活人体肝外胆管供血动脉三维可视化及临床应用研究
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摘要
研究背景：
肝移植术后缺血型胆道病变(ischemic-type biliary lesions, ITBL)、肝外胆管出血、损伤性胆管狭窄和胆道吻合口瘘发生均与胆管血运的破坏相关联。国内外针对肝外胆管血供的研究主要在尸体及动物模型上进行,并且供给肝外胆管血液的动脉均为腹腔动脉各分支的终末支血管,具有来源多、分布复杂和变异情况多的特点。因此,若能在术前获取、构建忠实于患者实际解剖的个体化肝外胆管血供三维立体模型,深刻了解活人体生理及病理情况下肝外胆管血供来源及分布的特点,可为临床胆道外科手术方案的合理选择及术后胆道并发症的预防提供个体化形态学依据。
亚毫米CT的出现和快速发展突破了活人体精细数据获取的瓶颈,基于CT断层图像的数字化三维重建技术在医学上的应用,使活人体肝外胆管血供三维可视化成为可能。医学图像三维可视化技术可将二维的断层图像转变为具有直观立体效果的图像,展现人体器官的三维结构形态,从而提供若干传统手法无法获得的解剖信息,不仅解决了尸体解剖标本价格昂贵和来源匮乏的不足,而且为临床外科操作提供更加真实准确的解剖学指导。其中高质量CT图像数据和精细分割技术则是医学图像处理和分析中的关键技术。
目前国内外的三维可视化软件在图像分割方法上多采用在二维CT图像上选取种子点的区域生长法。这种算法要求三维临近点要符合生长阈值要求,因此,只要在生长过程中有一步不符合生长条件,就立即停止生长,造成分割断裂,从而使得很多组织分割不完整、不精细,特别是管径较小的血管分割提取不出来,对不少应用场合产生不利影响。除此之外,在二维图像上选取种子点,用户对解剖知识要求高,往往选不到理想的种子点,从而影响了分割的效果。
基于上述问题,本课题基于高质量亚毫米CT数据,攻关研究基于体绘制交互的分割新方法,改变传统三维可视化软件不能对微细管道进行分割提取的缺陷,并将新的分割算法作为一个插件整合到具有自主知识产权的腹部医学图像三维可视化系统(Medical Image Three-Dimensional Visualization System, MI-3DVS)(软件专利号：2008SR18798),程序化构建活人体数字化肝外胆管血供3D模型,并根据肝外胆管血供的来源、分布特点进行数字化分型,探讨其在肝外胆管梗阻性疾病手术决策中的应用价值。
一基于亚毫米CT扫描数据的肝外胆管供血动脉三维可视化模型的构建
目的：
1.优化CT数据采集方法,获取高质量肝外胆管血供亚毫米CT数据；
2.研究基于体绘制交互的分割新算法,构建活人体肝外胆管血供3D模型；
3.研究数字化肝外胆管血供三维重建模型图像与传统解剖学图像,对数字化肝外胆管血供3D模型与传统解剖学图像进行比较研究。
方法：
1.研究对象：受检者10名,其中男性7例,女性3例；年龄36-62岁,平均43.2岁。
2.数据采集设备：
(1)64层螺旋CT-PHILIPS Brilliance64(荷兰PHILIPS公司)；双筒高压注射器及造影剂(碘比乐370mgI/ml)。
(2)图像后处理工作站为PHILIPS Brilliance64层螺旋CT自带的Mxview工作站；
(3)南方医科大学数字医学临床中心HP刀片式服务器、高配置计算机；
(4)腹部医学图像三维可视化系统；
3.高质量肝外胆管血供亚毫米CT数据采集方法：
(1)扫描前准备：扫描前20-30min口服500-1000m清水充盈胃肠道,扫描前立即喝清水500ml,以充盈胃肠道。
(2)平扫：常规平扫时患者取仰卧位,头足方向,由膈顶至肾下极,扫描参数：管电压120KV、管电流300mAs、每旋转1周时间为0.5s、螺距(pitch)0.984、层厚5mm,采用0.625×64排探测器组合,扫描视野60-70cm,矩阵512×512。
(3)CTA扫描采用试验注射法(小剂量预注射法)。
(4)常规增强扫描：CTA扫描结束后,于注射对造影剂开始后30-35s行动脉晚期扫描,50-55s行门静脉期扫描,每期扫描时间约6-8s。
(5)CT薄层扫描数据的传送及储存：在Mxview工作站进行CT断面图像数据薄层重建(0.625mm),格式为DICOM (Digital Imaging and Communications in Medicine)3.0,然后通过内部专线网络传输至南方医科大学数字医学临床中心HP刀片式服务器并存盘导出。
4.肝外胆管血供3D模型构建方法：
(1)基于体绘制交互的图像分割算法：先进行体绘制重建,通过窗宽和窗位调节,得到所需组织最清晰的三维图像,直接在体绘制图像上取得三维种子点,进行区域生长,同时在体绘制图像上显示生长的过程,当生长停止时可以通过人机交互,在体绘制三维图像上进行修补。特别对于微细血管,通过局部放大,并对断续小血管进行连接,再进行分割,可以把局部小血管提取出来。使得组织分割,特别对血管分割更精细,达到与体绘制相同的分辨率水平。当用户满意当前分割结果时可以立即将当前的分割结果保存,并进行快速的面绘制三维重建。
(2)把基于体绘制交互的分割算法作为一个分割插件整合到腹部医学图像三维可视化系统(MI-3DVS)中,将DICOM格式的亚毫米CT数据导入到MI-3DVS中进行配准、分割、三维重建。
①血管三维重建：使用基于体绘制交互的分割算法完成对亚毫米CT断层图像中的血管数据分割,采用面绘制方法进行脏器三维重建。
②胆道、胰腺等腹腔脏器重建：使用区域生长法完成分割,采用面绘制方法进行脏器三维重建。
(3)3D模型的后处理及立体结构观察分析
通过MI-3DVS中的面数据图形处理工具对3D模型进行平滑和去噪,然后将肝外胆管血供3D模型在空间上组合和显示,通过放大、缩小、旋转可视化3D模型来观察、分析肝外胆管供血动脉起源和分布特点。
5.与传统的解剖学图像进行对比分析：采用基于亚毫米CT数据的肝外胆管血供三维可视化模型图像,与传统的解剖学素描图像进行对比分析。
结果：
1.使用试验注射法采集的亚毫米CT数据图像质量高,胆道系统、肝外胆管周围动脉、胰腺及壶腹周围病变显示清晰。
2.肝外胆管血供的3D模型立体感强,可多方位自由旋转,能清晰显示肝外胆管血供的来源及分布特点,上段肝外胆管血供来源包括肝右动脉、胆囊动脉、肝左动脉和肝固有动脉；下段肝外胆管血供来源包括胰十二指肠上后动脉、胃十二指肠动脉、胆囊动脉和门静脉后动脉。
3.肝外胆管血供3D模型真实,立体感强,可以从不同角度进行三维空间的解剖关系观察；传统素描解剖学图谱只能显示平面的解剖结构,表现手法单一,但其可根据手术显微镜所观察的尸体标本灌注情况,还原绘制胆管周围动脉丛等3D模型无法显示的血管。
结论：
1.采集方法优化后的64层螺旋CT可以获得高质量的肝外胆管血供亚毫米CT数据,各脉管系统显影良好,能够区分出微细结构的影像学特征,能满足肝外胆管供血动脉分割、三维重建的要求。
2.基于体绘制交互的分割方法能够对肝外胆管供血小动脉进行分割、提取；使用MI-3DVS重建的3D模型能够真实反映患者肝外胆管及供血动脉立体解剖结构。
3.三维重建图像更为真实直观,更加便于学习和理解,虚拟重建图像形象逼真,能真实还原组织器官结构的本来面貌,是解剖学研究和学习的新途径。
二胆道梗阻性疾病肝外胆管血供三维可视化及临床应用研究
目的：
1.研究胆道梗阻患者肝外胆管血供分布特点并进行分型；
2.研究肝外胆管血供3D模型在肝外胆管梗阻性疾病手术决策中的应用价值。
方法：
1.研究对象：2012年1月至2012年12月南方医科大学珠江医院肝外胆管梗阻性疾病患者41例,其中男25例,女16例；年龄31～81岁,平均年龄46.3岁；肝外胆管平均直径24.3±5.1mm (16-34mm)。临床诊断：胆道结石15例,胆总管下端炎性狭窄5例,胰头部或壶腹周围肿瘤21例。
2.数据采集设备同第一部分。
3.亚毫米CT数据收集方法同第一部分。
4.肝外胆管血供数据分割及三维重建方法同第一部分。
5.根据胆囊管汇入肝外胆管位置将肝外胆管分成上、下段,依据3D模型中肝外胆管血供来源及分布的特点进行数字化分型：
上段肝外胆管血供分为2型,Ⅰ型为肝右动脉供血型,再根据是否联合其他动脉供血分出3个亚型；Ⅱ型为肝左动脉联合胆囊动脉供血型。
下段肝外胆管血供分成3型,Ⅰ型为胰十二指肠上后动脉供血型,再根据是否联合其他动脉供血分出3个亚型；Ⅱ型为胃十二指肠动脉及主要支供血型(胰十二指肠上后动脉除外)；Ⅲ型为起源于胃十二指肠动脉的胆囊动脉供血型。
6.术式决策及手术效果评价：
术前通过对41例患者肝外胆管血供3D模型进行三维可视化观察,详细了解肝外胆管血供来源及分布特点,并进行术前规划,包括术中胆总管切开位置、胆肠吻合方式及胆总管横断位置的选择。术后观察并记录并发症发生情况,主要包括有无胆道狭窄、胆肠吻合口狭窄、胆瘘、胆道出血等。
结果：
1.采集的肝外胆管血供亚毫米CT数据图像质量高,胆道系统、肝外胆管周围动脉、胰腺及壶腹周围病变显示清晰。
2.41例肝外胆管血供3D模型完全忠实于患者实际解剖特点,清楚显示个体化肝外胆管血供的起源、走行、分布及变异情况,同时还可以立体显示胆道结石、肿瘤与周围脏器及血管的立体解剖关系。
3.分别按照上、下段肝外胆管血供特点进行数字化分型：
41例患者上段肝外胆管血供IA型6例,占14.6%；IB型17例,占41.5%；IC型12例,占29.3%；Ⅱ型6例,占14.6%。
41例下段肝外胆管血供IA型13例,占31.7%；IB型13例,占31.7%；IC型4例,占9.8%；Ⅱ型7例,占17.0%；Ⅲ型4例,占9.8%。
4.41例均顺利行手术治疗,手术方式包括胆总管切开取石术15例,胆管空肠端侧吻合术22例(其中胰十二指肠切除术21例),保留十二指肠的胰头切除术1例,胆管空肠侧侧吻合术3例。术中胆道手术方式与术前规划完全符合。术中所见肝外胆管形态,肝外胆管血供走行情况、肝动脉变异情况,结石分布、肿瘤与血管毗邻关系均与术前3D模型相符。全组无术中及术后胆道出血、术后胆瘘发生,全组病人随访3-15个月,无肝外胆管狭窄、胆肠吻合口狭窄发生。
结论：
1.数字化肝外胆管血供分型有助于对上、下段肝外胆管血供类型进行正确诊断,并根据手术主要操作的肝外胆管部位进行术前评估,合理选择手术方式。
2.肝外胆管血供三维可视化模型可以真实反映肝外胆管梗阻患者的个体化肝外胆管血供特点,为胆道手术方案的制定提供详实的胆管血供信息,可以指导术中胆总管切开位置、胆肠吻合方式及胆总管横断位置的选择,增加手术成功率,减少术后胆道并发症的发生。
三三维可视化技术在胰十二指肠切除术合并肝动脉变异诊治中的应用
目的：
研究腹部医学图像三维可视化系统(MI-3DVS)在胰十二指肠切除术合并肝动脉变异患者诊治决策中的价值。
方法：
1.研究对象：2010年1月至2012年7月南方医科大学珠江医院和第三军医大学西南医院114例成功行胰十二指肠切除术的胰头或壶腹周围肿瘤患者。
2.亚毫米CT数据采集设备及3D重建方法同第二部分,21例CTA扫描采用试验注射法,93例CTA扫描采用团注追踪法。
3.手术方法及手术效果评价：
术前通过对3D模型进行多角度旋转观察,详细了解变异肝动脉情况,并结合病史资料进行诊断及肿瘤可切除性评估,制定详细手术方案。并对变异肝动脉起始部至肠系膜上动脉起始部的距离进行测量,最后与术中探查结果和术后腹腔动脉DSA结果相对照。
术后观察并记录并发症发生情况,包括有无肝脓肿、肝功能不全、胆肠吻合口瘘、胰瘘、腹腔出血、消化道出血等。
结果：
