16层螺旋CT测量肝脏体积在肝癌切除术中的应用研究

目的 研究16层螺旋CT在肝癌切除术前预测切除肝体积及残肝体积的准确性,结合肝功能进一步探讨残肝体积率在肝癌切除术中的应用价值. 资料与方法 对50例行肝癌根治性切除术的患者术前利用16层螺旋CT预测切除肝体积及残肝体积,进一步计算残肝体积率.其中24例患者术后用排水法测量实际肝切除体积.记录手术前、后肝功能Child-Pugh分级并进行比较,对所得数据进行t检验及相关分析. 结果 术后排水法测量实际肝切除体积与术前CT预测切除肝体积比较差异无统计学意义,CT术前预测肝切除体积准确性平均为(92.82±3.93)%.残肝体积率与术后肝功能损害呈负相关.术前肝功能Child-Pugh分级为A级的肝癌患者,残肝体积率为25%是一个可供参考的安全线,而术前Child-Pugh分级为B级的肝癌患者,则以50%为一个可以参考的安全线. 结论 16层螺旋CT在肝癌切除术前预测切除肝体积及残肝体积方面具有较高的准确性.残肝体积率的大小是评价术后肝功能的重要指标,但在评价时应该结合肝硬化等引起的肝功能变化情况.     

MDCT肝体积测量在肝切除术中的临床应用

目的:前瞻性研究术前MDCT评估术后残肝体积对肝切除手术的影响.方法:拟行肝切除患者27例,行4排螺旋CT增强扫描,3D模式测量残肝体积和切除肝脏体积,计算残肝体积与体表面积标化的肝体积比较,切除肝脏MDCT测量体积与术后即刻水测法肝体积行线性相关回归分析.结果:25例(25/27)行肝大部切除术,其中行右半肝切除术20例,左半肝切除术4例,肝Ⅳ、Ⅴ、Ⅷ三段联合切除术1例.术后平均残肝体积(461.7±176)cm3,相对术后残肝标化比(42±16)%,1例患者相对残肝标化比小于35%,临床放弃了手术;另一例术中发现肝门淋巴结转移,放弃手术改为动脉插管化疗.所有病例围手术期均未发生肝功能衰竭.结论:4排螺旋CT术前测量术后残脏体积,能够作为指导临床正确实施肝切除以及避免术后发生肝功能衰竭的重要依据之一.     

肝门部胆管癌大范围肝切除术前胆道引流作用的临床研究

目的评价大范围肝切除治疗伴有梗阻性黄疸的肝门部胆管癌术前胆道引流的作用。方法回顾性研究2005年6月至2011年4月在解放军总医院行大范围肝切除治疗的伴有梗阻性黄疸的肝门部胆管癌患者临床及术前影像学资料,测量预留肝体积,根据公式:余肝体积(RLV)/标准总肝体积(SLV)计算标准余肝率(standardizedremnant liver volume ratio,SRLVR)。根据术前胆道引流与否,分为两个亚组,比较两亚组术后近期结果。结果大范围肝切除治疗的伴有梗阻性黄疸的肝门部胆管癌共117例,所有病例均进行了肝体积测量,平均标准余肝率为52.3%,术后病死率为6.8%,总并发症发生率为41.9%,肝衰竭发生率为14.5%,感染性并发症发生率为9.7%,术后平均住院日数17.8 d(5～64 d)。多因素分析显示,SRLVR≤40%(OR:71.63,95%置信区间:8.07～635.96,P<0.001)和术前总胆红素>186.7μmol/L(OR:17.29,95%置信区间:1.97～151.92,P=0.01)为肝门部胆管癌术后肝衰竭的独立危险因素。SRLVR>40%时术前胆道引流亚组感染性并发症发生率显著高于非引流亚组,两亚组间术后病死率、总并发症发生率、肝衰竭发生率、术后住院日数差异无统计学意义,而SRLVR≤40%时,术前胆道引流亚组术后病死率、肝衰竭发生率、术后住院日数显著小于非引流亚组,两亚组间总并发症发生率、感染性并发症发生率差异无统计学意义。结论肝门部胆管癌伴有梗阻性黄疸患者肝切除术前,SRLVR≤40%时术前胆道引流显著降低术后病死率、肝衰竭发生率及术后住院日数,推荐常规使用术前胆道引流,而SRLVR>40%时术后感染性并发症发生率显著增加,选择性使用术前胆道引流更为合适。     

