本文選題：肝門板 + 肝硬化　； 參考：《中國人民解放軍軍醫(yī)進修學院》2008年碩士論文

【摘要】： 第一部分:肝門板的解剖及臨床應用 目的:了解肝門板(Hilar plate)的解剖結構,探討肝門板在肝切除中的臨床意義及對比分析經全肝血流阻斷與經肝門板選擇性血流阻斷兩種不同血流阻斷方法下肝切除技術,臨床療效。 方法:選取非肝病死亡尸體解剖患者肝臟3例及肝移植切除病肝伴有中重度肝硬化5例。分別解剖肝門板左主干支、左內葉支、左外葉上支、左外葉下支,右主干支、右后葉支、右前葉支,進行測量其寬度和深度。仔細觀察肝門板各支干與周圍管道的關系及與肝臟實質間的組織間隙。同時臨床篩選行左半肝切除患者24例,隨機分為兩組,分為經全肝血流阻斷組與經肝門板選擇性血流阻斷組,統(tǒng)計兩組術中出血量、手術時間、術后肝功能變化以及住院時間,對比分析兩種不同肝血流阻斷方式的肝切除技術。 結果:3例非肝病死亡患者肝臟肝門板左主干平均寬1.73cm、深1.53cm;左內葉支平均寬1.3cm、深1.07cm;左外上支平均寬1.07cm、深0.83cm;左外下支平均寬0.97cm、深0.7cm;右主干平均寬2.07cm、深1.73cm;右后葉支平均寬1.3cm、深1.3cm;右前葉支平均寬1.47cm、深1.1cm。5例肝硬化肝臟的肝門板左主干平均寬1.92cm、深1.16cm;左內葉支平均寬1.08cm、深0.94cm;左外上支平均寬1.06cm、深0.78cm;左外下支平均寬0.9cm、深0.68cm;右主干平均寬1.98cm、深1.62cm;右后葉支平均寬1.14cm、深1.12cm;右前葉支平均寬1.16cm、深1.04cm。肝門板與第一肝門入肝血管之間存在明顯的組織間隙,較少的小血管交通支。肝門板在正常肝臟和肝硬化肝臟的分布及大小基本上無明顯變化,組織間隙及位置相對固定。通過肝門板選擇性血流阻斷肝切除患者較全肝血流阻斷行肝切除患者術后住院時間無統(tǒng)計學意義(p＞0.05),在手術時間、術中出血量上以及肝功能狀態(tài)前者明顯優(yōu)于后者(p＜0.05)。 結論:①肝門板為肝門部一纖維組織,在肝門部增厚向肝內延伸至肝段支,在肝外為肝門板向肝內延伸為Glisson鞘。②肝硬化肝臟肝門板與正常肝臟肝門板測量結果顯示無變化,肝門板作為肝臟解剖上的一特殊結構,在肝臟病變過程中,相對穩(wěn)定。③肝門板與肝內管道之間有著明顯的組織間隙,與肝臟實質以及包繞的管道之間存在較少的交通血管支,為手術中分離血管進行血流阻斷以及膽道手術術中分離膽管創(chuàng)造了有利條件。④分離肝門板能有效降低肝門部膽管特別是左右膽管匯合部位的高度,有助于膽管修補、肝內膽管結石以及膽管癌手術治療視野的擴大。⑤經肝門板選擇性肝臟血流阻斷技術安全、可行,易于掌握,在臨床運用中對于肝切除術后患者的影響明顯低于全肝血流阻斷患者,值得臨床推廣使用。 第二部分:肝門板組織結構研究及其臨床意義 目的:了解肝門板組織構成以及包含神經、血管、淋巴管的情況,探討肝門板在膽管癌腫瘤轉移中的作用以及臨床意義。 方法:選取第一部分中3例非肝病死亡患者肝臟標本,以肝外左右膽管匯合部開始一直到肝內肝段支的肝門板進行橫斷面切除,選取合適斷面組織進行HE染色,觀察肝門板內血管、神經及淋巴管存在和分布情況。同時選取臨床2例病理明確診斷為膽管癌的患者,行膽管癌根治術,切去手術切除的左半肝內左主干支以及左內葉支和左外葉支,進行組織染色,觀察腫瘤的分布以及轉移情況。 結果:肝門板內分布有小的毛細血管、淋巴管以及神經組織。在肝門板內,血管、淋巴管相互伴行,與周圍肝臟實質未見有小的交通支存在。肝門板內主要以纖維組織構成,組織間隙內存在各種血管、淋巴管以及神經組織。肝門部膽管癌2例中,腫瘤細胞沿淋巴管、血管和神經向遠處轉移,但不典型。 結論:膽管癌以神經、淋巴轉移為為主要轉移途徑,肝門板內可見明確的神經、淋巴以及小的血管組織,故在一定程度上肝門板可能參與膽管癌的遠處轉移。膽管癌標本中肝門板內神經、淋巴管轉移不典型。
[Abstract]:The first part: the anatomy and clinical application of the liver door
Objective: to understand the anatomical structure of the Hilar plate and to explore the clinical significance of the liver door plate in the hepatectomy and to compare the clinical effect of two different blood blockage methods under the whole liver blood flow blocking and the selective blood flow blocking by the liver door plate.
