肝脏三维可视化重建技术在儿童复杂肝母细胞瘤肝切除术中的应用价值

赵頔; 叶进冬; 李华丽; 金奎; 刘翔; 李潇然; 段留新; 刘军桂; 吕伟; 段伟宏; 刘全达

doi:10.3969/j.issn.1001-5256.2021.09.025

肝脏三维可视化重建技术在儿童复杂肝母细胞瘤肝切除术中的应用价值

DOI: 10.3969/j.issn.1001-5256.2021.09.025

火箭军特色医学中心全军肝胆胃肠病中心肝胆外科，北京 100088

基金项目:

国家重点研发计划 (2017YFC0110401)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：赵頔、叶进冬负责资料分析，撰写论文；李华丽、金奎、刘翔、李潇然、段留新、刘军桂、吕伟参与收集数据，修改论文；段伟宏、刘全达负责课题设计，拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
段伟宏，changxinzhong@163.com

刘全达，liuquanda@sina.com

赵頔、叶进冬对本文贡献相同，同为第一作者

中图分类号: R735.7
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出版历程
- 收稿日期: 2021-01-18
- 录用日期: 2021-02-18
- 出版日期: 2021-09-20

Application of liver three-dimensional visualized reconstruction technique in hepatectomy for children with complicated hepatoblastoma

Department of Hepatobiliary Surgery, Research Institute of Hepatobiliary and Gastrointestinal Diseases, PLA Rocket Force Characteristic Medical Center, Beijing 100088, China

Research funding:

National Key R & D Program of China (2017YFC0110401)

摘要

摘要: 目的探讨肝脏三维可视化重建技术在儿童复杂肝母细胞瘤肝切除术中的应用价值。方法回顾分析2018年1月—2020年10月于火箭军特色医学中心实施了以根治性切除为目的的肝肿瘤切除术的30例肝母细胞瘤患儿的临床资料，根据术前是否行肝脏三维重建(IQQA-Liver系统)将所有患儿分为三维重建组(n=15)和对照组(n=15)，比较2组患儿围手术期临床参数以及短期预后和随访情况。符合正态分布的计量资料2组间比较采用独立样本t检验，不符合正态分布的计量资料2组间比较采用Mann-whitney U检验。计数资料2组间比较采用Fisher确切概率法。结果三维重建组较对照组平均年龄更大[(55.7±10.2)月vs (28.2± 2.7)月]、POSTTEXT Ⅲ/Ⅵ期(12例vs 5例)和肝静脉或下腔静脉受累者(11例vs 3例)更多，差异均有统计学意义(P值均＜0.05)。所有患儿均顺利完成手术，2组在出血量、手术时间、肝门阻断次数/时间、行肝段及部分肝切除例数方面，差异均无统计学意义(P值均＞0.05)。术后中位随访时间9.5个月，三维重建组2例复发，分别于术后10个月和12个月确诊，目前继续化疗中；对照组4例复发，高于三维重建组(P=0.651)，其中2例在术后7个月复发接受肝移植存活至今，另有2例复发后短期内死亡。结论三维可视化重建技术有助于更安全精准实施复杂儿童肝母细胞瘤肝切除术，尤其是可以使部分POSTTEXT Ⅲ/Ⅵ期患者安全实施扩大肝切除，从而避免行肝移植。
- 肝胚细胞瘤 /
- 肝切除术 /
- 成像, 三维 /
- 儿童
Abstract: Objective To investigate the application of liver three-dimensional (3D) visualized reconstruction technique in hepatectomy for children with complicated hepatoblastoma. Methods A retrospective analysis was performed for the clinical data of 30 children with hepatoblastoma who underwent hepatectomy for radical resection in PLA Rocket Force Characteristic Medical Center from January 2018 to October 2020, and according to whether liver 3D visualization with IQQA-Liver system was performed before surgery, the children were divided into 3D reconstruction group with 15 children and control group with 15 children. The two groups were compared in terms of perioperative parameters, short-term prognosis, and follow-up conditions. The independent samples t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the Fisher's exact test was used for comparison of categorical data between two groups. Results Compared with the control group, the 3D reconstruction group had a significantly higher mean age (55.7±10.2 years vs 28.2±2.7 years, P < 0.05) and a significantly higher number of patients with POSTTEXT stage III/VI hepatoblastoma (12 vs 5, P < 0.05) or involvement of the hepatic vein or the inferior vena cava (11 vs 3, P < 0.05). All children completed the surgery successfully, and there were no significant differences between the two groups in blood loss, time of operation, number of times and duration of hepatic portal occlusion, and number of children receiving segmental hepatectomy or partial hepatectomy (all P > 0.05). The median follow-up after surgery was 9.5 months. In the 3D reconstruction group, 2 children experienced recurrence and were diagnosed at 10 and 12 months, respectively, after surgery, and they were treated with chemotherapy at the moment; in the control group, 4 children experienced recurrence, which was higher than that in the 3D reconstruction group (P=0.651), and among these 4 children, 2 had recurrence at 7 months after surgery, received liver transplantation, and survived up to now, and the other 2 children died shortly after recurrence. Conclusion 3D visualized reconstruction technique helps to perform hepatectomy for children with complicated hepatoblastoma more safely and accurately, especially extended hepatectomy for patients with stage POST TEXT III/IV hepatoblastoma, thereby avoiding liver transplantation.
- Hepatoblastoma /
- Hepatectomy /
- Imaging, Three-Dimensional /
- Child