128层MSCT测量肝脏体积在肝巨大血管瘤精准切除中的应用研究

目的探讨128层螺旋CT肝脏体积测量对肝巨大血管瘤行精准肝切除的价值。方法选取2016年1月~2017年12月临床拟诊肝巨大血管瘤患者28例,术前均行CT常规平扫+肝脏三期增强扫描,将薄层图像传至GE AW4.6后处理工作站,采用肝脏体积测量软件(Volume),分析肝巨大血管瘤的位置、大小与周围血管的毗邻关系,从而生成全肝体积和肝血管瘤体积。经CT医师与普外科医师商讨制定手术方案,分析预切除肝体积,将手术标本采用水测法得出切除标本的总体积。将预切除肝体积与手术标本体积间进行线性相关分析。运用SPSS 20.0对所得数据进行t检验及相关分析。结果 28例患者中,肝脏海绵状血管瘤22例,硬化性血管瘤3例;血管内皮细胞瘤2例;毛细血管瘤1例。预切除肝脏体积介于(1650.52±475.90)cm3,手术标本体积介于(1670.64±420.25)cm3,两者间差异无统计学意义(P=0.213)。术前预切除体积百分比与术后标本比较,差异无统计学意义(P=0.232)。按照术前制定的手术切除方案,所有肝血管瘤均完整切除。预切除肝体积与手术标本体积间相关性显著,相关系数为0.924。结论 128层MSCT肝脏体积测量可作为普外科施行精准肝切除的重要影像学依据,并提供个体化指导。     

CT测量保留肝容积率对肝癌切除术前肝储备功能的评估价值

目的探讨CT测量保留肝容积率评估肝癌术前肝储备功能的价值。方法前瞻性研究原发性肝癌手术病人59例。所有病人均行肝脏双期增强CT扫描。术前用CT测量保留肝容积率,与术后切除容积和生存率进行级间差异性分析。结果保留肝容积率≤50%和>50%之间的生存率差异有统计学意义(χ2=4·9881,P<0·05);而肝切除率≤50%和>50%之间差异无统计学意义(χ2=0·0154,P>0·05)。结论保留肝容积率可以作为临床肝癌术前评估肝储备功能的重要指标之一。     

右肝切除后7天肝脏再生的全肝与肝脏分段CT容积分析

目的通过术前CT容积估算与右肝切除术后7天CT容积估算对照,评价肝脏的总体再生与分段再生,并研究不同手术指征及保留与不保留肝中静脉（MHV）病人CT容积估算,评估肝脏的再生。材料与方法研究经本地医学伦理委员会与国家医学委员会批准并获取知情同意通知。27例曾行右肝切除的病人术前与术后7天接受了多层螺旋CT扫描。     

肝切除术后代偿性肥大的核素和CT评价

作者用核素和CT扫描,结合典型病例的肝切除前后的体积变化,对肝脏术后代偿性肥大进行了研究。患者男性,54岁,化验见有肝功能损害和血清AFP值升高。血管造影诊断右叶肝细胞癌,后行肝叶切除术。术前CT和核素扫描均为肝脏肿瘤合     

活体肝移植术后移植肝段再生的多层螺旋CT研究

目的 探讨含肝中静脉(MHV)与不含MHV主支2种术式对移植肝Ⅴ、Ⅷ段再生的影响.方法 把25对进行了右半肝移植的供-受体按移植肝是否包含MHV分成2组,含MHV组(A组,14对)和不含MHV行Ⅴ、Ⅷ段MHV分支血管重建组(B组,11对),对供体术前、受体术后半月及3月时Ⅴ、Ⅷ段肝体积进行测量,记录2组供体术前、受体术后半月及3月时移植肝Ⅴ、Ⅶ段的体积数值,并计算再生率,然后对术后半月及3月时2组移植肝Ⅴ、Ⅷ段的肝再生率进行比较.结果 A组术后半月移植肝Ⅴ、Ⅷ段平均肝再生率分别是0.360±0.043、0.853±0.059,术后3月移植肝Ⅴ、Ⅷ段的平均肝再生率分别是0.253±0.043、0.708±0.059;B组术后半月移植肝Ⅴ、Ⅷ段平均肝再生率分别是0.306±0.049、0.815±0.066,术后3月移植肝Ⅴ、Ⅷ段平均肝再生率分别是0.161±0.049、0.627±0.066.术后半月和3月时,2组间移植肝Ⅴ、Ⅷ段平均肝再生率差异无统计学意义(P=0.685,P>0.05、P=0.738,P>0.05).结论 关于活体右半肝移植,不含MHV行MHV主要分支重建不影响移植肝Ⅴ、Ⅷ段肝再生.     

