术前基于三维可视化技术精准设计肝离断面在ALPPS中的应用

doi:10.3877/cma.j.issn.2095-3232.2020.02.014

中华肝脏外科手术学电子杂志 ›› 2020, Vol. 09 ›› Issue (02) : 158 -163. doi: 10.3877/cma.j.issn.2095-3232.2020.02.014

所属专题：文献；

临床研究

术前基于三维可视化技术精准设计肝离断面在ALPPS中的应用

谭凯¹, 杜锡林¹^,^†(

), 陈安¹, 杨涛¹, 臧莉¹, 贺小军¹, 刘周², 封兰兰³, 杨振宇¹

^1. 710038　西安，空军军医大学第二附属医院普通外科二病区
^2. 710038　西安，空军军医大学第二附属医院影像科
^3. 710038　西安，空军军医大学第二附属医院病理科

收稿日期:2019-12-05 出版日期:2020-04-10
通信作者: 杜锡林
基金资助:
国家自然科学基金(81172287)

Application of preoperative accurate define of liver transection plane in ALPPS based on 3D visualization technology

Kai Tan¹, Xilin Du¹^,^†(), An Chen¹, Tao Yang¹, Li Zang¹, Xiaojun He¹, Zhou Liu², Lanlan Feng³, Zhenyu Yang¹

^1. Department Ⅱ of General Surgery, the Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
^2. Department of Imaging, the Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China
^3. Department of Pathology, the Second Affiliated Hospital of Air Force Medical University, Xi'an 710038, China

Received:2019-12-05 Published:2020-04-10
Corresponding author: Xilin Du
About author:
Corresponding author: Du Xilin, Email:dxlin0705@163.com

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引用本文：

谭凯, 杜锡林, 陈安, 杨涛, 臧莉, 贺小军, 刘周, 封兰兰, 杨振宇. 术前基于三维可视化技术精准设计肝离断面在ALPPS中的应用[J/OL]. 中华肝脏外科手术学电子杂志, 2020, 09(02): 158-163.

Kai Tan, Xilin Du, An Chen, Tao Yang, Li Zang, Xiaojun He, Zhou Liu, Lanlan Feng, Zhenyu Yang. Application of preoperative accurate define of liver transection plane in ALPPS based on 3D visualization technology[J/OL]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2020, 09(02): 158-163.

目的

探讨术前采用三维可视化技术精准设计肝离断面在联合肝脏离断和门静脉结扎的分阶段肝切除术（ALPPS）中的应用价值。

方法

回顾性分析2015年3月至2019年5月在空军军医大学第二附属医院行ALPPS的9例患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男7例，女2例，平均年龄（54±10）岁。患者采用Myrian软件重建肝脏三维模型，分别采用Robin Smithuis &Eduard E. de Lange影像学肝界面划分法（RE切割法）与精准切割法评估剩余肝体积（FLR）。精准切割法是在RE切割法基础上，重点考虑肿瘤切缘。两种方法得出的FLR比较采用配对t检验。

结果

RE切割法的FLR为（419±144）ml，明显大于精准切割法的（403±135） ml （t=2.51，P=0.036）。两种方法FLR差值分别占标准肝体积（SLV）的范围为0.2%～4.5%，其中1例患者按RE切割法，FLR/SLV比值44.3%（在40%以上），而按精准切割法，FLR/SLV比值为39.8%（在40%以下）。9例患者最终7例成功实施了ALPPS，其中扩大右半肝切除6例，右半肝切除1例，其余2例未能完成第二步手术。

结论

单纯影像学肝界面划分法存在一定误差，实施ALPPS术前应基于三维可视化技术，结合影像学肝界面和肝裂分界线，并遵循肝癌切除原则才可精准设计肝离断面。

关键词: 肝切除术, 成像，三维, 癌，肝细胞, 胆管肿瘤

Objective

To explore the application value of preoperative accurate define of liver transection plane with three-dimensional (3D) visualization technology in associating liver partition and portal vein ligation for staged hepatectomy (ALPPS).

Methods

Clinical data of 9 patients undergoing ALPPS in the Second Affiliated Hospital of Air Force Medical University from March 2015 to May 2019 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 7 patients were male and 2 female, aged (54±10) years on average. 3D model of liver of the patients was reconstructed using Myrian software. The future liver remnant (FLR) was assessed before operation by liver division of Robin Smithuis & Eduard E. De Lange imaging (RE division) and precise division, respectively. Precise division focuses on the tumor cutting margin on the base of RE division. The FLR obtained by two methods was statistically compared by using paired t test.

Results

The FLR of RE division was (419±144) ml, significantly larger than (403±135) ml of precise division (t=2.51, P=0.036). The FLR difference value between two methods accounted for 0.2%-4.5% of standard liver volume (SLV). For1 patient, the FLR/SLV ratio was calculated as 44.3% (above 40%) by RE division, while 39.8% (below 40%) by precise division. Among 9 patients, 7 cases underwent ALPPS successfully including 6 cases of extended right hepatectomy and 1 case of right hepatectomy. The remaining 2 cases failed to undergo the second-stage operation.

Conclusions

The single imaging liver division method may have some errors. Prior to ALPPS, surgeons should combine imaging liver plane with the dividing line of liver lobes and follow the principle of liver cancer resection in order to accurately define the transection plane based on 3D visualization technology.

Key words: Hepatectomy, Imaging, three-dimensional, Carcinoma, hepatocellular, Bile duct neoplasms

图1 一例肝脏肿瘤患者RE肝脏切割法设计肝离断面

图2 一例肝脏肿瘤患者精准切割法设计肝离断面

图3 肝脏恶性肿瘤患者门静脉、肝动脉、肝静脉的三维成像

图4 肝癌对肝静脉走行的影响

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