Methods: 3 cases of autopsy with non liver disease and 5 cases of liver transplantation and severe liver cirrhosis were dissected. The left main branch of the liver door, the left internal branch, the left superior branch, the left lateral branch, the right main branch, the right posterior branch, the right anterior lobe, and the right anterior lobe were measured, and the width and depth of the branches were measured. 24 cases of left hemi hepatectomy were selected and divided into two groups randomly. The patients were divided into two groups, which were divided into the whole liver blood flow blocking group and the selective blood flow blocking group through the liver door. The amount of bleeding, the operation time, the postoperative liver function changes and the time of hospitalization were statistically analyzed in the two groups, and the two different liver types were compared and analyzed. The technique of hepatectomy with the way of blood flow blocking.
Results: the average width of the left main stem of liver liver door plate in 3 cases of non liver disease was 1.73cm, deep 1.53cm, the average width of left internal branch was 1.3cm, deep 1.07cm, the average width of left superior branch was 1.07cm, deep 0.83cm, the average width of left lateral branch was 0.97cm, deep 0.7cm, the mean width of the right trunk was 2.07cm, deep 1.73cm, the right posterior branch was broad 1.3cm, deep 1.3cm, the right anterior branch width averaged 1.1 deep, deep 1.1. The average width of the left main trunk of the liver of cm.5 liver cirrhosis was 1.92cm, deep 1.16cm, the average width of left internal branch was 1.08cm, deep 0.94cm, the average width of left superior branch was 1.06cm, deep 0.78cm, the average width 0.9CM, deep 0.68cm, the average width 1.98cm and deep 1.62cm of the right trunk, the right posterior branch and the breadth of the right posterior branch, the width of the right anterior branch and the deep hepatic portal. There was a clear tissue gap between the plate and the first hepatic portal into the hepatic vessels, with fewer small vascular traffic branches. The distribution and size of the liver door plate in normal liver and liver cirrhosis had no obvious change, and the space and position of the liver were relatively fixed. Postoperative hospitalization time was not statistically significant (P > 0.05). The operative time, intraoperative blood loss and liver function status were significantly better than those of the latter (P < 0.05).
Conclusion: (1) the hepatic portal is a fibrous tissue of the hepatic portal, extending into the hepatic portal and extending into the hepatic segment in the hepatic portal, and extending into the Glisson sheath in the hepatic portal plate to the liver. 2. The results of the liver portal plate and the normal liver door plate are not changed. The liver door plate is a special structure in the liver dissection. There is a clear intertissue gap between the hepatic portal and the intrahepatic duct, and there is a less traffic vessel between the liver parenchyma and the wrapped pipeline, which creates a favorable condition for the separation of blood vessels in the operation and the separation of the bile duct during the operation of the biliary tract. It is the height of the joint part of the left and right bile duct, which helps to repair the bile duct, the calculus of the intrahepatic bile duct and the enlargement of the field of vision for the treatment of cholangiocarcinoma. 5. The selective liver blood flow blocking technique is safe, feasible and easy to master. In clinical application, the influence of the patients after hepatectomy is obviously lower than that of the whole liver blood flow blocking patients, which is worthy of clinical practice. Promote the use.
The second part: the study and clinical significance of hepatic portal tissue structure
Objective: To investigate the composition of the hepatic hilar tissue, including the nerve, blood vessels and lymphatic vessels, and to explore the role and clinical significance of the hilar plate in the metastasis of cholangiocarcinoma.
Methods: in the first part, 3 cases of non liver disease dead patients were selected, and the liver door plate, which began to go to the hepatic segment of the liver, was excised with HE staining, and the distribution of blood vessels, nerve and lymphatic vessels in the liver door plate were observed and 2 cases of clinical pathology were selected. The patients who were diagnosed with cholangiocarcinoma underwent radical resection of cholangiocarcinoma, left main branches of left hemi liver, left internal branches and left external branches, and tissue staining was performed to observe the distribution and metastasis of the tumor.
Results: there were small capillaries, lymphatic vessels and nerve tissue in the liver door plate. There were no small traffic branches in the liver parenchyma. There were mainly fibrous tissue in the portal plate. There were various kinds of blood tubes, lymphatics and nerve tissue in the intertissue space. In 2 cases of hilar cholangiocarcinoma. The tumor cells metastases along lymphatic vessels, blood vessels and nerves, but not typical.
Conclusion: nerve, lymphatic metastasis is the main route of metastasis in cholangiocarcinoma. Clear nerve, lymph and small vascular tissue can be seen in the liver door plate, so the liver door may be involved in the distant metastasis of bile duct cancer to some extent.
【學位授予單位】：中國人民解放軍軍醫(yī)進修學院
【學位級別】：碩士
【學位授予年份】：2008
【分類號】：R322

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