计算机三维成像技术在肝静脉解剖变异方面的研究应用

发布时间：2018-08-03 07:03

【摘要】：背景伴随着科学技术的发展,特别是影像学技术的成熟,外科学特别是肝胆外科的发展进入了全新的数字时代,也为“精准外科”时代的来临提供了支持。具体来说,优质的影像学技术为肝胆外科医师在进行活体肝移植,离体肝切除自体肝移植等高难度手术时提供了更深一步的解剖依据和数据基础。近年来,基于解剖学和2D/3D影像学技术的发展,越来越多的外科医师们认识到了肝脏三维立体层面与二维之间的解剖学特异性和差异性,尤其是在第一肝门血管和胆管方面的变异对手术的设计和操作的影响。这些认识改变一些传统手术操作的理念,也增加了更多患者手术的可能性。然而,由于肝脏解剖与其它脏器的差异上,肝脏的出肝血流,如第二肝门和第三肝门的肝静脉系统也存在着解剖学差异性和特异性,三维重建技术不仅能更为精确的分析各型肝静脉的走形,引流区域,还能更好为手术的设计和操作提供帮助,最终使患者受益。鉴于目前这样的文献资料尚不全面,本实验就此类问题经行全面的研究和探讨。目的结合三维影像学技术,展开对肝脏静脉系统的解剖变异,以及其具有的外科学意义进行全面的回顾性研究并与传统的肝静脉分型进行对比,探讨肝静脉损伤后对肝脏的影响。方法连续性回顾98例病灶对静脉系统无影响的患者的MSCT资料，，以IQQA-Liver软件对肝静脉系统经行3D重建,结合2D资料进行观察,分析其特征以及引流区域的规律。结果在纳入研究的98例患者当中,男性46例,女性52例,平均55.33±11.32岁。所有患者均无明显肝硬化,或肝内胆管扩张和巨大肿瘤病灶等影响静脉走形的疾病。患者肝脏的平均体积为1272.65±322.04 ml,其中三支主要肝静脉的引流体积占总体积的百分比分别为肝右静脉35.58±12.41%(443.51±190.27m1),肝中静脉34.64±8.76%(445.53±173.71 m1)和最少的肝左静脉21.13±5.41%(266.89±94.51 m1)。在第二肝门处约有52%的患者肝左静脉与肝中静脉汇合成一支长约12.54±4.29mm的共干后进入肝后下腔静脉,剩余的48%患者的三支主要肝静脉则分别汇入腔静脉,未形成明显共干。除了经典分型中三支主要肝静脉以外,约43名患者拥有1支或更多的肝右后静脉,变异率为43.9%。依据Nakamura和Tsuzuki的分型,Ⅰ型(无明显肝右后静脉),Ⅱ型(有明显肝右后静脉,但直径小于肝右静脉主干)和Ⅲ型(肝右后静脉直径大于肝右静脉主干的)的出现率分别为56.1%,36.7%和7.1%。肝右后静脉的平均直径为4.65±1.14 mm,引流肝脏体积为179.27+128.79 ml(21.20-618.20 m1)占肝脏总体积的14.0±9.18%。其直径的大小与引流体积呈明显相关趋势(y=80.388x-194.268,r=0.709,p0.01)。并且伴随着右后静脉的发育程度(由Ⅰ型向Ⅲ型递增),肝右静脉的引流区域呈递减趋势。根据研究结果,98名患者的肝中静脉依据解剖学特征可分成经典主干拥有双分叉(A型),主干及单分叉型(B型),双主干型(C型)和主干无明显分叉型(D型)及,出现率分别为61.2%,24.5%,7.1%和7.1%。肝左静脉同样可以分为4型,单一主干型(A型,55.1%),双主干型(B型,23.5%),无明显分支型(C型,12.2%)和辐射型/无明显主干型(D型,10.2%)。除了三支肝脏主要静脉和肝右后静脉外,研究发现大多数患者还存在一些特殊肝静脉的解剖差异型。例如15.3%的患者存在着独立的第4段回流静脉,引流肝脏体积可达到139.49±52.51 ml，占全肝的9.84±2.53%。约76.5%的患者存在明显的脐裂静脉,而75.5%的患者存在着前裂静脉,两者在肝内呈对称形态。78.6%的病例有明显的左右侧浅静脉。22.4%的患者CT在重建后可见明显的尾状叶引流静脉。结论在基于传统二维影像学和尸体解剖学方面的认识对比下,肝静脉的变异率较门静脉系统更高,肝右后静脉的出现会明显影响肝右静脉的引流体积及手术中对静脉取舍的设计。部分病例中存在相对独立的4段肝静脉支,并引流相当量的肝脏体积。肝中和肝左静脉分型中的部分特殊类型,以及前裂和脐裂静脉的出现对术前及术中的手术操作具有明确的定位指导意义。而3D技术在立体解剖学方面的优势可以更好的在复杂手术前提供重要依据。故在常规手术前,应常规应用三维影像学技术,进而规避静脉损伤给患者带来的损害,而当同一肝叶内存在多条肝静脉时则可以降低术后静脉淤血的可能,减少肝脏衰竭的风险,为更多常规不可能完成的手术提供新的设计方案。
[Abstract]:With the development of science and technology, especially the maturation of imaging technology, the development of surgery, especially in the Department of hepatobiliary surgery, has entered a new digital age. It also provides support for the advent of the "precision surgery" era. Specifically, high quality imaging techniques are for living liver transplantation and isolated hepatectomy for physicians in Department of hepatobiliary surgery. In recent years, more and more surgeons have recognized the anatomical specificity and difference between the three-dimensional and the two-dimensional liver, especially in the first hepatic portal blood vessels and bile ducts, based on the development of anatomy and 2D/3D imaging technology. The effects of variation on the design and operation of the operation. These ideas change the concept of some traditional operations and increase the possibility of more patients. However, the hepatic blood flow, such as the second hepatic portal and the hepatic portal system of the third hilum, has an anatomical difference, as the liver anatomy is different from other organs. The three-dimensional reconstruction technique can not only analyze the shape of the hepatic veins more accurately, but also provide the help for the design and operation of the operation, and finally benefit the patient. The anatomical variations of the hepatic venous system, as well as the surgical significance of the hepatic vein, were reviewed and compared with the traditional hepatic vein classification, and the effects of hepatic vein injury on the liver were investigated. Methods the MSCT data of 98 patients with no influence on the venous system were reviewed, and IQQA-Liver The software was used to observe the 3D reconstruction of the hepatic vein system and the 2D data, and analyze its characteristics and the law of the drainage area. Among the 98 patients who were included in the study, 46 males and 52 females, with an average of 55.33 + 11.32 years, all had no obvious