肝右叶体积测量及肝裂定位的临床解剖学研究

发布时间：2018-06-23 01:43

  本文选题：肝段 + 体积测量　； 参考：《大连医科大学》2015年博士论文

【摘要】：随着精准医疗和个体化医疗理念的提出和临床医疗技术的不断进步,精准肝医疗也日益受到重视。基于肝段解剖的精准肝切除、确保残余肝脏解剖结构的完整和功能性体积的最大化是当今的研究热点。术前肝叶、段体积的测量评估是肝临床的迫切需求。在临床上,CT和MRI检查是肝脏体积测量应用最广泛的手段,有研究表明CT、MRI等测量结果与肝脏体积偏差不大。但是临床工作中仍然发现,这种测量结果与手术过程中的实际情况存在偏差。同时,越来越多的学者对Couinaud肝段法提出质疑,其中肝段定位误差比例最高、偏差距离最大的均在肝右叶。以往对肝段影像学定位误差的相关研究多集中在误差的大小以及是否符合Couinaud肝段法上。但是对于划分误差出现的原因并没有进行深入研究。而随着肝右后叶作为移植物进行肝移植及精准肝切除术的开展,对肝右叶间裂的空间形态及偏斜情况的准确描述不断提出新要求。为探寻肝脏体积测量与临床所见不符出现的原因、描述右叶间裂的空间形态,本研究采用肝脏分段分色灌注联合生物塑化断层技术、CT扫描技术、Photoshop CS5及AutoCAD等软件,对肝脏切片标本采用影像学分界和真实分界两种分界法的进行肝段的面积测量,计算右前叶、右后叶体积并进行对比研究;采用数据分析法深入探寻影像学差异出现的原因。为了更好的显示肝脏右叶各段的形态及右叶间裂的走行,本研究使用MIMICS软件建立肝右叶各段及右叶间裂的立体可视化模型,对肝右叶间裂的形态进行观察。此外,为进一步指导临床对右叶间裂的观察,本研究还对临床肝脏CT图像进行回顾性研究,采用MIP及VR重建方法观察右叶间裂形态,优化右叶间裂的影像学观察方法。所得结果将提高肝右叶疾病定位精确性,为临床右叶间裂、肝段定位诊断及精准肝段切除、肝段移植提供更可靠的形态学依据及数据参考。第一部分材料及方法:采用分段分色灌注方法及生物塑化切片技术制作5例肝脏分段分色灌注切片并逐层拍照。使用Photoshop CS5及Adobe Illustrator CS5软件将肝脏切片逐层配准并标记影像学分界,将图像导入AutoCAD软件测量肝脏切片上以影像学分界及不同颜色显示的肝段真实解剖分界测量右前叶及右后叶的各层面积,并计算各叶体积,将所得数据使用Spss 13.0软件进行统计分析,比较影像学分界法与真实解剖分界间存在的差异。结果:1.使用影像学标志和解剖学标志测量所得肝右叶体积分别为737.15± 220.30 cm~3和705.27±178.82cm~3。采用影像分界、真实解剖分界测得肝右前叶体积平均值分别为412.86±99.68cm~3和417.41 ±138.19cm~3,肝后叶体积平均值分别为325.14± 136.78cm~3 和 289.32±89.71cm~3。2.在肝脏分段灌注切片标本上采用影像学标志及真实解剖标志两种划分方法测量肝脏右前叶及右后叶体积无明显统计学差异。第二部分在第一部分的测量过程中观察到,依据两种不同的划分方法定位各层面的右前叶、右后叶时存在明显视觉偏差,而统计学结果却显示两种方法测量的体积无明显差异,为进一步寻找出现这样相悖结果的原因,本研究继续对之前所得数据进行深入分析。材料及方法:将肝脏切片AutoCAD测量所得的影像分界、真实分界两组数据逐层进行计算,得到各层面肝右前叶、右后叶的划分面积测量误差值(S误差)及误差率(Error rate,ER)。将各层影像划分错误率[(影像面积一真实面积)绝对值/影像面积]%为纵坐标,以肝脏切片层面为横坐标,获得得右前叶和右后叶的各层肝叶面积测量错误率曲线。并进一步进行逐层比较,将偏差值[影像面积一真实面积]作为纵坐标,肝脏切片层面为横坐标,获得肝叶面积测量偏差曲线。结果:1.右前叶所得面积偏差值曲线为前正后负的正弦曲线,而右后叶所得面积偏差值曲线正好相反为前负后正。由此可见在头侧层面更多的右前叶被划分入右后叶,导致右前叶偏小而右后叶偏大,而尾侧层面更多的右后叶被划入右前叶,最大偏差可达40cm~2。2.右前叶、右后叶错误率曲线均呈U形或V型,说明右前叶与右后叶划分在头侧层面和尾侧层面错误率均明显高于中间层面;第一部分及第二部分结论:1.肝脏分段分色切片标本是显示肝段、肝叶分界及测量解剖学体积的有效方法。2.影像学标志确定的肝右叶间裂对右前叶、右后叶进行划分,在头侧层面将使部分属于右前叶的Ⅷ段被划入右后叶的Ⅷ段,从而导致Ⅷ段体积偏小,Ⅶ段体积偏大;在尾侧层面将使部分属于右后叶的Ⅶ段被划入右前叶的Ⅴ段,从而导致Ⅵ段体积偏小,Ⅴ段体积偏大。3.右前叶或右后叶的体积测量由于头侧与尾侧的偏差相互抵消而显示出按照影像学标志测量肝叶体积准确性高。这是看不出以影像学标志对肝叶体积进行测量存在误差的原因。4.影像学标志定位肝右叶间裂在中间层面准确,在肝脏头侧和尾侧层面偏差大。第三部分在这部分研究中,通过三维重建方法对右叶肝段、肝裂进行显示和观察。材料与方法:本研究采用Adobe Photoshop CS5软件,将分段分色灌注的肝脏切片标本上以不同颜色显示的各肝段真实边界进行分割,这种肝脏切片标本在各层面上对于肝段的划分完全依据血管内灌注剂颜色不同而区分出的分界,是最真实可靠的肝段分界。将此肝脏图像导入MIMICS软件后对其进行三维重建,肝段间真实分界进行充分展示,对右叶间裂空间形态进行描述。结果:1.在MIMICS软件显示的断层图像中,右叶间裂在膈顶部未出现,随着图像向肝脏尾侧层面移动,右叶间裂逐渐出现,并且头侧层面靠后,尾侧层面靠前。头侧层面的右叶间裂与冠状面近似平行,至尾侧层面右叶间裂开始逐渐偏转成一斜面,与冠状面间出现明显夹角。2.使用MIMICS软件可以对肝脏分段分色灌注的切片标本进行肝段三维重建。然后加以组合显示,可清晰显示各段间比邻关系。3.右前叶与右后叶并非简单的前后,而是前上与后下的位置关系。并且,通过调整三维重建图像方位对右叶间裂进行观察发现,右叶间裂由后上向前下倾斜走行,该裂隙内部右前叶与右后叶间有很多凸凹处相互镶嵌。但是其并非是简单斜行平面,而是在向下走行的过程中不断外旋的曲面,其与正中矢状面的夹角不断增大。第四部分从前三部分研究可知,肝脏右叶间裂影像学定位的偏差对于测量肝脏体积的数值影响不大,但是对肝段归属的判断在肝脏头侧和尾侧层面误差显著。且在MIMICS重建中可见肝脏右叶间裂为一斜行扭转层面,因此临床影像学观察肝脏右叶间裂并定位肝脏右前叶、右后叶的方法仍有待改进。材料和方法:本课题对25例无肝脏疾病的CT肝脏增强图像进行回顾性研究,采用美国GE公司64排128层螺旋CT的ADW4.4后处理工作站进行图像重建及测量分析。采用影像学轴位图像、最大密度投影法(MIP)和容积重建(VR)方法对肝脏右叶血管分支进行重建。在轴位使用MIP法重建门脉分支,对应VR重建图像上门脉分支位置,调整图像重建层厚及重建层面,显示对应肝裂所在层面最清晰的图像,使用螺旋CT角度测量工具进行测量寻找右叶间裂最佳观察方法。结果:1.轴位观察测量采用影像学标志定位方法测量得到正中裂较矢状面偏右平均为51°,该方法观察正中裂与胆囊窝中点吻合度较高;而采用MIP法测量正中裂矢状面偏右平均为48°,在肝脏下缘观察肝正中裂88%与胆囊窝中点吻合。采用影像学标志定位方法测量,肝右叶间裂与矢状面夹角平均为97.8°;采用MIP法测量轴位CT图像测量,肝右叶间裂与矢状面夹角平均为116.5°,二者存在明显差异。但在轴位图像上有时不能同时显示右前支和右后支分叉及其分支所在位置,如果增厚重建层厚,则门静脉右前叶分支与右后叶分支之间存在较大交叉。2.矢状位观察测量但右前叶、右后叶门静脉分支间可见存在一明显的乏血管区,即为右叶间裂,右前叶、右后叶分支分别列于该裂隙两侧,该裂隙头侧偏后,尾侧偏前,与垂直轴冠状面之间的夹角为2.6 °～58.4 °,平均为32.97 °± 15.51°。当肝右叶间裂与垂直轴夹角较大时,膈顶部位全部为右前叶Ⅷ段,而尾侧部位全部为右后叶Ⅵ亚段。此时右前叶与右后叶为前上与后下的位置关系。而当肝右叶间裂接近冠状位时,右前叶与右后叶近似前后的位置关系。3.CT图像上每降低一层(扫描层厚)肝右叶间裂向前移动距离D=cot a×扫描层厚mm。第三部分及第四部分结论1.肝右叶间裂在CT图像MIP矢状位重建图像上观察最佳;2.右叶间裂为一由后上向前下走行的斜裂,且为一逐渐扭转的斜面。3.根据肝右叶间裂在矢状面上的倾斜角度,可可以指导临床在无明显影像标志的CT图像层面对右叶间裂进行定位。4.当肝右叶间裂与垂直轴夹角较大时,右前叶与右后叶为前上与后下的关系;而当肝右叶间裂接近冠状位时,右前叶与右后叶近似前后关系。