三维可视化技术在Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌计划性肝切除中的应用

 目的 探讨三维可视化技术在Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌计划性肝切除中的应用价值。方法 回顾性分析2015-01至2017-12上海东方肝胆外科医院收治的Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌36例患者的临床资料,应用三维可视化技术将患者320层螺旋二维CT图像进行三维可视化重建,通过观察肿瘤的部位、大小,与周围门静脉、肝动脉、肝静脉、肝内胆管之间的关系,进行肿瘤的可切除性评估,残肝体积比<40%,通过患侧门静脉栓塞、健侧胆道引流使残肝体积再生,残肝体积比>40%后按计划实施根治性切除,比较仿真手术与实际手术的区别。结果 应用三维可视化重建技术,立体形象地显示肿瘤与周围毗邻的关系,对肿瘤进行Bismuth-Corlette分型,Ⅲa型16例,Ⅲb型8例,Ⅳ12例。测量平均全肝体积(1386±146)ml,肿瘤平均体积(76±22)ml,预切除平均肝体积(896±168)ml,残肝平均体积(490±172)ml,残肝比(34.5±3.6)%,通过行健侧胆道引流患侧门静脉栓塞后,使残肝比>40%,均顺利按计划行肝门部胆管癌根治性切除。肿瘤三维重建后诊断分型准确率100%,重建模型解剖关系与术中实际情况大致相符。术前预切除肝脏体积和术后实际肝脏体积无统计学差异(t=1.148)。结论 三维可视化技术能够对肝门部胆管癌术前进行精确评估、精准规划,优化治疗方案,提高根治性切除(radical resection,R0)手术率。     

经导管门静脉栓塞诱导肝叶代偿性增生的临床应用研究

目的探讨经导管门静脉栓塞(PVE)诱导肝叶代偿性增生临床应用的可行性、安全性、有效性。方法对28例手术不能切除,但门静脉内无瘤栓的晚期肝癌患者,经导管行门静脉右支栓塞。PVE术前、后用CT测量左侧肝叶的体积,并测量栓塞前后的门静脉压力,监测肝功能和凝血功能。结果所有患者均成功行门静脉右支栓塞,其中1例PVE后顺利实行右肝切除术。PVE术前左侧肝叶的体积为(461.5±108.2)cm3,术后2、4、8周分别为(608.5±135.7)cm3、(660.2±133.8)cm3、(678.0±132.7)cm3,分别比术前增加(33.5±22.1)%、(45.4±23.8)%、(49.5±24.0)%;术前左侧肝叶占整个肝脏的体积百分比为(18.4±5.1)%,术后2、4、8周分别为(24.2±5.9)%、(26.3±5.8)%、(27.0±6.1)%。术后2周较术前体积增大差异有统计学意义(F=37.810,P<0.05),术后4周与术后2周间、术后8周与术后2周间、术后8周与术后4周间体积增大差异无统计学意义(P=0.206、0.091、0.085,P值均>0.05)。栓塞前门静脉压力为(17.8±2.9)cmH2O(1cmH2O=0.098kPa),PVE后为(18.3±2.9)cmH2O,栓塞前后差异有统计学意义(t=-14.810,P<0.05),但均在正常值范围内,未出现门静脉高压,肝功能损害轻,无并发症出现。结论经导管门静脉栓塞诱导肝叶代偿性增生在临床上的应用是可行的、安全的、有效的,可增加手术切除率,提高手术切除的安全性。     

肝内管道CT三维重建在囊性肝包虫病中的应用研究及意义

目的探讨肝内肝动脉、肝静脉和胆道等管道系统的螺旋CT三维重建在囊性肝包虫病的应用研究及意义。方法8例囊性肝包虫病患者术前进行肝内管道包括肝动脉、肝静脉、门静脉及胆管螺旋CT造影扫描,多轴向投照容积重建法三维重建,观察分析三维重建图像中肝动脉、肝静脉、门静脉及胆管的主要分支显影、形态、分布、受压和移位情况,分别将肝包虫囊肿的空间位置关系,与“外膜内完整摘除术”中实际情况进行对照。结果肝脏螺旋CT三维重建图像清晰地显示病变与肝内管道的三维空间关系,包括管道的受压移位并与包虫囊肿呈半抱球状。部分肝门静脉、肝管左右支夹角增大,部分胆管壁嵌于包虫外囊壁内。8例“外膜内完整摘除术”均成功,术中证实三维图像与实际情况相符。结论利用CT三维重建技术,对囊性肝包虫进行术前的准确定位、对指导囊性肝包虫“外膜内完整摘除术”的操作具有重大指导意义。     

