Nakano Hiroshi, Yamamura Takuya, Yamaguchi Susumu, Otsubo Takehito
Department of Gastroenterological Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
Hepatogastroenterology. 2007 Mar;54(74):595-8.
In patients with celiac axis occlusion, performance of pancreaticoduodenectomy involves sacrifice of the gastroduodenal artery which results in a risk of hepato-pancreato-biliary and other organic ischemia. Celiac axis occlusion does not recently seem an uncommon finding in cases of pancreaticoduodenectomy but diagnosis of celiac axis occlusion may be difficult in patients with former abdominal surgery. The present case report shows a patient with pancreatic head adenocarcinoma, in whom a preoperative diagnosis of celiac axis occlusion was not proved because of displacement of the celiomesenteric arterial branches based on former distal gastrectomy with Kocher's maneuver. A 56-year-old man with malignant obstruction of the lower bile duct was referred to our hospital for undergoing pancreaticoduodenectomy. In his past history, the patient had undergone distal gastrectomy reconstructed with Billroth I method due to gastric ulcer. In preoperative abdominal angiography, the celiac axis was not detected at the normal position and was incorrectly recognized to be anomalously originated from the superior mesenteric artery. During surgery, hepatic arterial flow was markedly diminished by clamping of the gastroduodenal artery. Celiac axis occlusion was then proved and the thick and tight median arcuate ligament was detected. Hepatic arterial blood flow was recovered by a complete division of the median arcuate ligament. Postoperative course of the patient was uneventful. In cases of pancreaticoduodenectomy, careful preoperative angiographic diagnosis is needed for patients with celiac axis occlusion who have undergone former gastric surgery because the celio-mesenteric arterial branches have been displaced by Kocher's maneuver. The present report also demonstrates another patient with a typical celiac axis stenosis.
在腹腔干闭塞的患者中，实施胰十二指肠切除术需要牺牲胃十二指肠动脉，这会导致肝胰胆及其他器官缺血的风险。腹腔干闭塞在胰十二指肠切除病例中似乎并非罕见，但对于曾接受腹部手术的患者，腹腔干闭塞的诊断可能存在困难。本病例报告展示了一名胰头腺癌患者，由于既往远端胃切除术及科克伦手法导致腹腔肠系膜动脉分支移位，术前未能证实腹腔干闭塞的诊断。一名56岁男性因低位胆管恶性梗阻被转诊至我院接受胰十二指肠切除术。该患者既往因胃溃疡接受过毕罗Ⅰ式远端胃切除术。术前腹部血管造影显示，腹腔干不在正常位置，被错误地认为异常起源于肠系膜上动脉。手术过程中，夹闭胃十二指肠动脉后肝动脉血流明显减少。随后证实存在腹腔干闭塞，并发现了增厚且紧绷的正中弓状韧带。通过完全切断正中弓状韧带，肝动脉血流得以恢复。患者术后恢复顺利。对于曾接受胃部手术且存在腹腔干闭塞的胰十二指肠切除患者，术前需进行仔细的血管造影诊断，因为科克伦手法会使腹腔肠系膜动脉分支发生移位。本报告还展示了另一例典型的腹腔干狭窄患者。
