動態(tài)MRI檢查結(jié)合3D HR-ARM技術(shù)對低位直腸癌保肛術(shù)后排便功能障礙的評價研究
發(fā)布時間：2018-07-13 17:50
【摘要】：目的應(yīng)用盆腔動態(tài)MR成像技術(shù)及排糞造影檢查,并結(jié)合3D肛門直腸壓力測定法(3D HR-ARM),為擬行保肛手術(shù)的低位直腸癌患者提供全面、直觀、無創(chuàng)、可重復(fù)性強的影像學(xué)術(shù)前評估,并從形態(tài)學(xué)及動力學(xué)分析患者術(shù)后出現(xiàn)低位前切除綜合征(LARS)的機制,分析LARS的影像學(xué)特點與肛腸動力學(xué)變化的相關(guān)性,為臨床制定適宜的治療方案提供一種全面、直觀、便捷、經(jīng)濟的影像學(xué)檢查技術(shù)。材料與方法收集天津市人民醫(yī)院2016年4月到2017年1月肛腸外科確診為低位直腸癌并擬行保肛手術(shù)治療的患者共42例。所有患者術(shù)前均行直腸指診、結(jié)腸鏡、盆腔常規(guī)及動態(tài)MRI、排糞造影及3D HR-ARM檢查。在檢查后一周內(nèi)行手術(shù)切除,術(shù)后送病理檢查。于術(shù)后三個月隨訪復(fù)查,共收集保肛手術(shù)治療后出現(xiàn)LARS的患者20例,將其納入病例組,再次復(fù)查盆腔常規(guī)及動態(tài)MRI及3D HR-ARM檢查。收集健康成年志愿者20例納入對照組,均行盆腔常規(guī)及動態(tài)MRI檢查。另收集110例無癥狀志愿者3D HR-ARM檢查數(shù)據(jù)。將術(shù)前盆腔MRI檢查所獲圖像結(jié)果與直腸指診、結(jié)腸鏡檢查和病理結(jié)果進行對比,運用ICC分析和Kappa檢驗比較盆腔MRI與其他三種檢查的一致性和相關(guān)性,并應(yīng)用卡方檢驗計算盆腔MRI對各項指標(biāo)診斷的準(zhǔn)確率、靈敏度、特異度、陽性預(yù)測值、陰性預(yù)測值。運用一般線性模型(GLM)單變量分析比較健康對照組與病例組術(shù)前各項測量指標(biāo)間的差異。運用配對T檢驗分析比較術(shù)前排糞造影與盆腔動態(tài)MRI、病例組術(shù)前與術(shù)后各項測量指標(biāo)間的差異。運用Pearson相關(guān)分析比較動態(tài)MRI、3D HR-ARM兩種檢查各項觀測指標(biāo)間的相關(guān)性。結(jié)果(1)盆腔MRI檢查對腫瘤下緣與肛緣距離的測量結(jié)果,與直腸指診及結(jié)腸鏡檢查的一致性較好(R=0.721,P0.01),對腫瘤腸周比例的測量結(jié)果,與術(shù)后病理或結(jié)腸鏡檢查的一致性中等(Kappa=0.661,P0.01),整體準(zhǔn)確率為83.33%。盆腔MRI檢查對腫瘤T、N分期的準(zhǔn)確率均較高,整體準(zhǔn)確率分別為88.10%和85.71%,與病理結(jié)果一致性較好(Kappa=0.729,P0.01;Kappa=0.743,P0.01)。(2)LARS患者術(shù)前動態(tài)MRI測得靜息相和力排相M線及提肛相內(nèi)括約肌厚度均大于對照組,差異均有統(tǒng)計學(xué)意義(P0.05)。LARS患者術(shù)后動態(tài)MRI測得三時相上的肛直角均大于術(shù)前,而恥骨直腸肌及外括約肌厚度均小于術(shù)前,差異均有統(tǒng)計學(xué)意義(P0.05)。(3)LARS患者術(shù)前排糞造影測得提肛相肛直角和力排相肛上距的均值均超出了正常值參考范圍。LARS患者術(shù)前動態(tài)MRI與排糞造影比較,三時相上肛直角間差異均無統(tǒng)計學(xué)意義(P0.05),M線與肛上距間無明顯相關(guān)性(P0.05)。(4)LARS患者術(shù)前3D HR-ARM測得肛門最大靜息壓、肛門平均靜息壓、高壓帶長度、肛門最大收縮壓均大于正常參考值;直腸壓力、直腸肛管壓力差、初始排便閾值、最大耐受閾值均小于正常參考值,差異均有統(tǒng)計學(xué)意義(P0.05);直腸肛門抑制反射(15.79±10.17cc)小于40cc,在正常范圍內(nèi)。LARS患者術(shù)后3D HR-ARM測得肛管松弛率、初始感覺閾值、初始排便閾值、最大耐受閾值均小于正常參考值,差異均有統(tǒng)計學(xué)意義(P0.05);直腸肛門抑制反射(13.68±6.84cc)小于40cc,亦在正常范圍內(nèi)。(5)LARS患者術(shù)后3D HR-ARM測得肛門最大靜息壓、肛門平均靜息壓、高壓帶長度、肛門最大收縮壓、初始感覺閾值、初始排便閾值及最大耐受閾值均小于術(shù)前,而直腸壓力、直腸肛管壓力差均大于術(shù)前,差異均有統(tǒng)計學(xué)意義(P0.01)。(6)術(shù)前動態(tài)MRI與3D HR-ARM相關(guān)性分析:腫瘤-齒線距離與最大耐受閾值呈負(fù)相關(guān)(r=-0.606),提肛時肛直角與肛門最大靜息壓及肛門最大收縮壓均呈負(fù)相關(guān)(r=-0.722,r=-0.616),提肛時H線與肛門最大收縮壓呈負(fù)相關(guān)(r=-0.620),提肛時M線與初始感覺閾值及初始排便閾值均呈負(fù)相關(guān)(r=-0.545,r=-0.803),提肛時恥骨直腸肌厚度與初始排便閾值呈正相關(guān)(r=0.794),提肛時外括約肌厚度與肛管松弛率呈負(fù)相關(guān)(r=-0.609)(P值均0.05)。(7)術(shù)后動態(tài)MRI與3D HR-ARM相關(guān)性分析:提肛時M線與初始排便閾值呈正相關(guān)(r=0.727),提肛時恥骨直腸肌厚度與高壓帶長度呈正相關(guān)(r=0.738),提肛時內(nèi)括約肌厚度與高壓帶長度及直腸肛管壓力差均呈負(fù)相關(guān)(r=-0.680,r=-0.729)(P值均0.01)。結(jié)論(1)盆腔動態(tài)MRI檢查的準(zhǔn)確率高,與直腸指診及結(jié)腸鏡檢查一致性較好,可為低位直腸癌術(shù)前評估和術(shù)后肛門直腸功能恢復(fù)情況的評價提供全面、量化、可重復(fù)性強的影像學(xué)依據(jù)。(2)動態(tài)MRI檢查與X線排糞造影檢查的一致性較好,可彌補X線排糞造影軟組織分辨率低的缺點,為評價肛門直腸功能提供了一種更加安全、便捷的影像學(xué)方法。(3)動態(tài)MRI及3D HR-ARM檢查均發(fā)現(xiàn)LARS患者術(shù)前控便能力尚好,但已存在盆底松弛、直腸感覺功能降低的表現(xiàn),且術(shù)后恥骨直腸肌和肛門括約肌收縮功能明顯降低,直腸感覺功能減弱明顯加重,說明術(shù)中盡可能避免上述肌肉損傷,術(shù)后盡早加強病變肌群功能恢復(fù)治療對LARS患者尤為重要。(4)動態(tài)MRI檢查技術(shù)不僅可直觀反映肛門直腸的動態(tài)變化,其量化指標(biāo)還與3D HR-ARM檢查存在顯著的相關(guān)性,為評價肛門直腸功能提供了一種更加有效、經(jīng)濟、便捷、可視化的影像學(xué)診斷的新思路。
[Abstract]:Objective to use the pelvic dynamic MR imaging technique and defecography, combined with the 3D anorectal pressure (3D HR-ARM), to provide a comprehensive, intuitive, noninvasive, reproducible pre academic assessment for low rectal cancer patients who are in the operation of the anus preserving operation, and to analyze the low position anterior resection syndrome (L) from the morphological and dynamic analysis of the patients after the operation (L The mechanism of ARS) to analyze the correlation between the imaging characteristics of LARS and the changes of anorectal dynamics, and to provide a comprehensive, intuitive, convenient and economical imaging examination technique for the establishment of a suitable treatment scheme. Materials and methods were collected from Tianjin People's Hospital in the Department of anus & intestine surgery