利用胰岛素代谢评估肝脏储备功能可行性的研究及肝脏血管3D重建在肝脏手术中的应用

发布时间：2019-05-23 17:31

【摘要】：肝脏外科手术仍是治疗肝胆外科疾病的主要方式。尽管外科治疗水平已经得到了很大的提高,但是肝功能衰竭仍然是肝脏切除术后主要的死亡原因。目前,大致有4类常用的评估肝脏储备功能的方法:(1)肝脏血清生化学试验;(2)肝脏功能定量试验;(3)综合评分系统;(4)肝脏体积测量;但是由于肝病的多样性及肝功能的复杂性,每种方法都有它的优越性和局限性。前期工作中我们发现利用胰岛素和C肽的浓度评估肝脏储备功能是可行的。在此基础上,我们利用口服糖耐量试验、胰岛素释放试验、C肽释放试验检测肝功能异常患者与肝功正常人群的血糖浓度、胰岛素浓度及C肽浓度,分析两组人群的浓度差异。筛选出一个较为灵敏的反映肝储备功能的胰岛素浓度时间点或者胰岛素浓度变化时段,作为评估肝脏储备功能的新指标。统计学分析结果显示:服糖后2h和服糖后3h两组人群血糖浓度、胰岛素浓度及C肽浓度存在显著性差异,此外,两组人群的空腹胰岛素浓度也是存在显著差异的;Child-Pugh评分A级与B、C级间胰岛素浓度存在显著性差异,但是Child-Pugh评分B级与C级间不存在显著性差异,胰岛素代谢的差异和肝脏Child-Pugh评分等级相关;并且我们认为服糖后2h到服糖后3h这个时间段胰岛素浓度的增加速率或变化率能更好的反映肝脏损伤情况,可以作为评估肝功能的参数;肝脏影响胰岛素的代谢,且肝功能异常降低肝脏对胰岛素的代谢能力。随着科学技术在医学领域的不断发展,肝胆外科已迈入精准时代,这就要求医师在切除肝脏病灶的同时,尽量减少正常肝脏组织的切除,避免周围血管的损伤,减少术中出血。然而,肝脏血管系统复杂且来源多的特点,决定了其损伤及变异的多样性和不确定性,使肝脏切除手术难度高、风险大。因此,肝脏血管结构的解剖学研究在肝脏外科的发展中起重要作用。传统的肝脏血管解剖多是来源于动物模型和尸体解剖标本,受血管灌注技术及尸体标本来源的限制,传统的肝脏血管解剖不能为现代精准肝脏外科手术提供三维解剖数据。随着对人体形态学的深入研究及数字化医疗的不断发展,3D可视化的人体解剖已经成为现实。术前在CT数据的基础上对患者肝内血管进行重建,能够得到源于数据又能全面观测肝内血管的3D重建模型,因为CT数据源于患者自身,3D重建模型反映的是个体的血管结构及病变情况。通过肝内血管3D重建模型医师能够直观的观察血管在肝内的走行、分布及变异,了解变异血管的来源、走行及生理功能。此外,在3D重建模型的基础上还能测量血管的直径、血管间的距离及血管与病灶间的距离。将3D重建模型应用于肝脏切除手术,医师能在术前了解患者血管的变异及解剖情况,为患者制定个性化的治疗方案,选择合理的手术方式,做好术前规划,减少术中血管的损伤及出血量,以提高手术的成功率,减少手术风险及术后并发症。
[Abstract]:Liver surgery is still the main way to treat hepatobiliary surgery. Although the level of surgical treatment has been greatly improved, liver failure remains the main cause of death after hepatectomy. At present, there are generally four commonly used methods of evaluating the liver reserve function: (1) the liver serum biochemical test; (2) the quantitative test of the liver function; (3) the comprehensive scoring system; (4) the liver volume measurement; but due to the diversity of the liver disease and the complexity of the liver function, Each method has its advantages and limitations. In the preliminary work we have found that the use of insulin and C-peptide concentrations to assess the liver reserve function is feasible. On this basis, we used the oral glucose tolerance test, the insulin release test and the C-peptide release test to detect the blood glucose concentration, insulin concentration and C-peptide concentration in the normal population of the liver function and analyze the difference in the concentration of the two groups. A more sensitive time point of the insulin concentration or the time of change in the insulin concentration was selected as a new index to assess the function of the liver reserve. The results of the statistical analysis showed that the blood glucose concentration, insulin concentration and C-peptide concentration in the two groups were significantly different after 2 h and 3 h after the administration of the sugar, and there was a significant difference in the fasting insulin concentration in the two groups. Child-Pugh scores A and B, There was a significant difference in the concentration of the interstage insulin, but there was no significant difference between the level of Child-Pugh and C stage, the difference of insulin metabolism and the grade of Child-Pugh of the liver. and we think that the increase rate or rate of change of the insulin concentration in the time period after 2 hours after serving the sugar can better reflect the liver injury condition, can be used as a parameter for evaluating the liver function, and the liver affects the metabolism of the insulin, And the liver function is abnormal, and the metabolism capacity of the liver to the insulin is reduced. With the development of science and technology in the medical field, the liver and gallbladder surgery has entered the precise time, which requires the physician to minimize the resection of the normal liver tissue while cutting the focus of the liver, to avoid the damage of the surrounding blood vessels, and to reduce the intraoperative bleeding. However, the complex and multi-source characteristics of the hepatic vascular system determine the diversity and uncertainty of the damage and variation of the liver, which makes the liver resection operation difficult and the risk is high. Therefore, the anatomical study of the hepatic vascular structure plays an important role in the development of liver surgery. The traditional hepatic vascular anatomy is derived from the animal model and the autopsy specimen, and is limited by the blood vessel perfusion technique and the source of the cadavers, and the traditional hepatic vascular anatomy can not provide the three-dimensional anatomical data for the modern precise liver surgery. With the deep study of human morphology and the development of digital medical treatment, 3D visualization of human anatomy has become a reality. On the basis of the CT data, the patient's hepatic blood vessel was reconstructed, and the 3D reconstruction model of the hepatic blood vessel can be fully observed from the data, because the CT data is derived from the patient's own, and the 3D reconstruction model reflects the vascular structure and the pathological condition of the individual. Through the hepatic vascular 3D reconstruction model, the course, distribution and variation of the blood vessel in the liver can be visually observed, and the source, the course and the physiological function of the variant blood vessel are known. In addition, the diameter of the blood vessel, the distance between the blood vessels and the distance between the blood vessel and the focus can also be measured on the basis of the 3D reconstruction model. The 3D reconstruction model is applied to the liver resection operation, and the physician can understand the variation and the anatomy of the blood vessel of the patient before the operation, develop a personalized treatment scheme for the patient, select a reasonable operation mode, perform pre-operation planning, reduce the damage and the blood loss of the blood vessels during the operation, So as to improve the success rate of the operation, reduce the operation risk and postoperative complications.
【学位授予单位】：昆明理工大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R657.3

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