1.腹部脏器3D模型可清楚显示肿瘤的大小及形态、血管的起源及走行、肿瘤与脏器及血管的立体解剖关系,共发现变异肝动脉14例(12.3%,14/114),包括替代肝右动脉起自肠系膜上动脉者9例(7.9%,9/114),替代肝总动脉起自肠系膜上动脉3例(2.6%,3/114),替代肝左动脉起自胃左动脉2例(1.8%,2/114),其中2例替代肝右动脉经过胰头组织实质,但无肿瘤浸润。3D模型中测量12例起源于肠系膜上动脉的变异肝动脉起始部至SMA起始部距离为15.3-38.8mm,平均25.9+6.9mm。
2.14例肝动脉变异患者均行标准的胰十二指肠切除术,和术中探查及术后DSA检查对比,MI-3DVS对变异肝动脉诊断的敏感度、特异度和准确率均为100%。MI-3DVS指导下的术前规划与术中探查结果均符合。14例肝动脉变异患者无围手术期死亡,术后无肝脓肿、胆瘘、肝功能衰竭等并发症发生。
结论：
MI-3DVS可以在胰十二指肠切除术前对变异肝动脉做出准确诊断,对个体化手术方案的制定提供详实的术前指导,能够增加手术成功率,减少术后并发症的发生。
Research Background
The occurrence of ischemic-type biliary lesions (ITBL), extrahepatic bile duct hemorrhage, traumatic biliary stricture and biliary anastomotic fistula after liver transplantation is related to destructed blood supply to the bile duct. Both domestic and oversea researches on the blood supply of extrahepatic bile duct are commonly conducted based on cadaveric human bodies and the animal models. Moreover, all the arteries supplying extahepatic bile duct are terminal vascular vessels of the branches of celiac artery, with multiple origins, complex distribution and multiple variations. The individualized three-dimensional model of the blood supplies to the extrahepatic bile duct can enrich our knowledge about the blood supplies to the extrahepatic bile duct both physiologically and pathologically. Therefore, the construction of the individualized three-dimensional model of the blood supplies to the extrahepatic bile duct before surgical operations would provide individualized morphological basis for the surgical planning and prevention of post-operative biliary complications.
Based on the medical application of the digitalized three-dimensional reconstruction technique of CT scanning images, as well as the emergence and rapid development of the submillimeter CT technology, the three-dimensional visualization of the supplying arteries to the extrahepatic bile duct in the living human body can be achieved. The three-dimensional visualization technology turns the two-dimensional CT images into images with3D effects to demonstrate the three-dimensional structure and morphology of organs in the human body, which provides much more anatomic details that the traditional techniques failed to provide. The newly emerging technology solves the problems of expensive autopsy specimens and their insufficient supply, and anatomically guides the clinical surgical procedures with high accuracy. Therein, the technologies for harvesting high quality CT image data and for fine segmentation are crucial for its medical application.
Currently, concerning the image segmentation technology in the3-dimensional visualization software package both domestically and internationally, regional growing of seed points based on the two-dimensional images is commonly applied. The algorithm requires the three-dimensional neighboring points to be within the growth threshold. Therefore, any procedure that is not fit for the growth condition during the growing process would terminate the growth to break down the segmentation, resulting in failed tissue segmentation with tactfulness and fineness. Especially, the minor arteries may fail to be extracted and segmented to adversely affect its applications. In addition, the choice of seed points on the two-dimensional images requires much knowledge in anatomy. Otherwise, the ideal seed points may fail to be chosen to adversely affect the segmentation.
Based on these problems, our study attempted to study on the new segmentation method based on interactive volume rendering with the high quality submillimeter CT data. The study targeted on the defect of the traditional three-dimensional visualization software that fails to achieve segmentation for minor vessels. The new segmentation algorithm would be integrated into the abdominal Medical Image Three-Dimensional Visualization System (MI-3DVS)(software potent NO.2008SR18798), which has independent intellectual property right. We prospected a programmed sequence to construct digital three-dimensional model of supplying arteries to the extrahepatic bile duct in the living human body. After that, we digitally categorized the supplying arteries to the extrahepatic bile duct based on their origin and distribution. Finally, the application of the3-dimenstional model in the surgical decision making for extrahepatic biliary obstructive diseases was explored.
Part I. Three-dimensional visualization model of arteries supplying the extrahepatic bile duct based on submillimeter CT data
Objective
(1) To optimize the method to collect CT data for high quality submillimeter CT data of the arteries supplying the extrahepatic bile duct;
(2) To establish a new segmentation algorithm based on new interactive volume rendering to construct a3dimensional model of arteries supplying the extrahepatic bile duct in the living human body;
(3) To compare the digital3dimensional model of arteries supplying the extrahepatic bile duct and the traditional anatomic images of arteries supplying the extrahepatic bile duct.
