螺旋CT三维成像在小儿巨大及复杂部位肝脏肿瘤诊治中的应用

目的应用螺旋CT三维成像辅助、指导小儿巨大肝脏肿瘤和复杂部位肝脏肿瘤的诊断及手术治疗。方法对近5年来肝脏巨大和位于肝门的复杂部位肝脏肿瘤18例进行分析、总结。10例使用螺旋CT三维成像检查。以辅助指导手术的具体操作。结果18例中肝右叶切除7例，右三叶切除3例，肝左叶3例，多发性1例，左三叶1例，3例为肝门部肝中叶或扩大肝中叶切除。其中肝母细胞瘤9例、畸胎瘤1例、肝细胞癌2例、肝腺瘤2例、错构瘤4例。10例三维成像者均获得清晰的肿瘤瘤体和与血管比邻关系的图像。16例行超过肝脏体积三分之一的肝叶切除，最大者切除瘤肝达4800g。全组成功手术切除，均康复出院。结论通过动态二三维立体的画面，特别是可以旋转的动态影像能清楚显示血管的走行、位置。对手术方案的选择、制定、肝脏切线的选择都提供很大的帮助。     

计算机辅助手术系统在儿童肝脏肿瘤根治术中的应用研究

目的研究计算机辅助手术系统(Computer-assisted surgery system,CAS)在儿童肝脏肿瘤根治术中的临床应用价值。方法对2015年10月至2017年3月在复旦大学附属儿科医院行肝脏肿瘤切除术的19例患儿术前利用CAS对CT图像进行三维重建。分析19例患儿的手术时间、术中出血量、术后ICU住院天数、肿瘤累及肝段数、血管变异以及肝脏体积剩余情况。结果 19例患儿手术时间为3.5(3.0,4.0)h,术中出血量为100(35,350)m L,术后ICU住院天数为1(1,2.7)d。在重建的19例患儿中存在门静脉变异,包括3例Ⅰ型,1例Ⅱ型,1例Ⅲ型。计算术后残留肝脏体积得出两段切除术的患儿剩余肝脏体积为68%～80%,左半肝切除术后患儿为57%～68%,右半肝切除术后患儿为53%～63%。结论术前三维模型重建能够为术者提供更加直观的解剖结构信息,提高手术切除的精准性,使得更多复杂肝脏肿瘤患儿获得手术根治切除的机会。     

不阻断肝门小儿巨大肝肿瘤切除术探讨

目的小儿巨大肝肿瘤切除术中，常规行肝门阻断，本研究对不阻断肝门行巨大肝肿瘤切除术进行探讨。方法从2001年7月至2004年12月，我院对16例患儿施行不阻断肝门巨大肝肿瘤切除术，患儿年龄28d～14岁，平均3．4岁。其中男12例，女4例，肿瘤直径11～23cm，平均14．6cm，其中右半肝和左外叶内分别有一肿块1例。肝母细胞瘤9例，肝错构瘤4例，肝血管瘤3例。结果本组16例患儿手术全部成功，不阻断肝门行右半肝（Ⅴ～Ⅷ）切除8例，右三叶切除4例，左三叶切除1例，左半肝切除1例，第二肝门及右下叶肝段切除各1例。患儿术中无死亡，血流动力学指标稳定。本组良性巨大肝肿瘤患儿术后随访7个月～3．5年，目前均健康生存，无肿瘤复发，生长发育正常；肝母细胞瘤9例患儿术后常规化疗，患儿已经随访6～45个月，目前无瘤生存8例，2年以上4例，肝功能正常，正常生活。另外1例左外叶和右叶同时发现肝母细胞瘤，手术分别切除后5个月脑肺转移，于术后7个月死亡。结论不阻断肝门巨大肝肿瘤切除术，是一种安全可行的手术。术者熟练的肝脏解剖知识和肝切除技术、紧密结合术前和术中影像学技术了解肿瘤与大血管关系、彻底结扎肿瘤侧入肝肝动脉和门静脉及肝左右静脉共干或肝右静脉，是手术成功的关键。     

