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目前,精准肝脏外科已经普遍被业内学者认识[1-2],右半肝活体肝移植(live donor liver transplantation,LDLT)术前对供肝的精准评估关系着移植肝的预后及供体的恢复。IQQA®-Liver肝脏CT影像解读分析系统提供了一个高自动化、全方位、即时、定量分析的综合平台,支持医师快速实时地对动态多期肝脏影像进行肝脏、肝段、病灶、血管(包括肝动脉、肝静脉、肝门脉)的分割、标记、容积测量以及相互空间关系的定量评估。本文分析了92例LDLT供体的临床资料,从右半肝体积评估及肝静脉引流域入手,评估IQQA-Liver三维系统在肝移植术精准手术选择中的临床价值。
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手动法、半自动法测量全肝体积(CTV 全和IQQAV 全)分别为(1356.36±217.81)cm3和(1368.05±220.78)cm3,二者相关系数为0.96,P≤0.01,二者高度相关。手动法、半自动法测量右半肝体积(CTV和IQQAV)分别为(858.06±154.95)cm3和(847.81±155.14)cm3,二者相关系数为0.93,P≤0.01,二者高度相关。RPVTV、EFHV及IOV的平均值及范围见表 1。IQQAV与IOV、CTV与IOV、RPVTV与IOV、EFHV与IOV的相关系数分别为0.82、0.81、0.77、0.81,P均 < 0.01。
组别 例数 $\bar x \pm s$ 最小值 最大值 CTV 全 92 1356.36±217.81 755.77 1897.51 IQQAV 全 92 1368.05±220.78 722.22 1949.78 CTV 92 858.06±154.95 459.88 1188.14 IQQAV 92 847.81±155.14 465.88 1220.03 IOV 92 726.37±124.33 380.00 1132.00 RPVTV 92 789.52±148.44 507.72 1250.57 EFHV 92 822.29±154.79 405.52 1038.43 注:表中,CTV 全为手动法测量的全肝体积;IQQAV 全为半自动法测量的全肝体积;CTV为手动法测量的右半肝体积;IQQAV为半自动法测量的右半肝体积;IOV为术中体积;RPVTV为门脉右支流域体积;EFHV为有效的功能肝体积。 表 1 不同体积测量方法所得的全肝体积及右半肝体积的平均值范围(cm3)
Table 1. The total hepatic volume and right hemihepatic volume measured by 5 methods followed(cm3)
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计算5种右半肝体积与其相应受体体重的比值,得到相应的GRWR,以0.8%、1.0%为界进行分级,结果见表 2及表 3。
组别 $\bar x \pm s$ 最小值 最大值 IOV-GRWR 1.01±0.21 0.68 1.85 CTV-GRWR 1.23±0.37 0.74 2.20 IQQAV-GRWR 1.22±0.37 0.78 2.26 RPVTV-GRWR 1.26±0.37 0.84 2.13 EFHV-GRWR 1.14±0.18 0.77 1.50 注:表中,IOV为术中体积;CTV为手动法测量的右半肝体积;IQQAV为半自动法测量的右半肝体积;RPVTV为门脉右支流域体积;EFHV为有效的功能肝体积;GRWR为移植物/受体体重比。 表 2 5种右半肝体积与相应受体体重比的平均值及范围(%)
Table 2. The graft-to-recipient body weight ratio from 5 methods followed(%)
组别 <0.8% 0.8%~1.0% >1.0% IOV-GRWR 9 47 36 CTV-GRWR 1 22 69 IQQAV-GRWR 1 20 71 EFHV-GRWR 2 25 65 RPVTV-GRWR 0 29 63 注:表中,IOV为术中体积;CTV为手动法测量的右半肝体积;IQQAV为半自动法测量的右半肝体积;RPVTV为门脉右支流域体积;EFHV为有效的功能肝体积;GRWR为移植物/受体体重比。 表 3 5组GRWR分级及相应例数
Table 3. Grades of GRWR and homologous mumber of cases
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92例供肝手术切面相关血管共254支,包括MHV属支104支,RHV属支93支,IRHV属支57支,254支静脉直径为(4.10±1.72)mm,相应流域体积为(54.70±44.21)cm3,其相关系数为0.73,P≤0.01(图 2)。
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本研究共59例选择扩大右半肝移植术(带MHV),33例选择右半肝移植术(不带MHV)。对比术中结果,行不带MHV术式的33例患者中,MHV属支<3 mm者4支,无重建;3~5 mm者18支,7支重建;5~7 mm者18支,17支重建,1支5 mm者未重建;≥7 mm者17支,均重建,其中1支搭桥。
CT手动法、IQQA半自动法及EFHV所计算的GRWR分别有1、1、2例<0.8%,CTV-GRWR最小值为0.74%,此受者的IQQAV-GRWR为0.85%,手术方式为带MHV术式,术后两周内肝功能恢复欠佳,经积极治疗,一个月后肝功能恢复正常。
IQQAV-GRWR最小值为0.78%的受者亦行带MHV术式,其对应的CTV-GRWR为0.81%,术中损坏膈肌致血气胸,术后10 d胆红素升高,肝功能持续下降,于术后7周再次行原位尸体肝移植,发现肿瘤种植转移,术中室颤,最后死亡。
EFHV-GRWR最小值为0.77%的受者术中MHV 5段、8段各一支(直径分别为5.7、4.2 mm)以冷保存的髂血管与受者肝中、肝左静脉共同开口搭桥吻合;RHV与受者RHV吻合,术后肝功能未见异常,伤口愈合良好后出院。EFHV-GRWR为0.79%的受者行带MHV术式,并重建肝右后下静脉,术后恢复良好。
IQQA-Liver对右半肝活体肝移植供肝体积及引流域精准评估的临床价值
Clinical significance of IQQA-Liver in the evaluation of liver volume and hepatic vein territory before live donor liver transplantation with a right lobe graft
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摘要:
目的 探讨IQQA-Liver三维系统对右半肝活体肝移植(LDLT)术前精准评估肝体积及引流域的实用价值。 方法 分别以手动法及半自动法测量92例供体全肝体积(CTV 全、IQQAV 全)及右半肝体积(CTV、IQQAV),测定门脉右支引流域体积(RPVTV),模拟肝切面及静脉重建方案计算有效的功能肝体积(EFHV),并将这4种术前体积分别与术中体积(IOV)进行对比,采用组间数据配对t检验及组间数据两两相关分析进行数据处理,以P≤0.05为差异有统计学意义。统计分析肝静脉各属支直径与相应引流域的相关性。 结果 CTV 全与IQQAV 全分别为(1356.36±217.81)cm3和(1368.05±220.78)cm3,二者相关系数为0.96;CTV与IQQAV分别为(858.06±154.95)cm3和(847.81±155.14)cm3,二者相关系数为0.93。IOV为(726.37±124.33)cm3,RPVTV为(789.52±148.44)cm3,EFHV为(822.29±154.79)cm3。IQQAV与IOV、CTV与IOV、RPVTV与IOV、EFHV与IOV的相关系数分别为0.82、0.81、0.77、0.81,P均 < 0.01。254支手术切面相关血管直径与相应引流域的相关系数为0.73,P≤0.01。 结论 半自动法所测体积与IOV的相关性良好,肝静脉各属支的直径不能完全反映引流域体积,术前应计算EFHV,为临床提供更精准的术前评估。 Abstract:Objective To investigate the clinical significance of an IQQA-Liver three dimensional system in the evaluation of hepatic volume and hepatic venous drainage territory before live donor liver transplantation(LDLT) with a right lobe graft. Methods The total hepatic volume and right hemihepatic volume of 92 donors were determined with IQQA semiautomatic method(IQQAVtotal and IQQAV) and traditional CT manual method(CTVtotal and CTV). Right portal vein territorial volume(RPVTV) of 92 donors were determined, and efficient functional hepatic volume(EFHV) were obtained by simulating hepatic section and venous reconstruction schedule. The preoperative right hemihepatic volume obtained via four methods were compared with the intraoperative volume(IOV) in LDLT and then evaluated through paired t test and correlation analysis between interclass data. P≤0.05 was considered statistically significant. The relationship of the diameter and the territorial volume of 254 hepatic vein were analyzed. Results The correlation coefficients were 0.96 for CTVtotal and IQQAVtotal and 0.93 for CTV and IQQAV. The correlation coefficients were 0.82, 0.81, 0.77, and 0.81 for IQQAV, CTV, RPVTV, EFHV, and IOV, respectively. The correlation coefficient was 0.73 between the diameter and territorial volume of the hepatic vein(P≤0.01). Conclusions The hemihepatic volume obtained through IQQA-Liver was associated with IOV. However, the diameter of the tributaries of the hepatic vein cannot completely represent homologous territorial volume. EFHV should be calculated to evaluate a patient′s status before operation is performed. -
表 1 不同体积测量方法所得的全肝体积及右半肝体积的平均值范围(cm3)
Table 1. The total hepatic volume and right hemihepatic volume measured by 5 methods followed(cm3)
组别 例数 $\bar x \pm s$ 最小值 最大值 CTV 全 92 1356.36±217.81 755.77 1897.51 IQQAV 全 92 1368.05±220.78 722.22 1949.78 CTV 92 858.06±154.95 459.88 1188.14 IQQAV 92 847.81±155.14 465.88 1220.03 IOV 92 726.37±124.33 380.00 1132.00 RPVTV 92 789.52±148.44 507.72 1250.57 EFHV 92 822.29±154.79 405.52 1038.43 注:表中,CTV 全为手动法测量的全肝体积;IQQAV 全为半自动法测量的全肝体积;CTV为手动法测量的右半肝体积;IQQAV为半自动法测量的右半肝体积;IOV为术中体积;RPVTV为门脉右支流域体积;EFHV为有效的功能肝体积。 表 2 5种右半肝体积与相应受体体重比的平均值及范围(%)
Table 2. The graft-to-recipient body weight ratio from 5 methods followed(%)
组别 $\bar x \pm s$ 最小值 最大值 IOV-GRWR 1.01±0.21 0.68 1.85 CTV-GRWR 1.23±0.37 0.74 2.20 IQQAV-GRWR 1.22±0.37 0.78 2.26 RPVTV-GRWR 1.26±0.37 0.84 2.13 EFHV-GRWR 1.14±0.18 0.77 1.50 注:表中,IOV为术中体积;CTV为手动法测量的右半肝体积;IQQAV为半自动法测量的右半肝体积;RPVTV为门脉右支流域体积;EFHV为有效的功能肝体积;GRWR为移植物/受体体重比。 表 3 5组GRWR分级及相应例数
Table 3. Grades of GRWR and homologous mumber of cases
组别 <0.8% 0.8%~1.0% >1.0% IOV-GRWR 9 47 36 CTV-GRWR 1 22 69 IQQAV-GRWR 1 20 71 EFHV-GRWR 2 25 65 RPVTV-GRWR 0 29 63 注:表中,IOV为术中体积;CTV为手动法测量的右半肝体积;IQQAV为半自动法测量的右半肝体积;RPVTV为门脉右支流域体积;EFHV为有效的功能肝体积;GRWR为移植物/受体体重比。 -
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