暂时阻断肝静脉后肝脏的血流改变及其意义：CT影像学研究

目的 研究犬肝静脉阻断后肝脏血流改变,并评估该技术在肝癌介入治疗中的应用价值。材料与方法 对6只犬行肝静脉球囊导管阻断,应用螺旋CT行肝脏双期扫描和同层动态增强扫描。结果 肝静脉受阻肝叶密度明显低于未阻肝叶,二者形成明显的分界,门静脉逆行增强显影,受阻肝叶肝实质及门静脉增强的平均峰值时间显滞后于未受阻者。结论 暂时阻断肝静脉后受阻区域总的血流量减少,血流速度变缓,门静脉变为引流静脉。暂时阻断肝静脉行肝动脉化疗栓塞术和局部高温固化疗效是一项有临床应用前景的技术。     

99mTc-GSA dynamic SPECT for regional hepatic functional reserve estimation: assessment of clinical value for hepatic resection]

We assessed the clinical value of three-dimensional functional mapping method employing GSA dynamic SPECT for the estimation of residual hepatic functional reserve before hepatic resection. Seventy-two consecutive patients of liver tumor were recruited in this study. Thirty-seven underwent segmentectomy or lobectomy and 35 did subsegmentectomy. GSA studies were carried out in all 72 patients before operation. Postoperative studies were performed in 70 patients about 1 month after operation, and 2 patients died of postoperative hepatic failure early after operation. In the preoperative study, liver functional images were divided into 4 segments according to liver anatomy and segmental GSA clearance was analyzed. The sum of GSA clearance of the segments immune from resection were calculated as predicted residual GSA clearance. Two patients who showed poor predicted residual hepatic GSA clearance died of postoperative hepatic failure within two months after operation (extended right lobectomy). There were good correlations between pre- and postoperative total liver clearance in patients underwent subsegmentectomy (r = 0.900, p < 0.0001, n = 35), and between predicted residual clearance and postoperative total clearance in patients underwent segmentectomy or lobectomy (r = 0.799, p < 0.0001, n = 35). After hepatic resection, there seemed to be discrepancies between hepatic volume expansion and functional restoration in some patients. Mean GSA clearance (clearance per unit volume) apparently decreased after operation in patients whose residual volume ratio (preoperative predicted residual liver volume/preoperative total liver volume) were less than 50% (p < 0.01, n = 12). These results suggested that three-dimensional functional mapping method employing GSA dynamic SPECT can provide quantitative information of postoperative hepatic function and reserve before hepatic resection. Changes of mean GSA clearance after hepatic resection suggested that hepatic function per unit volume changes in the process of hepatic regeneration.     

Safety of simultaneous colon and liver resection for colorectal liver metastases

BACKGROUND/AIM: Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS: Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS: In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION: By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.     

Clinical values for an index predicting postoperative residual liver function by pre-operative liver-scintigraphy in patients with liver disease

Hepatic resection is essential in treating hepatocellular carcinoma. However, before an operation, it is difficult to predict the functional reserve in the remnant following massive resection. We devised an original method by which effective liver volume was measured by liver scintigraphy. In order to predict the residual liver function before hepatic resection in a preoperative radiocolloid study, we obtained a predictive index by combining the K values with effective liver volumes which seemed to have the estimated residual liver function. Twenty-one patients with liver or biliary tract disease were selected at random for the present study. We divided them into 3 groups in accordance with prognosis after hepatic resection. There were statistically significant difference between the deceased group who died from hepatic failure and the group who died from causes other than hepatic failure; and between the deceased group who died from hepatic failure and the living group in the preictive index (p less than 0.01). Our data suggest that if the predictive index is above 0.45, the probability of hepatic failure after hepatic resection is low. We concluded that our predictive index is useful to use in preoperative prediction of post-hepatectomic residual liver function.     

中低强度有氧运动结合饮食控制对肥胖青少年血脂和肝脏功能的影响

目的:探讨4周中低强度有氧运动结合饮食控制对肥胖青少年减肥效果以及血脂和肝脏功能的影响。方法:以参加2007年上海巅峰运动减肥中心运动减肥夏令营的56名9～19岁肥胖青少年(男26名,女30名)为对象,测定其身体形态、安静状态心电图、空腹血糖、胰岛素、总胆固醇、甘油三酯、高密度脂蛋白、低密度脂蛋白、谷氨酸氨基转移酶(ALT)、丙氨酸氨基转移酶(AST)、-谷氨酰转肽酶(GGT),进行肝脏B超检查。根据运动负荷试验结果确定个体运动强度,范围在心率储备的20～40%。选择容易控制强度和长时间持续的运动方式,如游泳、快走、慢跑、健美操、娱乐性球类等。根据年龄、体重和基础代谢率计算个体每日热能需要量,遵循足量蛋白质和低脂的原则,由专业营养师配餐,保证生理需要量营养素供给。4周实验后测定相同指标并进行前后比较。结果:与实验前比较,4周后,(1)实验对象体重、BMI、体脂率明显下降;(2)空腹血脂、血糖和胰岛素均明显下降;(3)肝脏B超检查显示脂肪肝程度减轻,ALT、AST和GGT异常例数明显减少。结论:中低强度长时间运动结合足量蛋白质、低脂饮食是肥胖青少年减肥的有效途径,不仅明显改善体内脂类代谢,降低空腹胰岛素水平,提高组织细胞对胰岛素的敏感性,还可明显减轻肥胖青少年脂肪肝的程度,改善肝功能。     