from April 2016 to January 2017 and were diagnosed as low rectal cancer and were expected to have anus preserving. A total of 42 patients were treated with surgical treatment. All patients underwent rectal examination, colonoscopy, pelvic routine and dynamic MRI, defecography and 3D HR-ARM examination. After one week after examination, surgical resection was performed and pathological examination was performed after three months of operation. A total of 20 patients with LARS after the anus operation were collected and included in the case group. The pelvic routine and the dynamic MRI and 3D HR-ARM examinations were re examined. 20 healthy adult volunteers were collected in the control group and all the pelvic routine and dynamic MRI examinations were performed. Another 110 asymptomatic volunteers were collected from the 3D HR-ARM examination data. The image results of the preoperative pelvic MRI examination were compared with the rectal examination, colonoscopy and pathological results. ICC analysis and Kappa test were used to compare the consistency and correlation between pelvic MRI and the other three kinds of tests, and the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of pelvic MRI were calculated by chi square test. The normal linear model (GLM) single variable analysis was used to compare the pre operation of the healthy control group and the case group. The difference between the measurement indexes of the item. The difference between preoperative defecography and pelvic dynamic MRI was analyzed by paired T test. The difference between the preoperative and postoperative measurement indexes of the case group was compared. The correlation between the dynamic MRI and 3D HR-ARM two kinds of observation indexes was compared with the Pearson correlation analysis. Fruit (1) pelvic cavity MRI examination on the lower margin of the tumor and the margin of the anal margin The measured results, the consistency with the rectal examination and colonoscopy was better (R=0.721, P0.01). The results of the proportion of the peri intestinal tumor were moderate (Kappa=0.661, P0.01). The overall accuracy rate of the 83.33%. pelvic MRI examination was higher in the T, N staging, and the overall accuracy rate was 8, respectively. 8.10% and 85.71% were in good agreement with the pathological results (Kappa=0.729, P0.01; Kappa=0.743, P0.01). (2) the M line of resting phase and force phase and the thickness of the internal sphincter in the anus phase were greater in LARS patients than in the control group. The difference was statistically significant (P0.05) in patients with postoperative dynamic MRI, the anal right angle in the three phase was greater than that before the operation. The thickness of the pubis rectum and the external sphincter were all lower than that before the operation (P0.05). (3) the mean value of the anus anus right angle and the force row anus distance measured by the defecography before operation in LARS patients were all beyond the normal reference range of the reference range of.LARS patients, and the dynamic MRI was compared with the defecography, and there was no statistical difference between the anus right angle and the anus in the phase of the patients. (P0.05), there was no significant correlation between the M line and the supra anal distance (P0.05). (4) the maximal resting pressure of the anus, the mean resting pressure of the anus, the length of the high pressure zone and the maximum pressure of the anus were all greater than the normal reference value before the operation of LARS, and the rectal pressure, the poor rectal pressure, the threshold of initial defecation, and the maximum tolerance threshold were less than the normal reference value. The difference was statistically significant (P0.05); anorectal reflex (15.79 + 10.17cc) was less than 40CC, and the anal canal relaxation rate was measured by 3D HR-ARM in the normal range of.LARS patients. Initial sensory threshold, initial defecation threshold, maximum tolerance threshold