Methods
(1) The study recruited10subjects, including7males and3females, aged36-62years with an average age of43.2years.
(2) The equipments used to collect data include64layers spiral CT scanner (CT PHILIPS Brilliance64, made in Dutch); double tube high pressure syringe and contrast agents (Lopamiro in a dose of370mg I/ml); the self attached Mxview workstation for post processing of the images; HP blade server and high configuration computer (from Clinical Center of Digital Medicine, Southern Medical University, Guangzhou, China) and the abdominal three-dimensional visualization system.
(3) The procedures for collecting high quality submillimeter CT data of the arteries supplying the extrahepatic bile duct include:prescanning preparation, plain scanning, trial injection, routine enhanced scanning as well as the transmission and storage of thin layer CT scanning data.
Preparation before the scanning:20-30min before scanning,500-1000ml water was drunk to fill the gastrointestinal tract; And500ml water was drunk immediately before the scanning to fill the gastrointestinal tract.
Plain scanning:Routine plain scanning was performed with the subject in supine posture, scanning from the diaphragmatic top to the inferior kidney pole. The scanning parameters included120KV of the tube voltage,300mAs of the tube current,0.5s per rotation, pitch0.984, layer thickness5mm;0.625×64row of detectors, and scanning field of60-70cm, matrix512×512.
Trial injection:Small dose injection before scanning was performed for CTA scanning.
Routine enhanced scanning:After CTA scanning, late arterial scanning was performed35-55s after the injection of contrast agent; portal vein phase scanning50-55s after the injection of contrast agent; the scan time was about6-8s per phase.
Transmission and storage of thin layer CT scanning data:The thin layer CT scanning data (0.625mm) was reconstructed at the Mxview workstation, in the format of DICOM (Digital Imaging and Communications in Medicine)3.0. The data was transmitted via the internal special line network to the HP blade server in the Clinical Center of digital medicine (Southern Medical University, Guangzhou, China) for exportation and storage.
(4) The3D model of arteries supplying the extrahepatic bile duct was constructed based on the following procedures.
The interactive volume rendering reconstruction was performed. After the window width and level adjusted, the optimal3D image of the interested body part can be obtained. The3D seeds points were directly chosen from the volume rendering image for regional growing. Meanwhile, the growing process was demonstrated on the volume rendering image. In the cases of terminated growth, the volume rendering3D image can be fixed by human-computer interactions. Especially for microvascular vessels, the local microvascular vessels were extracted by local magnification, connecting intermittent small blood vessels, and segmentation. In such a way, the tissue segmentation, particularly the vascular segmentation can be more sophisticated with the same resolution level as the volume rendering. When the satisfying segmentation was achieved, it was saved immediately for rapid surface rendering3D reconstruction.
The interactive segmentation algorithm based on the volume rendering, as a plug-in, was integrated into the abdominal three dimensional visualization system (MI-3DVS). The submillimeter CT data in the format of DICOM was introduced into the MI-3DVS for registration, segmentation and3D reconstruction.①The vascular submillimeter CT data is segmented based on the interactive volume rendering of segmentation algorithm.3D reconstruction of organs was performed by using the surface rendering method.②By using the regional growing method, the segmentation was achieved for3D reconstruction of the organs with the surface rendering method.
The post-processing of the3D model was then performed for observation and analysis of the3D model.
With the surface data processing tool in the MI-3DVS, the3D model was smoothed and denoised for combination and demonstration of the arteries supplying the extrahepatic bile duct in the3D model. The visualized3D model was zoomed in, zoomed out and spinned for the observation and analysis of the arteries supplying the extrahepatic bile duct.
(5) The constructed3D visualization model for the arteries supplying the extrahepatic bile duct based on the submillimeter CT data was compared to the traditional anatomic images.
Results
(1) The quality of submillimeter CT images obtained via trial injection was optimal, with favorable demonstrations of the biliary lesions, peripheral arterial lesions of the extrahepatic bile duct, peripancreatic lesions and periampullar lesions.
(2) The3D model of arteries supplying the extrahepatic bile duct can be multidimensionally rotated to clearly demonstrate the origins and distributions of the arteries supplying the extrahepatic bile duct. The arteries supplying the superior segment of extrahepatic bile duct were found to be originated from the right hepatic artery, the gallbladder artery, the left hepatic artery and the proper hepatic artery. However, the arteries supplying the inferior segment of the extrahepatic bile duct were found to be originated from the superioposterior pancreatoduodenal artery, the astroduodenal artery, the gallbladder artery and the retroportal artery.
(3) The3D model of arteries supplying the extrahepatic bile duct can be multi-dimensionally observed and analyzed for the anatomical relationships. Traditional sketches can only display the anatomic structures on the surface. However, it has the advantage of demonstrating vascular vessels that the3D model fails to display, such as the artery plexus around the bile duct. The sketches are based on the cadaveric perfusion under a surgical microscope.
Conclusions:
(1)64layers spiral CT scanning with optimized data collecting method can obtain high quality submillimeter CT data of the arteries supplying the extrahepatic bile duct, with well demonstrated vasculature. It can facilitate to distinguish the imaging demonstrations of the micro-structures, which satisfies the requirements for segmentation and3D reconstruction of arteries supplying the extrahepatic bile duct.
(2) Based on volume rendering of interactive segmentation method, the scanning data of arterioles supplying the extrahepatic bile duct can be extracted and segmented for3D reconstruction. The3D model reconstructed by using MI-3DVS can display the three-dimensional anatomical structures of the extrahepatic bile duct and its blood supplying arteries.
(3) The reconstructed3D model is authentic and direct, which facilitates the learning of anatomic knowledge and related researches.
Part Ⅱ3D visualization of the arteries supplying the extrahepatic bile duct in patients with biliary obstructive diseases and its clinical application
Objective
(1) To study the distribution of arteries supplying the extrahepatic bile duct in patients with biliary obstructive diseases and their categorization.
(2) To evaluate the application value of the3D model in surgical decision making for patients with extrahepatic biliary obstructive diseases.
Methods
(1) The study recruited41patients with extrahepatic biliary obstructive diseases in Zhujiang hospital of Southern Medical University during Jan.2012and Dec.2012, including25males and16females, aged31-81years with an average of46.3years. The average diameter of the extrahepatic bile duct was24.3±5.1mm (ranging from16mm to34mm). The clinical diagnosis was biliary calculi in15cases, inflammatory stricture of the lower common bile duct in5cases, the pancreatic head or periampulla tumor in21cases.
(2) The data collecting procedures and the equipments used are the same as the previous part.
(3) The submillimeter CT data was collected by using CTA scanning and the procedures were the same as the previous part.
(4) The methods for data segmentation and3D reconstruction of arteries supplying the extrahepatic bile duct were the same as the previous part.
(5) According to the position of the cystic duct entering the extrahepatic bile duct, the extrahepatic bile duct is divided into superior and inferior segments. According to origins and distribution of arteries supplying the extrahepatic bile duct in the3D model, the digital categorization of supplying arteries was as the following:
The superior segment of the extrahepatic bile duct had two types of blood supply. Type Ⅰ is the blood supply from the right hepatic artery, which includes3subtypes based on the combination with other supplying arteries. Type Ⅱ is the blood supply from the left hepatic artery in combination with the gallbladder artery.
The blood supply to the inferior segment of the extrahepatic bile duct can be divided into3types. Type Ⅰ is by the superioposterior pancreatoduodenal artery, which can be further divided into3subtypes according to its combination supplying with other arteries. Type Ⅱ is by the gastroduodenal artery and its major branches (except for the superioposterior pancreatoduodenal artery). Type Ⅲ is by the gallbladder artery, which originates from the gastroduodenal artery.
(6) Surgical decision making, and the evaluation of the surgical outcome were performed.
After preoperative observation and analysis of the3D visualization model for the arteries supplying the extrahepatic bile duct in the41subjects, the origins and distribution of the arteries supplying their extrahepatic bile duct were understood in detail for preoperative surgical planning. The plan included the incision position of the common bile duct, biliary intestinal anastomosis and the transection position of the common bile duct. Postoperative observations were performed and the complications were recorded in detail. The complications commonly include biliary tract stenosis, biliary intestinal anastomotic stricture, biliary fistula and bile duct bleeding.
Results
(1) The submillimeter CT data of the arteries supplying the extrahepatic bile duct collected by bolus injection tracing has a high image quality. The images clearly demonstrated the biliary lesions, peripheral arterial lesions of the extrahepatic bile duct, and peripancreatic lesions and periampulla lesions.
