| BackgroundsEsophageal reconstruction has always been one of the focal points and difficulties in esophageal surgery. As the esophagus has to be resected locally or subtotally in many esophageal diseases nowadays, it is necessary to reconstruct esophagus for the resumption of oral feeding. Currently, clinical methods of esophageal reconstruction mainly include reconstruction with stomach, jejunum, colon and etc. Patients taking these surgeries can resume oral feeding, but there are many shortcomings such as big surgical trauma, disability of physiological function of the esophagus and postoperative complications. Therefore, domestic and foreign scholars have been seeking a simpler, safer, and more physiological way of esophageal reconstruction.The study of esophageal reconstruction at home and abroad mainly focus on artificial esophagus, which is, to be more precise, an artificial tubular device for short-term alternative to esophagus and induction of remodeling and functional reconstructing of new esophagus via the utilization of biomaterial science, biomedical engineering, tissue engineering and other technologies. Although the artificial esophagus research has made great progress, there are still many problems, including as follows:New esophageal stenosis, anastomotic fistula, pre-exfoliation of artificial esophagus and dysplasia of new senior structure of esophageal cells.Reconstruction esophagus with autologous tissue flap is a new attempt in the field in recent years. Domestic and foreign scholars confirmed that tubed pectoralis major myocutaneous flap has a reliable efficacy in reconstruction of hypopharyngeal and circumferential pharyngoesophageal defects after resection of advanced hypopharyngeal and cervical esophageal carcinoma, and it can be applied in reconstructing circumferential defects after radiotherapy and surgical resection of recurrent tumors. Wang Ruwen and etc repaired cervical esophageal stenosis and reconstructed cervical esophagus with platysma myocutaneous flap successfully. These clinical cases and animal experiments successfully implemented esophageal defect repair and esophageal reconstruction with autologous tissue flap, confirming its feasibility in this realm. But restricted by the blood vessels of platysma myocutaneous flap or pectoralis major myocutaneous flap, the repair or the reconstruction is limited to cervical esophagus.Diaphragm is the boundary between chest and peritoneal in anatomy of the tendon. It is composed of several groups of muscles and fasciae which originate from the bottom of the chest and arrange to the chest with a dome shape. Muscles of diaphragm are divided into three parts as sternum part, rib part and waist part according to the differences of their original positions. Muscle fibers of each part focus to the center and form a center tendon, which shows a trilobal figure. The middle lobe is convex to the xiphoid, the upper part of which integrates with fiber pericardium. The left and right lobes bend backwards.In 1961 Petrovsky.BV firstly reported that pedicled diaphragmatic flap was applied in repairing defects of esophageal wall, heart wall and aortic wall, covering wounds of liver and lung, closing bronchial stump, strengthening suture of it and so on. Yang Gengpu and etc were successful in repairing advanced intrathoracic esophageal rupture with pedicled diaphragmatic flap for 5 cases. Based on the surgery of Heller, Zou Shenglu and etc achieved good results in treatment of cardiac spasm with pedicled diaphragmatic flap. Brazilian scholar Paulo NM and etc made a success use of pedicled diaphragmatic flap in reconstruction of artificial esophageal defects in chests of healthy mongrel dogs in animal experiments. Surface of the flap was covered by mucosa of the esophagus observed under the microscope, and the boundary between the esophagus and the flap could not be distinguished.Both clinical practices and animal experiments show that pedicled diaphragmatic flap is a kind of ideal autologous tissue for reconstructing esophagus. Reasons may be: First, abundant blood supply of diaphragm and its good viability; Second, strong regenerative capability of interstitial cells in diaphragm and metaplastic possibility of them in forming esophageal mucosa in histology; Third, as a result of contractile function of diaphragm itself, it is expected to regain esophageal peristaltic function after the reconstruction. Thus, we consider it is fairly feasible to reconstruct esophagus by utilizing pedicled flap of the diaphragm. The success of the experiment will indicate that a newer and more physiological way of esophageal reconstruction is going to emerge.ObjectiveThe purpose of the study is to provide anatomically feasible evidences of tubed pedicled diaphragmatic flap in esophageal reconstruction and to form an anatomical basis for the subsequent animal