手术情况:42例患者均施行胰十二指肠切除术,其中腹腔镜手术14例,开放手术28例;术中SMV和(或)门静脉切除重建5例;术中输血18例;术后病理学检查结果均为胰头导管腺癌,R0切除30例、R1切除12例。42例患者中,32例Ⅰ型IPDV患者的术中出血量为650 mL(853 mL),术中输血15例,手术切缘情况(R0和R1切除)分别为20例和12例,SMV和(或)门静脉切除重建为4例;10例非Ⅰ型IPDV患者的上述指标分别为475 mL(480 mL),3例,10例和0例,1例。Ⅰ型IPDV和非Ⅰ型IPDV患者术中出血量、手术切缘情况比较,差异均有统计学意义(Z=94.000,χ^2=5.250,P<0.05);Ⅰ型IPDV和非Ⅰ型IPDV患者术中输血例数、SMV和(或)门静脉切除重建比较,差异均无统计学意义(χ^2=0.045,0.886,P>0.05)。结论薄层增强CT检查可分辨IPDV,IPDV有汇入SMV或空肠静脉干两种类型。胰十二指肠切除术中应注意处理汇入空肠静脉干的IPDV,汇入空肠静脉干的IPDV患者术中出血量更多,R0切除率更低。

Objective To investigate the imaging anatomy and clinical significance of the inferior pancreaticoduodenal veins (IPDVs). Methods The retrospective and descriptive study was conducted. The clinicopathological data of 42 patients with pancreatic head ductal adenocarcinoma who were admitted to Peking Union Medical College Hospital from January to June 2018 were collected. There were 24 males and 18 females, aged from 41 to 78 years, with an average age of 61 years. Patients received preoperative contrast-enhanced computed tomography (CT) examination with 1 mm slice thickness, and underwent corresponding surgery according to the preoperative evaluation. Observation indicators:(1) results of preoperative CT examination;(2) surgical situations. Normality of measurement data was analyzed using Shapiro-Wilk test. Measurement data with skewed distribution were described as M (QR) or M (range), and comparison between groups was analyzed by the Mann-Whitney U test. Count data were described as absolute number or percentage, and comparison between groups was analyzed by the chi-square test. Results (1)Results of preoperative CT examination: 42 patients received preoperative contrast-enhanced CT examination with 1 mm slice thickness.① The first jejunal venous trunk was identified in all the 42 patients. The first jejunal venous trunk crossed dorsal to the superior mesenteric artery (SMA) in 34 patients and ventral to the SMA in 8 patients.② Of 42 patients, 2 showed no IPDV, and 40 showed IPDV including 23 with 1 IPDV, 13 with 2 IPDVs, 3 with 3 IPDVs, and 1 with 4 IPDVs. A total of 62 IPDVs were identified in the 42 patients, with an average IPDV number of 1 (range, 0-4). There were 43 IPDVs drained into first or second jejunal venous trunks and 19 IPDVs drained into superior mesenteric vein (SMV).③ Of 42 patients, type Ⅰ IPDV was identified in 32 patients including 20 with 1 IPDV drained into jejunal venous trunk at dorsal side of SMA, 7 with 2 IPDVs drained into jejunal venous trunk at dorsal side of SMA, 2 with 3 IPDVs drained into jejunal venous trunk at dorsal side of SMA, and 3 with 1 IPDV drained into jejunal venous trunk at ventral side of SMA, and non-type Ⅰ IPDV was identified in 10 patients;type Ⅱ IPDV was identified in 18 patients including 17 with 1 IPDV drained into SMV and 1 with 2 IPDVs drained into SMV, and non-type Ⅱ IPDV was identified in 24 patients. Some patients can simultaneously had type Ⅰ and type Ⅱ IPDV.(2) Surgical situations: 42 patients underwent pancreatoduodenectomy, 14 of which underwent laparoscopic surgery and 28 underwent open surgery. There were 5 cases with SMV or portal vein reconstruction, and 18 with intraoperative blood transfusion. All the 42 patients were diagnosed as pancreatic ductal adenocarcinoma by postoperative pathological examination, including 30 of R0 resection and 12 of R1 resection. The volume of intraoperative blood loss, cases with intraoperative blood transfusion, cases with R0 and R1 resection (situation of surgical margin), cases with SMV or portal vein reconstruction were 650 mL(853 mL), 15, 20, 12, 4 in the 32 patients with type Ⅰ IPDV, and 475 mL (480 mL), 3, 10, 0, 1 in the 10 patients with non-type Ⅰ IPDV;there were significant differences in the volume of intraoperative blood loss and situation of surgical margin(Z=94.000,χ^2=5.250, P<0.05). There was no significant difference in the cases with intraoperative blood transfusion, cases with SMV or portal vein reconstruction between patients with type Ⅰ and non-type Ⅰ IPDV (χ^2=0.045, 0.886, P>0.05). Conclusions IPDVs can be distinguished on the contrast-enhanced CT with slice thickness, and classified as IPDVs drained into SMV or jejunal venous trunk. It is necessary to carefully deal with IPDVs drained into jejunal venous trunk in the pancreaticoduodenectomy due to its more volume of intraoperative blood loss and lower R0 resection rate.