[Abstract]:With the development of precision medical and individualized medical ideas and the continuous progress of clinical medical technology, precision liver medicine is becoming more and more important. Accurate liver resection based on segmental anatomy to ensure the complete and functional volume of residual liver anatomy is the hot spot of research. The preoperative liver leaf, segment volume measurement evaluation is the liver In clinical practice, CT and MRI are the most widely used methods for the measurement of liver volume. Studies have shown that the results of CT, MRI and other measurements have little deviation from the liver volume. However, in clinical work, it is still found that this measurement results from the actual situation in the operation process. At the same time, more and more scholars are on the liver of Couinaud. The location error of the hepatic segment is the highest and the maximum deviation is in the right lobe of the liver. Previous studies on the location error of the hepatic segment imaging are mostly focused on the size of the error and whether it conforms to the Couinaud liver segment method. However, there is no in-depth study on the reasons for the division of the error, but the right posterior lobe of the liver is with the right lobe. As a transplant for liver transplantation and accurate hepatectomy, new requirements have been put forward for the accurate description of the spatial morphology and deviation of the right interlobar fissure of the liver. In order to explore the reasons for the difference between the measurement of liver volume and the clinical findings, the spatial morphology of the right interleaf fissure is described. This study uses segmented color perfusion of the liver combined with bioplasticity. CT scanning, Photoshop CS5 and AutoCAD software were used to measure the area of liver segments by two kinds of demarcation and demarcation. The right anterior lobe and right posterior lobe volume were calculated and compared. In this study, MIMICS software was used to establish the stereoscopic visual model of the right lobe and right lobes in the right lobe of the liver, and to observe the shape of the right lobe fissure of the liver. In addition, in order to further guide the observation of the right interleaf cleft in the right lobe, a retrospective study of the CT image of the liver was carried out in this study. MIP and VR reconstruction methods were used to observe the morphology of right lobe fissure and optimize the imaging method of right lobe fissure. The results will improve the accuracy of right lobe disease location, the clinical right lobe fissure, liver segment location diagnosis and precise liver segment resection, liver segment transplantation provide more reliable morphological basis and data reference. The first part materials and methods: 5 cases of liver segmented color segmentation were made and photographed by sectional color perfusion method and bioplastic slice technique. The liver slices were registered and marked by Photoshop CS5 and Adobe Illustrator CS5 software. The images were introduced into AutoCAD software to measure the boundary of image and different colors. The area of the right anterior lobe and right posterior lobe was measured by the real dissection of the hepatic segment, and the volume of each leaf was calculated. The data were analyzed by Spss 13 software, and the difference between the image academic division method