动态MRI检查结合3D HR-ARM技术对低位直肠癌保肛术后排便功能障碍的评价研究

发布时间：2018-07-13 17:50

【摘要】：目的应用盆腔动态MR成像技术及排粪造影检查,并结合3D肛门直肠压力测定法(3D HR-ARM),为拟行保肛手术的低位直肠癌患者提供全面、直观、无创、可重复性强的影像学术前评估,并从形态学及动力学分析患者术后出现低位前切除综合征(LARS)的机制,分析LARS的影像学特点与肛肠动力学变化的相关性,为临床制定适宜的治疗方案提供一种全面、直观、便捷、经济的影像学检查技术。材料与方法收集天津市人民医院2016年4月到2017年1月肛肠外科确诊为低位直肠癌并拟行保肛手术治疗的患者共42例。所有患者术前均行直肠指诊、结肠镜、盆腔常规及动态MRI、排粪造影及3D HR-ARM检查。在检查后一周内行手术切除,术后送病理检查。于术后三个月随访复查,共收集保肛手术治疗后出现LARS的患者20例,将其纳入病例组,再次复查盆腔常规及动态MRI及3D HR-ARM检查。收集健康成年志愿者20例纳入对照组,均行盆腔常规及动态MRI检查。另收集110例无症状志愿者3D HR-ARM检查数据。将术前盆腔MRI检查所获图像结果与直肠指诊、结肠镜检查和病理结果进行对比,运用ICC分析和Kappa检验比较盆腔MRI与其他三种检查的一致性和相关性,并应用卡方检验计算盆腔MRI对各项指标诊断的准确率、灵敏度、特异度、阳性预测值、阴性预测值。运用一般线性模型(GLM)单变量分析比较健康对照组与病例组术前各项测量指标间的差异。运用配对T检验分析比较术前排粪造影与盆腔动态MRI、病例组术前与术后各项测量指标间的差异。运用Pearson相关分析比较动态MRI、3D HR-ARM两种检查各项观测指标间的相关性。结果(1)盆腔MRI检查对肿瘤下缘与肛缘距离的测量结果,与直肠指诊及结肠镜检查的一致性较好(R=0.721,P0.01),对肿瘤肠周比例的测量结果,与术后病理或结肠镜检查的一致性中等(Kappa=0.661,P0.01),整体准确率为83.33%。盆腔MRI检查对肿瘤T、N分期的准确率均较高,整体准确率分别为88.10%和85.71%,与病理结果一致性较好(Kappa=0.729,P0.01;Kappa=0.743,P0.01)。(2)LARS患者术前动态MRI测得静息相和力排相M线及提肛相内括约肌厚度均大于对照组,差异均有统计学意义(P0.05)。LARS患者术后动态MRI测得三时相上的肛直角均大于术前,而耻骨直肠肌及外括约肌厚度均小于术前,差异均有统计学意义(P0.05)。(3)LARS患者术前排粪造影测得提肛相肛直角和力排相肛上距的均值均超出了正常值参考范围。LARS患者术前动态MRI与排粪造影比较,三时相上肛直角间差异均无统计学意义(P0.05),M线与肛上距间无明显相关性(P0.05)。(4)LARS患者术前3D HR-ARM测得肛门最大静息压、肛门平均静息压、高压带长度、肛门最大收缩压均大于正常参考值;直肠压力、直肠肛管压力差、初始排便阈值、最大耐受阈值均小于正常参考值,差异均有统计学意义(P0.05);直肠肛门抑制反射(15.79±10.17cc)小于40cc,在正常范围内。LARS患者术后3D HR-ARM测得肛管松弛率、初始感觉阈值、初始排便阈值、最大耐受阈值均小于正常参考值,差异均有统计学意义(P0.05);直肠肛门抑制反射(13.68±6.84cc)小于40cc,亦在正常范围内。(5)LARS患者术后3D HR-ARM测得肛门最大静息压、肛门平均静息压、高压带长度、肛门最大收缩压、初始感觉阈值、初始排便阈值及最大耐受阈值均小于术前,而直肠压力、直肠肛管压力差均大于术前,差异均有统计学意义(P0.01)。(6)术前动态MRI与3D HR-ARM相关性分析:肿瘤-齿线距离与最大耐受阈值呈负相关(r=-0.606),提肛时肛直角与肛门最大静息压及肛门最大收缩压均呈负相关(r=-0.722,r=-0.616),提肛时H线与肛门最大收缩压呈负相关(r=-0.620),提肛时M线与初始感觉阈值及初始排便阈值均呈负相关(r=-0.545,r=-0.803),提肛时耻骨直肠肌厚度与初始排便阈值呈正相关(r=0.794),提肛时外括约肌厚度与肛管松弛率呈负相关(r=-0.609)(P值均0.05)。(7)术后动态MRI与3D HR-ARM相关性分析:提肛时M线与初始排便阈值呈正相关(r=0.727),提肛时耻骨直肠肌厚度与高压带长度呈正相关(r=0.738),提肛时内括约肌厚度与高压带长度及直肠肛管压力差均呈负相关(r=-0.680,r=-0.729)(P值均0.01)。结论(1)盆腔动态MRI检查的准确率高,与直肠指诊及结肠镜检查一致性较好,可为低位直肠癌术前评估和术后肛门直肠功能恢复情况的评价提供全面、量化、可重复性强的影像学依据。(2)动态MRI检查与X线排粪造影检查的一致性较好,可弥补X线排粪造影软组织分辨率低的缺点,为评价肛门直肠功能提供了一种更加安全、便捷的影像学方法。(3)动态MRI及3D HR-ARM检查均发现LARS患者术前控便能力尚好,但已存在盆底松弛、直肠感觉功能降低的表现,且术后耻骨直肠肌和肛门括约肌收缩功能明显降低,直肠感觉功能减弱明显加重,说明术中尽可能避免上述肌肉损伤,术后尽早加强病变肌群功能恢复治疗对LARS患者尤为重要。(4)动态MRI检查技术不仅可直观反映肛门直肠的动态变化,其量化指标还与3D HR-ARM检查存在显著的相关性,为评价肛门直肠功能提供了一种更加有效、经济、便捷、可视化的影像学诊断的新思路。
[Abstract]:Objective to use the pelvic dynamic MR imaging technique and defecography, combined with the 3D anorectal pressure (3D HR-ARM), to provide a comprehensive, intuitive, noninvasive, reproducible pre academic assessment for low rectal cancer patients who are in the operation of the anus preserving operation, and to analyze the low position anterior resection syndrome (L) from the morphological and dynamic analysis of the patients after the operation (L The mechanism of ARS) to analyze the correlation between the imaging characteristics of LARS and the changes of anorectal dynamics, and to provide a comprehensive, intuitive, convenient and economical imaging examination technique for the establishment of a suitable treatment scheme. Materials and methods were collected from Tianjin People's Hospital in the Department of anus & intestine surgery from April 2016 to January 2017 and were diagnosed as low rectal cancer and were expected to have anus preserving. A total of 42 patients were treated with surgical treatment. All patients underwent rectal examination, colonoscopy, pelvic routine and dynamic MRI, defecography and 3D HR-ARM examination. After one week after examination, surgical resection was performed and pathological examination was performed after three months of operation. A total of 20 patients with LARS after the anus operation were collected and included in the case group. The pelvic routine and the dynamic MRI and 3D HR-ARM examinations were re examined. 