【摘要】：肝臟外科手術(shù)仍是治療肝膽外科疾病的主要方式。盡管外科治療水平已經(jīng)得到了很大的提高,但是肝功能衰竭仍然是肝臟切除術(shù)后主要的死亡原因。目前,大致有4類常用的評估肝臟儲備功能的方法:(1)肝臟血清生化學(xué)試驗;(2)肝臟功能定量試驗;(3)綜合評分系統(tǒng);(4)肝臟體積測量;但是由于肝病的多樣性及肝功能的復(fù)雜性,每種方法都有它的優(yōu)越性和局限性。前期工作中我們發(fā)現(xiàn)利用胰島素和C肽的濃度評估肝臟儲備功能是可行的。在此基礎(chǔ)上,我們利用口服糖耐量試驗、胰島素釋放試驗、C肽釋放試驗檢測肝功能異�；颊吲c肝功正常人群的血糖濃度、胰島素濃度及C肽濃度,分析兩組人群的濃度差異。篩選出一個較為靈敏的反映肝儲備功能的胰島素濃度時間點(diǎn)或者胰島素濃度變化時段,作為評估肝臟儲備功能的新指標(biāo)。統(tǒng)計學(xué)分析結(jié)果顯示:服糖后2h和服糖后3h兩組人群血糖濃度、胰島素濃度及C肽濃度存在顯著性差異,此外,兩組人群的空腹胰島素濃度也是存在顯著差異的;Child-Pugh評分A級與B、C級間胰島素濃度存在顯著性差異,但是Child-Pugh評分B級與C級間不存在顯著性差異,胰島素代謝的差異和肝臟Child-Pugh評分等級相關(guān);并且我們認(rèn)為服糖后2h到服糖后3h這個時間段胰島素濃度的增加速率或變化率能更好的反映肝臟損傷情況,可以作為評估肝功能的參數(shù);肝臟影響胰島素的代謝,且肝功能異常降低肝臟對胰島素的代謝能力。隨著科學(xué)技術(shù)在醫(yī)學(xué)領(lǐng)域的不斷發(fā)展,肝膽外科已邁入精準(zhǔn)時代,這就要求醫(yī)師在切除肝臟病灶的同時,盡量減少正常肝臟組織的切除,避免周圍血管的損傷,減少術(shù)中出血。然而,肝臟血管系統(tǒng)復(fù)雜且來源多的特點(diǎn),決定了其損傷及變異的多樣性和不確定性,使肝臟切除手術(shù)難度高、風(fēng)險大。因此,肝臟血管結(jié)構(gòu)的解剖學(xué)研究在肝臟外科的發(fā)展中起重要作用。傳統(tǒng)的肝臟血管解剖多是來源于動物模型和尸體解剖標(biāo)本,受血管灌注技術(shù)及尸體標(biāo)本來源的限制,傳統(tǒng)的肝臟血管解剖不能為現(xiàn)代精準(zhǔn)肝臟外科手術(shù)提供三維解剖數(shù)據(jù)。隨著對人體形態(tài)學(xué)的深入研究及數(shù)字化醫(yī)療的不斷發(fā)展,3D可視化的人體解剖已經(jīng)成為現(xiàn)實。術(shù)前在CT數(shù)據(jù)的基礎(chǔ)上對患者肝內(nèi)血管進(jìn)行重建,能夠得到源于數(shù)據(jù)又能全面觀測肝內(nèi)血管的3D重建模型,因為CT數(shù)據(jù)源于患者自身,3D重建模型反映的是個體的血管結(jié)構(gòu)及病變情況。通過肝內(nèi)血管3D重建模型醫(yī)師能夠直觀的觀察血管在肝內(nèi)的走行、分布及變異,了解變異血管的來源、走行及生理功能。此外,在3D重建模型的基礎(chǔ)上還能測量血管的直徑、血管間的距離及血管與病灶間的距離。將3D重建模型應(yīng)用于肝臟切除手術(shù),醫(yī)師能在術(shù)前了解患者血管的變異及解剖情況,為患者制定個性化的治療方案,選擇合理的手術(shù)方式,做好術(shù)前規(guī)劃,減少術(shù)中血管的損傷及出血量,以提高手術(shù)的成功率,減少手術(shù)風(fēng)險及術(shù)后并發(fā)癥。
[Abstract]:Liver surgery is still the main way to treat hepatobiliary surgery. Although the level of surgical treatment has been greatly improved, liver failure remains the main cause of death after hepatectomy. At present, there are generally four commonly used methods of evaluating the liver reserve function: (1) the liver serum biochemical test; (2) the quantitative test of the liver function; (3) the comprehensive scoring system; (4) the liver volume measurement; but due to the diversity of the liver disease and the complexity of the liver function, Each method has its advantages and limitations. In the preliminary work we have found that the use of insulin and C-peptide concentrations to assess the liver reserve function is feasible. On this basis, we used the oral glucose tolerance test, the insulin release test and the C-peptide release test to detect the blood glucose concentration, insulin concentration and C-peptide concentration in the normal population of the liver function and analyze the difference in the concentration of the two groups. A more sensitive time point of the insulin concentration or the time of change in the insulin concentration was selected as a new index to assess the function of the liver reserve. The results of the statistical analysis showed that the blood glucose concentration, insulin concentration and C-peptide concentration in the two groups were significantly different after 2 h and 3 h after the administration of the sugar, and there was a significant difference in the fasting insulin concentration in the two groups. Child-Pugh scores A and B, There was a significant difference in the concentration