三维可视化联合3D打印在Bismuth-Corlette III、IV型肝门部胆管癌个体化精准外科治疗中的应用

目的 探讨三维可视化3D打印在Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌个体化精准外科治疗中的应用价值。方法 回顾性分析南方医科大学珠江医院肝胆外科2016年5月~2019年3月在三维可视化3D打印指导下10例肝门部胆管癌外科手术治疗患者。收集患者薄层CT数据，进行三维重建后打印3D模型，观察肿瘤与肝内胆管、肝动脉、门静脉和肝静脉系统的三维立体关系，进行术前模拟手术并制定手术方案，将3D打印模型带入手术室进行术中实时导航，指导手术治疗。结果 10例患者均成功构建三维可视化打印3D模型，进行 Bismuth-Corlette三维可视化分型：Ⅲa型4例、Ⅲb型4例、Ⅳ型2例，其中门静脉变异4例，肝动脉变异3例。门静脉“三分叉”变异2例；“工字型”变异1例；1例罕见的门静脉右前支缺如变异；2例既有门静脉变异又出现肝动脉变异。肝动脉变异3例，1例肝左动脉起自胃左动脉，2例肝右动脉起自肠系膜上动脉。其中Ⅲb型4例行左半肝切除术; Ⅲa型4例行右半肝切除；Ⅳ型1例行围肝门区域切除，1例行左半肝切除术。此组患者术前三维可视化3D打印模型及术前规划与术中情况均一致。手术时间452±75.12 min，术中出血量356±62.35 mL，术后住院时间15±4.61 d。术后出现胆漏1例,少量胸腔积液3例，经通畅引流及内科治疗后康复出院，围手术期无肝功能衰竭及死亡病例。结论 三维可视化联合3D打印对Bismuth-Corlette Ⅲ、Ⅳ肝门部胆管癌进行准确的术前评估、手术规划，优化手术方案，尤其在肝内血管变异情况下，有助于提高手术安全性，降低手术风险。

Application of 3D visualization and 3D printing in individualized precision surgery forBismuth-Corlette type III and IV hilar cholangiocarcinoma

Objective To explore the application of 3D visualization and 3D printing in individualized precision surgicaltreatment of Bismuth-Corlette type III and IV hilar cholangiocarcinoma. Methods We retrospectively analyzed the data of 10patients with hilar cholangiocarcinoma undergoing surgeries under the guidance of 3D visualization and 3D printing in theDepartment of Hepatobiliary Surgery, Zhujiang Hospital from May 2016 to March 2019. Thin-section CT data of the patientswere collected for 3D reconstruction and 3D printing, and the 3D printed models were used for observing the 3D relationshipof tumor with the intrahepatic bile duct, hepatic artery, portal vein and hepatic vein system and for performing preoperativesimulated surgery and surgical planning. The 3D printed models were subsequently used for real-time intraoperativenavigation to guide surgeries in the operating room. Results 3D visualization models were successfully reconstructed for allthe 10 patients and printed into 3D models. The 3D visualization types in Bismuth-Corlette classification included type IIIa (4cases), type IIIb (4 cases), and type IV (2 cases); 4 patients showed portal vein variation, 3 had hepatic artery variation, and 2had both portal vein and hepatic artery variations. Two patients were found to have trifurcation type of portal vein variation,one had "I-shaped" variation, and one showed the absence of the right anterior branch of the portal vein; 3 patients had hepaticartery variations with the left hepatic artery originating from the left gastric artery (1 case) and the right hepatic arteryoriginating from the superior mesenteric artery (2 cases). Four patients with type IIIb underwent left hepatectomy; 4 with typeIIIa received right hepatectomy; 1 patient with of type IV received peripheral hepatic resection and another underwent lefthepatectomy. The results of preoperative 3D reconstruction, 3D printed model and preoperative planning were consistent withthe intraoperative findings. The operative time was 452±75.12 min with a mean intraoperative blood loss of 356±62.35 mL and amean hospital stay of 15 ± 4.61 days in these cases. One patient had bile leakage and 3 patients had pleural effusionpostoperatively, and they were discharged after drainage and medications. No liver failure or death occurred in these casesperioperatively. Conclusion 3D visualization and 3Dprinting can facilitate accurate preoperative assessment,surgical planning and surgical procedure optimization forBismuth-Corlette type III and IV hilar cholangiocarcinomato improve surgical safety and reduce surgical risksespecially in cases of intrahepatic vascular variations.