急性胰腺炎伴胰周积液向胸腔引流通道的影像解剖学研究
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摘要
研究背景
伴随着急性胰腺炎胰周积液向纵隔引流通道的形成，纵隔内的液体积聚有转变为胰胸膜瘘和纵隔假性囊肿的可能性。作为胰腺炎的重症并发症，由于对上述两病变的病理解剖认识不足，容易造成误诊。CT对上述两病变的瘘管作出正确诊断的能力一直存在争议。对急性胰腺炎胰周积液向纵隔引流通道的影像解剖研究，有助于提高胰胸膜瘘和纵隔假性囊肿的阳性诊断率，也有助于对二者采取恰当的治疗措施。
研究目的
首先，由于左膈下腹膜外间隙是胰周积液向胸腔引流通道上极易累及的间隙，为此研究其与毗邻间隙详细空间关系。其次，阐明急性胰腺炎伴胰周积液通向纵隔引流通道的具体解剖学路径。最后，通向纵隔的引流通道累及膈脚后间隙的几率较高，且纵隔内的液体积聚将进一步发展成胸腔积液。又由于胸腔积液是急性胰腺炎的重症危险因子，本研究将建立基于急性胰腺炎伴膈脚后间隙受累(RCSI) CT征象的评分体系，以预测胸腔积液的发生及患者的预后。本研究主要由三个部分组成。第一部分运用可视化技术在任意断面和三维空间探究左膈下腹膜外间隙的解剖学特征和它与毗邻间隙的空间关系，尤其是其与胃裸区的关系。第二部分为了提高对胰胸膜瘘和纵隔假性囊肿诊断的正确性，结合CT图像和2号中国可视人(CVH2)图像我们研究了在急性胰腺炎不同严重度情况下，以及在不同胰腺坏死区域所生成的胰周积液通过膈肌裂孔向纵隔引流通道的分布情况。第三部分则研究基于膈脚后间隙受累CT征象的评分系统，将其与CT严重程度指数(CTSI)比较,用以评价胸腔积液的发生和急性胰腺炎的严重程度。
材料方法
第一部分，运用源自中国可视人数据库、美国可视人数据库和中国虚拟人数据库的上腹部薄层横断面图像，在上述图像上观察左膈下腹膜外间隙解剖学特征及其与毗邻间隙的空间关系。此外，结合Mimics和Amira软件，在CVH2断面上提取左膈下腹膜外间隙与其毗邻间隙的轮廓，进行三维重建以印证其上述解剖特点。基于CVH2和CT断面，利用多平面重建技术呈现左膈下腹膜外间隙的解剖定位。第二部分，从CVH2数据库提取包含各个引流通道的连续横断面图像，结合回顾性分析2010年内经诊治的患有急性胰腺炎的51个患者的CT图像，采用多平面重建技术(MPR)探究CT图像上的引流通道，并将其与CVH2图像上显示的引流通道进行对比研究，并且根据急性胰腺炎的严重程度观察这些患者的引流通道的分布情况。第三部分，在回顾分析了2010年入院3–5天的241名急性胰腺炎患者的对比增强CT图像的基础上，利用Delphi法建立了包括评价累及膈脚后间隙的感染状况和胰周积液扩散进入或逸出膈脚后间隙的RCSI影像评分系统。聘请两位放射学家独立评价了RCSI和CTSI积分。使用ROC(受试者工作特性)曲线计算RCSI和CTSI评分系统的预测积分，上述积分可用来评价胸腔积液是否发生和急性胰腺炎的严重程度。
主要结果
对左膈下腹膜外间隙的解剖特征及其与毗邻间隙的空间关系的研究中，明确了左膈下腹膜外间隙由左膈下脂肪间隙和胃裸区共同构成。贲门角脂肪垫的出现促使左膈下腹膜外间隙前外侧面的形态由三角形转变为梯形。另外，左膈下腹膜外间隙在前内侧和右后方分别与小网膜和肝裸区毗邻。
对急性胰腺炎伴胰周积液向纵隔引流通道的研究证实了进入纵隔的最重要的两条通道：一是从胰周间隙经过系膜后平面到达左膈下腹膜外间隙，随后经食管裂孔进入膈脚后间隙；二是从胰周间隙不经过系膜后平面直接通联左膈下腹膜外间隙，随后经食管裂孔进入膈脚后间隙。其次，胰头坏死病例比胰体坏死病例所形成经食管裂孔进入纵隔的引流通道数量少，但累及引流通道的程度更重。此外，本研究首次阐述了位于肋膈肌和脚膈肌之间的狭窄间隙可以作为进入膈脚后间隙的引流通道。
利用CT探究急性胰腺炎时RCSI评分系统表明：RCSI积分能正确地预测胸腔积液是否发生，由此预测胸腔积液发生的RCSI和CTSI评分的ROC曲线下面积分别是0.852±0.026和0.810±0.027，而用以预测急性胰腺炎严重程度的RCSI和CTSI评分的ROC曲线下面积分别是0.816±0.031和0.977±0.010。对本组资料运用ROC分析显示CTSI积分为3是识别急性重症胰腺炎的最佳阳性判断值。
研究结论
可视化技术首次被运用于腹腔间隙的空间毗邻关系的研究，该技术是探究其它腹部间隙之间通联关系的有效新方法，该技术的应用将推动如炎症和腹腔内转移癌等腹部疾病的动态扩散的研究。
进一步明确了通向纵隔引流通道的具体解剖学路径，诊断胰胸膜瘘和纵隔假性囊肿的敏感性将会提高。随着病程进展不同引流通道的出现或消失可以作为CT严重程度指数的有益补充，这将帮助临床医生对上述两种病变采取最佳治疗方案。
RCSI评分系统能够预测胸腔积液的发生(并且此时该评分系统优于CTSI评分系统)，此外RCSI评分系统还能预测急性胰腺炎的严重程度。
Background:
Accompanied by the constitution of draining pathways from the peripancreatic spaceto the mediastinum, fluid collections in the mediastinum has the potentiality to transformto the pancreaticopleural fistula and the mediastinal pseudocyst. As sever complicationsof pancreatitis, the clinicians often made misdiagnosis to the above two entities due tonot fully recognization of their pathological anatomy. The overall ability of CT toprovide accurate delineation of the fistula of above two entities is disputable. Theradiological anatomic study of draining pathways from the peripancreatic space to themediastinum will be beneficial for the promotion of the positive diagnosis of themediastinal pseudocyst and pancreaticopleural fistula, and it may help clinicians to applythe optimal treatment for the above two entities.
Objective:
Firstly, the left extraperitoneal space (LES) is the frequently involved space ondraining pathways to the mediastinum. So the detailed spatial relationships to its relatedspaces were studied. Secondly, the detailed pathways from the peripancreatic space to themediastinum in acute pancreatitis were formulated. Finally, there is a high frequency thatthe retrocrural space is involved on pathways to the mediastinum, and fluid collections inthe mediastinum may further develop to the pleural effusion. As we know the pleuraleffusion is the risk factor for severity in the acute pancreatitis. The scoring system basedon the CT manifestations of retrocrural space involvement (RCSI) in acute pancreatitiswould be eatablished. This scoring system was used to predict the occurrence of thepleural effusion and the prognosis of patients.
This study is composed by three parts. The first part is the study of the anatomicfeatures of the LES and its spatial associations with related spaces by visualizationtechnology, in random sections and in three-dimensions (3D). The second part is thestudy of the anatomic pathways of peripancreatic fluid extension through diaphragmatichiatuses to mediastinum that may potentially transform to fistulas under different diseaseseverity or different necrotic area of pancreas in acute pancreatitis combined CT imageswith Second Chinese Visible Human (CVH2) images, so that the diagnostic accuracy of the pancreaticopleural fistula and mediastinal pseudocyst will be increased. The thirdpart is the study of a scoring system based on the RCSI, compared it with the CT severityindex (CTSI), in evaluating the occurrence of pleural effusion and the severity of acutepancreatitis.