and the real dissection was compared. Results: 1. the right lobe volume of the liver was 7 by using imaging markers and anatomical markers, respectively. The images of 37.15 + 220.30 cm~3 and 705.27 + 178.82cm~3. were demarcated. The mean value of the right anterior lobe of the liver was 412.86 + 99.68cm~3 and 417.41 + 138.19cm~3, respectively. The mean value of the volume of the posterior lobe of the liver was 325.14 + 136.78cm~3 and 289.32 + 89.71cm~3.2. respectively. There was no significant difference in the volume of the right anterior lobe and right posterior lobe of the liver. The second part observed the right anterior lobe at all levels in the first part of the measurement of the right anterior lobe and the right posterior lobe in the first part of the measurement. There was a significant difference between the right anterior lobe and the right posterior lobe, while the statistical results showed that the two methods measured the two methods. There is no obvious difference in volume. In order to further find the reasons for such a contrary result, this study continues to analyze the previous data. Materials and methods: the image demarcation of the liver slice AutoCAD measurement, the real dividing two sets of data by layer by layer, the right anterior lobe of the liver and the right posterior leaf area measurement are measured. Error rate (S error) and error rate (Error rate, ER). The error rate [(a real area of image area) absolute value / image area of each layer is as ordinate, and the liver slice level is a horizontal coordinate, and the error rate curve of the liver leaf area of the right anterior and right posterior leaves is measured. As a real area of area] as a vertical coordinate, the liver slice layer is a horizontal coordinate, and the deviation curve of the liver leaf area measurement is obtained. Results: the curve of the area deviation value of the 1. right anterior lobe is the sine curve of the front and back negative, and the curve of the area deviation value of the right posterior lobe is just opposite to the front negative. The right anterior lobe was divided into the right posterior lobe, causing the right anterior lobe to be small and the right posterior lobe larger, and more right posterior lobe of the tail side was inserted into the right anterior lobe, the maximum deviation could reach 40cm~2.2. right anterior lobe, and the error rate curve of the right posterior lobe was U or V. The error rate of the right anterior lobe and right posterior lobe was significantly higher than the middle level; first, the error rate was higher than the middle level; first, the error rate was higher than the middle level; first, the error rate was higher than the middle level; first Part two and part two: 1. the segmented slice specimen of liver is an effective method to display the hepatic segment, the boundary of the hepatic lobe and the measurement of the anatomical volume. The right anterior lobe, the right posterior lobe is divided into the right lobe, and the VIII segment belonging to the right anterior lobe will be divided into the VIII in the right posterior lobe at the head and side level, which leads to the VIII. The volume of the segment is small and the Volume VII is large, and the VII section of the right posterior lobe will be divided into the V section of the right anterior lobe at the tail side, which leads to the small volume of the section VI. The volume of the V section of the.3. right anterior or right posterior lobe is measured by the offset of the deviation between the head