本文選題：三維可視化　切入點：ICG分子熒光成像　出處：《南方醫(yī)科大學(xué)》2017年碩士論文

【摘要】：研究目的肝臟腫瘤的精準(zhǔn)手術(shù)導(dǎo)航對于提高手術(shù)的安全性以及有效性具有重要的意義。近年來,在計算機技術(shù)基礎(chǔ)上發(fā)展的三維可視化系統(tǒng)作為一種形態(tài)學(xué)方面的成像手段,被廣泛應(yīng)用于肝膽外科的手術(shù)導(dǎo)航。而吲哚菁綠(indocyanine green,ICG)分子熒光成像則是一種新興的影像學(xué)方法,可以從細(xì)胞功能水平實現(xiàn)人體組織結(jié)構(gòu)的實時成像。本課題將三維可視化與ICG分子熒光成像技術(shù)聯(lián)合應(yīng)用于肝臟腫瘤手術(shù)中,從形態(tài)解剖水平和細(xì)胞功能水平進行手術(shù)導(dǎo)航,并結(jié)合實際的臨床應(yīng)用,評估該導(dǎo)航模式的實用價值。方法2015年04月至2017年01月間,南方醫(yī)科大學(xué)珠江醫(yī)院肝膽一科共31例肝臟腫瘤病人在三維可視化聯(lián)合ICG分子熒光成像技術(shù)指導(dǎo)下進行手術(shù)。所有病人術(shù)前均通過三維可視化系統(tǒng)進行三維立體重建及三維可視化分析,確定初步的手術(shù)方案。術(shù)前24h以0.25-0.5 mg/kg的劑量標(biāo)準(zhǔn)經(jīng)外周靜脈注射ICG后,術(shù)中使用ICG分子熒光成像技術(shù)對腫瘤進行實時的定位及邊界界定,確定肝切除范圍。擬行解剖性肝切除術(shù)的病人,術(shù)中先游離并阻斷擬切除肝葉/段所對應(yīng)的門靜脈分支,經(jīng)外周靜脈追加1mlICG溶液(2.5mg/ml)后進行熒光檢測,根據(jù)熒光信號的分布確定肝葉/段的界線及肝切除范圍。離斷肝實質(zhì)后,再對肝斷面進行ICG分子熒光檢測,協(xié)助判斷有無腫瘤殘余以及膽漏。術(shù)后通過比較離體腫瘤標(biāo)本熒光成像的最大徑與三維可視化腫瘤模型的最大徑,評估ICG分子熒光成像在肝臟腫瘤邊界判斷中的準(zhǔn)確性。結(jié)果31例病人均獲得結(jié)構(gòu)清晰、立體感強的三維可視化模型,并進行了個體化的手術(shù)規(guī)劃。術(shù)中在ICG分子熒光成像技術(shù)輔助下,實時呈現(xiàn)了肝臟腫瘤的定位與邊界信息。比較離體腫瘤標(biāo)本的熒光成像最大徑與三維可視化腫瘤模型的最大徑,其差異無統(tǒng)計學(xué)意義(t=-1.874,p=0.071),Pearson相關(guān)性檢驗提示二者具有高度相關(guān)性(r=0.991,P0.001)。3例病人術(shù)中使用ICG分子熒光成像技術(shù)顯示了半肝切除的范圍,所呈現(xiàn)的熒光界線清晰、完整,實現(xiàn)了肝臟實質(zhì)的三維染色,與阻斷相應(yīng)門靜脈和肝動脈后肝臟缺血范圍一致。1例病人通過ICG分子熒光成像技術(shù)檢出肝斷面殘余腫瘤,擴大肝切除范圍后,再次使用熒光檢測,無腫瘤殘余,肝切緣病理結(jié)果為陰性。最終本組病人肝切緣術(shù)中熒光檢測結(jié)果和術(shù)中冰凍病理診斷相一致,均為陰性,R0切除率為100%。此外,術(shù)中通過ICG分子熒光成像技術(shù)發(fā)現(xiàn)肝斷面膽漏1例,經(jīng)處理后再次采用熒光成像檢測,原膽漏處無熒光聚集,術(shù)后無膽漏發(fā)生。本組病人術(shù)后膽漏的總體發(fā)生率為3.2%(1/31)。結(jié)論三維可視化聯(lián)合ICG分子熒光成像技術(shù)可在術(shù)中實時定位肝臟腫瘤并協(xié)助腫瘤邊界及肝切除范圍的界定,同時可高敏感地發(fā)現(xiàn)肝斷面的殘余腫瘤及膽漏,在肝臟腫瘤的手術(shù)導(dǎo)航中具有一定的實用價值。
[Abstract]:Objective to improve the safety and effectiveness of liver tumor surgery with accurate surgical navigation.In recent years, the 3D visualization system developed on the basis of computer technology, as a morphological imaging method, has been widely used in hepatobiliary surgery surgery navigation.Indocyanine green indocyanine green ICG molecular fluorescence imaging is a new imaging method, which can realize real-time imaging of human tissue structure at the level of cell function.In this paper, 3D visualization and ICG molecular fluorescence imaging were combined in liver tumor surgery, and the practical value of the navigation model was evaluated according to the level of morphologic anatomy and cell function.Methods from April 2015 to January 2017, a total of 31 patients with liver tumors in the Department of Hepatobiliary, Zhujiang Hospital, Southern Medical University, were operated on under the guidance of three-dimensional visualization and ICG molecular fluorescence imaging.Three dimensional reconstruction and visualization analysis were performed on all patients before operation.After ICG