本文選題：肝段 + 體積測(cè)量��； 參考：《大連醫(yī)科大學(xué)》2015年博士論文

【摘要】：隨著精準(zhǔn)醫(yī)療和個(gè)體化醫(yī)療理念的提出和臨床醫(yī)療技術(shù)的不斷進(jìn)步,精準(zhǔn)肝醫(yī)療也日益受到重視�；诟味谓馄实木珳�(zhǔn)肝切除、確保殘余肝臟解剖結(jié)構(gòu)的完整和功能性體積的最大化是當(dāng)今的研究熱點(diǎn)。術(shù)前肝葉、段體積的測(cè)量評(píng)估是肝臨床的迫切需求。在臨床上,CT和MRI檢查是肝臟體積測(cè)量應(yīng)用最廣泛的手段,有研究表明CT、MRI等測(cè)量結(jié)果與肝臟體積偏差不大。但是臨床工作中仍然發(fā)現(xiàn),這種測(cè)量結(jié)果與手術(shù)過程中的實(shí)際情況存在偏差。同時(shí),越來越多的學(xué)者對(duì)Couinaud肝段法提出質(zhì)疑,其中肝段定位誤差比例最高、偏差距離最大的均在肝右葉。以往對(duì)肝段影像學(xué)定位誤差的相關(guān)研究多集中在誤差的大小以及是否符合Couinaud肝段法上。但是對(duì)于劃分誤差出現(xiàn)的原因并沒有進(jìn)行深入研究。而隨著肝右后葉作為移植物進(jìn)行肝移植及精準(zhǔn)肝切除術(shù)的開展,對(duì)肝右葉間裂的空間形態(tài)及偏斜情況的準(zhǔn)確描述不斷提出新要求。為探尋肝臟體積測(cè)量與臨床所見不符出現(xiàn)的原因、描述右葉間裂的空間形態(tài),本研究采用肝臟分段分色灌注聯(lián)合生物塑化斷層技術(shù)、CT掃描技術(shù)、Photoshop CS5及AutoCAD等軟件,對(duì)肝臟切片標(biāo)本采用影像學(xué)分界和真實(shí)分界兩種分界法的進(jìn)行肝段的面積測(cè)量,計(jì)算右前葉、右后葉體積并進(jìn)行對(duì)比研究;采用數(shù)據(jù)分析法深入探尋影像學(xué)差異出現(xiàn)的原因。為了更好的顯示肝臟右葉各段的形態(tài)及右葉間裂的走行,本研究使用MIMICS軟件建立肝右葉各段及右葉間裂的立體可視化模型,對(duì)肝右葉間裂的形態(tài)進(jìn)行觀察。此外,為進(jìn)一步指導(dǎo)臨床對(duì)右葉間裂的觀察,本研究還對(duì)臨床肝臟CT圖像進(jìn)行回顧性研究,采用MIP及VR重建方法觀察右葉間裂形態(tài),優(yōu)化右葉間裂的影像學(xué)觀察方法。所得結(jié)果將提高肝右葉疾病定位精確性,為臨床右葉間裂、肝段定位診斷及精準(zhǔn)肝段切除、肝段移植提供更可靠的形態(tài)學(xué)依據(jù)及數(shù)據(jù)參考。第一部分材料及方法:采用分段分色灌注方法及生物塑化切片技術(shù)制作5例肝臟分段分色灌注切片并逐層拍照。使用Photoshop CS5及Adobe Illustrator CS5軟件將肝臟切片逐層配準(zhǔn)并標(biāo)記影像學(xué)分界,將圖像導(dǎo)入AutoCAD軟件測(cè)量肝臟切片上以影像學(xué)分界及不同顏色顯示的肝段真實(shí)解剖分界測(cè)量右前葉及右后葉的各層面積,并計(jì)算各葉體積,將所得數(shù)據(jù)使用Spss 13.0軟件進(jìn)行統(tǒng)計(jì)分析,比較影像學(xué)分界法與真實(shí)解剖分界間存在的差異。結(jié)果:1.使用影像學(xué)標(biāo)志和解剖學(xué)標(biāo)志測(cè)量所得肝右葉體積分別為737.15± 220.30 cm~3和705.27±178.82cm~3。采用影像分界、真實(shí)解剖分界測(cè)得肝右前葉體積平均值分別為412.86±99.68cm~3和417.41 ±138.19cm~3,肝后葉體積平均值分別為325.14± 136.78cm~3 和 289.32±89.71cm~3。2.在肝臟分段灌注切片標(biāo)本上采用影像學(xué)標(biāo)志及真實(shí)解剖標(biāo)志兩種劃分方法測(cè)量肝臟右前葉及右后葉體積無明顯統(tǒng)計(jì)學(xué)差異。第二部分在第一部分的測(cè)量過程中觀察到,依據(jù)兩種不同的劃分方法定位各層面的右前葉、右后葉時(shí)存在明顯視覺偏差,而統(tǒng)計(jì)學(xué)結(jié)果卻顯示兩種方法測(cè)量的體積無明顯差異,為進(jìn)一步尋找出現(xiàn)這樣相悖結(jié)果的原因,本研究繼續(xù)對(duì)之前所得數(shù)據(jù)進(jìn)行深入分析。材料及方法:將肝臟切片AutoCAD測(cè)量所得的影像分界、真實(shí)分界兩組數(shù)據(jù)逐層進(jìn)行計(jì)算,得到各層面肝右前葉、右后葉的劃分面積測(cè)量誤差值(S誤差)及誤差率(Error rate,ER)。將各層影像劃分錯(cuò)誤率[(影像面積一真實(shí)面積)絕對(duì)值/影像面積]%為縱坐標(biāo),以肝臟切片層面為橫坐標(biāo),獲得得右前葉和右后葉的各層肝葉面積測(cè)量錯(cuò)誤率曲線。并進(jìn)一步進(jìn)行逐層比較,將偏差值[影像面積一真實(shí)面積]作為縱坐標(biāo),肝臟切片層面為橫坐標(biāo),獲得肝葉面積測(cè)量偏差曲線。結(jié)果:1.右前葉所得面積偏差值曲線為前正后負(fù)的正弦曲線,而右后葉所得面積偏差值曲線正好相反為前負(fù)后正。由此可見在頭側(cè)層面更多的右前葉被劃分入右后葉,導(dǎo)致右前葉偏小而右后葉偏大,而尾側(cè)層面更多的右后葉被劃入右前葉,最大偏差可達(dá)40cm~2。2.右前葉、右后葉錯(cuò)誤率曲線均呈U形或V型,說明右前葉與右后葉劃分在頭側(cè)層面和尾側(cè)層面錯(cuò)誤率均明顯高于中間層面;第一部分及第二部分結(jié)論:1.肝臟分段分色切片標(biāo)本是顯示肝段、肝葉分界及測(cè)量解剖學(xué)體積的有效方法。2.影像學(xué)標(biāo)志確定的肝右葉間裂對(duì)右前葉、右后葉進(jìn)行劃分,在頭側(cè)層面將使部分屬于右前葉的Ⅷ段被劃入右后葉的Ⅷ段,從而導(dǎo)致Ⅷ段體積偏小,Ⅶ段體積偏大;在尾側(cè)層面將使部分屬于右后葉的Ⅶ段被劃入右前葉的Ⅴ段,從而導(dǎo)致Ⅵ段體積偏小,Ⅴ段體積偏大。3.右前葉或右后葉的體積測(cè)量由于頭側(cè)與尾側(cè)的偏差相互抵消而顯示出按照影像學(xué)標(biāo)志測(cè)量肝葉體積準(zhǔn)確性高。這是看不出以影像學(xué)標(biāo)志對(duì)肝葉體積進(jìn)行測(cè)量存在誤差的原因。4.影像學(xué)標(biāo)志定位肝右葉間裂在中間層面準(zhǔn)確,在肝臟頭側(cè)和尾側(cè)層面偏差大。第三部分在這部分研究中,通過三維重建方法對(duì)右葉肝段、肝裂進(jìn)行顯示和觀察。材料與方法:本研究采用Adobe Photoshop CS5軟件,將分段分色灌注的肝臟切片標(biāo)本上以不同顏色顯示的各肝段真實(shí)邊界進(jìn)行分割,這種肝臟切片標(biāo)本在各層面上對(duì)于肝段的劃分完全依據(jù)血管內(nèi)灌注劑顏色不同而區(qū)分出的分界,是最真實(shí)可靠的肝段分界。