累及肝门部小儿肝脏肿瘤的外科处理

目的 累及肝门的巨大和原发于肝门的小儿肝脏肿瘤往往被视为切除最为困难的肝脏肿瘤,本文探讨此类肿瘤手术术前判断的重要性和其可切除性及手术的安全性.方法 单独或同时累及第一、第二、第三肝门的巨大或原发于肝门的肝脏肿瘤27例,年龄3个月～15岁,平均5.2岁.男12例,女15例.23例手术切除,4例累及肝门的同时存在肝内多发性占位,家属放弃治疗.肿瘤主要压迫的为肝动、静脉根部、门静脉或/和肝后腔静脉;进腹允分暴露肿瘤后精细处理被肿瘤累及的肝门,然后在间歇件第一肝门阻断下切除肿瘤,切肝前根据需要预置腔静脉阻断带备用.结果 23例肝脏肿瘤均顺利切除,无手术死亡及严重并发症发牛;平均手术时间170 min,平均输血量120 ml;术后病理诊断:肝母细胞瘤10例、肝错构瘤5例、肝细胞癌4例、肝脏腺瘤2例、肝脏内皮细胞肉瘤1例、肝畸胎瘤1例.8例良性肝肿瘤术后随访11个月～9年均健康.15例恶性肿瘤中,6例于手术后5个月～2年半死于复发、转移或其他并发症,其余临床无瘤存活.结论 切除累及肝门的巨大或原发于肝门的小儿肝脏肿瘤虽具一定挑战性,但只要方法得当仍然是可行和安全的手术,提高恶性肿瘤的长期牛存率仍是今后努力的方向.     

计算机辅助手术系统三维成像与二维影像在小儿肝中叶肿瘤手术规划中的对比分析

目的通过与二维影像的对比, 分析计算机辅助手术系统三维成像在小儿肝中叶肿瘤术前手术规划中的临床指导作用。方法回顾性分析2016年1月至2021年6月在青岛大学附属医院行肝中叶肿瘤手术的23例患儿临床资料, 其中男16例, 女7例;手术时平均年龄为22.3个月。术前通过观察二维CT影像初步制定手术切除方案, 再对同一患儿行肝中叶肿瘤的三维成像, 由同资历医生进行深度分析并最终制定手术切除方案, 比较两种方案的差异。结果所有患儿均按照计算机辅助手术系统规划成功切除肿瘤, 所有患儿随访均获得良好的预后。其中9例患儿经三维重建评估后肿瘤与血管的特殊位置关系、血管变异程度或残肝体积的大小均与二维影响结果差异较大, 按三维成像修改手术方案后手术成功进行, 剩余残肝体积增大。结论计算机辅助手术系统三维成像对小儿肝中叶肿瘤术前手术规划效果明显优于二维影像。     

基于计算机辅助手术系统的儿童肝脏肿瘤与门静脉关系的影像学分析

目的对儿童肝脏肿瘤与门静脉重要分支的位置关系、压迫、侵袭情况进行医学数字影像分析,探讨海信CAS系统在儿童肝脏肿瘤手术中的临床价值。方法收集2015年1月至2016年12月间由青岛大学附属医院及浙江大学医学院附属儿童医院收治的56例肝脏肿瘤患儿的CT数据。其中男童30例,女童26例,年龄1个月至12岁,平均年龄5.5岁;肝母细胞瘤42例,肝细胞癌5例,婴儿型血管内皮细胞瘤5例,间叶性错构瘤1例,未分化肉瘤1例,畸胎瘤肝转移2例;运用海信CAS系统对其增强CT数据进行三维重建,对肝脏肿瘤及门静脉分支的位置关系、压迫、侵蚀情况进行分析,虚拟手术切除肿瘤,测量残余肝脏体积并计算残余肝脏体积百分比。结果 56例患儿中,肿瘤位于肝左叶7例,其中肿瘤侵犯门静脉左支主干(门静脉2级分支)6例,肿瘤侵犯门静脉左支3级分支1例;肿瘤位于肝右叶40例,其中肿瘤侵犯门静脉右支主干(门静脉2级分支)33例,肿瘤侵犯门静脉右支3、4级分支7例;肿瘤位于肝中叶8例,其中肿瘤侵蚀门静脉左支、右支主干(门静脉2级分支)5例,肿瘤未侵蚀门静脉左支、右支主干(门静脉2级分支),仅对门静脉左支、右支主干(门静脉2级分支)形成压迫3例;全肝病变1例。结论利用海信CAS系统进行三维重建所得的数字模型能够清晰、准确地显示小儿肝脏肿瘤与门静脉分支的关系,对儿童肝脏手术有重要的指导意义。     