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图 1 术前增强CT检查和三维可视化重建图像

注：a~b，全肝多发肿瘤，仅大部分左肝内叶和部分左肝外叶存在正常肝实质，肿瘤侵犯右肝蒂、右肝静脉，中肝静脉和左肝静脉的部分2级分支受累；c~d，三维可视化重建正面和反面观，证实CT影像所示，右肝蒂受累(箭头)，中肝静脉主干完整；供应左肝内叶矢状部肝蒂3级以上分支和肿瘤关系密切。

下载: 全尺寸图片幻灯片

图 2 手术过程

注：a, 充分游离肝周韧带；b, 术中超声协助下在距离肿瘤1 cm处勾勒预切除术线；第二肝门处肿瘤左侧缘先行微波消融，从而可以降低肿瘤扩散风险，也缩小阴性切缘范围，以保留更多肝实质；c, 扩大右半肝切除后的右肝断面(可见右肝静脉断端和显露的中肝静脉)；d, 超声定位下勾勒左肝外叶病灶预切除线，因为介入后肿瘤坏死彻底，预切除线紧邻肿瘤边界；e, 切除肿瘤后残余肝脏大体观；f, 切除标本。

下载: 全尺寸图片幻灯片

图 3 术后第6天复查腹部CT检查结果

注：a，未见明显胸腔积液，肝静脉未见异常；b，未见明显腹腔积液、肝肿瘤残留及其他并发症，肝内血管无血栓形成，残肝体积明显增大。

下载: 全尺寸图片幻灯片

表 1 2组患儿术前一般资料比较

项目	三维重建组(n=15)	对照组(n=15)	统计值	P值
男/女(例)	10/5	8/7		0.710
年龄(月)	55.7±10.2	28.2±2.7	t=2.603	0.019
化疗(次)	5.0±1.0	5.0±0.5	t=0.836	0.410
ALT (U/L)	22.0±4.4	20.9±2.6	t=0.214	0.832
AFP(ng/ml)	6240(686~16 805)	2800(947~18 465)	Z=-0.041	0.967
血红蛋白(g/L)	99.8±3.8	95.8±4.4	t=0.692	0.495
血小板计数(×10⁹/L)	194±23	225±35	t=-0.709	0.484
POSTTEXT分期(例)				0.025
Ⅰ期	0	0
Ⅱ期	3	10
Ⅲ期	8	5
Ⅳ期	4	0
多发病灶(例)	11	11		1.000
肝静脉或下腔静脉受累(例)	11	3		0.009
门静脉受累(例)	8	4		0.264
尾状叶受累(例)	3	2		1.000
肿瘤破裂/出血(例)	5	1		0.169
肿瘤大小(cm)	7.0±0.6	6.0±1.1	t=0.852	0.401
远处转移(例)	3	3		1.000

下载: 导出CSV

表 2 2组患儿手术方式及术中指标比较

项目	三维重建组(n=15)	对照组(n=15)	t值	P值
出血量(ml)	520±123	562±195	-0.182	0.857
手术时间(min)	301±21	257±24	1.38 3	0.178
肝门阻断次数(次)	3.0±0.2	2.0±0.1	1.90 1	0.068
肝门阻断时间(min)	38.0±3.2	30.0±2.7	2.00 6	0.055
手术方式(例)
肝S4段切除术	1	0
肝S2~3段切除术	0	1
肝S4段切除联合肝S2~3段部分切除术	0	1
肝S2~4段切除术	1	3
肝S1, 2~4段切除术	1	0
肝S1, 2~4，5, 8段切除术	1	0
肝S1, 2~4，5, 8段切除术联合门静脉切开取栓术	0	1
肝S1段切除、S5, 8段局部切除、S6, 7段局部切除术	0	1
肝S5~8段切除术	1	1
肝S5~8段切除，S2~3段部分切除术	1	0
肝S1, 5~8切除术	0	1
肝S4段部分切除, 5~8段切除术	1	0
肝S4, 5~8段切除术	2	3
肝S4, 5~8段切除术联合门脉癌栓取出术	1	0
肝S4, 5, 8段切除术	1	2
肝S5, 7, 8段切除	1	0
肝S1切除术	1	0
肝S5段切除	0	1
肝S1, 4段切除，右肝胆管切开取栓，下腔静脉后段切除血管置换术	1	0
肝S1/S4切除，腹腔多发转移灶切除术	1	0

下载: 导出CSV

表 3 2组患儿术后情况比较

项目	三维重建组(n=15)	对照组(n=15)	统计值	P值
术后1 d
ALT(U/L)	132.8(99.7~312.4)	225.8(153.6~290.2)	Z=-1.224	0.221
TBil (μmol/L)	40.7(26.8~61.2)	25.9(20.0~44.4)	Z=-1.472	0.141
术后3 d
ALT(U/L)	92.3(65.2~156.2)	104.0(76.3~167.0)	Z=-0.726	0.468
TBil (μmol/L)	13.5(11.8~25.7)	16.2(9.7~35.5)	Z=-0.104	0.917
住院时间(d)	9.0±0.6	9.0±0.6	t=0.645	0.524
术后输血量(ml)	210±60	200±47	t=0.130	0.897
术后并发症(人次)	18	20
胸腔积液	11	8		0.450
腹腔积液	3	5		0.682
肺部感染	2	1		1
胆漏	1	2		1
切口感染	0	1		1
乳糜漏	0	1		1
轻中度肝损伤	0	1		1
泌尿系感染	0	1		1
门静脉血栓	1	0		1

下载: 导出CSV

表 4 2组患儿肝母细胞瘤病理分型

病理类型	三维重建组(n=15)	对照组(n=15)
上皮型(例)	12	13
胎儿型	11	7
胚胎型	1	1
粗小梁型	0	1
上皮混合型	0	4
上皮间叶混合型(例)	3	2

下载: 导出CSV

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