数字化三维重建技术在肝癌精准肝切除术中的应用
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摘要
目的:探讨数字化三维重建技术在肝癌精准肝切除术中的临床应用。方法:选择2015年10月—2017年10月收治的21例原发性肝癌(肿瘤直径>5cm)患者,术前行肝脏CT平扫加增强检查,利用Myrian三维重建软件对肝脏进行三维重建处理,对患者肝内血管,肿瘤位置、大小及两者的毗邻关系进行分析,计算全肝体积(TLV)、标准肝体积(SLV)、功能性肝体积(FLV)、肿瘤体积(Tu V)、拟切除肝体积(v RLV)、拟切除标本体积(v RSV)及残肝体积(RLV),并测量术中实际切除标本重量(a RSW)及标本体积(a RSV),检验v RSV的准确性并对v RSV、a RSV及a RSW进行相关性分析。结果:21例患者TLV为(1827.9±314.8)cm~3,Tu V为(593.4±283.2)cm~3,v RLV为(511.2±180.0)cm~3,v RSV为(1104.6±292.3)cm~3。术后测量a RSW为(1212.9±278.46)g,用排水法测量a RSV为(1101.0±280.4)cm~3。v RSV与a RSV比较无统计学意义(P=0.76)。Pearson相关性分析显示a RSV与v RSV、a RSW与v RSV、a RSW与a RSV之间呈高度正相关(r=0.9964、0.9201、0.9345,均P<0.0001)。术前虚拟手术方案与实际手术方案均吻合,术后21例均未出现肝性脑病及肝功能衰竭,围手术期无病例死亡。结论:术前行肝脏三维重建结合肝功能评估,对肿瘤精确定位、自动化分割、定量分析,特别是肝体积计算和虚拟肝切除术对肝癌精准肝切除术的手术方案选择有重要价值。
Objective: To investigate the clinical application of digital three-dimensional reconstruction technique in precise hepatectomy for liver cancer. Methods: Twenty one patients with primary liver cancer(tumor diameter >5 cm) treated from October 2015 to October 2017 were selected. All patients underwent plain and contrast enhanced CT scan of the liver before operation. Three-dimensional reconstruction of the liver was performed by Myrian reconstruction software. The intrahepatic vessels,location and size of the tumor and their relationship in the patients were analyzed,and the total liver volume(TLV),standard liver volume(SLV),functional liver volume(FLV),tumor volume(Tu V),virtual resection liver volume(v RLV),virtual resection specimen volume(v RSV) and residual liver volume(RLV) were calculated. The intraoperative actual specimen weight(a RSW) and actual specimen volume(a RSV) were determined. After that,the accuracy of v RSV was examined and analyzed and the correlations among v RSV,a RSV and a RSW were analyzed.Results: In the 21 patients,the TLV was(1 827.9±314.8) cm~3,Tu V was(593.4±283.2) cm~3,v RLV was(511.2±180.0) cm~3 and v RSV was(1 104.6±292.3) cm~3; the a RSW obtained after operation was(1 212.9±278.46) g. There was no significant difference between v RSV and a RSV(P=0.76). Pearson test showed that there were significantly positive correlation between a RSV and v RSV,a RSW and v RSV and a RSW and a RSV(r=0.9 964,0.9 201,0.9 345,all P<0.0 001). The preoperative virtual surgery simulations were consistent with the actual surgical protocols. None of the 21 patients had hepatic encephalopathy or liver failure after operation,and no death occurred during the perioperative period.Conclusion: The three-dimensional reconstruction of liver combined with liver function assessment before operation has great value for surgical procedure selection of precise liver cancer resection,for its precise tumor positioning,automatic segmentation and quantitative analysis,especially liver volume calculation and virtual liver resection.
Objective: To investigate the clinical application of digital three-dimensional reconstruction technique in precise hepatectomy for liver cancer. Methods: Twenty one patients with primary liver cancer(tumor diameter >5 cm) treated from October 2015 to October 2017 were selected. All patients underwent plain and contrast enhanced CT scan of the liver before operation. Three-dimensional reconstruction of the liver was performed by Myrian reconstruction software. The intrahepatic vessels,location and size of the tumor and their relationship in the patients were analyzed,and the total liver volume(TLV),standard liver volume(SLV),functional liver volume(FLV),tumor volume(Tu V),virtual resection liver volume(v RLV),virtual resection specimen volume(v RSV) and residual liver volume(RLV) were calculated. The intraoperative actual specimen weight(a RSW) and actual specimen volume(a RSV) were determined. After that,the accuracy of v RSV was examined and analyzed and the correlations among v RSV,a RSV and a RSW were analyzed.Results: In the 21 patients,the TLV was(1 827.9±314.8) cm~3,Tu V was(593.4±283.2) cm~3,v RLV was(511.2±180.0) cm~3 and v RSV was(1 104.6±292.3) cm~3; the a RSW obtained after operation was(1 212.9±278.46) g. There was no significant difference between v RSV and a RSV(P=0.76). Pearson test showed that there were significantly positive correlation between a RSV and v RSV,a RSW and v RSV and a RSW and a RSV(r=0.9 964,0.9 201,0.9 345,all P<0.0 001). The preoperative virtual surgery simulations were consistent with the actual surgical protocols. None of the 21 patients had hepatic encephalopathy or liver failure after operation,and no death occurred during the perioperative period.Conclusion: The three-dimensional reconstruction of liver combined with liver function assessment before operation has great value for surgical procedure selection of precise liver cancer resection,for its precise tumor positioning,automatic segmentation and quantitative analysis,especially liver volume calculation and virtual liver resection.