experiments and clinical applications.MethodsThe ducts of 12 Chinese adult anticorrosion specimens are perfused and rinsed with diluted ammonia solution, and then the specimens are perfused with red latex through two-side of the femoral arteries by the infusion tubes bilaterally. The infusion will be satisfied when red latex can be seen in the blood vessels from subcutaneous tissues of the incised plantar skins. Dissect and observe the origin, the course, the distribution and the communicating anastomosis of bilateral diaphragmatic neuro-vascularity. The original outer diameters, lengths and other data of the diaphragmatic neuro-vascularity are measured with apparatus. While anatomy is processing, high-definition photographs should be taken with the data being recorded. Use Microsoft office Excel 2007 software to process data. Experimental data were described and analyzed in x±s.Results12 specimens are perfused in good condition of rich blood supply in the diaphragm, mainly including inferior phrenic artery, pericardiacophrenic artery, muscle phrenic artery, superior phrenic artery, and the branches of the lower posterior intercostal artery, which form a wide range of collateral anastomosis in the diaphragm. Among the above, the inferior phrenic artery is the main blood vessel supplying the diaphragm. Diaphragm is controlled by the phrenic nerve, which arranges between the subclavian artery and vein into the thorax, and then accompanies with the pericardiacophrenic artery and vein. The phrenic nerve arranges downside along the both sides of the mediastinum in the chest, and arranges into the diaphragm at the transition of the pericardial diaphragm. The lengths of the mediastinum part of the phrenic nerve are (22.70±2.30)cm on the left and (17.20±2.10)cm on the right.1.1. The inferior phrenic artery1.1.1 The origin of the inferior phrenic arteryCount a total of 24 inferior phrenic arteries among 12 specimens. The most are the ones originating from the trunk of the celiac artery with a total of 11, accounting for 45.83% of the total origin; nine originate from the abdominal aorta, accounting for 37.5%; three originate from the renal artery, accounting for 12.51%; the last one is the right inferior phrenic artery originating from the left gastric artery, accounting for 4.17%. There are six of the left inferior phrenic arteries originating from the trunk of the abdominal artery, accounting for 50% of the original arteries. There are five of the right inferior phrenic arteries originating from the trunk of the abdominal artery, accounting for 41.67% of the original arteries.1.1.2 The course and distribution of the inferior phrenic arteryOuter original diameters of left and right inferior phrenic arteries are respectively (1.52±0.06)mm and (1.61±0.04)mm. The left and right inferior phrenic arteries respectively send out superior adrenal artery at the distance of (17.51±0.48)mm and (13.91±1.63)mm away from the original site. After dominating the upper part of the adrenal, outer diameters of secondary blood vessels of them are respectively(1.32±0.05)mm and (1.46±0.03)mm. The left secondary blood vessel arranges forward through the left costal angle, and branches into anterior one and posterior one at the right edge of the left lobe of the central tendon behind the esophagus. Anterior branch arranges at the boundary of the anterior lobe and left lobe of the center tendon, crosses the diaphragm into the pleural diaphragm and sends out three branches from the left lobe of the central tendon and pericardium. One of them laterally arranges and communicates with the left pericardiacophrenic artery, which nurtures the left lobe of central tendon and pericardium; One of them arranges forward, which nurtures the left of the central lobe of the central tendon and the left of the diaphragmatic sterna; another arranges to the left front, which nurtures the anterior of the left lobe of the central tendon and the rib diaphragm. The posterior branch arranges backward, located in the back of the left lobe of the central tendon and waist diaphragm. The right inferior phrenic artery arranges forward through the right costal angle, branches into anterior one and posterior one behind the inferior vena cava and the left of the right lobe of the central tendon. The anterior one arranges forward along the right posterior of the inferior vena cava, crosses the diaphragm into the pleural diaphragm and sends out three branches from the right lobe of the central tendon. One branch laterally arranges and communicates right pericardiacophrenic artery, which nurtures the right lobe of the central tendon and pericardium; One arranges forward, which nurtures the right of the central lobe of the central tendon and the right of the diaphragmatic sterna; another arranges to the right anterior, which nurtures the front of the right lobe of central tendon