术中和经皮三维超声胆道造影技术在胆管解剖变异诊断中的价值

Intra-operative and percutaneous three-dimensional contrast-enhanced ultrasonic cholangiography in the diagnosis of biliary anomalies

目的 探讨术中和经皮三维超声胆道造影技术（three-dimensional contrast-enhanced ultrasonic cholangiography, 3D-CEUSC）对胆管变异的诊断能力和价值。方法 13例健康活体肝移植供体开腹术中胆囊管插管，14例因胆管梗阻性病变经皮留置T管或PTCD管，分别经引流管注入稀释的超声造影剂后，行术中3D-CEUSC或者经皮3D-CEUSC，评估可分辨的最高胆管分支级别、肝内第一、二、三级胆管分支的显示率及有无胆管解剖变异。结果 术中3D-CEUSC可显示的胆管最高分支级别的中位数是4级，而经皮3D-CEUSC为3级，两者之间差异有统计学意义（P=0.01）。术中3D-CEUSC对肝内第一、二、三级胆管分支的显示率依次为100%（23/23）、96.2%（50/52）和82.7%（86/104），经皮3D-CEUSC则为100%（24/24）、94.6%（54/56）和60.7%（68/112），第一、二级胆管分支两者比较差别无统计学意义（P值均为1），第三级胆管分支两者比较差别有统计学意义（P＜0.0001）。术中3D-CEUSC检出3例胆管变异，经皮3D-CEUSC检出4例胆管变异，均得到X线胆道造影的证实。结论 术中及经皮3D-CEUSC可以准确诊断胆管解剖变异，均可作为肝胆手术术前及术中评估胆道解剖的一种影像学技术。

Objective To investigate the role of intra-operative and percutaneous three-dimensional contrast-enhanced ultrasonic cholangiography （3D-CEUSC） in the diagnosis of biliary anomalies. Methods Diluted SonoVue, an ultrasonic contrast agent, was injected into the cystic duct of 13 living liver donors via a cannula for intra-operative 3D-CEUSC, while injection via a T tube or a PTCD tube were done in 14 patients for percutaneous 3D-CEUSC. The maximum branching order of the intra-hepatic bile ducts, the percentages of display of the first-, second-, and third-order intra-hepatic bile ducts, and the rates of detection of biliary anatomical anomalies were evaluated. Results The median of the maximum branching order of the intra-hepatic bile ducts shown was fourth-order on intra-operative 3D-CEUSC and third-order on percutaneous 3D-CEUSC, respectively. The difference was significant （P=0.01）. From the first- to the third-order of intra-hepatic bile ducts, the percentages of display for intra-operative 3D-CEUSC were 100% （23/23）, 96.2% （50/52） and 82.7% （86/104）, respectively, while they were 100% （24/24）, 94.6% （54/56） and 60.7% （68/112） for percutaneous 3D-CEUSC. The differences were not significant when comparing the first- and the second-order branches of intra-hepatic bile ducts as shown either on intra-operative or percutaneous 3D-CEUSC （P=1）. The percentages of display of the third-order branches using intra-operative 3D-CEUSC was higher than that of percutaneous 3D-CEUSC （P〈0.0001）. Three biliary anatomical anomalies were detected by intra-operative 3D-CEUSC and 4 anomalies were detected by percutaneous 3D-CEUSC. All of these anomalies were confirmed by X-ray cholangiography. Conclusion Both intra-operative and percutaneous 3D-CEUSC could diagnose biliary anatomical anomalies accurately. These procedures may become important techniques to evaluate the biliary anatomy in hepatobiliary surgery pre-operatively or intra-operatively.