(2) The3D models based on the41subjects are completely identical to the actual anatomic structures of the arteries supplying the extrahepatic bile duct, with clear demonstrations of the origin, course, distribution and variation of individual blood supply to the extrahepatic bile duct. Meanwhile, the3D demonstrations of the anatomic relationship between biliary calculi and tumors with their adjacent organs and blood vessels can also be demonstrated.
(3) According to the blood supplies to the respective superior and inferior segments of the extrahepatic bile duct, the digital categorization of the blood supply is as the following:
In the41patients, the blood supply to the superior segment of the extrahepatic bile duct includes6cases of type IA (14.6%);17cases of type IB (41.5%);12cases of type IC (29.3%); and6cases of type Ⅱ (14.6%).
In the41patients, the blood supply to the inferior segment of the extrahepatic bile duct includes13cases of type IA (31.7%);13cases of type IB (31.7%);4cases of type IC (9.8%);7cases of type II7(17.0%); and4cases of type III (9.8%).
(4) All41patients successfully received the surgical treatment. The surgical procedures include15cases of choledocholithotomy,22cases of terminal anastomosis of bile duct and jejunum (including21cases of pancreatoduodenal resection),1case of pancreatic head resection with retained duodenum,3cases of lateral anastomosis of the bile duct and the jejunum. The intraoperative surgical procedures are identical to those of preoperative planning. The intraoperative findings of the morphology of the extrahepatic bile duct as well as the course and variations of the arteries supplying the extrahepatic bile duct are in line with the preoperative findings from the3D model. In addition, the distributions of the lithiasis and the tumors as well as their relationship with the adjacent blood vessels are also in line with preoperative findings from the3D model. No complication occurred in all the patients in the3-15months follow-up, such as intraoperative and postoperative biliary tract bleeding, postoperative bile fistula, extrahepatic bile duct stricture, biliary intestinal anastomotic stricture.
Conclusions
(1) The digital categorization of the blood supply to the extrahepatic bile duct contributes to the accurate diagnosis of the superior and inferior segments of the extrahepatic bile duct. Meanwhile, the preoperative assessment of the surgical location contributes to the choice of surgical procedures.
(2) The3D model of the arteries supplying the extrahepatic bile duct can authentically demonstrate the individualized blood supply of the extrahepatic bile duct for patients with extrahepatic biliary obstruction. Therefore, it provides detailed information about the arteries supplying the surgical location and facilitates the surgical planning, including intraoperative incision location, biliary and intestinal anastomosis and common bile duct transection position. In such way, the surgical success rate can be increased and the incidence of postoperative complications can be decreased.
Part III Application of3D visualization in duodenopancreatectomy and hepatic artery variation
Objective
To explore the application value of the MI-3DVS in patients with hepatic artery variation receiving duodenopancreatectomy.
Methods
(1) The study recruited114patients with pancreatic head tumor and periampullary tumor who had successfully received duodenopancreatectomy in Zhujiang Hospital (Southern Medical University, Guangzhou, China) and Southwest Hospital (Third Military Medical University, Chongqing, China) from Jan.2010to Jul.2012.
(2) The equipments for collecting submillimeter CT data and3D reconstruction were the same as the previous part. Trial injection method was performed for CTA scanning in21cases, bolus injection tracing method was performed for CTA scanning in93cases.
(3) The surgical procedures and the surgical outcome assessment: Before the operation, we observed the3D models from multiple perspectives to understand the hepatic artery variation. In combination with the case history, the diagnosis was made and tumor resectibility was assessed. And the detailed surgical plan was formulated. Based on the3D model, we also measured the distance from the origin of variant hepatic artery to the origin of the superior mesenteric artery. The intraoperative findings were finally compared to the postoperative DSA findings of the abdominal artery.
After the operation, the occurrence of the complications was observed and recorded including hepatic abscesses, hepatic dysfunctions, biliary intestinal anastomotic fistula, pancreatic fistula, abdominal hemorrhage, pulmonary infections and gastrointestinal hemorrhage.
Results
(1) The abdominal3D models can clearly display the size and shape of tumor, the origin and course of the blood vessels, as well as the3D anatomic relationship between tumors and organs, blood vessels. We totally found14cases (12.3%,14/114) with variant hepatic artery including9cases (7.9%,9/114) with replacing right hepatic artery originating from the superior mesenteric artery and3cases (2.6%,3/114) of replacing common hepatic artery originating from the superior mesenteric artery, and2cases (1.8%,2/114) of replacing common hepatic artery originating from the left gastric artery. In these14cases,2cases had their replacing right hepatic artery passing through the parenchymal pancreatic head, but with no tumor infiltration. The12cases of3D models were measured the distance from the origin of the variant hepatic artery originating from the superior mesenteric artery to the origin of the SMA. The distances ranged from15.3mm to38.8mm, with an average of25.9±6.9mm.
(2) The14patients all received standard procedures of duodenopancreatectomy. Compared to the intraoperative findings and postoperative DSA examination, the sensitivity, specificity and accuracy of MI-3DVS to variant hepatic artery is100%. The preoperative planning guided by MI-3DVS is in line with the intraoperative findings. No perioperative death occurred in all the14patients. No postoperative complications occurred in all14patients, including hepatic abscesses, biliary fistula and liver failure.
Conclusions
MI-3DVS can accurately diagnose hepatic artery variation before duodenopancreatectomy. Therefore, it contributes to the formulation of preoperative surgical plans. It also increases the success rate of the surgical operations and decreases the occurrence of postoperative complications.
肝移植术后缺血型胆道病变(ischemic-type biliary lesions, ITBL)、肝外胆管出血、损伤性胆管狭窄和胆道吻合口瘘发生均与胆管血运的破坏相关联。国内外针对肝外胆管血供的研究主要在尸体及动物模型上进行,并且供给肝外胆管血液的动脉均为腹腔动脉各分支的终末支血管,具有来源多、分布复杂和变异情况多的特点。因此,若能在术前获取、构建忠实于患者实际解剖的个体化肝外胆管血供三维立体模型,深刻了解活人体生理及病理情况下肝外胆管血供来源及分布的特点,可为临床胆道外科手术方案的合理选择及术后胆道并发症的预防提供个体化形态学依据。
