三维可视化技术在合并肝动脉变异的胰十二指肠切除术中的应用

Application of three-dimensional visualization technology in pancreaticoduodenectomy for patientswith variant hepatic artery

目的研究医学图像三维可视化系统（MI-3DVS）在合并肝动脉变异的胰十二指肠切除术患者诊治决策中的价值。方法2010年1月至2012年7月，将114例行PD术患者的腹部64层螺旋CT薄层扫描数据导入MI-3DVS进行程序化分割、配准及三维重建。根据3D模型分别观察变异肝动脉的起源、走行等情况和腹部脏器及血管不同组合下的立体解剖关系，制定术前规划，最后与术中探查结果和术后腹腔动脉DSA结果相对照。结果腹部脏器3D模型可清楚显示肿瘤的大小及形态、血管的起源及走行、肿瘤与脏器及血管的立体解剖关系，共诊断变异肝动脉14例，包括替代肝右动脉起自肠系膜上动脉者9例（7．9％），替代肝总动脉起自肠系膜上动脉3例（2．6％），替代肝左动脉起自胃左动脉2例（1．8％）。和术中探查及术后DSA检查对比，MI-3DVS对变异肝动脉诊断的敏感度、特异度和准确率均为100％。14例肝动脉变异患者均行标准的胰十二指肠切除术，MI-3DVS指导下的术前规划与术中探查结果均相符合，术后无肝脓肿、胆漏、肝功能衰竭等严重并发症发生。结论MI-3DVS可以在胰十二指肠切除术前对变异肝动脉做出准确诊断，对个体化手术方案的制定提供详实的术前指导，增加手术成功率，减少术后并发症的发生。

Objective To explore the application value of the MI-3DVS in patients with hepatic artery variation receiving duodenopancreatectomy. Methods A total of 114 patients who had undergone pancreatoduodenectomy were retrospectively summarized and analyzed during January 2010 to July 2012. The clinical data of 64-slice muhidetector CT angiography （64-MDCTA） scanning was introduced into MI-3 DVS for procedural segmentation, registration and 3-dimensional reconstruction. Based on the reconstructed 3-dimensional model, the origination and bifurcations of variant hepatic artery was observed. And its anatomical relationships with abdominal organs and vessels were also observed. Thereafter, preoperative procedures planning was formulated. The findings were compared to those found during the operation and by postoperative digital subtraction angiography （DSA） of coeliac artery. Results The abdominal 3D models can clearly display the size and shape of tumor, the origin and course of the blood vessels, as well as the 3D anatomic relationship between tumors and organs, blood vessels. A total of 14 cases （12. 3% , 14/114 ） were found with variant, including 9 cases （7.9%） with replaced right hepatic artery arising from superior mesenteric artery, 3 cases （ 2. 6% ） with replaced common hepatic artery arising from superior mesenteric artery, 2 cases （1.8%） with replaced left hepatic artery arising from left gastric artery. The 14 patients all received standard procedures of duodenopanereatectomy. Compared to the intraoperative findings and postoperative DSA examination, the sensitivity, specificity and accuracy of MI-3DVS to variant hepatic arteryis 100%. The preoperative planning guided by MI-3DVS is in line with the intraoperative findings. No postoperative complications occurred in all 14 patients, including hepatic abscesses, biliary fistula and liver failure. Conclusions MI-3DVS can accurately diagnose hepatic artery variation before duodenopancreatectomy. Therefore, it contributes to the formulation of preoperative surgical plans. It also increases the success rate of the surgical operations and decreases the occurrence of postoperative complications.