and the rib diaphragm. The posterior branch arranges backward, located in the back of the right lobe of the central tendon and waist diaphragm1.2 Pericardiacophrenic artery1.2.1 The origin of the pericardiacophrenic arteryPericardiacophrenic arteries are the two branches of internal thoracic artery with each one on the left and the right. They originate from proximal side of the ipsilateral internal thoracic artery, accompany with the phrenic nerve and the pericardiacophrenic vein at the mediastinum, which nurture phrenic nerve.1.2.2 The course and distribution of the pericardiacophrenic arteryArranging downside along the pericardium of both sides, pericardiacophrenic artery branches into two to three for the pericardium nutrition. The terminal branch supplies pericardiacophrenic muscle transition. After the communication with the anterior branch of the inferior phrenic artery, the terminal branch nurtures the both sides of the central tendon of diaphragm. Because the outer diameter of the terminal branch is small, the range of blood supply is narrow.-1.3 Musculophrenic artery1.3.1 The origin of the musculophrenic artery Musculophrenic arteries are the terminal branches of the internal thoracic artery with each one on the left and the right. When the internal thoracic artery arranges to the sixth costal cartilage, it sends out two terminal branches at the sternum, which are separately the lateral musculophrenic artery and the medial musculophrenic artery of the superior epigastric artery.1.3.2 The course and distribution of the musculophrenic arteryMusculophrenic arteries arrange outside down along the anterior chest wall, and sends out a number of small anterior intercostal arteries on the inner surface of the 6-9 ribs. They anastomose with the branch of the posterior intercostal artery among the ribs and form vascular arcade, which accompany with muscle bundles of rib diaphragm into the diaphragm and nurtures it. Theyt anastomose with the ribs of the inferior phrenic artery at rib diaphragm.1.4 Superior phrenic artery1.4.1 The origin of the superior phrenic arteryThere is only one superior phrenic artery, which is directly sent out by the arota from the aortic hiatus. The outer diameter of its original site is (0.77±0.02)mm.1.4.2 The course and distribution of superior phrenic arteryThe free length of it is (1.24±0.02)cm. The main range of blood supply is to the waist diaphragm, where it anastomoses with the posterior branch of the inferior phrenic artery.1.5 The branches of the lower posterior intercostal artery1.5.1 The origin of the lower posterior intercostal arteryAfter aorta sends out the posterior intercostal arteries, each of them surpass over the intercostal space, arranges up and forward to the costal angle, then arranges forward at the costal angle between the pleura and the posterior intercostal membrane and finally arranges between the inner intercostal muscles and the most inner intercostal muscles.1.5.2 The course and distribution of the lower posterior intercostal arteryThe posterior intercostal arteries of 7-12 ribs send out short branches along their way, which nurture waist diaphragm and anastomose with the anterior intercostal artery at the lateral chest wall.Conclusions1. In this study, by dissecting 12 human diaphragm specimens, we conclude that the blood supply of the diaphragm is quite rich. There are five major blood-supply vessels, including inferior phrenic artery, pericardiacophrenic artery, superior phrenic artery, musculophrenic artery and the branches of the lower posterior intercostal arteries, which form a wide range of collateral anastomosis in the diaphragm. The inferior phrenic artery is the primary blood-supply vessels for the diaphragm among them. The inferior phrenic artery and its branches are widely distributed in the center tendon and the diaphragm of sternum, ribs and waist. Diaphragm is controlled by the phrenic nerve, which arranges between the subclavian artery and vein into the thorax, and then accompanies with the pericardiacophrenic artery and the vein. The phrenic nerve arranges down along the both sides of the mediastinum in the chest, and arranges into the diaphragm at the transition of the pericardial diaphragm.2. Integrated the conditions of the origin, the course, the outer diameters, the distribution, the lengths and communicating anastomosis of every levels of the blood vessels in diaphragm, we deem that pericardiacophrenic artery, superior phrenic artery, musculophrenic artery and the lower posterior intercostal artery are not suitable for the vascular pedicle of pedicled diaphragmatic flap. 3. From anatomical considerations, we believe that it is absolutely feasible to reconstruction esophagus with pedicled diaphragmatic flap which takes the inferior phrenic artery as the vascular pedicle. |
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