超声造影在肝肿瘤热消融术中评估胆囊损伤的应用

The application of contrast-enhanced ultrasound in evaluating gallbladder injury during the thermal ablation of liver tumors

目的探讨超声造影在胆囊旁肝肿瘤的热消融术中评估胆囊损伤的价值。方法选取2016年1月至2017年3月在中山大学附属第三医院接受射频或微波消融治疗的患者40例,共42个胆囊旁肝肿瘤。采用常规超声检查评估患者术前术后胆囊壁厚度变化情况的同时,消融术中即时行超声造影检查评估胆囊壁血流灌注情况,判断胆囊壁损伤情况,并进行后续处理。通过随访评估胆囊旁肝肿瘤消融治疗的有效性、安全性。术前、术中及术后胆囊壁厚度的比较采用配对符号秩和检验。结果与消融术前比较,40例接受消融治疗患者的胆囊壁术中评估有8例患者胆囊壁明显增厚。术中超声造影检查除2例评估为胆囊壁血流灌注缺损外,其他患者胆囊壁灌注较好,这2例患者行腹腔镜胆囊切除术并病理证实胆囊壁热损伤坏死(其中1例出现胆囊穿孔),另有4例患者因多发胆囊结石行切除胆囊。34例保留胆囊患者中有6例在术后3 d内复查仍有胆囊壁增厚,后续随访中4例恢复,2例保持胆囊壁增厚状态,但均未出现胆囊消融热损伤相关症状。患者术中、术后的胆囊壁厚度与术前比较,差异均有统计学意义[5.00 mm(4.00~6.25 mm)vs 3.50 mm(3.00~5.00 mm),Z=-3.741,P<0.001;5.0 mm(3.0~8.0 mm)vs 3.5 mm(3.0~5.0 mm),Z=-3.735,P<0.001]。术后1个月增强CT/MRI检查证实41个病灶消融完全,完全消融率为97.6%(41/42),所有消融完全病灶至随访结束均未发生局部肿瘤进展。结论在超声引导下胆囊旁肝肿瘤消融术中即时行超声造影检查能够通过反映胆囊壁血流灌注状态判断胆囊壁消融热损伤情况。

Objective To discuss the value of contrast-enhanced ultrasound（CEUS） in evaluating gallbladder injury during the thermal ablation of liver tumors adjacent to the gallbladder. MethodsFrom January 2016 to March 2017, 40 patients with 42 hepatic tumors adjacent to the gallbladder who underwent ultrasonography-guided percutaneous microwave ablation or radiofrequency ablation in the Third Affiliated Hospital of Sun Yat-sen University were included in the study. Ultrasonography（US） was used to assess the change of gallbladder wall thickness before and after procedure. CEUS was used to assess the perfusion of gallbladder wall and determine the gallbladder injury immediately after ablation. Patients with bad perfusion of gallbladder wall accept combined treatment with cholecystectomy. The safety and therapeutic efficacy of the procedures were assessed in follow-up examinations. The change of gallbladder wallthickness were compared by signed ranks sum test. Results Assessed by US immediately after the ablations, gallbladder wall thickening adjacent to the ablated zone was noted in 8 of 40 patients. According the results of CEUS immediately after ablations, 38 patients was evaluated with good perfusion of gallbladder wall and 2 patients was evaluated with bad perfusion, who were treated with cholecystectomy. Perforation of the gallbladder was found in one of them. However, the necrosis of serosal tissue in gallbladder wall was confirmed by postoperative pathology. Another 4 patients with multiple gallbladder stones were also treated with cholecystectomy. Gallbladder wall thickening developed in six patients（17.6%） within 3 days after the ablation. Wall thickening showed complete disappearance on subsequent follow up US in 4 patients, and showed existence in 2 patients. However, complications related to the ablation such as acute cholecystitis and gallbladder perforation were not noted in 34 patients without cholecystectomy. There was significant difference in gallbladder wall thickness between preoperative and intraoperative assessment [5.00 mm（4.00-6.25 mm）vs 3.50 mm（3.00-5.00 mm）, Z=-3.741, P〈0.001], as well as between preoperative and postoperative assessment [5.0 mm（3.0-8.0 mm） vs 3.5 mm（3.0-5.0 mm）, Z=-3.735, P〈0.001]. The complete ablation rate was 97.6%（41/42） based on one-month follow-up CT or MR imaging. Local tumor progression was not found in these completely ablated tumors during the follow-up period. Conclusion Immediatepost-procedural CEUS can be used to demonstrate the perfusion of gallbladder wall in US-guided ablation of hepatic tumors adjacent to the gallbladder, which is helpful to determine thermal injury of the gallbladder.