20 healthy adult volunteers were collected in the control group and all the pelvic routine and dynamic MRI examinations were performed. Another 110 asymptomatic volunteers were collected from the 3D HR-ARM examination data. The image results of the preoperative pelvic MRI examination were compared with the rectal examination, colonoscopy and pathological results. ICC analysis and Kappa test were used to compare the consistency and correlation between pelvic MRI and the other three kinds of tests, and the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of pelvic MRI were calculated by chi square test. The normal linear model (GLM) single variable analysis was used to compare the pre operation of the healthy control group and the case group. The difference between the measurement indexes of the item. The difference between preoperative defecography and pelvic dynamic MRI was analyzed by paired T test. The difference between the preoperative and postoperative measurement indexes of the case group was compared. The correlation between the dynamic MRI and 3D HR-ARM two kinds of observation indexes was compared with the Pearson correlation analysis. Fruit (1) pelvic cavity MRI examination on the lower margin of the tumor and the margin of the anal margin The measured results, the consistency with the rectal examination and colonoscopy was better (R=0.721, P0.01). The results of the proportion of the peri intestinal tumor were moderate (Kappa=0.661, P0.01). The overall accuracy rate of the 83.33%. pelvic MRI examination was higher in the T, N staging, and the overall accuracy rate was 8, respectively. 8.10% and 85.71% were in good agreement with the pathological results (Kappa=0.729, P0.01; Kappa=0.743, P0.01). (2) the M line of resting phase and force phase and the thickness of the internal sphincter in the anus phase were greater in LARS patients than in the control group. The difference was statistically significant (P0.05) in patients with postoperative dynamic MRI, the anal right angle in the three phase was greater than that before the operation. The thickness of the pubis rectum and the external sphincter were all lower than that before the operation (P0.05). (3) the mean value of the anus anus right angle and the force row anus distance measured by the defecography before operation in LARS patients were all beyond the normal reference range of the reference range of.LARS patients, and the dynamic MRI was compared with the defecography, and there was no statistical difference between the anus right angle and the anus in the phase of the patients. (P0.05), there was no significant correlation between the M line and the supra anal distance (P0.05). (4) the maximal resting pressure of the anus, the mean resting pressure of the anus, the length of the high pressure zone and the maximum pressure of the anus were all greater than the normal reference value before the operation of LARS, and the rectal pressure, the poor rectal pressure, the threshold of initial defecation, and the maximum tolerance threshold were less than the normal reference value. The difference was statistically significant (P0.05); anorectal reflex (15.79 + 10.17cc) was less than 40CC, and the anal canal relaxation rate was measured by 3D HR-ARM in the normal range of.LARS patients. Initial sensory threshold, initial defecation threshold, maximum