64排CT在左外叶小儿活体肝移植中移植肝体积测量中的应用

目的 探讨应用64排CT测量左外叶小儿活体肝移植供肝体积与手术中实际切除肝重量的相关性,建立回归方程,为术前估计肝切除重量提供依据.方法 对我院12例左外叶小儿活体肝移植供体肝脏64排CT肝薄层扫描肝静脉期图像进行重建,相应软件计算肝脏体积,换算供肝重量,并与手术中实际切除肝脏重量对比,采用SPSS 15.0进行直线回归分析,并建立回归方程.结果 64排CT肝体积测量值(281.99±52.10)ml与术中切除肝组织重量(248.70±49.46)g存在差异(P<0.05)并显著相关(R=0.905,P<0.001);建立回归方程W术中(g)=0.860×V术前(ml)+6.368.结论 64排CT可用于左外叶小儿活体肝移植术前供肝体积测量,应用回归方程,可较准确地预测术中移植物重量,可为术前确定肝切除范围提供重要参考.     

26例婴儿肝脏肿瘤的临床与病理相关性分析

目的 探讨婴儿肝脏肿瘤的临床病理特点及肿瘤标志物水平与组织病理类型之间的关系.方法 回顾性分析2000年4月至2010年4月本院收治的26例肝脏肿瘤婴儿的临床病理资料.结果 26例肝脏肿瘤患儿中,23例行一期手术,术后均经组织病理检查确诊.其中肝脏恶性肿瘤16例,以肝母细胞瘤为主（15/16）;肝脏良性肿瘤7例,以肝血管瘤（3/7）和肝错构瘤为主（3/7）.婴儿肝脏恶性与良性肿瘤比为2.29∶1,发病以恶性肿瘤为主,但肝脏良恶性肿瘤之间年龄分布及临床表现比较无统计学意义（P＞0.05）.肝脏恶性肿瘤婴儿AFP水平明显超出同年龄段正常水平,与良性肿瘤相比,AFP阳性率差异有显著统计学意义（P=0.007）.结合术后病理结果,患儿术前诊断正确率达95.65%.23例手术患儿肿瘤均成功切除,3例患儿家长放弃治疗.讨论婴儿肝脏良恶性肿瘤的临床表现缺乏特异性,首发症状以腹部肿块多见.多数肝脏肿瘤患儿尽管肿瘤巨大,病变累及肝门,但肿瘤周围多有假性包膜形成,其与肝门的关系往往是推挤压迫,而不是浸润包埋,肿瘤多可成功手术切除.监测不同年龄段患儿AFP水平,并与生理性AFP水平进行比较,有助于婴儿肝脏肿瘤的早期诊断及良恶性鉴别.     