cirrhosis, or the hepatic biliary Guan Kuozhang and the huge tumor lesions affected the venous form. The average volume of the liver was 1272.65 + 322.04 ml, and the percentage of the total volume of the drainage volume of the three main hepatic veins was 35.58 + 12.41% (443.51 + 190.27m1) of the right hepatic vein, 34.64 + 8.76% (445.53 + 173.71 M1) of the middle hepatic vein and the least left hepatic vein 21.13 + 5.41% (266.89 + M1). In% of the patients, the left hepatic vein and the middle hepatic vein were used to synthesize a total of about 12.54 + 4.29mm of the hepatic vein into the posterior inferior vena cava. The remaining three main hepatic veins of the remaining 48% patients were remitted to the vena cava, and there was no obvious common dry. In addition to the three main hepatic veins, about 43 patients had 1 or more right posterior hepatic veins in the classical classification. The rate of variation was 43.9%. based on the typing of Nakamura and Tsuzuki, type I (no obvious right posterior vein of the liver), type II (with obvious right posterior hepatic vein, but smaller than the trunk of the right hepatic vein) and type III (the diameter of the right posterior hepatic vein larger than the right trunk of the liver) was 56.1%, and the average diameter of the right posterior vein of the liver was 4.65 + 1.14 mm, 36.7% and 7.1%., respectively. The volume of the drainage liver is 179.27+128.79 ml (21.20-618.20 M1), which accounts for 14 + 9.18%. of the total liver volume. The diameter of the liver is significantly related to the volume of the drainage volume (y=80.388x-194.268, r=0.709, P0.01). And with the development of the right posterior vein (from type I to type III), the drainage area of the right hepatic vein is decreasing. Results of the 98 patients, the hepatic veins were divided into two branches (A type), trunk and single bifurcation type (B type), double trunk type (C type) and trunk no obvious bifurcation type (D type), and the incidence rate was 61.2%, 24.5%, 7.1% and 7.1%., respectively, 4 type, single trunk type (A type, 55.1%), double trunk type (B). Type, 23.5%), no obvious branching (type C, 12.2%) and radiated / unobvious trunk type (D type, 10.2%). In addition to three main hepatic veins and right posterior hepatic veins, the study found that most patients also have some special hepatic veins dissection. For example, 15.3% of patients have independent fourth reflux veins, and the volume of drainage liver can reach 1. 39.49 + 52.51 ml, accounting for 9.84 + 2.53%. about 76.5% of the whole liver, there were obvious cleft veins in the patients, and 75.5% of the patients had the anterior fissure veins. The two cases with symmetrical.78.6% in the liver were obviously.22.4% in the left and right lateral veins, and CT was visible after the reconstruction of the caudate lobe. In comparison with the cognitive and autopsy anatomy, the variation rate of the hepatic vein is higher than that of the portal vein system. The appearance of the right posterior hepatic vein obviously affects the drainage volume of the right hepatic vein and the design of the venous withdrawal during the operation. In some cases, there are relatively independent 4 segments of the hepatic vein, and the volume of the liver is drained. Some special types of venous typing, as well as the appearance of the anterior and umbilical fissure veins have a definite orientation for preoperative and intraoperative operation, and the advantages of 3D technique in stereoscopic anatomy can provide an important basis for the complicated surgery. While avoiding the damage caused by venous injury, the presence of multiple hepatic veins in the same liver can reduce the possibility of postoperative venous congestion, reduce the risk of liver failure, and provide a new design for more routinely uncompleted operations.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R322.47;R657.3

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