were less than normal reference values, and the difference was statistically significant (P0.05); anorectal reflex reflex (13.68) 6.84cc) was less than 40CC and was in the normal range. (5) the maximum anal resting pressure of the anus, the average resting pressure of the anus, the length of the anus, the maximum contractile pressure of the anus, the initial sensory threshold, the threshold of the initial defecation and the maximum tolerance threshold were lower than those before the operation, and the difference of the rectal pressure and the rectal anus pressure difference were all greater than those before the LARS. Statistical significance (P0.01). (6) the correlation analysis between the dynamic MRI and 3D HR-ARM before operation: the tumor tooth line distance was negatively correlated with the maximum tolerance threshold (r=-0.606). The anal right angle in the anus was negatively correlated with the maximum anus resting pressure and the maximum anus systolic pressure (r=-0.722, r=-0.616), and the H line was negatively correlated with the maximum contractile pressure of the anus (r=-0.620) and anus anus during the anus. The M line was negatively correlated with the initial sensory threshold and initial defecation threshold (r=-0.545, r=-0.803). The thickness of the pubis rectum was positively correlated with the threshold of the initial defecation (r=0.794). The thickness of the external sphincter was negatively correlated with the anal canal relaxation (r=-0.609) (P 0.05). (7) the correlation analysis of the dynamic MRI and 3D HR-ARM after the operation: M line in the anus. There was a positive correlation with the threshold of the initial defecation (r=0.727). The thickness of the pubis rectum was positively correlated with the length of the high pressure band (r=0.738). The thickness of the internal sphincter was negatively correlated with the length of the high pressure band and the anorectal pressure difference (r=-0.680, r=-0.729). (1) the accuracy of the pelvic dynamic MRI examination was high, with the rectal finger diagnosis and the knot. The conformance of enteroscopy is good. It can provide a comprehensive, quantitative and reproducible imaging basis for preoperative evaluation of low rectal cancer and postoperative recovery of anorectal function. (2) the consistency of the dynamic MRI examination and X-ray defecography is better, which can make up the shortcomings of the low resolution of the soft tissue of the X-ray defecography, and to evaluate the anus straight. Intestinal function provides a more safe and convenient imaging method. (3) dynamic MRI and 3D HR-ARM examination showed that the ability of LARS patients to control stool before operation was still good, but there was a lower pelvic floor relaxation, lower rectal sensory function, and the postoperative contractile function of the pubis and anal sphincter decreased and the rectal sensory function weakened obviously. It is very important to avoid the above muscle injury during the operation as much as possible. It is very important for LARS patients to strengthen the functional recovery therapy at the early stage after operation. (4) dynamic MRI examination can not only directly reflect the dynamic changes of anus and rectum, but also have a significant correlation with 3D HR-ARM examination, which provides a better evaluation of anorectal function. Add effective, economical, convenient, and visualized new ideas for imaging diagnosis.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735.37;R445.2
本文編號：2120267
