三维可视化系统联合纤维胆道镜在肝胆管结石病治疗中的应用

Application of three-dimensional visualization system combined with choledochofiberscope for the treat- ment of hepatolithiasis

目的探讨三维可视化系统联合纤维胆道镜在肝胆管结石病治疗中的应用价值。方法回顾性分析2012年1月至2013年1月厦门大学附属成功医院收治的30例肝胆管结石病患者的临床资料。所有患者术前行CT检查，应用IQQA—Liver系统将CT二维图像转换成三维图像，了解结石的位置及与周围毗邻关系。在三维图像上制订预手术方案，测量肝脏体积、预切除肝脏体积。术中采用传统方法取石联合使用纤维胆道镜行胆管探查、冲洗，胆道镜下碎石、取石。术后比较实际手术方案与预手术方案的区别。复查CT计算结石残留率，计算实际切除肝脏体积。实际切除肝脏体积与术前预切除肝脏体积的相关性检验采用Pearson等级相关分析。结果30例患者均成功完成三维重建，其结果清楚地显示结石大小、位置及其与周围血管、胆管的毗邻关系。其中拟行胆总管切开取石24例，肝实质切开取石6例，肝部分切除术15例，胆管狭窄成形＋胆管空肠Roux-eB-Y吻合术16例。三维重建测得拟行肝部分切除术的15例患者肝脏体积为（1390±148）mL，预切除肝脏体积为（275±156）mL。术前三维可视化重建对胆管、结石及重要血管的解剖学评估结果与术中所见大致相符。30例患者实际行胆总管切开取石24例，肝实质切开取石6例，肝部分切除术15例，胆肠吻合16例。规划手术方案与实际手术方式符合率为100．0％（30／30）。患者均常规进行胆道镜探查，其中经胆道镜取石23例。术中实际切除肝脏体积为（261±148）mL。预切除肝脏体积的平均误差率为5．4％。术前预切除肝脏体积与术后实际切除肝脏体积呈正相关（r=0．902，P〈0．05）。患者手术时间为（121±65）min，术中出血量为（158±78）mL。30例患者术后均未出现胆汁漏，切口感染发生率为3．3％（1／30）。术后2周至3个月复查CT或胆道造影，证实结石取尽27例，结石残留率为10．0％（3／30）。结论三维可视化系统联合纤维胆道镜在肝胆管结石病治疗中具有一定的临床应用及指导价值。

Objective To investigate the clinical value of three-dimensional visualization system combined with choledochofiberscope in the treatment of hepatolithiasis. Methods The clinical data of 30 patients with hepatolithiasis who were admitted to the Chenggong Hospital of Xiamen University from January 2012 to January 2013 were retrospectively analyzed. The preoperative two-dimensional images of computed tomography （CT） was converted to the three-dimensional images by IQQA-Liver system. The location of the stones and their relationship with adjacent organs were learned. The surgical plan was made based on the three-dimensional images, and the liver volume and liver volume planed to be excised were measured. Bile duct exploration, washing, lithotripsy and lithotomy were performed using the traditional method combined with choledochofiberscopy. The rate of residual stones and actual volume of liver resected were calculated. The correlation between the volume of actual liver resected and predicted liver resection volume was analyzed by calculating the Pearson correlation coefficient. Results The three-dimensional reconstruction of the CT data of the 30 patients clearly displayed the size, location of the tumor, as well as its relationship with adjacent blood vessels and bile ducts. Surgical plan was made according tothe result of three-dimensional reconstruction, including 24 cases of choledochotomy, 15 cases of partial liver resection, and 16 cases of bile duct stricture repairment ＋ cholangioenterostomy. The volume of liver of the 15 patients who were planed to receive partial liver resection was （1 390 ＋ 148 ）mL, and the volume of liver planed to be resected was （275 ＋ 156） mL. Preoperative evaluation of the anatomy of blood vessels, stones and bile ducts based on three-dimensional images was confirmed with operative findings. In actual practice, there were 24 patients received choledochotomy, 6 received liver parenchyma cutting, 15 received partial liver resection and 16 received cholangioenterostomy. The agreement rate of the surgical plan and the actual practice was 1130.0% （30/30）. The actual volume of liver resected was （261 -＋ 148）mL. The mean error rate of the volume of liver planed to be resected was 5.4%. The predicted liver resection volume was positively correlated with the actual liver resection volume （ r = O. 902 ~ P 〈 0.05 ）. Exploration with choledochoscope was routinely performed, including 23 cases of lithotomy through choledochofiberscope. The operation time was （121 ＋ 65 ）minutes, and the volume of intraopera- tive blood loss was （ 158 ＋ 78） mL. No bile leakage was detected, and the incidence of incisional infection was 3.3% （1/30）. The results of CT or eholedochoscopy showed that the rate of residual stones after surgery was 10.0% （3/30）. Conclusion Three-dimensional visualization system combined with choledochofiberscopy is helpful in the treatment of hepatolithisis.