三维重建虚拟手术规划在肝门部胆管癌手术中的应用价值

Application value of 3D reconstruction virtual surgery planning in the surgical treatment of hilar cholangiocarcinoma

  • 摘要: 目的:探讨三维重建虚拟手术规划在肝门部胆管癌手术中的应用价值。
    方法:采用回顾性横断面研究方法。收集2014年1月至2017年9月福建医科大学附属第一医院收治的36例肝门部胆管癌患者的临床病理资料。术前应用IQQA-Liver系统对CT检查图像进行三维可视化重建及虚拟手术规划,基于虚拟手术规划结果结合术中具体实际情况行精准肿瘤切除术。观察指标:(1)虚拟手术规划情况。(2)手术及术后情况。(3)随访和生存情况。采用门诊和电话方式进行随访,了解患者术后生存及肿瘤复发、转移情况。随访时间截至2017年11月。正态分布的计量资料以±s表示,术前虚拟手术规划指标与实际手术指标比较采用t检验。采用Kaplan-Meier法计算术后生存时间。
    结果:(1)虚拟手术规划情况:36例患者均完成三维重建及虚拟手术规划。三维重建结果可清楚显示肿瘤大小、与周围血管及胆管空间毗邻关系。36例患者经三维重建虚拟手术规划评估肿瘤Bismuth-Corlette分型为Ⅱ型2例、Ⅲa型13例、Ⅲb型14例、Ⅳ型7例,肿瘤体积为(76±26)mL,全肝体积为(1 319±306)mL,预切除肝脏体积为(588±128)mL,剩余肝脏体积为(731±269)mL。(2)手术及术后情况:36例患者中,16 例行左半肝切除术,12例行右半肝切除术,5例行扩大左半肝切除术,3例行扩大右半肝切除术;36例患者均联合行肝尾状叶切除术;1例联合行肝动脉切除重建术,2例联合行门静脉楔形切除修补术,1例联合行门静脉切除后端端吻合术。36例患者手术时间为(368±134)min,术中出血量为(474±288)mL。36例患者中,3例发生术后肺部感染,3例发生腹腔感染,2例发生腹腔淋巴液漏,均经保守治疗后痊愈。36例患者术后住院时间为(19±7)d。36例患者术后肿瘤Bismuth-Corlette分型为:Ⅱ型2例、Ⅲa型11例、Ⅲb型13例、Ⅳ型10例。三维重建图像肿瘤分型的准确率为91.7%(33/36)。36例患者实际切除肝脏体积为(551±141)mL,与预切除肝脏体积比较,差异无统计学意义(t=1.148,P>0.05)。(3)随访和生存情况:36例患者中,31例获得术后随访,随访时间为2~39个月,中位随访时间为16个月。31例患者术后中位生存时间为13个月,随访期间9例患者发生肿瘤复发、转移。
    结论:三维重建虚拟手术规划能准确完成肝门部胆管癌术前评估,为制订手术方案提供重要参考。

     

    Abstract: Objective:To investigate the application value of three-dimensional (3D) reconstruction virtual surgery planning in the surgical treatment of hilar cholangiocarcinoma.
    Methods:The retrospective cross-sectional study was conducted. The clinical data of 36 patients with hilar cholangiocarcinoma who were admitted to the First Affiliated Hospital of Fujian Medical University between January 2014 and September 2017 was collected. Before operation, images of 3D virtual surgery planning were respectively reconstructed and determined using IQQA-Liver imaging analysis system, and then precise resection of tumor was performed based on results of virtual surgical planning and intraoperative conditions. Observation indicators: (1) virtual surgical planning; (2) surgical and postoperative situations; (3) follow-up and survival. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival and tumor recurrence or metastasis up to November 2017. Measurement data with normal distribution were represented as ±s. Comparison between indicator of preoperative virtual surgical planning and surgical indicators was analyzed by the t test. The postoperative survival time was calculated by the Kaplan-Meier method.
    Results:(1) Virtual surgical planning: 36 patients accomplished 3D visualization reconstruction and virtual surgical planning. Three D visualization reconstruction clearly showed adjacent relationship between tumor size and surrounding vessels or bile duct space. Type Ⅱ, Ⅲa, Ⅲb and Ⅳ of Bismuth-Corlette Classification were detected in 2, 13, 14 and 7 patients by 3D visualization system, respectively. The tumor volume, whole liver volume, predicted liver resection volume and remnant liver volume were respectively (76±26)mL, (1 319±306)mL, (588±128)mL and (731±269)mL. (2) Surgical and postoperative situations: of 36 patients, 16, 12, 5 and 3 patients underwent left hemigepatectomy, right hemigepatectomy, extended left hemigepatectomy and extended right hemigepatectomy, respectively, and all of them were combined with caudate lobectomy of liver. Combined resection and reconstruction of hepatic artery, combined wedge resection and repair of the portal vein and combined end-to-end anastomosis after resection of the portal vein were detected in 1, 2 and 1 patients ,respectively. Operation time and volume of intraoperative blood loss of 36 patients were respectively (368±134)minutes and (474±288)mL. Thirty-six patients with postoperative complications were cured by conservative treatment, including 3 with pulmonary infection, 3 with intra-abdominal infection and 2 with intra-abdominal lymphatic fistula. Duration of hospital stay of 36 patients was (19±7)days. Type Ⅱ, Ⅲa, Ⅲb and Ⅳ of postoperative Bismuth-Corlette Classification were detected in 2, 11, 13 and 10 patients, respectively. Accuracy of tumor classification through 3D visualization reconstruction was 91.7%(33/36). Actual liver resection volume of 36 patients was (551±141)mL, and was not significantly different from predicted liver resection volume (t=1.148, P>0.05). (3) Follow-up and survival: 31 of 36 patients were followed up for 2-39 months after surgery, with a median time of 16 months. The postoperative median survival time was 13 months, and 9 patients had tumor recurrence or metastasis during the follow-up.
    Conclusions:The 3D reconstruction virtual surgery planning can accurately complete the preoperative evaluation, meanwhile, it can also provide important reference for the surgical therapy of hilar cholangiocarcinoma.

     

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