三维重建术前规划在腹腔镜超声引导的肝癌射频消融术中的应用探讨

Significance of three-dimensional reconstruction as a method of preoperative planning of laparoscopic radiofrequency ablation

目的 探讨三维重建术前规划对腹腔镜超声引导下肝癌射频消融术的意义.方法 2014年1月至2015年12月解放军总医院肝胆外科连续对32例肝癌患者的肝脏进行三维重建,并根据三维重建模型进行术前规划,以指导腹腔镜下射频消融术（LRFA）（3D-LRFA组）;按照1：2的比例配对同期开展的未经术前三维重建规划的腹腔镜超声引导下LRFA的64例患者资料（LRFA组）.采用多层螺旋CT对3D-LRFA组患者进行肝胆胰平扫＋三期增强扫描检查,通过IQQA（R）-Liver肝脏评估和介入治疗计划辅助系统完成肝脏三维重建图像.测量三维重建系统中肿瘤的最大径和范围,选择合适的射频针型号（长度和射频长轴径）和针数,模拟射频效果和范围,规划设计合理的针道,设计引导射频针进针的腹腔镜超声探查角度、模拟超声探查融合图像.收集两组患者术中及术后数据,两组资料之间计量资料的比较采用t检验或秩和检验,计数资料采用x2检验或Fisher确切概率法分析.患者的肿瘤复发和生存情况用Kaplan-Meier法绘制生存曲线,行Log-rank （Mantel-Cox）检验.结果 与LRFA组[（216.8 ±66.2）min、（389.1±183.4）s]相比,3D-LRFA组的手术时间[（173.3±59.4） min]和进针时间[（242.2±90.8）s]均明显缩短（t=-3.138,P=0.002;t=-2.340,P=0.021）.两组术中出血量（P =0.170）、首次消融符合率（P =0.871）、术后Clavien-Dindo Ⅰ～Ⅱ级和Ⅲ级并发症发生率（P=0.181）的差异均无统计学意义.3D-LRFA组术后住院时间[（4.3±3.1）d]较LRFA组[（6.3±3.9）d]短（t=-2.527,P=0.013）、术后ALT变化程度[（285±102） U/L]较LRFA组[（330±102） U/L]小（t=-2.038,P=0.044）、术后肿瘤坏死因子-α水平[（139 ±43） ng/L]较LRFA组[（167 ±64） ng/L]低（t=-2.233,P=0.028）.两组患者的无瘤生存期的差异有统计学意义（x2=4.049,P=0.044）.3D-LRFA组和LRFA组患者12个月无瘤生存率分别为77.6％和65.7％,LRFA组患者中位无瘤生存期为16.0个月,而3D-LRFA组大于24.0个月.结论基于患者真实影像信息的肝脏重建模型可在术前模拟患者肿瘤位置、重要管道结构、规划手术治疗的方案,节省LRFA术中进针时间、缩短手术时间、缩短平均住院日、延长无瘤生存时间.

Objective To discuss the significance of three-dimensional reconstruction as a method of preoperative planning of laparoscopic radiofrequency ablation （LRFA）.Methods Thirty-two cases of LRFA admitted from January 2014 to December 2015 in Department of Hepatobiliary Surgery,Chinese People＆#39;s Liberation Army General Hospital were analyzed （3D-LRFA group）.Three-dimensional （3D） reconstruction were taken as a method of preoperative planning in 3D-LRFA group.Other 64 LRFA cases were paired over the same period without three-dimensional reconstruction before the operation （LRFA group）.Hepatobiliary system contrast enhanced CT scan of 3D-RFA patients were taken by multi-slice spiral computed tomography（MSCT）,and the DICOM data were processed by IQQA（R）-Liver and IQQA（R）-guide to make 3D reconstruction.Using 3D reconstruction model,diameter and scope of tumor were measured,suitable size （length and radiofrequency length） and number of RFA electrode were chosen,scope and effect of radiofrequency were simulated,reasonable needle track （s） was planed,position and angle of laparoscopic ultrasound （LUS） probe was designed and LUS image was simulated.Data of operation and recovery were collected and analyzed.Data between two sets of measurement data were compared with t test or rank sum test,and count data with x2 test or Fisher exact probability test.Tumor recurrence rate was analyzed with the Kaplan-Meier survival curve and Log-rank （Mantel-Cox） test.Results Compared with LRFA group （（216.8±66.2） minutes,（389.1 ±183.4） s）,3D-LRFA group （（173.3 ±59.4） minutes,（242.2 ± 90.8） s） has shorter operation time（t =-3.138,P =0.002） and shorter mean puncture time（t =-2.340,P =0.021）.There was no significant difference of blood loss （P =0.170）,ablation rate （P =0.871） and incidence of complications（P =1.000）.Compared with LRFA group （（6.3 ± 3.9）days,（330 ± 102）U/L,（167 ±64） ng/L）,3D-LRFA group （（4.3 ± 3.1） days,（285 ± 102） U/L,（139 ± 43） ng/L） had shorter post-operative stay（t =-2.527,P =0.016）,less post-operation ALT changes （t =-2.038,P =0.048） and post-operative TNF-αt changes （t =-2.233,P =0.027）.Disease-free survival between two groups was significantly different （x2 =4.049,P =0.046）.Disease-free survival of 12 months survival rates were 77.6% and 65.7% in 3D-LRFA group and LRFA group,respectively.The median disease-free survival was 16.0 months in LRFA group and over 24.0 months in 3D-LRFA group.Conclusions Three-dimensional model of liver reconstruction based on image information is a powerful tool in liver surgery planning.It helps to simulate tumor location and vital tubular structure,make plan for interventional treatment,and therefore mean puncture time and operation time is shortened,influence on liver function is reduced,hospital stay is decreased and DFS is prolonged.