目的 探讨三维可视化技术在Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌计划性肝切除中的应用价值。方法 回顾性分析2015-01至2017-12上海东方肝胆外科医院收治的Bismuth-Corlette Ⅲ、Ⅳ型肝门部胆管癌36例患者的临床资料,应用三维可视化技术将患者320层螺旋二维CT图像进行三维可视化重建,通过观察肿瘤的部位、大小,与周围门静脉、肝动脉、肝静脉、肝内胆管之间的关系,进行肿瘤的可切除性评估,残肝体积比<40%,通过患侧门静脉栓塞、健侧胆道引流使残肝体积再生,残肝体积比>40%后按计划实施根治性切除,比较仿真手术与实际手术的区别。结果 应用三维可视化重建技术,立体形象地显示肿瘤与周围毗邻的关系,对肿瘤进行Bismuth-Corlette分型,Ⅲa型16例,Ⅲb型8例,Ⅳ12例。测量平均全肝体积(1386±146)ml,肿瘤平均体积(76±22)ml,预切除平均肝体积(896±168)ml,残肝平均体积(490±172)ml,残肝比(34.5±3.6)%,通过行健侧胆道引流患侧门静脉栓塞后,使残肝比>40%,均顺利按计划行肝门部胆管癌根治性切除。肿瘤三维重建后诊断分型准确率100%,重建模型解剖关系与术中实际情况大致相符。术前预切除肝脏体积和术后实际肝脏体积无统计学差异(t=1.148)。结论 三维可视化技术能够对肝门部胆管癌术前进行精确评估、精准规划,优化治疗方案,提高根治性切除(radical resection,R0)手术率。

Objective To explore the applicability of three-dimensional visualization technology in the planned hepatectomy of type Ⅲ and Ⅳ hilar cholangiocarcinoma. Methods The clinical data of thirty-six patients with type Ⅲ and Ⅳ hilar cholangiocarcinoma treated between January 2015 and December 2017 in the Department of Hepatobiliary Surgery was retrospectively analyzed. Three-dimensional visualization technology was used to reconstruct the 320 slice spiral 2D CT image of patients. By observing the location and size of the tumors and finding out about the relationship between the tumors and the peripheral portal vein, hepatic artery, hepatic vein and intrahepatic bile duct, the resectability of the tumors was assessed. Planned hepatectomy was proposed if the ratio of the residual liver volume was less than 40%. The volume of the residual liver was regenerated via portal vein embolization and biliary drainage. After 2 or 3 weeks, 3D visual reconstruction was performed a second time. Once the ratio of the residual liver volume was more than 40%, radical hepatectomy was carried out as planned. The difference between simulated surgery and actual surgery was studied. Results Three-dimensional visual reconstruction technology was used to display the relationship between the tumors and their surrounding tissues. Bismuth-Corlette classification suggested that there were 16 cases of ⅢA, 8 cases of ⅢB and 12 cases of Ⅳ. The average volume was (1386±146) ml for whole livers,(76±22) ml for tumors,(896±168) ml for the pre-resected liver, and (490±172) ml for residual livers. The ratio of the residual liver volume (34.5%±3.6%) was measured. When the ratio of the residual liver volume exceeded 40% after embolization of the portal vein on the healthy side of biliary drainage, radical resection of hilar cholangiocarcinoma was performed. The accuracy of three-dimensional reconstruction was 100%. The anatomic relationship of the reconstruction model was consistent with what was observed in the course of surgery. There was no significant difference between the volume of the pre-resected liver and the actual volume of the postoperative liver (t=1.148). Conclusions 3D visualization technology can accurately assess hilar cholangiocarcinoma before operation, optimize the treatment plan and improve the R0 resection rate.