不阻断肝门肝切除在小儿肝脏肿瘤切除术中的应用

小儿肝脏肿瘤主要以肝母细胞瘤、肝血管瘤、肝错构瘤多见。肝叶切除目前仍是肝脏原发和继发性肿瘤治疗的最佳治疗手段。常规阻断肝门会造成肝脏缺血、回心血量下降，影响肝脏功能恢复和引起血液动力学改变。我们自2001年1月至2007年5月采用不阻断肝门规则性肝切除技术治疗小儿肝脏肿瘤37例，手术肿瘤完整切除率100％，手术期间的死亡率为零，术后无肝功能衰竭，现总结探讨不阻断肝门肝切除的应用。     

常温下长时间阻断入肝血供和选择性阻断肝静脉在小儿肝脏肿瘤切除术中的应用

小儿肝脏肿瘤切除术中的主要危险是大出血，笔者根据小儿肝脏解剖和生理特点，采用长时间阻断入肝血供及选择性阻断肝静脉行肝脏肿瘤切除术１５例。该方法便于操作，术中出血量明显减少，术后患儿恢复顺利，无并发症。临床观察小儿肝脏温缺血时限可达５２分钟。     

Clinical applications of computerized tomography 3-D reconstruction imaging for diagnosis and surgery in children with large liver tumors or tumors at the hepatic hilum

The present study assessed the benefits of 3-D reconstruction of spiral computerized tomography (CT) scans for the diagnosis of and surgical guidance to large liver tumors or tumors at the hepatic hilum. We retrospectively analyzed the cases of 18 children with large liver tumors or with tumors at the hepatic hilum treated in past 5 years. The ages ranged from 45 days to 14 years. Ten cases were examined using the three-dimensional reconstruction using 64 slice spiral CT and eight patients underwent conventional CT or conventional enhanced CT scanning. In 16 cases, the volume of tissue removed exceeded one-third the entire volume of the liver (considered “large” tumors). The largest tumor removed weighed 4.8 kg. In two cases, the excised tissue represented less than one-third of the total liver volume, but in these cases the location of the tumor was considered “complex” due to the proximity to major hepatic vessels. Seven tumors were located in the right lobe, three in the left lateral segment, three in medial segment, three extended beyond the right lobe and two extended beyond the left lateral segment. Pathological diagnoses included hepatoblastoma (n = 9), hepatocellular carcinoma (n = 2), mesenchymal hamartoma (n = 4), teratoma (n = 1) and adenoma (n = 2). The 3-D reconstructed images could be rotated to view the image from several sides, were semitransparent and allowed for the measurement of tumor size and determination of spatial relation to blood vessels. All 18 children had curative resections as indicated by “tumor-free” microscopic margins. No major intra- or postoperative complications were encountered. Three-dimensional CT imaging can provide high quality images of the tumors and location of the tumor relative to vital hepatic blood vessels. This technique offers a kind of comparatively accurate method compared with traditional imaging techniques, it could help the surgeon identify the tumor borders accurately and devise a comparative safe surgical strategy. With its help the surgeon could identify vital hepatic blood vessels before operation, so they can avoid massive hemorrhaging and avoid massive hemorrhaging during operation. This technique should be more widely applied in the resection of large or complex liver tumors.     

Liver transplantation for a hilar inflammatory myofibroblastic tumor

A 7-yr-old boy presented with obstructive jaundice secondary to an inflammatory myofibroblastic tumor centered on the hepatic hilum and extending into the liver. The tumor was further complicated by portal vein phlebitis and occlusion. Attempted resection of the tumor with portal vein reconstruction and bilioenteric drainage was unsuccessful and he required urgent orthotopic liver transplantation. In contrast to more peripheral inflammatory myofibroblastic tumors in the liver, hilar lesions are locally aggressive, causing occlusive portal phlebitis and biliary obstruction. Successful management may include the need for liver transplantation.     