肝脏灌注异常在肝脓肿诊断中的价值

目的研究肝脏灌注异常在肝脓肿诊断中的价值,探讨肝灌注异常形成的相关因素。方法随机选择1998-02—2003-10肝脓肿病例共34例作为研究组,并随机选择同期不伴有门静脉癌栓的肝癌34例作为对照组。全肝平扫后,于开始注射对比剂后20s行全肝动脉期扫描。观察动脉期CT表现,并分析肝灌注异常形成的相关因素。结果动脉期扫描肝脏灌注异常共26例,其中肝脓肿18例,肝癌8例,均表现为不规则斑片状、楔形高密度区。肝灌注异常的形成与病灶的部位无关,而与病程有相关性。结论肝脏灌注异常是肝脓肿的又一重要的增强CT表现,在肝脓肿的诊断中有重要价值。     

肝脓肿的CT诊断

目的分析不同病理演变时期肝脓肿的CT表现,提高对肝脓肿的诊断水平。方法回顾分析经临床病理证实的50例不同发病时期肝脓肿的CT平扫及三期强化特点,并与肝癌、肝转移瘤、肝血管瘤等对照分析。结果按照肝脓肿病变发展阶段不同,其CT表现可分3种。早期肝脓肿(10例,有2种表现形式:小房腔性和团块状肝脓肿),典型肝脓肿(38例)和纤维肉芽肿性肝脓肿(2例)。结论肝脓肿在不同病理演变时期CT平扫表现不同,动态三期强化扫描有助于提高肝脓肿诊断符合率。     

肝癌射频治疗的CT影像分析

目的CT评价集束电极射频治疗肝癌的早期效果。方法采用CT增强扫描对45例肝癌患者集束电极射频治疗前后肿瘤大小和密度的变化、肿瘤凝固性坏死区的范围及治疗后增强扫描的特征进行观察。结果集束电极射频治疗后30d,45例肝癌患者57个肿块进行CT复查,28%（16/57）的肝癌病灶缩小,47%（27/57）的肝癌病灶大小无变化,25%（15/57）的肝癌病灶较术前增大,与治疗前相比无统计学差异。治疗后≤5cm的病灶增大占29%（9/31）,＞5cm的病灶增大占23%（6/26）。病灶的CT值均减低约15HU左右,与治疗前相比有统计学差异（P＜0．05）,71.9%（41/57）的病灶呈完全凝固性坏死,增强扫描表现为坏死区域无强化。结论CT对肝癌集束电极射频治疗前后肿瘤的大小和密度变化以及肿瘤凝固性坏死大小的观察,给肝癌射频治疗效果及预后提供重要指标,为重复治疗提供依据。     

Hepatic perfusion CT imaging analyzed by the dual-input one-compartment model

AIM: To improve liver-perfusion imaging by using the dual-input one-compartmental model. METHODS: Single-level dynamic computed tomography (dynamic CT) was taken at the height of the hepatic hilum after a rapid intravenous injection using 40 ml of iodinated contrast material. From the time-density curve of each pixel on CT, we calculated blood-flow rate constants of liver inflow and outflow. For inflow, two constants were calculated at arterial and portal veins. We postulated that blood flow between hepatic vessels and the hepatic parenchyma could be analyzed by using the calculated constants, and made equations for liver perfusion mapping. The perfusion images obtained by this method were compared with those made by the maximum slope method. RESULTS: We applied the method to a patient with hepatolithiasis. On dynamic CT, there was an abnormal enhancement pattern in the posterior segment of the liver. Perfusion CT images made by the dual-input one-compartment model demonstrated abnormal portal perfusion of the liver. In contrast, those made by the maximum-slope method did not represent the perfusion pattern well. CONCLUSION: The dual-input one-compartmental model makes it possible to obtain more detailed information on liver hemodynamics.