[Abstract]:Objective to use the pelvic dynamic MR imaging technique and defecography, combined with the 3D anorectal pressure (3D HR-ARM), to provide a comprehensive, intuitive, noninvasive, reproducible pre academic assessment for low rectal cancer patients who are in the operation of the anus preserving operation, and to analyze the low position anterior resection syndrome (L) from the morphological and dynamic analysis of the patients after the operation (L The mechanism of ARS) to analyze the correlation between the imaging characteristics of LARS and the changes of anorectal dynamics, and to provide a comprehensive, intuitive, convenient and economical imaging examination technique for the establishment of a suitable treatment scheme. Materials and methods were collected from Tianjin People's Hospital in the Department of anus & intestine surgery from April 2016 to January 2017 and were diagnosed as low rectal cancer and were expected to have anus preserving. A total of 42 patients were treated with surgical treatment. All patients underwent rectal examination, colonoscopy, pelvic routine and dynamic MRI, defecography and 3D HR-ARM examination. After one week after examination, surgical resection was performed and pathological examination was performed after three months of operation. A total of 20 patients with LARS after the anus operation were collected and included in the case group. The pelvic routine and the dynamic MRI and 3D HR-ARM examinations were re examined. 20 healthy adult volunteers were collected in the control group and all the pelvic routine and dynamic MRI examinations were performed. Another 110 asymptomatic volunteers were collected from the 3D HR-ARM examination data. The image results of the preoperative pelvic MRI examination were compared with the rectal examination, colonoscopy and pathological results. ICC analysis and Kappa test were used to compare the consistency and correlation between pelvic MRI and the other three kinds of tests, and the accuracy, sensitivity, specificity, positive predictive value and negative predictive value of pelvic MRI were calculated by chi square test. The normal linear model (GLM) single variable analysis was used to compare the pre operation of the healthy control group and the case group. The difference between the measurement indexes of the item. The difference between preoperative defecography and pelvic dynamic MRI was analyzed by paired T test. The difference between the preoperative and postoperative measurement indexes of the case group was compared. The correlation between the dynamic MRI and 3D HR-ARM two kinds of observation indexes was compared with the Pearson correlation analysis. Fruit (1) pelvic cavity MRI examination on the lower margin of the tumor and the margin of the anal margin The measured results, the consistency with the rectal examination and colonoscopy was better (R=0.721, P0.01). The results of the proportion of the peri intestinal tumor were moderate (Kappa=0.661, P0.01). The overall accuracy rate of the 83.33%. pelvic MRI examination was higher in the T, N staging, and the overall accuracy rate was 8, respectively. 8.10% and 85.71% were in good agreement with the pathological results (Kappa=0.729, P0.01; Kappa=0.743, P0.01). (2) the M line of resting phase and force phase and the thickness of the internal sphincter in the anus phase were greater in LARS patients than in the control group. The difference was statistically significant (P0.05) in patients with postoperative dynamic MRI, the anal right angle in the three phase was greater than that before the operation. The thickness of the pubis rectum and the external sphincter were all lower than that before the operation (P0.05). (3) the mean value of the anus anus right angle and the force row anus distance measured by the defecography before operation in LARS patients were all beyond the normal reference range of the reference range of.LARS patients, and the dynamic MRI was compared with the defecography, and there was no statistical difference between the anus right angle and the anus in the phase of the patients. (P0.05), there was no significant correlation between the M line and the supra anal distance (P0.05). (4) the maximal resting pressure of the anus, the mean resting pressure of the anus, the length of the high pressure zone and the maximum pressure of the anus were all greater than the normal reference value before the operation of LARS, and the rectal pressure, the