引文
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[16]相迪,戴建国.原发性肝癌的综合治疗研究进展[J].山东医药,2017,57(20):111-113.doi:10.3969/j.issn.1002-266X.2017.20.037.Xiang D,Dai JG.Research progress of comprehensive treatment of liver cancer[J].Shandong Medical Journal,2017,57(20):111-113.doi:10.3969/j.issn.1002-266X.2017.20.037.
[17]张朋飞,于松宁,雷鹏,等.3D打印技术在精准肝切除术前评估的应用[J].中国普通外科杂志,2017,26(7):831-837.doi:10.3978/j.issn.1005-6947.2017.07.004.Zhang PF,Yu SN,Lei P,et al.Application of 3D printing technology in preoperative assessment of precise hepatectomy[J].Chinese Journal of General Surgery,2017,26(7):831-837.doi:10.3978/j.issn.1005-6947.2017.07.004.
[18]Radtke A,Nadalin S,Sotiropoulos GC,et al.Computer-assisted operative planning in adult living donor liver transplantation:a new way to resolve the dilemma of the middle hepatic vein[J].World JSurg,2007,31(1):175-185.doi:10.1007/s00268-005-0718-1.
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[2]Jemal A,Bray F,Center MM,et al.Global cancer statistics[J].CACancer J Clin,2011,61(2):69-90.doi:10.3322/caac.20107.
[3]贾萌.三维重建技术联合腹腔镜精准肝切除术治疗原发性肝癌的临床疗效观察[J].肝胆外科杂志,2017,25(2):115-117.doi:10.3969/j.issn.1006-4761.2017.02.009.Jia M.Observation on the clinical efficacy of three dimensional reconstruction technique combined with laparoscopic precise hepatectomy for primary liver cancer[J].Journal of Hepatobiliary Surgery,2017,25(2):115-117.doi:10.3969/j.issn.1006-4761.2017.02.009.
[4]汪勇,王小明.三维重建技术在肝癌诊疗中的研究进展[J].沈阳医学院学报,2014,16(4):229-230.doi:10.3969/j.issn.1008-2344.2014.04.013.Wang Y,Wang XM.Research progress of three-dimensional reconstruction in diagnosis and treatment of liver cancer[J].Journal of Shenyang Medical College,2014,16(4):229-230.doi:10.3969/j.issn.1008-2344.2014.04.013.
[5]中华人民共和国卫生和计划生育委员会医政医管局.原发性肝癌诊疗规范(2017年版)[J].中华消化外科杂志,2017,16(7):635-647.doi:10.3760/cma.j.issn.1673-9752.2017.07.001.Bureau of Medical Administration,National Health and Family Planning Commission of the PRC.Standardization of diagnosis and treatment for hepatocellular carcinoma(2017 edition)[J].Chinese Journal of Digestive Surgery,2017,16(7):635-647.doi:10.3760/cma.j.issn.1673-9752.2017.07.001.
[6]荚卫东.精准肝切除治疗肝细胞癌关键技术[J].中国普通外科杂志,2014,23(1):1-5.doi:10.7659/j.issn.1005-6947.2014.01.001.Jia WD.Key techniques in precise hepatectomy for hepatocellular carcinoma[J].Chinese Journal of General Surgery,2014,23(1):1-5.doi:10.7659/j.issn.1005-6947.2014.01.001.
[7]Yeo CT,Mac Donald A,Ungi T,et al.Utility of 3D Reconstruction of 2D Liver Computed Tomography/Magnetic Resonance Images as a Surgical Planning Tool for Residents in Liver Resection Surgery[J].J Surg Educ,2018,75(3):792-797.doi:10.1016/j.jsurg.2017.07.031.
[8]张松,潘树波,谢坤,等.精准肝脏外科理念在肝细胞肝癌治疗中的价值[J].安徽医科大学学报,2016,51(1):94-97.Zhang S,Pan SB,Xie K,et al.Clinical value of precision liver surgery concept in the treatment of hepatocellular carcinoma[J].Acta Universitatis Medicinalis Anhui,2016,51(1):94-97.