and the tail side, which shows the measurement of the volume of the hepatic lobe according to the imaging signs. This is the reason why there is no error in the measurement of the volume of the hepatic lobe with the imaging signs. The.4. imaging sign is accurate in the middle level of the right lobe of the liver, and there is a large deviation between the head side and the tail side of the liver. In this part, the right lobe liver segment and the liver fissure are displayed and observed in the third part of the study. Materials and methods: This study uses the Adobe Photoshop CS5 software to divide the segmented liver slices on the true boundaries of the liver segments displayed in different colors. The liver segments are divided completely on the liver segments on the various levels according to the different color of intravascular perfusion agents. It is the most authentic and reliable. The liver segment was divided. After the liver image was introduced into MIMICS software, three-dimensional reconstruction was carried out, and the true boundary between the segments of the liver was fully demonstrated and the spatial morphology of the right interleaf fissure was described. Results: 1. in the fault images shown by the MIMICS software, the right interleaf fissure did not appear on the top of the diaphragm, and as the image moved to the tail side of the liver, the right interleaf fissure was separated. The right lateral cleft in the head and side is approximately parallel to the coronal plane, and the right interleaf cleft in the tail side is gradually deflected into an oblique plane, and the obvious angle between the caudal plane and the coronal plane,.2., can be used to reconstruct the segment of the liver segment by MIMICS software. In combination, it can clearly show that the right anterior lobe and right posterior lobe are not simple before and after the adjacent relationship.3., but the relationship between the front and the upper and the lower, and the right interleaf cleft is observed by adjusting the azimuth of the three-dimensional reconstruction image, and the right interleaf cleft is leaning from the back to the forward and forward, and the right anterior lobe and the right posterior lobe in the fracture are between the right and right lobes. There are a lot of convex and concave places inlaid each other. But it is not a simple oblique plane, but a curved surface in the course of walking downward. The angle between the median sagittal plane is increasing. The fourth part of the previous three studies shows that the deviation of the imaging location of the right interleaf fissure in the liver has little effect on the measurement of the volume of the liver, but The judgment of the hepatic segment belonged to the head side and the tail side of the liver was significant. And in the MIMICS reconstruction, the right interlobe fissure of the liver was seen as a oblique line. Therefore, the clinical imaging observation of the right lobe of the liver and the right anterior lobe of the liver and the right posterior lobe still need to be improved. Materials and methods: this subject has 25 cases of CT without liver disease. A retrospective study of liver enhancement images was made by using the ADW4.4 post processing workstation of 64 rows of 128 slice spiral CT in the United States GE company for image reconstruction and measurement. The image branch image, the maximum density projection (MIP) and the volume reconstruction (VR) method were used to reconstruct the branches of the right lobe of the liver. The axis