亚毫米CT的出现和快速发展突破了活人体精细数据获取的瓶颈,基于CT断层图像的数字化三维重建技术在医学上的应用,使活人体肝外胆管血供三维可视化成为可能。医学图像三维可视化技术可将二维的断层图像转变为具有直观立体效果的图像,展现人体器官的三维结构形态,从而提供若干传统手法无法获得的解剖信息,不仅解决了尸体解剖标本价格昂贵和来源匮乏的不足,而且为临床外科操作提供更加真实准确的解剖学指导。其中高质量CT图像数据和精细分割技术则是医学图像处理和分析中的关键技术。
目前国内外的三维可视化软件在图像分割方法上多采用在二维CT图像上选取种子点的区域生长法。这种算法要求三维临近点要符合生长阈值要求,因此,只要在生长过程中有一步不符合生长条件,就立即停止生长,造成分割断裂,从而使得很多组织分割不完整、不精细,特别是管径较小的血管分割提取不出来,对不少应用场合产生不利影响。除此之外,在二维图像上选取种子点,用户对解剖知识要求高,往往选不到理想的种子点,从而影响了分割的效果。
基于上述问题,本课题基于高质量亚毫米CT数据,攻关研究基于体绘制交互的分割新方法,改变传统三维可视化软件不能对微细管道进行分割提取的缺陷,并将新的分割算法作为一个插件整合到具有自主知识产权的腹部医学图像三维可视化系统(Medical Image Three-Dimensional Visualization System, MI-3DVS)(软件专利号：2008SR18798),程序化构建活人体数字化肝外胆管血供3D模型,并根据肝外胆管血供的来源、分布特点进行数字化分型,探讨其在肝外胆管梗阻性疾病手术决策中的应用价值。
一基于亚毫米CT扫描数据的肝外胆管供血动脉三维可视化模型的构建
目的：
1.优化CT数据采集方法,获取高质量肝外胆管血供亚毫米CT数据；
2.研究基于体绘制交互的分割新算法,构建活人体肝外胆管血供3D模型；
3.研究数字化肝外胆管血供三维重建模型图像与传统解剖学图像,对数字化肝外胆管血供3D模型与传统解剖学图像进行比较研究。
方法：
1.研究对象：受检者10名,其中男性7例,女性3例；年龄36-62岁,平均43.2岁。
2.数据采集设备：
(1)64层螺旋CT-PHILIPS Brilliance64(荷兰PHILIPS公司)；双筒高压注射器及造影剂(碘比乐370mgI/ml)。
(2)图像后处理工作站为PHILIPS Brilliance64层螺旋CT自带的Mxview工作站；
(3)南方医科大学数字医学临床中心HP刀片式服务器、高配置计算机；
(4)腹部医学图像三维可视化系统；
3.高质量肝外胆管血供亚毫米CT数据采集方法：
(1)扫描前准备：扫描前20-30min口服500-1000m清水充盈胃肠道,扫描前立即喝清水500ml,以充盈胃肠道。
(2)平扫：常规平扫时患者取仰卧位,头足方向,由膈顶至肾下极,扫描参数：管电压120KV、管电流300mAs、每旋转1周时间为0.5s、螺距(pitch)0.984、层厚5mm,采用0.625×64排探测器组合,扫描视野60-70cm,矩阵512×512。
(3)CTA扫描采用试验注射法(小剂量预注射法)。
(4)常规增强扫描：CTA扫描结束后,于注射对造影剂开始后30-35s行动脉晚期扫描,50-55s行门静脉期扫描,每期扫描时间约6-8s。
(5)CT薄层扫描数据的传送及储存：在Mxview工作站进行CT断面图像数据薄层重建(0.625mm),格式为DICOM (Digital Imaging and Communications in Medicine)3.0,然后通过内部专线网络传输至南方医科大学数字医学临床中心HP刀片式服务器并存盘导出。
4.肝外胆管血供3D模型构建方法：
(1)基于体绘制交互的图像分割算法：先进行体绘制重建,通过窗宽和窗位调节,得到所需组织最清晰的三维图像,直接在体绘制图像上取得三维种子点,进行区域生长,同时在体绘制图像上显示生长的过程,当生长停止时可以通过人机交互,在体绘制三维图像上进行修补。特别对于微细血管,通过局部放大,并对断续小血管进行连接,再进行分割,可以把局部小血管提取出来。使得组织分割,特别对血管分割更精细,达到与体绘制相同的分辨率水平。当用户满意当前分割结果时可以立即将当前的分割结果保存,并进行快速的面绘制三维重建。
(2)把基于体绘制交互的分割算法作为一个分割插件整合到腹部医学图像三维可视化系统(MI-3DVS)中,将DICOM格式的亚毫米CT数据导入到MI-3DVS中进行配准、分割、三维重建。
①血管三维重建：使用基于体绘制交互的分割算法完成对亚毫米CT断层图像中的血管数据分割,采用面绘制方法进行脏器三维重建。
②胆道、胰腺等腹腔脏器重建：使用区域生长法完成分割,采用面绘制方法进行脏器三维重建。
(3)3D模型的后处理及立体结构观察分析
通过MI-3DVS中的面数据图形处理工具对3D模型进行平滑和去噪,然后将肝外胆管血供3D模型在空间上组合和显示,通过放大、缩小、旋转可视化3D模型来观察、分析肝外胆管供血动脉起源和分布特点。
5.与传统的解剖学图像进行对比分析：采用基于亚毫米CT数据的肝外胆管血供三维可视化模型图像,与传统的解剖学素描图像进行对比分析。
结果：
1.使用试验注射法采集的亚毫米CT数据图像质量高,胆道系统、肝外胆管周围动脉、胰腺及壶腹周围病变显示清晰。
2.肝外胆管血供的3D模型立体感强,可多方位自由旋转,能清晰显示肝外胆管血供的来源及分布特点,上段肝外胆管血供来源包括肝右动脉、胆囊动脉、肝左动脉和肝固有动脉；下段肝外胆管血供来源包括胰十二指肠上后动脉、胃十二指肠动脉、胆囊动脉和门静脉后动脉。
3.肝外胆管血供3D模型真实,立体感强,可以从不同角度进行三维空间的解剖关系观察；传统素描解剖学图谱只能显示平面的解剖结构,表现手法单一,但其可根据手术显微镜所观察的尸体标本灌注情况,还原绘制胆管周围动脉丛等3D模型无法显示的血管。
结论：
1.采集方法优化后的64层螺旋CT可以获得高质量的肝外胆管血供亚毫米CT数据,各脉管系统显影良好,能够区分出微细结构的影像学特征,能满足肝外胆管供血动脉分割、三维重建的要求。
2.基于体绘制交互的分割方法能够对肝外胆管供血小动脉进行分割、提取；使用MI-3DVS重建的3D模型能够真实反映患者肝外胆管及供血动脉立体解剖结构。
3.三维重建图像更为真实直观,更加便于学习和理解,虚拟重建图像形象逼真,能真实还原组织器官结构的本来面貌,是解剖学研究和学习的新途径。
二胆道梗阻性疾病肝外胆管血供三维可视化及临床应用研究
目的：
1.研究胆道梗阻患者肝外胆管血供分布特点并进行分型；
2.研究肝外胆管血供3D模型在肝外胆管梗阻性疾病手术决策中的应用价值。
方法：
1.研究对象：2012年1月至2012年12月南方医科大学珠江医院肝外胆管梗阻性疾病患者41例,其中男25例,女16例；年龄31～81岁,平均年龄46.3岁；肝外胆管平均直径24.3±5.1mm (16-34mm)。临床诊断：胆道结石15例,胆总管下端炎性狭窄5例,胰头部或壶腹周围肿瘤21例。
2.数据采集设备同第一部分。
3.亚毫米CT数据收集方法同第一部分。
4.肝外胆管血供数据分割及三维重建方法同第一部分。
5.根据胆囊管汇入肝外胆管位置将肝外胆管分成上、下段,依据3D模型中肝外胆管血供来源及分布的特点进行数字化分型：
上段肝外胆管血供分为2型,Ⅰ型为肝右动脉供血型,再根据是否联合其他动脉供血分出3个亚型；Ⅱ型为肝左动脉联合胆囊动脉供血型。
下段肝外胆管血供分成3型,Ⅰ型为胰十二指肠上后动脉供血型,再根据是否联合其他动脉供血分出3个亚型；Ⅱ型为胃十二指肠动脉及主要支供血型(胰十二指肠上后动脉除外)；Ⅲ型为起源于胃十二指肠动脉的胆囊动脉供血型。
6.术式决策及手术效果评价：
术前通过对41例患者肝外胆管血供3D模型进行三维可视化观察,详细了解肝外胆管血供来源及分布特点,并进行术前规划,包括术中胆总管切开位置、胆肠吻合方式及胆总管横断位置的选择。术后观察并记录并发症发生情况,主要包括有无胆道狭窄、胆肠吻合口狭窄、胆瘘、胆道出血等。
结果：
1.采集的肝外胆管血供亚毫米CT数据图像质量高,胆道系统、肝外胆管周围动脉、胰腺及壶腹周围病变显示清晰。
2.41例肝外胆管血供3D模型完全忠实于患者实际解剖特点,清楚显示个体化肝外胆管血供的起源、走行、分布及变异情况,同时还可以立体显示胆道结石、肿瘤与周围脏器及血管的立体解剖关系。
3.分别按照上、下段肝外胆管血供特点进行数字化分型：
41例患者上段肝外胆管血供IA型6例,占14.6%；IB型17例,占41.5%；IC型12例,占29.3%；Ⅱ型6例,占14.6%。
41例下段肝外胆管血供IA型13例,占31.7%；IB型13例,占31.7%；IC型4例,占9.8%；Ⅱ型7例,占17.0%；Ⅲ型4例,占9.8%。
4.41例均顺利行手术治疗,手术方式包括胆总管切开取石术15例,胆管空肠端侧吻合术22例(其中胰十二指肠切除术21例),保留十二指肠的胰头切除术1例,胆管空肠侧侧吻合术3例。术中胆道手术方式与术前规划完全符合。术中所见肝外胆管形态,肝外胆管血供走行情况、肝动脉变异情况,结石分布、肿瘤与血管毗邻关系均与术前3D模型相符。全组无术中及术后胆道出血、术后胆瘘发生,全组病人随访3-15个月,无肝外胆管狭窄、胆肠吻合口狭窄发生。
结论：
1.数字化肝外胆管血供分型有助于对上、下段肝外胆管血供类型进行正确诊断,并根据手术主要操作的肝外胆管部位进行术前评估,合理选择手术方式。
2.肝外胆管血供三维可视化模型可以真实反映肝外胆管梗阻患者的个体化肝外胆管血供特点,为胆道手术方案的制定提供详实的胆管血供信息,可以指导术中胆总管切开位置、胆肠吻合方式及胆总管横断位置的选择,增加手术成功率,减少术后胆道并发症的发生。
三三维可视化技术在胰十二指肠切除术合并肝动脉变异诊治中的应用
目的：
研究腹部医学图像三维可视化系统(MI-3DVS)在胰十二指肠切除术合并肝动脉变异患者诊治决策中的价值。
方法：
1.研究对象：2010年1月至2012年7月南方医科大学珠江医院和第三军医大学西南医院114例成功行胰十二指肠切除术的胰头或壶腹周围肿瘤患者。
2.亚毫米CT数据采集设备及3D重建方法同第二部分,21例CTA扫描采用试验注射法,93例CTA扫描采用团注追踪法。
3.手术方法及手术效果评价：
术前通过对3D模型进行多角度旋转观察,详细了解变异肝动脉情况,并结合病史资料进行诊断及肿瘤可切除性评估,制定详细手术方案。并对变异肝动脉起始部至肠系膜上动脉起始部的距离进行测量,最后与术中探查结果和术后腹腔动脉DSA结果相对照。
术后观察并记录并发症发生情况,包括有无肝脓肿、肝功能不全、胆肠吻合口瘘、胰瘘、腹腔出血、消化道出血等。
结果：
1.腹部脏器3D模型可清楚显示肿瘤的大小及形态、血管的起源及走行、肿瘤与脏器及血管的立体解剖关系,共发现变异肝动脉14例(12.3%,14/114),包括替代肝右动脉起自肠系膜上动脉者9例(7.9%,9/114),替代肝总动脉起自肠系膜上动脉3例(2.6%,3/114),替代肝左动脉起自胃左动脉2例(1.8%,2/114),其中2例替代肝右动脉经过胰头组织实质,但无肿瘤浸润。3D模型中测量12例起源于肠系膜上动脉的变异肝动脉起始部至SMA起始部距离为15.3-38.8mm,平均25.9+6.9mm。
2.14例肝动脉变异患者均行标准的胰十二指肠切除术,和术中探查及术后DSA检查对比,MI-3DVS对变异肝动脉诊断的敏感度、特异度和准确率均为100%。MI-3DVS指导下的术前规划与术中探查结果均符合。14例肝动脉变异患者无围手术期死亡,术后无肝脓肿、胆瘘、肝功能衰竭等并发症发生。
结论：
MI-3DVS可以在胰十二指肠切除术前对变异肝动脉做出准确诊断,对个体化手术方案的制定提供详实的术前指导,能够增加手术成功率,减少术后并发症的发生。
Research Background
The occurrence of ischemic-type biliary lesions (ITBL), extrahepatic bile duct hemorrhage, traumatic biliary stricture and biliary anastomotic fistula after liver transplantation is related to destructed blood supply to the bile duct. Both domestic and oversea researches on the blood supply of extrahepatic bile duct are commonly conducted based on cadaveric human bodies and the animal models. Moreover, all the arteries supplying extahepatic bile duct are terminal vascular vessels of the branches of celiac artery, with multiple origins, complex distribution and multiple variations. The individualized three-dimensional model of the blood supplies to the extrahepatic bile duct can enrich our knowledge about the blood supplies to the extrahepatic bile duct both physiologically and pathologically. Therefore, the construction of the individualized three-dimensional model of the blood supplies to the extrahepatic bile duct before surgical operations would provide individualized morphological basis for the surgical planning and prevention of post-operative biliary complications.
Based on the medical application of the digitalized three-dimensional reconstruction technique of CT scanning images, as well as the emergence and rapid development of the submillimeter CT technology, the three-dimensional visualization of the supplying arteries to the extrahepatic bile duct in the living human body can be achieved. The three-dimensional visualization technology turns the two-dimensional CT images into images with3D effects to demonstrate the three-dimensional structure and morphology of organs in the human body, which provides much more anatomic details that the traditional techniques failed to provide. The newly emerging technology solves the problems of expensive autopsy specimens and their insufficient supply, and anatomically guides the clinical surgical procedures with high accuracy. Therein, the technologies for harvesting high quality CT image data and for fine segmentation are crucial for its medical application.