將此肝臟圖像導(dǎo)入MIMICS軟件后對(duì)其進(jìn)行三維重建,肝段間真實(shí)分界進(jìn)行充分展示,對(duì)右葉間裂空間形態(tài)進(jìn)行描述。結(jié)果:1.在MIMICS軟件顯示的斷層圖像中,右葉間裂在膈頂部未出現(xiàn),隨著圖像向肝臟尾側(cè)層面移動(dòng),右葉間裂逐漸出現(xiàn),并且頭側(cè)層面靠后,尾側(cè)層面靠前。頭側(cè)層面的右葉間裂與冠狀面近似平行,至尾側(cè)層面右葉間裂開始逐漸偏轉(zhuǎn)成一斜面,與冠狀面間出現(xiàn)明顯夾角。2.使用MIMICS軟件可以對(duì)肝臟分段分色灌注的切片標(biāo)本進(jìn)行肝段三維重建。然后加以組合顯示,可清晰顯示各段間比鄰關(guān)系。3.右前葉與右后葉并非簡(jiǎn)單的前后,而是前上與后下的位置關(guān)系。并且,通過調(diào)整三維重建圖像方位對(duì)右葉間裂進(jìn)行觀察發(fā)現(xiàn),右葉間裂由后上向前下傾斜走行,該裂隙內(nèi)部右前葉與右后葉間有很多凸凹處相互鑲嵌。但是其并非是簡(jiǎn)單斜行平面,而是在向下走行的過程中不斷外旋的曲面,其與正中矢狀面的夾角不斷增大。第四部分從前三部分研究可知,肝臟右葉間裂影像學(xué)定位的偏差對(duì)于測(cè)量肝臟體積的數(shù)值影響不大,但是對(duì)肝段歸屬的判斷在肝臟頭側(cè)和尾側(cè)層面誤差顯著。且在MIMICS重建中可見肝臟右葉間裂為一斜行扭轉(zhuǎn)層面,因此臨床影像學(xué)觀察肝臟右葉間裂并定位肝臟右前葉、右后葉的方法仍有待改進(jìn)。材料和方法:本課題對(duì)25例無肝臟疾病的CT肝臟增強(qiáng)圖像進(jìn)行回顧性研究,采用美國(guó)GE公司64排128層螺旋CT的ADW4.4后處理工作站進(jìn)行圖像重建及測(cè)量分析。采用影像學(xué)軸位圖像、最大密度投影法(MIP)和容積重建(VR)方法對(duì)肝臟右葉血管分支進(jìn)行重建。在軸位使用MIP法重建門脈分支,對(duì)應(yīng)VR重建圖像上門脈分支位置,調(diào)整圖像重建層厚及重建層面,顯示對(duì)應(yīng)肝裂所在層面最清晰的圖像,使用螺旋CT角度測(cè)量工具進(jìn)行測(cè)量尋找右葉間裂最佳觀察方法。結(jié)果:1.軸位觀察測(cè)量采用影像學(xué)標(biāo)志定位方法測(cè)量得到正中裂較矢狀面偏右平均為51°,該方法觀察正中裂與膽囊窩中點(diǎn)吻合度較高;而采用MIP法測(cè)量正中裂矢狀面偏右平均為48°,在肝臟下緣觀察肝正中裂88%與膽囊窩中點(diǎn)吻合。采用影像學(xué)標(biāo)志定位方法測(cè)量,肝右葉間裂與矢狀面夾角平均為97.8°;采用MIP法測(cè)量軸位CT圖像測(cè)量,肝右葉間裂與矢狀面夾角平均為116.5°,二者存在明顯差異。但在軸位圖像上有時(shí)不能同時(shí)顯示右前支和右后支分叉及其分支所在位置,如果增厚重建層厚,則門靜脈右前葉分支與右后葉分支之間存在較大交叉。2.矢狀位觀察測(cè)量但右前葉、右后葉門靜脈分支間可見存在一明顯的乏血管區(qū),即為右葉間裂,右前葉、右后葉分支分別列于該裂隙兩側(cè),該裂隙頭側(cè)偏后,尾側(cè)偏前,與垂直軸冠狀面之間的夾角為2.6 °～58.4 °,平均為32.97 °± 15.51°。當(dāng)肝右葉間裂與垂直軸夾角較大時(shí),膈頂部位全部為右前葉Ⅷ段,而尾側(cè)部位全部為右后葉Ⅵ亞段。此時(shí)右前葉與右后葉為前上與后下的位置關(guān)系。而當(dāng)肝右葉間裂接近冠狀位時(shí),右前葉與右后葉近似前后的位置關(guān)系。3.CT圖像上每降低一層(掃描層厚)肝右葉間裂向前移動(dòng)距離D=cot a×掃描層厚mm。第三部分及第四部分結(jié)論1.肝右葉間裂在CT圖像MIP矢狀位重建圖像上觀察最佳;2.右葉間裂為一由后上向前下走行的斜裂,且為一逐漸扭轉(zhuǎn)的斜面。3.根據(jù)肝右葉間裂在矢狀面上的傾斜角度,可可以指導(dǎo)臨床在無明顯影像標(biāo)志的CT圖像層面對(duì)右葉間裂進(jìn)行定位。4.當(dāng)肝右葉間裂與垂直軸夾角較大時(shí),右前葉與右后葉為前上與后下的關(guān)系;而當(dāng)肝右葉間裂接近冠狀位時(shí),右前葉與右后葉近似前后關(guān)系。
[Abstract]:With the development of precision medical and individualized medical ideas and the continuous progress of clinical medical technology, precision liver medicine is becoming more and more important. Accurate liver resection based on segmental anatomy to ensure the complete and functional volume of residual liver anatomy is the hot spot of research. The preoperative liver leaf, segment volume measurement evaluation is the liver In clinical practice, CT and MRI are the most widely used methods for the measurement of liver volume. Studies have shown that the results of CT, MRI and other measurements have little deviation from the liver volume. However, in clinical work, it is still found that this measurement results from the actual situation in the operation process. At the same time, more and more scholars are on the liver of Couinaud. The location error of the hepatic segment is the highest and the maximum deviation is in the right lobe of the liver. Previous studies on the location error of the hepatic segment imaging are mostly focused on the size of the error and whether it conforms to the Couinaud liver segment method. However, there is no in-depth study on the reasons for the division of the error, but the right posterior lobe of the liver is with the right lobe. As a transplant for liver transplantation