Material and Methods:
In the first part of this study, we integrated with Mimics and Amira software. Weused thin-slice cross-sectional images of the upper abdomen, retrieved from the Chineseand American Visible Human dataset and the Chinese Virtual Human dataset, to displayanatomic features of the LES and spatial relationships of the LES to its related spaces,especially the gastric bare area. The anatomic location of the LES was presented on3Dsections reconstructed from CVH2images and CT images.
In the second part of this study, successive cross-sectional images includingdraining pathways were retrieved from CVH2dataset. CT images of51patients withacute pancreatitis treated during the year of2011were reviewed. Draining pathways onCT images were explored by using the multiply reconstructed technology compared withthose pathways on CVH2images. The distribution of the draining pathways of patientswith pacreatitis was observed according to the disease severity.
In the third part of this study, we reviewed contrast-enhanced CT images of241patients with acute pancreatitis taken within3–5days of admission in2010. The RCSIscoring system, which includes assessment of infectious conditions involving theretrocrural space and spreading of peripancreatic fluid into or out of the retrocrural space,was established by use of the Delphi method. Two radiologists independently assessedthe RCSI and CTSI scores. The predictive points of the of RCSI and CTSI scoringsystems in evaluating the occurrence of pleural effusion and severity of acute pancreatitiswere estimated using receiver operating characteristic (ROC) curves.
Principal Findings:
The studies of the anatomic features of the LES and spatial relationships to itsrelated spaces have ascertained that the LES consisted of the left sub-diaphragmatic fatspace and gastric bare area. The appearance of the fat pad at the cardiac notchcontributed to converting the shape of the anteroexternal surface of the LES fromtriangular to trapezoidal. Moreover, the LES was adjacent to the lesser omentum and thehepatic bare area in the anterointernal and right rear direction, respectively.
The research about the anatomic pathways of peripancreatic fluid draining tomediastinum in acute pancreatitis have confirmed that the most important two routes intomediastinum were from the peripancreatic space to the LES via or via not theretromesenteric plane, and further to the retrocrural space across esophageal hiatus.Secondly, the opened draining pathways across esopheageal hiatus into the retrocruralspace in pancreatic head necrosis were less than that in pancreatic body cases, but theseverity had increased. Besides, we firstly formulated the presence of pathways via thenarrow space between the costal and crural diaphragm into the retrocrural space.
We investigated the RCSI scoring system in acute pancreatitis by using CT. And wedemonstrated that the RCSI score could accurately predict the occurrence of pleuraleffusion. The area under the ROC curve for the RCSI versus CTSI score was0.852±0.026versus0.810±0.027for predicting the occurrence of pleural effusion, and0.816±0.031versus0.977±0.010for the severity of acute pancreatitis. Applying ROCanalysis to our data showed that a CTSI score of3was the best cutoff value, above whichsevere acute pancreatitis could identified.
Conclusion:
The visualization technique has been used in studying the adjacent relationship ofabdominal spaces for the first time. This technique is a promising new method forexploring detailed communication relationships among other abdominal spaces, and willpromote research on the dynamic extension of abdominal diseases, such as inflammatorydiseases and intra-abdominal carcinomatosis.
After the entire anatomy of draining pathways to mediastinum is defined in detail,the sensitivity of detecting the mediastinal pseudocyst and pancreaticopleural fistula willbe increased. With the pathological progress, the appearance or disappearance ofdraining routes may serve as complements to the CT severity index, thus it may helpclinicians to apply the optimal treatment for the above two entities.
The RCSI scoring system can predict the occurrence of pleural effusion (better thanthe CTSI score), and the severity of acute pancreatitis.
