腹腔镜超声引导下注射吲哚菁绿肝段染色在解剖性肝切除术中的应用研究

Application of ICG fluorescence staining by intraoperative laparoscopic ultrasound guiding portal branch puncture approach in anatomical segmentectomy

目的探讨腹腔镜超声引导下门静脉穿刺注射吲哚菁绿(ICG)荧光肝段染色在解剖性肝段切除术中应用的安全性和可行性。方法2018年2-5月间在华中科技大学同济医学院运用腹腔镜超声术中引导门静脉穿刺注射ICG荧光染色,行腹腔镜解剖性肝段切除的患者22例。术前分析超声、CT或MRI等影像资料判定肿瘤所在肝段及门静脉分支流域分布;术中利用腹腔镜超声定位肿瘤及目标肝段门静脉,腹腔镜超声引导下门静脉穿刺注射ICG 0.125~0.250 mg。在Pinpoint腹腔镜系统荧光融合模式下行腹腔镜解剖性肝段切除术。观察指标:①术中情况:肿瘤直径、门静脉穿刺成功率、目标肝段染色效果、术中并发症、手术时间、术中出血量、输血、中转开腹情况。②术后情况:术后并发症情况(以Clavien-Dindo分级为标准)、住院时间。结果22例肝肿瘤患者均在腹腔镜超声引导注射ICG肝段染色辅助下完成解剖性肝切除手术,均为肝细胞性肝癌。①术中情况:22例患者采用腹腔镜超声引导门静脉穿刺成功率达100%。22例患者门静脉注射ICG荧光染色效果:18例荧光染色效果满意,满意度为81.8%(18/22);4例未达到预期效果(染色不均匀2例,相邻肝段染色2例)。所有患者术中注射ICG均无过敏等并发症发生。手术时间为97~325(209±89)min,其中超声引导下目标门静脉穿刺注射ICG时间为3~25(11±5)min。无术中输血和中转开腹的情况。22例患者肿瘤直径为2.2~7.0(3.9±1.3)cm。②术后情况:22例患者中,4例发生Clavien-Dindo Ⅰ~Ⅱ级并发症(下肢深静脉血栓1例,胸腔积液3例)均经治疗后好转;无Ⅲ级以上严重并发症,无围术期死亡患者。22例患者术后住院时间为5.0~14.0(7±2)d。结论腹腔镜超声引导门静脉穿刺注射ICG荧光染色获得确切持久的肝表面及实质内部荧光标记,可实时引导断肝操作中肝断面的选择,帮助外科医师完成真正意义上的腹腔镜解剖性肝段切除。

Objective To investigate the safety and feasibility of indocyanine green (ICG) fluorescence staining guided by laparoscopic ultrasound guiding portal branch puncture approach in anatomical segmentectomy of the liver. Methods The clinical data of 22 patients with malignant liver diseases underwent anatomical segmentectomy between February 2018 and May 2018 were retrospectively analyzed. ICG 0.125~0.250 mg was directly injected into the portal branches supplying blood flow to the tumor-bearing hepatic segment, after puncturing of the target portal branch under intraoperative laparoscopic ultrasound guidance in all patients. The fluorescence imaging system (Pinpoint) was used for the resection procedure. Observation indicators: intraoperative conditions (tumor diameter, success rate of portal branches puncture, success rate of staining the target hepatic segment, intraoperative complications, time of operation, volume of intraoperative blood loss, blood transfusion, and transit of laparotomy). Postoperative conditions: postoperative complications, and length of hospital stay. Results Twenty-two patients with liver tumors were all performed anatomical hepatectomy assisted by laparoscopic ultrasound guiding ICG injection for liver segment staining. All the liver tumors were hepatocellular carcinoma.①Intraoperative conditions: The portal branches puncture successful rate was 100%(22/22). Eighteen patients achieved expected effect of ICG fluorescence staining, with a satisfaction rate of 81.8%(18/22) and 4 failed to get expected effect, including 2 with uneven dying, and 2 with adjacent hepatic segmental staining induced to unclear boundary. No complication such as allergy occurred in all patients after ICG injection. The mean operation time was (209±89)min(range: 97~325 min) and the target portal branches ICG puncture injection time under intraoperative laparoscopic ultrasound guidance was (11 ± 5)min (range 3-25 min). There was no intraoperative blood transfusion or transit of laparotomy.Average tumor diameter was (3.9±1.3)cm(range: 2.2-7.0 cm).②Postoperative conditions of 22 patients, 4 with grade Ⅰ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 3 with pleural effusion), no patient had grade Ⅲ and above complications, and no perioperative death occurred. Average duration of hospital stay was (7±2) days in 22 patients (range: 5.0-14.0 days). Conclusions ICG fluorescence staining guided by laparoscopic ultrasound guiding portal branch puncture, obtains accurate and lasting fluorescence markers on the liver surface and inside the parenchyma. ICG staining guides the selection of liver section in the operation of liver in real time, and helps surgeons to perform laparoscopic anatomical segmentectomy of the liver.