and accurate hepatectomy, new requirements have been put forward for the accurate description of the spatial morphology and deviation of the right interlobar fissure of the liver. In order to explore the reasons for the difference between the measurement of liver volume and the clinical findings, the spatial morphology of the right interleaf fissure is described. This study uses segmented color perfusion of the liver combined with bioplasticity. CT scanning, Photoshop CS5 and AutoCAD software were used to measure the area of liver segments by two kinds of demarcation and demarcation. The right anterior lobe and right posterior lobe volume were calculated and compared. In this study, MIMICS software was used to establish the stereoscopic visual model of the right lobe and right lobes in the right lobe of the liver, and to observe the shape of the right lobe fissure of the liver. In addition, in order to further guide the observation of the right interleaf cleft in the right lobe, a retrospective study of the CT image of the liver was carried out in this study. MIP and VR reconstruction methods were used to observe the morphology of right lobe fissure and optimize the imaging method of right lobe fissure. The results will improve the accuracy of right lobe disease location, the clinical right lobe fissure, liver segment location diagnosis and precise liver segment resection, liver segment transplantation provide more reliable morphological basis and data reference. The first part materials and methods: 5 cases of liver segmented color segmentation were made and photographed by sectional color perfusion method and bioplastic slice technique. The liver slices were registered and marked by Photoshop CS5 and Adobe Illustrator CS5 software. The images were introduced into AutoCAD software to measure the boundary of image and different colors. The area of the right anterior lobe and right posterior lobe was measured by the real dissection of the hepatic segment, and the volume of each leaf was calculated. The data were analyzed by Spss 13 software, and the difference between the image academic division method and the real dissection was compared. Results: 1. the right lobe volume of the liver was 7 by using imaging markers and anatomical markers, respectively. The images of 37.15 + 220.30 cm~3 and 705.27 + 178.82cm~3. were demarcated. The mean value of the right anterior lobe of the liver was 412.86 + 99.68cm~3 and 417.41 + 138.19cm~3, respectively. The mean value of the volume of the posterior lobe of the liver was 325.14 + 136.78cm~3 and 289.32 + 89.71cm~3.2. respectively. There was no significant difference in the volume of the right anterior lobe and right posterior lobe of the liver. The second part observed the right anterior lobe at all levels in the first part of the measurement of the right anterior lobe and the right posterior lobe in the first part of the measurement. There was a significant difference between the right anterior lobe and the right posterior lobe, while the statistical results showed that the two methods measured the two methods. There is no obvious difference in volume. In order to further find the reasons for such a contrary result, this study continues to analyze