三维可视化联合吲哚菁绿分子荧光成像在肝脏肿瘤手术导航中的应用

发布时间：2018-04-02 21:36

本文选题：三维可视化　切入点：ICG分子荧光成像　出处：《南方医科大学》2017年硕士论文

【摘要】：研究目的肝脏肿瘤的精准手术导航对于提高手术的安全性以及有效性具有重要的意义。近年来,在计算机技术基础上发展的三维可视化系统作为一种形态学方面的成像手段,被广泛应用于肝胆外科的手术导航。而吲哚菁绿(indocyanine green,ICG)分子荧光成像则是一种新兴的影像学方法,可以从细胞功能水平实现人体组织结构的实时成像。本课题将三维可视化与ICG分子荧光成像技术联合应用于肝脏肿瘤手术中,从形态解剖水平和细胞功能水平进行手术导航,并结合实际的临床应用,评估该导航模式的实用价值。方法2015年04月至2017年01月间,南方医科大学珠江医院肝胆一科共31例肝脏肿瘤病人在三维可视化联合ICG分子荧光成像技术指导下进行手术。所有病人术前均通过三维可视化系统进行三维立体重建及三维可视化分析,确定初步的手术方案。术前24h以0.25-0.5 mg/kg的剂量标准经外周静脉注射ICG后,术中使用ICG分子荧光成像技术对肿瘤进行实时的定位及边界界定,确定肝切除范围。拟行解剖性肝切除术的病人,术中先游离并阻断拟切除肝叶/段所对应的门静脉分支,经外周静脉追加1mlICG溶液(2.5mg/ml)后进行荧光检测,根据荧光信号的分布确定肝叶/段的界线及肝切除范围。离断肝实质后,再对肝断面进行ICG分子荧光检测,协助判断有无肿瘤残余以及胆漏。术后通过比较离体肿瘤标本荧光成像的最大径与三维可视化肿瘤模型的最大径,评估ICG分子荧光成像在肝脏肿瘤边界判断中的准确性。结果31例病人均获得结构清晰、立体感强的三维可视化模型,并进行了个体化的手术规划。术中在ICG分子荧光成像技术辅助下,实时呈现了肝脏肿瘤的定位与边界信息。比较离体肿瘤标本的荧光成像最大径与三维可视化肿瘤模型的最大径,其差异无统计学意义(t=-1.874,p=0.071),Pearson相关性检验提示二者具有高度相关性(r=0.991,P0.001)。3例病人术中使用ICG分子荧光成像技术显示了半肝切除的范围,所呈现的荧光界线清晰、完整,实现了肝脏实质的三维染色,与阻断相应门静脉和肝动脉后肝脏缺血范围一致。1例病人通过ICG分子荧光成像技术检出肝断面残余肿瘤,扩大肝切除范围后,再次使用荧光检测,无肿瘤残余,肝切缘病理结果为阴性。最终本组病人肝切缘术中荧光检测结果和术中冰冻病理诊断相一致,均为阴性,R0切除率为100%。此外,术中通过ICG分子荧光成像技术发现肝断面胆漏1例,经处理后再次采用荧光成像检测,原胆漏处无荧光聚集,术后无胆漏发生。本组病人术后胆漏的总体发生率为3.2%(1/31)。结论三维可视化联合ICG分子荧光成像技术可在术中实时定位肝脏肿瘤并协助肿瘤边界及肝切除范围的界定,同时可高敏感地发现肝断面的残余肿瘤及胆漏,在肝脏肿瘤的手术导航中具有一定的实用价值。
[Abstract]:Objective to improve the safety and effectiveness of liver tumor surgery with accurate surgical navigation.In recent years, the 3D visualization system developed on the basis of computer technology, as a morphological imaging method, has been widely used in hepatobiliary surgery surgery navigation.Indocyanine green indocyanine green ICG molecular fluorescence imaging is a new imaging method, which can realize real-time imaging of human tissue structure at the level of cell function.In this paper, 3D visualization and ICG molecular fluorescence imaging were combined in liver tumor surgery, and the practical value of the navigation model was evaluated according to the level of morphologic anatomy and cell function.Methods from April 2015 to January 2017, a total of 31 patients with liver tumors in the Department of Hepatobiliary, Zhujiang Hospital, Southern Medical University, were operated on under the guidance of three-dimensional visualization and ICG molecular fluorescence imaging.Three dimensional reconstruction and visualization analysis were performed on all patients before operation.After ICG was injected into peripheral vein 24 hours before operation, ICG molecular fluorescence imaging technique was used to locate the tumor in real time and to determine the range of hepatectomy.In patients undergoing anatomic hepatectomy, the portal vein branches corresponding to the liver lobe / segment were first dissociated and blocked, and the fluorescence was detected by adding 2.5 mg / ml of 1mlICG solution through peripheral vein.According to the distribution of fluorescence signal, the boundary of liver lobe / segment and the range of hepatectomy were determined.After dissection of liver parenchyma, ICG molecular fluorescence detection was performed on the liver section to determine the residual tumor and bile leakage.The accuracy of ICG molecular fluorescence imaging in judging liver tumor boundary was evaluated by comparing the maximum diameter of fluorescence imaging in vitro with that of 3D visual tumor model.Results three-dimensional visual models with clear structure and strong stereosynthesis were obtained in all 31 patients and individualized operation planning was carried out.With the help of ICG molecular fluorescence imaging, the location and boundary information of liver tumors were presented in real time.The maximum diameter of fluorescence imaging was compared with that of 3D visual tumor model in vitro.The difference was not statistically significant. Pearson correlation test showed that there was a high correlation between the two methods. The range of hemihepatectomy was demonstrated by using ICG molecular fluorescence imaging technique, and the fluorescence boundary was clear and complete.Three-dimensional staining of liver parenchyma was realized, which was consistent with the ischemic range of liver after occlusion of portal vein and hepatic artery. Residual tumors in liver transection were detected by ICG molecular fluorescence imaging. After hepatectomy was expanded, fluorescence detection was used again.There was no residual tumor, and the pathological results of hepatic margin were negative.In the end, the results of intraoperative fluorescence detection were consistent with those of frozen pathological diagnosis in this group of patients, all of which were negative and R0 resectable rate was 100%.In addition, intraoperative ICG molecular fluorescence imaging technique was used to detect 1 case of bile leakage in the transect of liver. After treatment, fluorescence imaging was used again. There was no fluorescence accumulation in the original bile leakage and no bile leakage occurred after operation.The overall incidence of postoperative biliary leakage in this group was 3.2 / 31%.Conclusion Three-dimensional visualization combined with ICG molecular fluorescence imaging can locate liver tumors in real time during operation and help to define the tumor boundary and hepatectomy range. At the same time, the residual tumors and bile leakage on liver section can be detected sensitively.It has certain practical value in the operation navigation of liver tumor.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7

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