tolerance threshold were less than normal reference values, and the difference was statistically significant (P0.05); anorectal reflex reflex (13.68) 6.84cc) was less than 40CC and was in the normal range. (5) the maximum anal resting pressure of the anus, the average resting pressure of the anus, the length of the anus, the maximum contractile pressure of the anus, the initial sensory threshold, the threshold of the initial defecation and the maximum tolerance threshold were lower than those before the operation, and the difference of the rectal pressure and the rectal anus pressure difference were all greater than those before the LARS. Statistical significance (P0.01). (6) the correlation analysis between the dynamic MRI and 3D HR-ARM before operation: the tumor tooth line distance was negatively correlated with the maximum tolerance threshold (r=-0.606). The anal right angle in the anus was negatively correlated with the maximum anus resting pressure and the maximum anus systolic pressure (r=-0.722, r=-0.616), and the H line was negatively correlated with the maximum contractile pressure of the anus (r=-0.620) and anus anus during the anus. The M line was negatively correlated with the initial sensory threshold and initial defecation threshold (r=-0.545, r=-0.803). The thickness of the pubis rectum was positively correlated with the threshold of the initial defecation (r=0.794). The thickness of the external sphincter was negatively correlated with the anal canal relaxation (r=-0.609) (P 0.05). (7) the correlation analysis of the dynamic MRI and 3D HR-ARM after the operation: M line in the anus. There was a positive correlation with the threshold of the initial defecation (r=0.727). The thickness of the pubis rectum was positively correlated with the length of the high pressure band (r=0.738). The thickness of the internal sphincter was negatively correlated with the length of the high pressure band and the anorectal pressure difference (r=-0.680, r=-0.729). (1) the accuracy of the pelvic dynamic MRI examination was high, with the rectal finger diagnosis and the knot. The conformance of enteroscopy is good. It can provide a comprehensive, quantitative and reproducible imaging basis for preoperative evaluation of low rectal cancer and postoperative recovery of anorectal function. (2) the consistency of the dynamic MRI examination and X-ray defecography is better, which can make up the shortcomings of the low resolution of the soft tissue of the X-ray defecography, and to evaluate the anus straight. Intestinal function provides a more safe and convenient imaging method. (3) dynamic MRI and 3D HR-ARM examination showed that the ability of LARS patients to control stool before operation was still good, but there was a lower pelvic floor relaxation, lower rectal sensory function, and the postoperative contractile function of the pubis and anal sphincter decreased and the rectal sensory function weakened obviously. It is very important to avoid the above muscle injury during the operation as much as possible. It is very important for LARS patients to strengthen the functional recovery therapy at the early stage after operation. (4) dynamic MRI examination can not only directly reflect the dynamic changes of anus and rectum, but also have a significant correlation with 3D HR-ARM examination, which provides a better evaluation of anorectal function. Add effective, economical, convenient, and visualized new ideas for imaging diagnosis.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.37;R445.2

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