Currently, concerning the image segmentation technology in the3-dimensional visualization software package both domestically and internationally, regional growing of seed points based on the two-dimensional images is commonly applied. The algorithm requires the three-dimensional neighboring points to be within the growth threshold. Therefore, any procedure that is not fit for the growth condition during the growing process would terminate the growth to break down the segmentation, resulting in failed tissue segmentation with tactfulness and fineness. Especially, the minor arteries may fail to be extracted and segmented to adversely affect its applications. In addition, the choice of seed points on the two-dimensional images requires much knowledge in anatomy. Otherwise, the ideal seed points may fail to be chosen to adversely affect the segmentation.
Based on these problems, our study attempted to study on the new segmentation method based on interactive volume rendering with the high quality submillimeter CT data. The study targeted on the defect of the traditional three-dimensional visualization software that fails to achieve segmentation for minor vessels. The new segmentation algorithm would be integrated into the abdominal Medical Image Three-Dimensional Visualization System (MI-3DVS)(software potent NO.2008SR18798), which has independent intellectual property right. We prospected a programmed sequence to construct digital three-dimensional model of supplying arteries to the extrahepatic bile duct in the living human body. After that, we digitally categorized the supplying arteries to the extrahepatic bile duct based on their origin and distribution. Finally, the application of the3-dimenstional model in the surgical decision making for extrahepatic biliary obstructive diseases was explored.
Part I. Three-dimensional visualization model of arteries supplying the extrahepatic bile duct based on submillimeter CT data
Objective
(1) To optimize the method to collect CT data for high quality submillimeter CT data of the arteries supplying the extrahepatic bile duct;
(2) To establish a new segmentation algorithm based on new interactive volume rendering to construct a3dimensional model of arteries supplying the extrahepatic bile duct in the living human body;
(3) To compare the digital3dimensional model of arteries supplying the extrahepatic bile duct and the traditional anatomic images of arteries supplying the extrahepatic bile duct.
Methods
(1) The study recruited10subjects, including7males and3females, aged36-62years with an average age of43.2years.
(2) The equipments used to collect data include64layers spiral CT scanner (CT PHILIPS Brilliance64, made in Dutch); double tube high pressure syringe and contrast agents (Lopamiro in a dose of370mg I/ml); the self attached Mxview workstation for post processing of the images; HP blade server and high configuration computer (from Clinical Center of Digital Medicine, Southern Medical University, Guangzhou, China) and the abdominal three-dimensional visualization system.
(3) The procedures for collecting high quality submillimeter CT data of the arteries supplying the extrahepatic bile duct include:prescanning preparation, plain scanning, trial injection, routine enhanced scanning as well as the transmission and storage of thin layer CT scanning data.
Preparation before the scanning:20-30min before scanning,500-1000ml water was drunk to fill the gastrointestinal tract; And500ml water was drunk immediately before the scanning to fill the gastrointestinal tract.
Plain scanning:Routine plain scanning was performed with the subject in supine posture, scanning from the diaphragmatic top to the inferior kidney pole. The scanning parameters included120KV of the tube voltage,300mAs of the tube current,0.5s per rotation, pitch0.984, layer thickness5mm;0.625×64row of detectors, and scanning field of60-70cm, matrix512×512.
Trial injection:Small dose injection before scanning was performed for CTA scanning.
Routine enhanced scanning:After CTA scanning, late arterial scanning was performed35-55s after the injection of contrast agent; portal vein phase scanning50-55s after the injection of contrast agent; the scan time was about6-8s per phase.
Transmission and storage of thin layer CT scanning data:The thin layer CT scanning data (0.625mm) was reconstructed at the Mxview workstation, in the format of DICOM (Digital Imaging and Communications in Medicine)3.0. The data was transmitted via the internal special line network to the HP blade server in the Clinical Center of digital medicine (Southern Medical University, Guangzhou, China) for exportation and storage.
(4) The3D model of arteries supplying the extrahepatic bile duct was constructed based on the following procedures.
The interactive volume rendering reconstruction was performed. After the window width and level adjusted, the optimal3D image of the interested body part can be obtained. The3D seeds points were directly chosen from the volume rendering image for regional growing. Meanwhile, the growing process was demonstrated on the volume rendering image. In the cases of terminated growth, the volume rendering3D image can be fixed by human-computer interactions. Especially for microvascular vessels, the local microvascular vessels were extracted by local magnification, connecting intermittent small blood vessels, and segmentation. In such a way, the tissue segmentation, particularly the vascular segmentation can be more sophisticated with the same resolution level as the volume rendering. When the satisfying segmentation was achieved, it was saved immediately for rapid surface rendering3D reconstruction.
The interactive segmentation algorithm based on the volume rendering, as a plug-in, was integrated into the abdominal three dimensional visualization system (MI-3DVS). The submillimeter CT data in the format of DICOM was introduced into the MI-3DVS for registration, segmentation and3D reconstruction.①The vascular submillimeter CT data is segmented based on the interactive volume rendering of segmentation algorithm.3D reconstruction of organs was performed by using the surface rendering method.②By using the regional growing method, the segmentation was achieved for3D reconstruction of the organs with the surface rendering method.