of the interstage insulin, but there was no significant difference between the level of Child-Pugh and C stage, the difference of insulin metabolism and the grade of Child-Pugh of the liver. and we think that the increase rate or rate of change of the insulin concentration in the time period after 2 hours after serving the sugar can better reflect the liver injury condition, can be used as a parameter for evaluating the liver function, and the liver affects the metabolism of the insulin, And the liver function is abnormal, and the metabolism capacity of the liver to the insulin is reduced. With the development of science and technology in the medical field, the liver and gallbladder surgery has entered the precise time, which requires the physician to minimize the resection of the normal liver tissue while cutting the focus of the liver, to avoid the damage of the surrounding blood vessels, and to reduce the intraoperative bleeding. However, the complex and multi-source characteristics of the hepatic vascular system determine the diversity and uncertainty of the damage and variation of the liver, which makes the liver resection operation difficult and the risk is high. Therefore, the anatomical study of the hepatic vascular structure plays an important role in the development of liver surgery. The traditional hepatic vascular anatomy is derived from the animal model and the autopsy specimen, and is limited by the blood vessel perfusion technique and the source of the cadavers, and the traditional hepatic vascular anatomy can not provide the three-dimensional anatomical data for the modern precise liver surgery. With the deep study of human morphology and the development of digital medical treatment, 3D visualization of human anatomy has become a reality. On the basis of the CT data, the patient's hepatic blood vessel was reconstructed, and the 3D reconstruction model of the hepatic blood vessel can be fully observed from the data, because the CT data is derived from the patient's own, and the 3D reconstruction model reflects the vascular structure and the pathological condition of the individual. Through the hepatic vascular 3D reconstruction model, the course, distribution and variation of the blood vessel in the liver can be visually observed, and the source, the course and the physiological function of the variant blood vessel are known. In addition, the diameter of the blood vessel, the distance between the blood vessels and the distance between the blood vessel and the focus can also be measured on the basis of the 3D reconstruction model. The 3D reconstruction model is applied to the liver resection operation, and the physician can understand the variation and the anatomy of the blood vessel of the patient before the operation, develop a personalized treatment scheme for the patient, select a reasonable operation mode, perform pre-operation planning, reduce the damage and the blood loss of the blood vessels during the operation, So as to improve the success rate of the operation, reduce the operation risk and postoperative complications.
【學(xué)位授予單位】：昆明理工大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R657.3

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