the previous data. Materials and methods: the image demarcation of the liver slice AutoCAD measurement, the real dividing two sets of data by layer by layer, the right anterior lobe of the liver and the right posterior leaf area measurement are measured. Error rate (S error) and error rate (Error rate, ER). The error rate [(a real area of image area) absolute value / image area of each layer is as ordinate, and the liver slice level is a horizontal coordinate, and the error rate curve of the liver leaf area of the right anterior and right posterior leaves is measured. As a real area of area] as a vertical coordinate, the liver slice layer is a horizontal coordinate, and the deviation curve of the liver leaf area measurement is obtained. Results: the curve of the area deviation value of the 1. right anterior lobe is the sine curve of the front and back negative, and the curve of the area deviation value of the right posterior lobe is just opposite to the front negative. The right anterior lobe was divided into the right posterior lobe, causing the right anterior lobe to be small and the right posterior lobe larger, and more right posterior lobe of the tail side was inserted into the right anterior lobe, the maximum deviation could reach 40cm~2.2. right anterior lobe, and the error rate curve of the right posterior lobe was U or V. The error rate of the right anterior lobe and right posterior lobe was significantly higher than the middle level; first, the error rate was higher than the middle level; first, the error rate was higher than the middle level; first, the error rate was higher than the middle level; first Part two and part two: 1. the segmented slice specimen of liver is an effective method to display the hepatic segment, the boundary of the hepatic lobe and the measurement of the anatomical volume. The right anterior lobe, the right posterior lobe is divided into the right lobe, and the VIII segment belonging to the right anterior lobe will be divided into the VIII in the right posterior lobe at the head and side level, which leads to the VIII. The volume of the segment is small and the Volume VII is large, and the VII section of the right posterior lobe will be divided into the V section of the right anterior lobe at the tail side, which leads to the small volume of the section VI. The volume of the V section of the.3. right anterior or right posterior lobe is measured by the offset of the deviation between the head and the tail side, which shows the measurement of the volume of the hepatic lobe according to the imaging signs. This is the reason why there is no error in the measurement of the volume of the hepatic lobe with the imaging signs. The.4. imaging sign is accurate in the middle level of the right lobe of the liver, and there is a large deviation between the head side and the tail side of the liver. In this part, the right lobe liver segment and the liver fissure are displayed and observed in the third part of the study. Materials and methods: This study uses the Adobe Photoshop CS5 software to divide the segmented liver slices on the true boundaries of the liver segments displayed in different colors. The liver segments are divided completely on the liver segments on the