多排螺旋CT灌注成像联合术中超声检查在达芬奇机器人手术系统治疗胰岛素瘤中定位诊断的价值

Value of the combination of multi-slice spiral computed tomography perfusion scan and intraoperative ultrasonography for localizing insulinoma in the da Vinci robotic surgical system

目的 探讨多排螺旋CT灌注成像联合术中超声检查在达芬奇机器人手术系统治疗胰岛素瘤术中的定位诊断价值.方法 回顾性分析2013年7月至2014年7月北京协和医院收治的20例胰岛素瘤患者的临床资料.患者术前采用多排螺旋CT灌注成像检查评估,术中采用超声检查定位肿瘤,并依据肿瘤的不同位置采用达芬奇机器人手术系统施行手术.分析多排螺旋CT灌注成像联合术中超声检查对胰岛素瘤定位诊断的准确率,并记录患者的手术时间、术中出血量、围手术期并发症、手术前后血糖值等指标.术后采用门诊和电话方式随访,随访时间截至2014年7月31日.正态分布数据用（x）±s表示,偏态分布数据用M（范围）表示,计量资料采用t检验.结果 20例患者中共检出21个肿瘤,多排螺旋CT灌注成像定位诊断准确率为90.0％（18/20）,多排螺旋CT灌注成像联合术中超声定位检查诊断准确率为100.0％（20/20）.正常胰腺组织血流量值为（97±37）mL/（100 mL·min）,血容量值为（20±14）mL/100 mL,渗透性值为（38±22） mL/（100mL·min）.肿瘤组织血流量值为（170 ± 50） mL/（100 mL·min）,血容量值为（26±14） mL/100 mL,渗透性值为（51 ±42） mL/（100 mL·min）.其中肿瘤组织血流量值明显高于正常胰腺组织血流量值（=5.58,P＜0.05）,而血容量、渗透性值比较,差异无统计学意义（t=1.31,1.18,P＞0.05）.21个肿瘤位置分别位于：胰头部11个、胰体部6个、胰尾部4个.20例患者中,采用达芬奇机器人手术系统行胰岛素瘤摘除术19例（1例中转开腹手术）,采用达芬奇机器人手术系统行保留脾脏的胰体尾切除术1例.手术时间为（146±54）min,中位术中出血量为50 mL（20～1 000 mL）,患者无术后出血、感染、死亡等并发症发生.术后11例患者发生A级胰瘘、9例发生B级胰瘘.患者术前血糖为（3.8±1.0） mmol/L,术后60 min血糖为（6.4±1.8）mmol/L,两者比较,差异有统计学意义（t=6.69,P＜0.05）.截至随访日期所有患者临床症状消失,临床症状缓解率达100.0％（20/20）.结论 多排螺旋CT灌注成像联合术中超声定位能显著提高胰岛素瘤的检出率及定位诊断准确率,有利于提高达芬奇机器人手术系统治疗胰岛素瘤的手术疗效.

Objective To investigate the value of the multi-slice spiral computed tomograpby (MSCT) perfusion scan and intraoperative ultrasonography (IOUS) for localizing insulinoma in the da Vinci robotic surgical system.Methods The clinical data of 20 patients with insulinoma who were admitted to the Peking Union Hospital from July 2013 to July 2014 were retrospectively analyzed.The condition of the patients was evaluated by MSCT perfusion scan before operation,and the tumor was located by uhrasonograhy during the operation.The operation methods were selected according to the location of the tumors.The diagnostic accuracy of the MSCT perfusion scan and IOUS for locating insulinoma was analyzed,and the operation time,volume of intraoperative blood loss,perioperative complications,pre-and postoperative levels of blood glucose were recorded.Patients were followed up via out-patient cxamination and phone call till July 31,2014.The count data were presented by x ± s and were analyzed using the t test.Results Twenty-one insulinomas were detected in the 20 patients.The accurate rate of the MSCT perfusion scan was 90.0％ (18/20) in locating the tumor,and the accurate rate of the MSCT perfusion scan and intraoperative ultrasonography was 100.0％ (20/20).The blood flow,blood volume,permeability were (97 ±37)mL/(100 mL · min),(20 ± 14)mL/100 mL and (38 ±22)mL/(100 mL · min) in the normal pancreatic tissues,and (170 ±50)mL/(100 mL · min),(26 ± 14) mL/100 mL and (51 ±42)mL/(100 mL · min)in the tumor tissues.The blood flow of the tumor tissues was significantly higher than that of the normal pancreatic tissues (t =5.58,P ＜0.05),while no significant difference was detected in the blood volume and permeability between the tumor tissues and the normal pancreatic tissues (t =1.31,1.18,P ＞ 0.05).Eleven insulinomas were located at the head of the pancreas,6 at the body of the pancreas and 4 at the tail of the pancreas.Of the 20 patients,19 received enucleation of the insulinoma in the da Vinci robotic surgical system (1 of the them was converted to open surgery),and 1 patient received spleen-preserving distal pancreatectomy in the da Vinci robotic surgical system.The operation time and median volume of blood loss were (146 ±54) minutes and 50 mL (range,20-1 000 mL),respectively.No complications such as bleeding,infection or death occurred after the operation.Eleven patients were complicated with grade A pancreatic fistula and 9 with grade B pancreatic fistula.The levels of blood glucose before operation and at 60 minutes after the operation were (3.8 ± 1.0) mmol/L and (6.4 ± 1.8) mmol/L,with significant difference (t =6.69,P ＜ 0.05).The symptoms were dismissed at the deadline of the follow-up,with the remission rate of 100.0％ (20/20).Conclusion Combination of MSCT perfusion scan and IOUS could improve the diagnostic rate of insulinoma,and significantly increase the efficacy of da Vinci robotic surgical system for treating insulinoma.