伴随着急性胰腺炎胰周积液向纵隔引流通道的形成，纵隔内的液体积聚有转变为胰胸膜瘘和纵隔假性囊肿的可能性。作为胰腺炎的重症并发症，由于对上述两病变的病理解剖认识不足，容易造成误诊。CT对上述两病变的瘘管作出正确诊断的能力一直存在争议。对急性胰腺炎胰周积液向纵隔引流通道的影像解剖研究，有助于提高胰胸膜瘘和纵隔假性囊肿的阳性诊断率，也有助于对二者采取恰当的治疗措施。
研究目的
首先，由于左膈下腹膜外间隙是胰周积液向胸腔引流通道上极易累及的间隙，为此研究其与毗邻间隙详细空间关系。其次，阐明急性胰腺炎伴胰周积液通向纵隔引流通道的具体解剖学路径。最后，通向纵隔的引流通道累及膈脚后间隙的几率较高，且纵隔内的液体积聚将进一步发展成胸腔积液。又由于胸腔积液是急性胰腺炎的重症危险因子，本研究将建立基于急性胰腺炎伴膈脚后间隙受累(RCSI) CT征象的评分体系，以预测胸腔积液的发生及患者的预后。本研究主要由三个部分组成。第一部分运用可视化技术在任意断面和三维空间探究左膈下腹膜外间隙的解剖学特征和它与毗邻间隙的空间关系，尤其是其与胃裸区的关系。第二部分为了提高对胰胸膜瘘和纵隔假性囊肿诊断的正确性，结合CT图像和2号中国可视人(CVH2)图像我们研究了在急性胰腺炎不同严重度情况下，以及在不同胰腺坏死区域所生成的胰周积液通过膈肌裂孔向纵隔引流通道的分布情况。第三部分则研究基于膈脚后间隙受累CT征象的评分系统，将其与CT严重程度指数(CTSI)比较,用以评价胸腔积液的发生和急性胰腺炎的严重程度。
材料方法
第一部分，运用源自中国可视人数据库、美国可视人数据库和中国虚拟人数据库的上腹部薄层横断面图像，在上述图像上观察左膈下腹膜外间隙解剖学特征及其与毗邻间隙的空间关系。此外，结合Mimics和Amira软件，在CVH2断面上提取左膈下腹膜外间隙与其毗邻间隙的轮廓，进行三维重建以印证其上述解剖特点。基于CVH2和CT断面，利用多平面重建技术呈现左膈下腹膜外间隙的解剖定位。第二部分，从CVH2数据库提取包含各个引流通道的连续横断面图像，结合回顾性分析2010年内经诊治的患有急性胰腺炎的51个患者的CT图像，采用多平面重建技术(MPR)探究CT图像上的引流通道，并将其与CVH2图像上显示的引流通道进行对比研究，并且根据急性胰腺炎的严重程度观察这些患者的引流通道的分布情况。第三部分，在回顾分析了2010年入院3–5天的241名急性胰腺炎患者的对比增强CT图像的基础上，利用Delphi法建立了包括评价累及膈脚后间隙的感染状况和胰周积液扩散进入或逸出膈脚后间隙的RCSI影像评分系统。聘请两位放射学家独立评价了RCSI和CTSI积分。使用ROC(受试者工作特性)曲线计算RCSI和CTSI评分系统的预测积分，上述积分可用来评价胸腔积液是否发生和急性胰腺炎的严重程度。
主要结果
对左膈下腹膜外间隙的解剖特征及其与毗邻间隙的空间关系的研究中，明确了左膈下腹膜外间隙由左膈下脂肪间隙和胃裸区共同构成。贲门角脂肪垫的出现促使左膈下腹膜外间隙前外侧面的形态由三角形转变为梯形。另外，左膈下腹膜外间隙在前内侧和右后方分别与小网膜和肝裸区毗邻。
对急性胰腺炎伴胰周积液向纵隔引流通道的研究证实了进入纵隔的最重要的两条通道：一是从胰周间隙经过系膜后平面到达左膈下腹膜外间隙，随后经食管裂孔进入膈脚后间隙；二是从胰周间隙不经过系膜后平面直接通联左膈下腹膜外间隙，随后经食管裂孔进入膈脚后间隙。其次，胰头坏死病例比胰体坏死病例所形成经食管裂孔进入纵隔的引流通道数量少，但累及引流通道的程度更重。此外，本研究首次阐述了位于肋膈肌和脚膈肌之间的狭窄间隙可以作为进入膈脚后间隙的引流通道。
利用CT探究急性胰腺炎时RCSI评分系统表明：RCSI积分能正确地预测胸腔积液是否发生，由此预测胸腔积液发生的RCSI和CTSI评分的ROC曲线下面积分别是0.852±0.026和0.810±0.027，而用以预测急性胰腺炎严重程度的RCSI和CTSI评分的ROC曲线下面积分别是0.816±0.031和0.977±0.010。对本组资料运用ROC分析显示CTSI积分为3是识别急性重症胰腺炎的最佳阳性判断值。
研究结论
可视化技术首次被运用于腹腔间隙的空间毗邻关系的研究，该技术是探究其它腹部间隙之间通联关系的有效新方法，该技术的应用将推动如炎症和腹腔内转移癌等腹部疾病的动态扩散的研究。
进一步明确了通向纵隔引流通道的具体解剖学路径，诊断胰胸膜瘘和纵隔假性囊肿的敏感性将会提高。随着病程进展不同引流通道的出现或消失可以作为CT严重程度指数的有益补充，这将帮助临床医生对上述两种病变采取最佳治疗方案。
RCSI评分系统能够预测胸腔积液的发生(并且此时该评分系统优于CTSI评分系统)，此外RCSI评分系统还能预测急性胰腺炎的严重程度。
Background:
Accompanied by the constitution of draining pathways from the peripancreatic spaceto the mediastinum, fluid collections in the mediastinum has the potentiality to transformto the pancreaticopleural fistula and the mediastinal pseudocyst. As sever complicationsof pancreatitis, the clinicians often made misdiagnosis to the above two entities due tonot fully recognization of their pathological anatomy. The overall ability of CT toprovide accurate delineation of the fistula of above two entities is disputable. Theradiological anatomic study of draining pathways from the peripancreatic space to themediastinum will be beneficial for the promotion of the positive diagnosis of themediastinal pseudocyst and pancreaticopleural fistula, and it may help clinicians to applythe optimal treatment for the above two entities.
Objective:
Firstly, the left extraperitoneal space (LES) is the frequently involved space ondraining pathways to the mediastinum. So the detailed spatial relationships to its relatedspaces were studied. Secondly, the detailed pathways from the peripancreatic space to themediastinum in acute pancreatitis were formulated. Finally, there is a high frequency thatthe retrocrural space is involved on pathways to the mediastinum, and fluid collections inthe mediastinum may further develop to the pleural effusion. As we know the pleuraleffusion is the risk factor for severity in the acute pancreatitis. The scoring system basedon the CT manifestations of retrocrural space involvement (RCSI) in acute pancreatitiswould be eatablished. This scoring system was used to predict the occurrence of thepleural effusion and the prognosis of patients.
This study is composed by three parts. The first part is the study of the anatomicfeatures of the LES and its spatial associations with related spaces by visualizationtechnology, in random sections and in three-dimensions (3D). The second part is thestudy of the anatomic pathways of peripancreatic fluid extension through diaphragmatichiatuses to mediastinum that may potentially transform to fistulas under different diseaseseverity or different necrotic area of pancreas in acute pancreatitis combined CT imageswith Second Chinese Visible Human (CVH2) images, so that the diagnostic accuracy of the pancreaticopleural fistula and mediastinal pseudocyst will be increased. The thirdpart is the study of a scoring system based on the RCSI, compared it with the CT severityindex (CTSI), in evaluating the occurrence of pleural effusion and the severity of acutepancreatitis.