小儿腹腔镜下肝切除术4例

目的报告4例小儿腹腔镜肝切除术的临床经验。方法采用4—5mm套管,腹压10—12mmHg。解剖性肝左叶切除在肝外游离结扎肝左动脉和门静脉左支。超声刀离断浅部肝实质,深部用CUSA解剖出管道、Ligasure凝切,线型Endovascular离断肝静脉。非规则性肝切除不阻断或解剖肝门。切除标本套袋后经扩大的脐部或下腹部Trocar切口取出。结果男女各2例,年龄3个月至4岁,手术时间100～340min,出血量20一200mL。无术中术后并发症。肝肉芽肿患儿随访6年未发现其他部位肉芽肿,肝血管瘤随访5个月无症状。2例肝母细胞瘤患儿中,1例正在化疗中,另1例采取观察随访。结论选择合适病例,小儿腹腔镜肝切除术安全可行。     

Use of a donor iliac vein graft for reconstruction of the inferior vena cava in liver transplantation for hepatoblastoma with caval extension

Complete microscopic tumor resection is critical for successful treatment of hepatoblastoma, and this may include when liver transplantation is required. For tumors involving the IVC or PV, complete resection should include the involved IVC or PV to ensure full tumor clearance. When this is required, the venous reconstruction at transplant or post‐excision can be challenging. We present the management of an 18‐month‐old girl with PRETEXT Stage IV (P, V, F) hepatoblastoma and IVC involvement, where native caval resection and reconstruction was required. The preoperative staging following neoadjuvant chemotherapy was POSTTEXT Stage IV (P, V, F). An orthotopic liver transplantation was performed using a left lateral segment graft from a deceased adult donor. With native hepatectomy, retrohepatic IVC resection from just above the hepatic venous confluence to just above the entry of the right adrenal vein was performed. For caval reconstruction, a venous graft from a deceased donor was used. The graft included the lower IVC with the right common iliac vein and a short stump of the left common iliac vein. The common iliac was a perfect size match for the IVC, and the three natural ostia matched the upper cava, lower cava, and the outflow from the donor left hepatic vein. The patient had an uneventful postoperative course and remains well and disease‐free 2 years after transplant with continued patency of the reconstructed cava. When indicated, a donor iliac vein graft with its natural ostia should be considered in caval reconstruction for pediatric liver transplantation.     

临时性门腔静脉架桥联合流出道改良重建在部分供肝肝移植中应用的实验研究

目的 通过动物肝移植实验,探索门腔静脉架桥和改良肝静脉出口重建这一联合方法的可行性及价值.方法 选择20～25 kg和10～15 kg健康杂交犬各12只,组成供体组和受体组,并随机配对.供体手术取左外侧叶及左中央叶为供肝,然后完全阻断门静脉.受体犬先预置门腔静脉之间端侧吻合架桥的分流通道,切肝门静脉阻断时开放,供肝植入...     

联合肝脏离断和门静脉结扎二步肝切除术在儿童肝肿瘤治疗中的应用

联合肝脏离断和门静脉结扎的二步肝切除(associated liver partition and portal vein ligation for staged hepatectomy,ALPPS)手术方案具有短期内残肝体积迅速增大的特点,在预估残肝体积(future liver remnant,FLR)不足的成人肝肿瘤手术中已获得推广。儿童肝脏肿瘤往往体积相对较大,尤其是肝母细胞瘤常侵犯多个肝段,或占据肝脏中央解剖部位,存在根治性肝切除术导致FLR不足的情况,有实施这一术式的价值。目前ALPPS在儿童肝脏肿瘤中的应用尚处于起步阶段。一般认为,术前评估FLR30%的病例可考虑实施本术式;术前应对患儿肝体积、肝功能以及肿瘤的可切除性进行精准评估;两次手术间隔时间以7~14 d为宜。手术并发症主要包括肝功能不足、出血和胆漏。关于儿童肝肿瘤中该术式的临床疗效评估尚待进一步总结。     