position was reconstructed by MIP method. The position of the VR reconstruction image is rebuilt, the image reconstruction layer thickness and the reconstruction level are adjusted to show the most clear image at the level of the liver fissure, and the best observation method of finding the right interleaf fissure with the spiral CT angle measurement tool is used. Results: the 1. axis observation measurement uses the imaging sign positioning method to measure the median fissure sagittal. The mean deviation between the right and right sides was 51 degrees. This method observed that the median fissure of the median and the middle of the gallbladder fossa was higher, while the median of the median split sagittal plane was 48 degrees on the right, and 88% of the median liver fissure was observed at the middle of the lower edge of the liver with the middle of the gallbladder fossa. The average angle between the right lobe and the sagittal plane was 97.8 degrees by using the image marker positioning method. The average angle of the right lobe of the liver and the sagittal plane was measured by the MIP method. The MIP method was used to measure the axial CT image. The average angle between the right lobe and the sagittal plane was 116.5 degrees, and there was a significant difference between the two. But the right anterior and right posterior branches and its branches were not displayed at the same time on the axial image. If the thickened reconstructive layer was thickened, there was a large cross between the right anterior and right posterior branches of the portal vein. .2. sagittal observation and measurement but right anterior lobe, there is a clear vascular area between the branches of the right posterior portal vein, that is, right interleaf fissure, right anterior lobe and right posterior lobe on both sides of the fissure. The fissure is behind the head side, the tail side is before the side, and the angle between the caudal side is 2.6 to 58.4 degrees, and the average is 32.97? 15.51 degrees. The right anterior lobe was all right anterior lobe VIII while the right anterior lobe VIII was all of the right anterior lobe, while the right anterior lobe and right posterior lobe were the relationship between the upper and the lower parts, while the right anterior lobe was close to the coronal position when the right lobe was close to the coronal position, and the position of the right anterior lobe and the right posterior lobe was similar to the.3.CT image. Scanning layer thick) the forward moving distance between the right lobe of the liver D=cot a x scanning layer thickness mm. third and part four conclusion the 1. right lobe fissure of the liver is best observed on the CT image MIP sagittal reconstruction image; the 2. right interleaf fissure is a slit from the posterior upward and downward, and a gradually torsional oblique.3. is based on the right interlobe fissure in the sagittal plane. The oblique angle can guide the clinic to locate the right interleaf fissure in the CT image layer without obvious image signs. When the angle of the right lobe between the right lobe and the vertical axis is larger, the right anterior lobe and the right posterior lobe are the relationship between the upper and the lower. While the right anterior lobe is close to the coronal position, the right anterior lobe is similar to the right posterior lobe when the right lobe is close to the coronal position.
【学位授予单位】：大连医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R322.47;R657.3

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