[9]Jones RP,Brudvik KW,Franklin JM,et al.Precision surgery for colorectal liver metastases:Opportunities and challenges of omicsbased decision making[J].Eur J Surg Oncol,2017,43(5):875-883.doi:10.1016/j.ejso.2017.02.014.
[10]Bliznakova K, Kolev N, Buliev I, et al. Computer aided preoperative evaluation of the residual liver volume using computed tomography images[J].J Digit Imaging,2015,28(2):231-239.doi:10.1007/s10278-014-9737-5.
[11]王桂林,梅铭惠,席江伟.标准残肝体积在肝硬化肝脏功能储备评估的应用[J].中华肝胆外科杂志,2013,19(1):15-18.doi:10.3760/cma.j.issn.1007-8118.2013.01.006.Wang GL,Mei MH,Xi JW.The application of standard remnant liver volume to assessment of cirrhotic liver function reserve[J].Chinese Journal of Hepatobiliary Surgery,2013,19(1):15-18.doi:10.3760/cma.j.issn.1007-8118.2013.01.006.
[12]唐敏,杨尚文,王磊,等.基于64排螺旋CT扫描数据的肝血管解剖变异分析[J].放射学实践,2013,28(4):436-439.doi:10.3969/j.issn.1000-0313.2013.04.022.Tang M,Yang SW,Wang L,et al.Application of 64-slice spiral CT in the analysis of anatomic variation of hepatic vessels[J].Radiologic Practice, 2013, 28(4):436–439. doi:10.3969/j.issn.1000-0313.2013.04.022.
[13]贾长库,翁杰,陈有科,等.以解剖性肝切除为基础的精准肝切除治疗肝胆恶性肿瘤[J].中国普通外科杂志,2013,22(1):109-112.doi:10.7659/j.issn.1005-6947.2013.01.025.Jia CK,Weng J,Chen YK,et al.Anatomic hepatectomy as basis for precise hepatectomy in the treatment of malignant hepatobiliary tumors[J].Chinese Journal of General Surgery,2013,22(1):109-112.doi:10.7659/j.issn.1005-6947.2013.01.025.
[14]蔺虹名,宋文,郭少贤,等.标准残肝体积分数联合Child-Pugh评分在大肝癌γ-SBRT治疗前的风险评估价值[J].中国医学装备,2017,14(3):24-28.doi:10.3969/J.ISSN.1672-8270.2017.03.006.Lin HM,Song W,Guo SX,et al.The research for risk assessment value of SFLVR associated with the Child-Pugh beforeγ-SBRT for large liver cancer[J].China Medical Equipment,2017,14(3):24-28.doi:10.3969/J.ISSN.1672-8270.2017.03.006.
[15]陈晓亮,王川红,宋志,等.肝血管成像三维重建联合区域血流阻断美蓝持久染色在精准肝切除手术中的应用[J].中国普通外科杂志,2015,24(7):1001-1006.doi:10.3978/j.issn.1005-6947.2015.07.015.Chen XL,Wang CH,Song Z,et al.Application of hepatic angiography with 3-D reconstruction plus regional blood flow occlusion and persistent methylene blue dyeing in precise hepatectomy[J].Chinese Journal of General Surgery,2015,24(7):1001-1006.doi:10.3978/j.issn.1005-6947.2015.07.015.
[16]相迪,戴建国.原发性肝癌的综合治疗研究进展[J].山东医药,2017,57(20):111-113.doi:10.3969/j.issn.1002-266X.2017.20.037.Xiang D,Dai JG.Research progress of comprehensive treatment of liver cancer[J].Shandong Medical Journal,2017,57(20):111-113.doi:10.3969/j.issn.1002-266X.2017.20.037.
[17]张朋飞,于松宁,雷鹏,等.3D打印技术在精准肝切除术前评估的应用[J].中国普通外科杂志,2017,26(7):831-837.doi:10.3978/j.issn.1005-6947.2017.07.004.Zhang PF,Yu SN,Lei P,et al.Application of 3D printing technology in preoperative assessment of precise hepatectomy[J].Chinese Journal of General Surgery,2017,26(7):831-837.doi:10.3978/j.issn.1005-6947.2017.07.004.
[18]Radtke A,Nadalin S,Sotiropoulos GC,et al.Computer-assisted operative planning in adult living donor liver transplantation:a new way to resolve the dilemma of the middle hepatic vein[J].World JSurg,2007,31(1):175-185.doi:10.1007/s00268-005-0718-1.
[19]Erbay N,Raptopoulos V,Pomfret EA,et al.Living donor liver transplantation in adults:vascular variants important in surgical planning for donors and recipients.[J].AJR Am J Roentgenol,2003,181(1):109-114.doi:10.2214/ajr.181.1.1810109.
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