various levels according to the different color of intravascular perfusion agents. It is the most authentic and reliable. The liver segment was divided. After the liver image was introduced into MIMICS software, three-dimensional reconstruction was carried out, and the true boundary between the segments of the liver was fully demonstrated and the spatial morphology of the right interleaf fissure was described. Results: 1. in the fault images shown by the MIMICS software, the right interleaf fissure did not appear on the top of the diaphragm, and as the image moved to the tail side of the liver, the right interleaf fissure was separated. The right lateral cleft in the head and side is approximately parallel to the coronal plane, and the right interleaf cleft in the tail side is gradually deflected into an oblique plane, and the obvious angle between the caudal plane and the coronal plane,.2., can be used to reconstruct the segment of the liver segment by MIMICS software. In combination, it can clearly show that the right anterior lobe and right posterior lobe are not simple before and after the adjacent relationship.3., but the relationship between the front and the upper and the lower, and the right interleaf cleft is observed by adjusting the azimuth of the three-dimensional reconstruction image, and the right interleaf cleft is leaning from the back to the forward and forward, and the right anterior lobe and the right posterior lobe in the fracture are between the right and right lobes. There are a lot of convex and concave places inlaid each other. But it is not a simple oblique plane, but a curved surface in the course of walking downward. The angle between the median sagittal plane is increasing. The fourth part of the previous three studies shows that the deviation of the imaging location of the right interleaf fissure in the liver has little effect on the measurement of the volume of the liver, but The judgment of the hepatic segment belonged to the head side and the tail side of the liver was significant. And in the MIMICS reconstruction, the right interlobe fissure of the liver was seen as a oblique line. Therefore, the clinical imaging observation of the right lobe of the liver and the right anterior lobe of the liver and the right posterior lobe still need to be improved. Materials and methods: this subject has 25 cases of CT without liver disease. A retrospective study of liver enhancement images was made by using the ADW4.4 post processing workstation of 64 rows of 128 slice spiral CT in the United States GE company for image reconstruction and measurement. The image branch image, the maximum density projection (MIP) and the volume reconstruction (VR) method were used to reconstruct the branches of the right lobe of the liver. The axis position was reconstructed by MIP method. The position of the VR reconstruction image is rebuilt, the image reconstruction layer thickness and the reconstruction level are adjusted to show the most clear image at the level of the liver fissure, and the best observation method of finding the right interleaf fissure with the spiral CT angle measurement tool is used. Results: the 1. axis observation measurement uses the imaging sign positioning