应用后腹腔镜技术切除肾上腺肿瘤

目的探讨经后腹腔镜手术治疗小儿肾上腺肿瘤的可行性及临床疗效。方法2001年1月至2011年12月,作者收治10例腹部肿物患儿,其中男4例,女6例,年龄23~54个月,平均年龄37个月,影像学检查显示肾上腺区占位性病变,8例位于右侧,2例位于左侧。肿物直径3~4cm,平均32cm。均接受后腹腔镜下肾上腺肿物切除术。术后对所有患儿进行跟踪随访。结果患儿手术过程均顺利,手术时间130~160min,平均137min,术中出血少,无一例输血。术后第1天进食水,术后住院时间5~9d,平均6d。无腹膜后血肿或出血等并发症发生。病理检查结果：1例为神经节细胞瘤,9例为节细胞性神经母细胞瘤。所有患儿获随访2～94个月,平均48个月,均存活,生长发育正常, B超、CT等检查无复发。结论应用后腹腔镜手术治疗小儿肾上腺肿瘤安全有效,值得推广。     

Clinical application of a three-dimensional imaging technique in infants and young children with complex liver tumors

Introduction

Three-dimensional (3D) imaging instead of two-dimensional (2D) computed tomography (CT) for diagnosis and preoperative planning in infants and young children with complex liver tumors is a promising technique for precision hepatectomy.

Methods

This study was a retrospective analysis of 26 infants and young children with giant liver tumors involving the hepatic hilum who underwent precise hepatectomy at the Affiliated Hospital of Qingdao University between February 2012 and January 2015. All patients received upper abdominal contrast-enhanced CT scanning before surgery. 16 patients used Hisense CAS system for 3D reconstruction as the reconstruction group. While ten patients underwent 3D CT reconstruction by the CT Workstation as the control group. The clinical outcomes were analyzed and compared between the two groups. The 3D reconstruction of abdominal organs and blood vessels was generated using the Hisense CAS system. Diagnosis and preoperative planning assisted by the system was used for preoperative and intraoperative decision-making for precise hepatectomy.

Results

All patients underwent successful surgery. The 3D models clearly demonstrated the association of liver tumors with the intrahepatic vascular system and provided a preoperative assessment of resectability, assisting surgeons in preoperative procedural planning. Anatomic hepatectomy was successfully completed in the reconstruction group. The mean operation time was shorter in the reconstruction group (137.81 ± 17.51 min) than in the control group (192 ± 34.66 min) (P < 0.01). The mean intraoperative blood loss was lesser in the reconstruction group (21.81 ± 14.05 ml) than in the control group (53.50 ± 21.35 ml) (P < 0.01). The difference was statistically significant.

Discussion

2D CT scan images cannot accurately display the spatial relationship between the tumor and surrounding vasculature. The 3D reconstruction model used in this study gave detailed and accurate anatomical information and allowed for the assessment of tumor resectability and provided a detailed road map for preoperative decision-making and predicted the postoperative liver function.

Conclusions

3D visualization technology provides preoperative assessment and allows individualized surgical planning. Surgical controllability, accuracy, and safety can be improved in infants and young children undergoing precise hepatectomy for complex liver tumors.

     

儿童囊性肾瘤和囊性部分分化型肾母细胞瘤的诊治分析

目的总结儿童囊性肾瘤和囊性部分分化型肾母细胞瘤的临床、病理特点,探讨合理的治疗方法。方法回顾性分析本院收治的7例儿童囊性肾瘤、6例囊性部分分化型肾母细胞瘤患儿的临床资料,包括年龄、临床表现、影像学及病理检查结果、治疗和预后。结果13例患儿中,男8例,女5例,年龄4个月至4岁,平均1岁7个月。左侧6例,右侧5例,双侧2例。腹部包块9例,B超偶然发现4例,术前均行B超和增强CT检查。5例7侧行肿瘤剜除术,8例行瘤肾切除术。术后随访6个月至7年,未见肿瘤复发,保留肾脏的5例中,7侧残肾功能良好。结论囊性。肾瘤和囊性部分分化型肾母细胞瘤患儿术前无法鉴别,手术完整切除是主要的治疗方法,肿瘤位于肾脏一极或双侧者可行保留肾脏的肿瘤剜除术。囊性肾瘤为良性病变,术后无需化疗,囊性部分分化型。肾母细胞瘤为低度恶性或潜在恶性,Ⅰ期者可单纯手术治疗,Ⅱ期以上需行手术＋化疗。