门静脉左支矢状部邻近解剖结构的二维与三维影像术前评估

Preoperative evaluation on the anatomical structures adjacent to the umbilical portion of the left por- tal vein using two-dimensional and three-dimensional imagings

目的分析门静脉矢状部（U点）邻近解剖的影像学特征，探讨其对肝门部胆管癌诊治的影响。方法回顾性分析2014年1月至2016年2月于我院收治的47例肝门部胆管癌BismuthI、Ⅱ、ⅢIa型患者影像学资料，47例均行上腹部增强CT检查及三维图像重建。结果肝Ⅱ段胆管（B2）、Ⅲ段胆管（B3）及Ⅳ段胆管（B4）汇合方式与u点关系：31例患者（65．9％）B2与B3汇合于U点后方或左侧，4例（8．5％）汇合于u点右侧；6例（12．8％）B4与B3于u点右侧汇合，B2再汇入形成左肝管；6例（12．8％）存在少见的汇合方式。B4汇入方式：10例（21．3％）呈中央型；35例（74．5％）呈周围型；2例（4．2％）呈混合型。经三维图像测量左侧尾状叶分支（B11）与B2、B3汇合部距离：汇合部在u点左侧或后方时为（31．6±6．2）mm，在右侧时为（13．7±4．7）mm，两者差异有统计学意义（P〈0．05）；B11与B4开M处距离：中央型和混合型为（7．1±2．0）mm，周围型为（16．4±4．0）mm，差异有统计学意义（P〈0．05）。肝左动脉：4例（8．5％）存在起源异常，6例（12．8％）存在走行异常。二维影像与三维重建在胆管汇合方式及肝左动脉判断方面一致性极好。结论熟悉U点邻近的解剖对于肝门部胆管癌术前评估及预判至关重要。动态观察其二维影像可完成精准的术前评估，但对于复杂的病例，三维重建能够实现更好的手术规划。

Objective To study the anatomical variations adjacent to the umbilical portion of the left portal vein （U-point） radiologically and to determine their impact on treatment of hilar cholangiocarcino- ma （HCCA）. Methods From January 2014 to February 2016, 47 consecutive patients who were diagnosed to suffer from Bismuth type Ⅰ ,Ⅱ or Ⅲ a HCCA in our institution were retrospectively studied. All these pa- tients underwent enhanced CT examination preoperatively and three-dimensional （3D） models were then re- constructed. Results Any variations of the left biliary system in relation to the U-point were analyzed. The findings showed that： B2 and B3 united above or lateral to the U-point in 31 patients （65.9%） ; B2 and B3 united medial to the U-point in 4 patients （8.5%） ; and B4 converged into B3 prior to B2 in 6 patients （ 12. 8% ）. Rare variations were observed in 6 patients （ 12.8% ）. For the confluence pattelaas of B4 ： the central type was found in 10 patients （21.3%） , the peripheral type in 35 patients （74.5%） and the com- bined type in 2 patients （4.2%）. Analysis of the relationship between Bll and the confluence of B2 and B3 showed the distance to be （31.6±6.2） mm in the above or the lateral patterns and （13.7 ±4.7） mm in the medial pattern. The difference was significant （P 〈0.05）. The distance from Bll to B4 was （7. 1 ± 2. 0） mm in the central and combined types but （16.4 ± 4.0） mm in the peripheral type. The difference was significant （ P 〈 0.05 ）. The left hepatic artery showed variations in the origin and course pattern in 4 （8.5%） and 6 patients （12.8%） , respectively. The two-dimensional （2D） and 3D imagings showed ex- cellent consistency in the evaluation of variations of the left biliary system in relation to the U-point and the left hepatic artery. Conclusions It is very important to know the variations of the left biliary and the vascu- lar systems adjacent to the U-point in preoperative evaluating on reseetability of HCCA. An accurate assess- ment could be accomplished using 2D imaging alone. However, 3D reconstruction is a useful technique to use in complex case with locally advanced tumors.