摘要
第一部分 超声造影在微波定量消融脾组织治疗脾大脾亢中的应用
目的 评价超声造影在微波定量消融脾组织治疗脾大脾亢中的应用价值。资料与方法将13只健康成年杂种犬(体重15-17Kg)通过结扎脾静脉主干根部及其在脾门处的主要属支(LSV，ligation of the splenic vein)的方法建立淤血性脾肿大、脾功能亢进的动物模型。于LSV术后3周时在开腹状态下行脾组织微波消融治疗(splenic microwave ablation therapy)。术中将2～6根微波电极在与脾长轴垂直的方向依次插入脾组织，微波电极远离脾门大血管处。微波消融的能量时间组合分别为60W 300s，50W 360s，40W 450s。分别在术后即刻、1周、4周、8周应用新型超声造影剂SonoVue~(TM)在低机械指数灰阶成像条件下对30个凝固区行超声造影检查，判断脾凝固区的大小、边界、坏死程度，并与常规超声对比以评价其在判断脾组织凝固区范围、坏死程度的应用价值。术后取出脾脏，顺脾凝固区的长轴切开凝固灶，测量凝固区的范围，常规石蜡包埋切片，HE染色，观察不同时间凝固区的病理学改变。结果 (1) SonoVue~(TM)结合低机械指数造影成像可清晰显示脾组织微波凝固区的边界，对边界的显示优于常规灰阶超声；超声造影状态下所测凝固区的长径、宽径与术后大体标本所测数值无显著性差异(P＜0.05)；(2) 超声造影判断脾组织不完全凝固性坏死的敏感性90％，特异性100％，敏感性高于彩色多普勒(70％)，但无显著性差异(P=0.582)。(3) 10个不完全坏死灶均为脾组织微波消融术后即刻标本，病理学显示凝固区呈大片凝固性坏死，坏死区内仍残存少量、散在的白髓，其
解放军军医进修学院博士学位论文
内可见中央动脉，中央动脉尚未发生完全坏死;20个完全性坏死灶分别为脾
组织微波消融术后1、4、8周后标本，病理学显示凝固区为完全性凝固性坏死，
血管壁发生凝固性坏死，其内见血栓形成，术后1周凝固区周围开始形成纤维
包膜，术后4、8周凝固区周围见完整的纤维包膜。结论:(1)应用新型声学
造影剂sonoVueTM在低机械指数灰阶造影成像条件下可清晰显示凝固区的边
界，为一形态规则、边界平滑的近椭圆形凝固区，对凝固区边界的显示优于常
规灰阶超声。(2)S。noVueTM对判断微波凝固区的坏死程度具有较大的应用价
值，其判断凝固区未完全坏死的敏感性、特异性分别为90%、100%。
Part I The value of contrast sonography in the splenic microwave ablation therapy for secondary splenomegaly and
hypersplenism
Objective To assess the value of contrast sonography in the splenic microwave ablation therapy for secondary splenomegaly and hypersplenism. Materials and Methods Thirteen healthy mongrel dogs weighing 15-17 kg were used in this study. Congestive splenomegaly was induced by ligation of the main splenic vein (LSV) at the confluent to portal vein and its collateral branches at the hilum of the spleen. At the end of 3rd week of LSV, splenic microwave ablation was performed in these animals. Two-six needles were inserted into the splenic parenchyma sequentially and the microwave power was set at 60W 300s, 50W 360s and 40W 450s respectively. Gray-scale contrast-enhanced ultrasonography and CDFI were performed immediately after the therapy and at 1, 4, 8 weeks posttherapy respectively . The microbubble US contrast agent that we used in this study was SonoVue? Gray-scale real-time contrast-enhanced sonography was performed after injection of SonoVue?(BR1, Bracco, Milan, Italy) . DU8 scanner ( Esaote Technos) with
LA532 E 8-3 high frequency transducer was used in this study. When the parameters such as time-compensated gain, depth, focus were optimized, they were held constant for each examination. The mechanical index was 0.089. The dogs were sacrificed after the sonography. Specimen of spleens were obtained to make routine histopathological studies. Results (1) SonoVue?combined with
gray-scale contrast-enhanced sonography could be used to display the margin of the necrotic region in the spleen. There was no difference between the dimensions of the necrotic region displayed by contrast sonography and those by splenic specimen. (2) The sensitivity and specificity of SonoVue?to assess the uncomplete necrosis in spleen were 90% and 100% respectively. (3) All the 10 ablated regions immediately after therapy were uncomplete necrosis and microscopically some residual white pulps and its central artery could be seen in the necrotic region. 20 ablated regions at 1, 4, 8 weeks posttherapy respectively were completely necrotic and fibrotic encapsule was formed around the necrotic area. Conclusions Gray-scale contrast-enhanced sonography could be used to evaluate the degree of necrosis of the ablated lesion and to display the margin of ablated lesion in the spleen.
引文
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