【摘要】 目的探讨多层螺旋计算机体层摄影术(MSCT)三维重建在肝癌患者术前评估及术后预测肝功能代偿情况的应用价值。方法本前瞻性研究对象为2010年2月至2011年2月在吉林大学中日联谊医院肝胆胰外科行根治性肝切除术的38例肝癌患者。男31例,女7例,年龄33~83岁,中位年龄54岁。患者均签署知情同意书,符合医学伦理学规定。术前应用多层面重组(MPR)、最大密度投影(MIP)和容积显示(VR)3种方式进行MSCT三维重建。采用χ2检验和Fisher确切概率法比较3种重建方式的血管显示率,采用秩和检验比较肝预测体积和实际体积差异,采用方差分析和q检验比较残肝分数与术后肝功能Child-Pugh分级的关系。结果本组38例肝MSCT三维重建图像均可清晰显示腹主动脉、腹腔干、肝总动脉、肝固有动脉、门静脉系统及其属支,3种重建方式对肿瘤和血管显示各具特点。MSCT三维重建所能显示肝动脉和门静脉的最小分支均为Ⅵ级。MPR、MIP、VR3种重建方式对肝动脉Ⅲ级的显示率分别为8%(3/38)、100%(38/38)、100%(38/38),MIP和VR对肝动脉Ⅲ级的显示率明显优于MPR(P<0.001);MIP与VR对肝动脉Ⅵ级显示率分别为16%(6/38)、3%(1/38),MIP明显优于VR(P=0.047)。MPR、MIP、VR 3种重建方式对门静脉Ⅲ级显示率分别为5%(2/38)、100%(38/38)、100%(38/38),MIP和VR对门静脉Ⅲ级显示率明显优于MPR(P<0.001)。术前MSCT测量的肿瘤预测体积中位数116(12~1 002)cm3与肿瘤实际体积125(8~987)cm3比较差异无统计学意义(Z=-0.099,P=0.921);预测切肝体积215(36~1 294)cm3与实际切肝体积212(40~1 234)cm3,比较差异无统计学意义(Z=-0.31,P=0.975)。肝功能Child-Pugh分级A级残肝分数(83.1±6.3)%、B级残肝分数(61.7±5.4)%、C级残肝分数(38.9±2.3)%,3组总体比较差异有统计学意义(F=97.425,P<0.001),两两比较差异均有统计学意义(均为P<0.001)。结论术前MSCT三维重建可以清晰显示肝脏病变和血管,能准确测量肝脏肿瘤体积和预切除肝脏体积,对术前评估及预测术后肝功能代偿有一定价值。MPR三维重建图像对手术的宏观指导意义较大,而应用MIP和VR的三维重建图像则是制定手术计划的重要影像学依据。更多还原

【Abstract】 Objective To assess the application value of three-dimensional reconstructionwith the multislice spiral computed tomography(MSCT) in preoperative evaluation and predicting the postoperative liver compensatory situation in patients with hepatocellular carcinoma. Methods Thirty-eight patients with hepatocellular carcinoma(31 males and 83 females; 33 to 83 years of age; 54 years of mean age) who underwent radical hepatectomy in Hepato-biliary and Pancreatic Surgery Department of China-Japan Union Hospital of Jilin University,from February 2010 to February 2011 were enrolled in this prospective study. Local ethical committee approval had been received and that the informed consent of all participating subjects was obtained. Three-dimensional reconstruction was made by MPR,MIP and VR before the operation. The vascular visualization rate of three reconstruction pattern was compared by Chi-square and Fisher exact probability. Rank sum test was used to compare the difference between the predictive volume and actual volume of the liver. The relation between the percentage of remnant liver and the postoperative liver function of Child-Pugh grade was analyzed by one-way ANOVA and Student-Newman-Keuls q test. Results The abdominal aorta,celiac trunk,common hepatic artery,proper hepatic artery,portal system and branches of the 38 patients were clearly visualized by MSCT images. Different characteristics of tumors and vascular appearance were observed in the three patterns. The smallest visualized branches of hepatic artery and portal vein were both grade Ⅵ. The visualization rate of grade Ⅲ hepatic artery were 8%(3/38) by MPR,100%(38/38) by MIP,100%(38/38) by VR respectively. The visualization rate of MIP and VR were significantly higher compared with MPR(P<0.001). The visualization rate of grade Ⅵ hepatic artery by MIP and VR were 16%(6/38),3%(1/38),The MIP images was significantly better than the VR(P=0.047). The visualization rate of grade Ⅲ portal vein were 5%(2/38) by MRP,100%(38/38) by MIP,100%(38/38) by VR. The visualization rate of MIP and VR were significantly higher than that of the MPR(P <0.001). There was no significant difference between the predictive liver volume [116(12-1 002 cm3] and the actual volume [125(8-987) cm3] by MSCT before operation(Z =-0.099,P=0.921). There was no significant difference between expected resection volume [215(36-1 294)cm3] and actual resection volume [212(40-1 234)cm3] was not statistically significant(Z=-0.31,P=0.975). The percentage of remnant liver for Child-Pugh grade A patients was(83.1±6.3)%,for Child-Pugh grade B was(61.7 ±5.4)% and for Child-Pugh grade C was(38.9 ±2.3)%. There was significant difference among the three grades(F=97.425,P<0.001). The differences of each other among the three grades were statistically significant(all in P<0.001). Conclusions The liver lesion and vascular can be clearly visualized by three-dimensional reconstruction with MSCT preoperatively and the tumor volume and expected resection liver volume can also be accurately measured. The technique may be helpful for preoperative evaluation and predicting the postoperative liver compensatory function. MPR three-dimensional reconstruction is useful in making operation plans,while the MIP and VR techniques are helpful for specific operation design.更多还原