poor rectal pressure, the threshold of initial defecation, and the maximum tolerance threshold were less than the normal reference value. The difference was statistically significant (P0.05); anorectal reflex (15.79 + 10.17cc) was less than 40CC, and the anal canal relaxation rate was measured by 3D HR-ARM in the normal range of.LARS patients. Initial sensory threshold, initial defecation threshold, maximum tolerance threshold were less than normal reference values, and the difference was statistically significant (P0.05); anorectal reflex reflex (13.68) 6.84cc) was less than 40CC and was in the normal range. (5) the maximum anal resting pressure of the anus, the average resting pressure of the anus, the length of the anus, the maximum contractile pressure of the anus, the initial sensory threshold, the threshold of the initial defecation and the maximum tolerance threshold were lower than those before the operation, and the difference of the rectal pressure and the rectal anus pressure difference were all greater than those before the LARS. Statistical significance (P0.01). (6) the correlation analysis between the dynamic MRI and 3D HR-ARM before operation: the tumor tooth line distance was negatively correlated with the maximum tolerance threshold (r=-0.606). The anal right angle in the anus was negatively correlated with the maximum anus resting pressure and the maximum anus systolic pressure (r=-0.722, r=-0.616), and the H line was negatively correlated with the maximum contractile pressure of the anus (r=-0.620) and anus anus during the anus. The M line was negatively correlated with the initial sensory threshold and initial defecation threshold (r=-0.545, r=-0.803). The thickness of the pubis rectum was positively correlated with the threshold of the initial defecation (r=0.794). The thickness of the external sphincter was negatively correlated with the anal canal relaxation (r=-0.609) (P 0.05). (7) the correlation analysis of the dynamic MRI and 3D HR-ARM after the operation: M line in the anus. There was a positive correlation with the threshold of the initial defecation (r=0.727). The thickness of the pubis rectum was positively correlated with the length of the high pressure band (r=0.738). The thickness of the internal sphincter was negatively correlated with the length of the high pressure band and the anorectal pressure difference (r=-0.680, r=-0.729). (1) the accuracy of the pelvic dynamic MRI examination was high, with the rectal finger diagnosis and the knot. The conformance of enteroscopy is good. It can provide a comprehensive, quantitative and reproducible imaging basis for preoperative evaluation of low rectal cancer and postoperative recovery of anorectal function. (2) the consistency of the dynamic MRI examination and X-ray defecography is better, which can make up the shortcomings of the low resolution of the soft tissue of the X-ray defecography, and to evaluate the anus straight. Intestinal function provides a more safe and convenient imaging method. (3) dynamic MRI and 3D HR-ARM examination showed that the ability of LARS patients to control stool before operation was still good, but there was a lower pelvic floor relaxation, lower rectal sensory function, and the postoperative contractile function of the pubis and anal sphincter decreased and the rectal sensory function weakened obviously. It is very important to avoid the above muscle injury during the operation as much as possible. It is very important for LARS patients to strengthen the functional recovery therapy at the early stage after operation. (4) dynamic MRI examination can not only directly reflect the dynamic changes of anus and rectum, but also have a significant correlation with 3D HR-ARM examination, which provides a better evaluation of anorectal function. Add effective, economical, convenient, and visualized new ideas for imaging diagnosis.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735.37;R445.2
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