The post-processing of the3D model was then performed for observation and analysis of the3D model.
With the surface data processing tool in the MI-3DVS, the3D model was smoothed and denoised for combination and demonstration of the arteries supplying the extrahepatic bile duct in the3D model. The visualized3D model was zoomed in, zoomed out and spinned for the observation and analysis of the arteries supplying the extrahepatic bile duct.
(5) The constructed3D visualization model for the arteries supplying the extrahepatic bile duct based on the submillimeter CT data was compared to the traditional anatomic images.
Results
(1) The quality of submillimeter CT images obtained via trial injection was optimal, with favorable demonstrations of the biliary lesions, peripheral arterial lesions of the extrahepatic bile duct, peripancreatic lesions and periampullar lesions.
(2) The3D model of arteries supplying the extrahepatic bile duct can be multidimensionally rotated to clearly demonstrate the origins and distributions of the arteries supplying the extrahepatic bile duct. The arteries supplying the superior segment of extrahepatic bile duct were found to be originated from the right hepatic artery, the gallbladder artery, the left hepatic artery and the proper hepatic artery. However, the arteries supplying the inferior segment of the extrahepatic bile duct were found to be originated from the superioposterior pancreatoduodenal artery, the astroduodenal artery, the gallbladder artery and the retroportal artery.
(3) The3D model of arteries supplying the extrahepatic bile duct can be multi-dimensionally observed and analyzed for the anatomical relationships. Traditional sketches can only display the anatomic structures on the surface. However, it has the advantage of demonstrating vascular vessels that the3D model fails to display, such as the artery plexus around the bile duct. The sketches are based on the cadaveric perfusion under a surgical microscope.
Conclusions:
(1)64layers spiral CT scanning with optimized data collecting method can obtain high quality submillimeter CT data of the arteries supplying the extrahepatic bile duct, with well demonstrated vasculature. It can facilitate to distinguish the imaging demonstrations of the micro-structures, which satisfies the requirements for segmentation and3D reconstruction of arteries supplying the extrahepatic bile duct.
(2) Based on volume rendering of interactive segmentation method, the scanning data of arterioles supplying the extrahepatic bile duct can be extracted and segmented for3D reconstruction. The3D model reconstructed by using MI-3DVS can display the three-dimensional anatomical structures of the extrahepatic bile duct and its blood supplying arteries.
(3) The reconstructed3D model is authentic and direct, which facilitates the learning of anatomic knowledge and related researches.
Part Ⅱ3D visualization of the arteries supplying the extrahepatic bile duct in patients with biliary obstructive diseases and its clinical application
Objective
(1) To study the distribution of arteries supplying the extrahepatic bile duct in patients with biliary obstructive diseases and their categorization.
(2) To evaluate the application value of the3D model in surgical decision making for patients with extrahepatic biliary obstructive diseases.
Methods
(1) The study recruited41patients with extrahepatic biliary obstructive diseases in Zhujiang hospital of Southern Medical University during Jan.2012and Dec.2012, including25males and16females, aged31-81years with an average of46.3years. The average diameter of the extrahepatic bile duct was24.3±5.1mm (ranging from16mm to34mm). The clinical diagnosis was biliary calculi in15cases, inflammatory stricture of the lower common bile duct in5cases, the pancreatic head or periampulla tumor in21cases.
(2) The data collecting procedures and the equipments used are the same as the previous part.
(3) The submillimeter CT data was collected by using CTA scanning and the procedures were the same as the previous part.
(4) The methods for data segmentation and3D reconstruction of arteries supplying the extrahepatic bile duct were the same as the previous part.
(5) According to the position of the cystic duct entering the extrahepatic bile duct, the extrahepatic bile duct is divided into superior and inferior segments. According to origins and distribution of arteries supplying the extrahepatic bile duct in the3D model, the digital categorization of supplying arteries was as the following:
The superior segment of the extrahepatic bile duct had two types of blood supply. Type Ⅰ is the blood supply from the right hepatic artery, which includes3subtypes based on the combination with other supplying arteries. Type Ⅱ is the blood supply from the left hepatic artery in combination with the gallbladder artery.
The blood supply to the inferior segment of the extrahepatic bile duct can be divided into3types. Type Ⅰ is by the superioposterior pancreatoduodenal artery, which can be further divided into3subtypes according to its combination supplying with other arteries. Type Ⅱ is by the gastroduodenal artery and its major branches (except for the superioposterior pancreatoduodenal artery). Type Ⅲ is by the gallbladder artery, which originates from the gastroduodenal artery.
(6) Surgical decision making, and the evaluation of the surgical outcome were performed.
After preoperative observation and analysis of the3D visualization model for the arteries supplying the extrahepatic bile duct in the41subjects, the origins and distribution of the arteries supplying their extrahepatic bile duct were understood in detail for preoperative surgical planning. The plan included the incision position of the common bile duct, biliary intestinal anastomosis and the transection position of the common bile duct. Postoperative observations were performed and the complications were recorded in detail. The complications commonly include biliary tract stenosis, biliary intestinal anastomotic stricture, biliary fistula and bile duct bleeding.
Results
(1) The submillimeter CT data of the arteries supplying the extrahepatic bile duct collected by bolus injection tracing has a high image quality. The images clearly demonstrated the biliary lesions, peripheral arterial lesions of the extrahepatic bile duct, and peripancreatic lesions and periampulla lesions.
(2) The3D models based on the41subjects are completely identical to the actual anatomic structures of the arteries supplying the extrahepatic bile duct, with clear demonstrations of the origin, course, distribution and variation of individual blood supply to the extrahepatic bile duct. Meanwhile, the3D demonstrations of the anatomic relationship between biliary calculi and tumors with their adjacent organs and blood vessels can also be demonstrated.
(3) According to the blood supplies to the respective superior and inferior segments of the extrahepatic bile duct, the digital categorization of the blood supply is as the following:
In the41patients, the blood supply to the superior segment of the extrahepatic bile duct includes6cases of type IA (14.6%);17cases of type IB (41.5%);12cases of type IC (29.3%); and6cases of type Ⅱ (14.6%).
In the41patients, the blood supply to the inferior segment of the extrahepatic bile duct includes13cases of type IA (31.7%);13cases of type IB (31.7%);4cases of type IC (9.8%);7cases of type II7(17.0%); and4cases of type III (9.8%).
(4) All41patients successfully received the surgical treatment. The surgical procedures include15cases of choledocholithotomy,22cases of terminal anastomosis of bile duct and jejunum (including21cases of pancreatoduodenal resection),1case of pancreatic head resection with retained duodenum,3cases of lateral anastomosis of the bile duct and the jejunum. The intraoperative surgical procedures are identical to those of preoperative planning. The intraoperative findings of the morphology of the extrahepatic bile duct as well as the course and variations of the arteries supplying the extrahepatic bile duct are in line with the preoperative findings from the3D model. In addition, the distributions of the lithiasis and the tumors as well as their relationship with the adjacent blood vessels are also in line with preoperative findings from the3D model. No complication occurred in all the patients in the3-15months follow-up, such as intraoperative and postoperative biliary tract bleeding, postoperative bile fistula, extrahepatic bile duct stricture, biliary intestinal anastomotic stricture.
Conclusions
(1) The digital categorization of the blood supply to the extrahepatic bile duct contributes to the accurate diagnosis of the superior and inferior segments of the extrahepatic bile duct. Meanwhile, the preoperative assessment of the surgical location contributes to the choice of surgical procedures.
(2) The3D model of the arteries supplying the extrahepatic bile duct can authentically demonstrate the individualized blood supply of the extrahepatic bile duct for patients with extrahepatic biliary obstruction. Therefore, it provides detailed information about the arteries supplying the surgical location and facilitates the surgical planning, including intraoperative incision location, biliary and intestinal anastomosis and common bile duct transection position. In such way, the surgical success rate can be increased and the incidence of postoperative complications can be decreased.
Part III Application of3D visualization in duodenopancreatectomy and hepatic artery variation
Objective
To explore the application value of the MI-3DVS in patients with hepatic artery variation receiving duodenopancreatectomy.
Methods
(1) The study recruited114patients with pancreatic head tumor and periampullary tumor who had successfully received duodenopancreatectomy in Zhujiang Hospital (Southern Medical University, Guangzhou, China) and Southwest Hospital (Third Military Medical University, Chongqing, China) from Jan.2010to Jul.2012.
(2) The equipments for collecting submillimeter CT data and3D reconstruction were the same as the previous part. Trial injection method was performed for CTA scanning in21cases, bolus injection tracing method was performed for CTA scanning in93cases.