Material and Methods:
In the first part of this study, we integrated with Mimics and Amira software. Weused thin-slice cross-sectional images of the upper abdomen, retrieved from the Chineseand American Visible Human dataset and the Chinese Virtual Human dataset, to displayanatomic features of the LES and spatial relationships of the LES to its related spaces,especially the gastric bare area. The anatomic location of the LES was presented on3Dsections reconstructed from CVH2images and CT images.
In the second part of this study, successive cross-sectional images includingdraining pathways were retrieved from CVH2dataset. CT images of51patients withacute pancreatitis treated during the year of2011were reviewed. Draining pathways onCT images were explored by using the multiply reconstructed technology compared withthose pathways on CVH2images. The distribution of the draining pathways of patientswith pacreatitis was observed according to the disease severity.
In the third part of this study, we reviewed contrast-enhanced CT images of241patients with acute pancreatitis taken within3–5days of admission in2010. The RCSIscoring system, which includes assessment of infectious conditions involving theretrocrural space and spreading of peripancreatic fluid into or out of the retrocrural space,was established by use of the Delphi method. Two radiologists independently assessedthe RCSI and CTSI scores. The predictive points of the of RCSI and CTSI scoringsystems in evaluating the occurrence of pleural effusion and severity of acute pancreatitiswere estimated using receiver operating characteristic (ROC) curves.
Principal Findings:
The studies of the anatomic features of the LES and spatial relationships to itsrelated spaces have ascertained that the LES consisted of the left sub-diaphragmatic fatspace and gastric bare area. The appearance of the fat pad at the cardiac notchcontributed to converting the shape of the anteroexternal surface of the LES fromtriangular to trapezoidal. Moreover, the LES was adjacent to the lesser omentum and thehepatic bare area in the anterointernal and right rear direction, respectively.
The research about the anatomic pathways of peripancreatic fluid draining tomediastinum in acute pancreatitis have confirmed that the most important two routes intomediastinum were from the peripancreatic space to the LES via or via not theretromesenteric plane, and further to the retrocrural space across esophageal hiatus.Secondly, the opened draining pathways across esopheageal hiatus into the retrocruralspace in pancreatic head necrosis were less than that in pancreatic body cases, but theseverity had increased. Besides, we firstly formulated the presence of pathways via thenarrow space between the costal and crural diaphragm into the retrocrural space.
We investigated the RCSI scoring system in acute pancreatitis by using CT. And wedemonstrated that the RCSI score could accurately predict the occurrence of pleuraleffusion. The area under the ROC curve for the RCSI versus CTSI score was0.852±0.026versus0.810±0.027for predicting the occurrence of pleural effusion, and0.816±0.031versus0.977±0.010for the severity of acute pancreatitis. Applying ROCanalysis to our data showed that a CTSI score of3was the best cutoff value, above whichsevere acute pancreatitis could identified.
Conclusion:
The visualization technique has been used in studying the adjacent relationship ofabdominal spaces for the first time. This technique is a promising new method forexploring detailed communication relationships among other abdominal spaces, and willpromote research on the dynamic extension of abdominal diseases, such as inflammatorydiseases and intra-abdominal carcinomatosis.
After the entire anatomy of draining pathways to mediastinum is defined in detail,the sensitivity of detecting the mediastinal pseudocyst and pancreaticopleural fistula willbe increased. With the pathological progress, the appearance or disappearance ofdraining routes may serve as complements to the CT severity index, thus it may helpclinicians to apply the optimal treatment for the above two entities.
The RCSI scoring system can predict the occurrence of pleural effusion (better thanthe CTSI score), and the severity of acute pancreatitis.
引文
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