method to measure the median fissure sagittal. The mean deviation between the right and right sides was 51 degrees. This method observed that the median fissure of the median and the middle of the gallbladder fossa was higher, while the median of the median split sagittal plane was 48 degrees on the right, and 88% of the median liver fissure was observed at the middle of the lower edge of the liver with the middle of the gallbladder fossa. The average angle between the right lobe and the sagittal plane was 97.8 degrees by using the image marker positioning method. The average angle of the right lobe of the liver and the sagittal plane was measured by the MIP method. The MIP method was used to measure the axial CT image. The average angle between the right lobe and the sagittal plane was 116.5 degrees, and there was a significant difference between the two. But the right anterior and right posterior branches and its branches were not displayed at the same time on the axial image. If the thickened reconstructive layer was thickened, there was a large cross between the right anterior and right posterior branches of the portal vein. .2. sagittal observation and measurement but right anterior lobe, there is a clear vascular area between the branches of the right posterior portal vein, that is, right interleaf fissure, right anterior lobe and right posterior lobe on both sides of the fissure. The fissure is behind the head side, the tail side is before the side, and the angle between the caudal side is 2.6 to 58.4 degrees, and the average is 32.97? 15.51 degrees. The right anterior lobe was all right anterior lobe VIII while the right anterior lobe VIII was all of the right anterior lobe, while the right anterior lobe and right posterior lobe were the relationship between the upper and the lower parts, while the right anterior lobe was close to the coronal position when the right lobe was close to the coronal position, and the position of the right anterior lobe and the right posterior lobe was similar to the.3.CT image. Scanning layer thick) the forward moving distance between the right lobe of the liver D=cot a x scanning layer thickness mm. third and part four conclusion the 1. right lobe fissure of the liver is best observed on the CT image MIP sagittal reconstruction image; the 2. right interleaf fissure is a slit from the posterior upward and downward, and a gradually torsional oblique.3. is based on the right interlobe fissure in the sagittal plane. The oblique angle can guide the clinic to locate the right interleaf fissure in the CT image layer without obvious image signs. When the angle of the right lobe between the right lobe and the vertical axis is larger, the right anterior lobe and the right posterior lobe are the relationship between the upper and the lower. While the right anterior lobe is close to the coronal position, the right anterior lobe is similar to the right posterior lobe when the right lobe is close to the coronal position.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2015
【分類號(hào)】：R322.47;R657.3

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1 張健飛;肝右葉體積測(cè)量及肝裂定位的臨床解剖學(xué)研究[D];大連醫(yī)科大學(xué);2015年

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