(3) The surgical procedures and the surgical outcome assessment: Before the operation, we observed the3D models from multiple perspectives to understand the hepatic artery variation. In combination with the case history, the diagnosis was made and tumor resectibility was assessed. And the detailed surgical plan was formulated. Based on the3D model, we also measured the distance from the origin of variant hepatic artery to the origin of the superior mesenteric artery. The intraoperative findings were finally compared to the postoperative DSA findings of the abdominal artery.
After the operation, the occurrence of the complications was observed and recorded including hepatic abscesses, hepatic dysfunctions, biliary intestinal anastomotic fistula, pancreatic fistula, abdominal hemorrhage, pulmonary infections and gastrointestinal hemorrhage.
Results
(1) The abdominal3D models can clearly display the size and shape of tumor, the origin and course of the blood vessels, as well as the3D anatomic relationship between tumors and organs, blood vessels. We totally found14cases (12.3%,14/114) with variant hepatic artery including9cases (7.9%,9/114) with replacing right hepatic artery originating from the superior mesenteric artery and3cases (2.6%,3/114) of replacing common hepatic artery originating from the superior mesenteric artery, and2cases (1.8%,2/114) of replacing common hepatic artery originating from the left gastric artery. In these14cases,2cases had their replacing right hepatic artery passing through the parenchymal pancreatic head, but with no tumor infiltration. The12cases of3D models were measured the distance from the origin of the variant hepatic artery originating from the superior mesenteric artery to the origin of the SMA. The distances ranged from15.3mm to38.8mm, with an average of25.9±6.9mm.
(2) The14patients all received standard procedures of duodenopancreatectomy. Compared to the intraoperative findings and postoperative DSA examination, the sensitivity, specificity and accuracy of MI-3DVS to variant hepatic artery is100%. The preoperative planning guided by MI-3DVS is in line with the intraoperative findings. No perioperative death occurred in all the14patients. No postoperative complications occurred in all14patients, including hepatic abscesses, biliary fistula and liver failure.
Conclusions
MI-3DVS can accurately diagnose hepatic artery variation before duodenopancreatectomy. Therefore, it contributes to the formulation of preoperative surgical plans. It also increases the success rate of the surgical operations and decreases the occurrence of postoperative complications.
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[13]陈卫军,应大君,刘正津.胆总管和肝总管的血供及其临床意义[J].中国临床解剖学杂志,1994,12(3)：161-164.
[14]周泽民,方驰华,钟世镇.数字化虚拟胰腺三维重建图像与传统解剖学图像的比较[J].第四军医大学学报,2005,26(18)：1653-1656.
[15]方驰华,周五一,黄立伟,等.虚拟中国人女性一号肝脏图像三维重建和虚拟手术的切割[J].中华外科杂志,2005,43(11)：682-6.
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[1]Northover JM, Terblenche J. A New look at arterialsupply of bile duck in man and its surgical implication[J]. Br J Surg,1979,66(6):379-384.
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[4]王开阳,付华群.医源性胆管缺血性损伤[J].国际外科学杂志,2009,36(2)：75-77.
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[6]SAHANI D, SAINI S, PENA C, et al. Using multidetector CT for preoperative vascular evaluation of liver neoplasms technique and results[J]. Ajr. American Journal of Roentgenology,2002,179(1):53-59.
[7]KAPOOR V, BRANCATELLI G, FEDERLE M P, et al. Multidetector CT arteriography with volumetric three-dimensional rendering to evaluate patients with metastatic colorectal disease for placement of a floxuridine infusion pump[J]. Ajr. American Journal of Roentgenology,2003,181(2):455-463.
[8]傅德良,杨峰,龙江,等.胰十二指肠切除术中肝动脉变异的临床特征研究[J].中华肝胆外科杂志,2008,14(3)：195-196.
[9]高红桥,杨尹默,庄岩,等.胰十二指肠切除中合并肝动脉变异患者的诊治[J].中华外科杂志,2008,46(7)：522-524.
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[10]Park WW, Michels NA, Ghost GM. Blood supply of the common bile duct[J]. SGO,1963,117(1):47.
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[12]陈卫军,应大君,刘正津.肝外胆道血供来源和分布及其临床意义[J].中国临床解剖学杂志,1994,12(4)：248-250.
[13]陈卫军,应大君,刘正津.胆总管和肝总管的血供及其临床意义[J].中国临床解剖学杂志,1994,12(3)：161-164.
[14]周泽民,方驰华,钟世镇.数字化虚拟胰腺三维重建图像与传统解剖学图像的比较[J].第四军医大学学报,2005,26(18)：1653-1656.
[15]方驰华,周五一,黄立伟,等.虚拟中国人女性一号肝脏图像三维重建和虚拟手术的切割[J].中华外科杂志,2005,43(11)：682-6.
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[1]Northover JM, Terblenche J. A New look at arterialsupply of bile duck in man and its surgical implication[J]. Br J Surg,1979,66(6):379-384.
[2]Cameron G R, Hou CT. An experimental study of stricture of the common bile duct in the guinea-pig[J]. JPB,1962,83(1):265.
[3]Chung RS, Hitch DC, Armstrong DN. The role of tissue ischemia in the pathogenesis of anastomotic stricture[J]. Surgery,1988,104(5):824-829.
[4]王开阳,付华群.医源性胆管缺血性损伤[J].国际外科学杂志,2009,36(2)：75-77.
[5]黄志强.黄志强胆道外科手术学[M].北京：解放军出版社,1991：178.
[6]Park WW, MichelsNA, GhostGM. Blood supply of the common bile duct[J]. SGO,1963,117(1):47.
[7]Northover JM, Terblanche J. Bile duct blood supply:Its importance in human liver transplantation[J]. Transplantation,1978,26:67.
[8]陈卫军,应大君,刘正津.肝外胆道血供来源和分布及其临床意义[J].中国临床解剖学杂志,1994,12(4)：248-250.
[9]陆仁枝,宋志坚,唐厚君.CT序列图像分割的实现及分割结果的重建[J].计算机工程,2003,13(29)：152-4.
[10]Adams R, Bischof L. Seeded region growing [J]. IEEE Trans Pattern Anal Machine Intelligence,1994,16(6):641-7.
[11]裘法祖,王健本,张祜曾.腹部外科临床解剖学[M].第1版.济南：山东科学技术出版社,2001：213-216.
[12]陈卫军,应大君,刘正津.胆总管和肝总管的血供及其临床意义[J].中国 临床解剖学杂志,1994,12(3)：161-164。
[13]熊炯忻,张树华,陶京,等.改良的保留十二指肠胰头全切除术[J].中华普外科手术学杂志(电子版),2009,3(1)：397-400.
[14]MICHELS N. Newer anatomy of the liver and its variant blood supply and collateral circulation[J]. American Journal of Surgery,1966,112(3):337-347.
[15]方驰华.电视腹腔镜下变异胆囊动脉解剖及临床意义[J].中国微创外科杂志,2001,1(2)：71-72.
[16]何振平,王敖川.肝动脉结扎治疗胆道大出血临床体会[J].实用外科杂志,1989,19(5)：239.
[1]MICHELS N. Newer anatomy of the liver and its variant blood supply and collateral circulation[J]. American Journal of Surgery,1966,112(3):337-347.
[2]FANG Chi-hua, XIE Ao-wen, CHEN Mian-ling, et al. Application of a visible simulation surgery technique in preoperation planning for intrahepatic calculi[J]. World Journal of Surgery,2010,34(2):327-335.
[3]SHUKLA P J, BARRETO S G, KULKARNI A, et al. Vascular anomalies encountered during pancreatoduodenectomy:do they influence outcomes?[J]. Annals of Surgical Oncology,2010,17(1):186-193.
[4]BIEHL T R, TRAVERSO L W, HAUPTMANN E, et al. Preoperative visceral angiography alters intraoperative strategy during the Whipple procedure[J]. American Journal of Surgery,1993,165(5):607-612.
[5]TRAVERSO L W, FREENY P C. Pancreaticoduodenectomy. the importance of preserving hepatic blood flow to prevent biliary fistula[J]. The American Surgeon,1989,55(7):421-426.
[6]SAHANI D, SAINI S, PENA C, et al. Using multidetector CT for preoperative vascular evaluation of liver neoplasms technique and results[J]. Ajr. American Journal of Roentgenology,2002,179(1):53-59.
[7]KAPOOR V, BRANCATELLI G, FEDERLE M P, et al. Multidetector CT arteriography with volumetric three-dimensional rendering to evaluate patients with metastatic colorectal disease for placement of a floxuridine infusion pump[J]. Ajr. American Journal of Roentgenology,2003,181(2):455-463.
[8]傅德良,杨峰,龙江,等.胰十二指肠切除术中肝动脉变异的临床特征研究[J].中华肝胆外科杂志,2008,14(3)：195-196.
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