was injected into peripheral vein 24 hours before operation, ICG molecular fluorescence imaging technique was used to locate the tumor in real time and to determine the range of hepatectomy.In patients undergoing anatomic hepatectomy, the portal vein branches corresponding to the liver lobe / segment were first dissociated and blocked, and the fluorescence was detected by adding 2.5 mg / ml of 1mlICG solution through peripheral vein.According to the distribution of fluorescence signal, the boundary of liver lobe / segment and the range of hepatectomy were determined.After dissection of liver parenchyma, ICG molecular fluorescence detection was performed on the liver section to determine the residual tumor and bile leakage.The accuracy of ICG molecular fluorescence imaging in judging liver tumor boundary was evaluated by comparing the maximum diameter of fluorescence imaging in vitro with that of 3D visual tumor model.Results three-dimensional visual models with clear structure and strong stereosynthesis were obtained in all 31 patients and individualized operation planning was carried out.With the help of ICG molecular fluorescence imaging, the location and boundary information of liver tumors were presented in real time.The maximum diameter of fluorescence imaging was compared with that of 3D visual tumor model in vitro.The difference was not statistically significant. Pearson correlation test showed that there was a high correlation between the two methods. The range of hemihepatectomy was demonstrated by using ICG molecular fluorescence imaging technique, and the fluorescence boundary was clear and complete.Three-dimensional staining of liver parenchyma was realized, which was consistent with the ischemic range of liver after occlusion of portal vein and hepatic artery. Residual tumors in liver transection were detected by ICG molecular fluorescence imaging. After hepatectomy was expanded, fluorescence detection was used again.There was no residual tumor, and the pathological results of hepatic margin were negative.In the end, the results of intraoperative fluorescence detection were consistent with those of frozen pathological diagnosis in this group of patients, all of which were negative and R0 resectable rate was 100%.In addition, intraoperative ICG molecular fluorescence imaging technique was used to detect 1 case of bile leakage in the transect of liver. After treatment, fluorescence imaging was used again. There was no fluorescence accumulation in the original bile leakage and no bile leakage occurred after operation.The overall incidence of postoperative biliary leakage in this group was 3.2 / 31%.Conclusion Three-dimensional visualization combined with ICG molecular fluorescence imaging can locate liver tumors in real time during operation and help to define the tumor boundary and hepatectomy range. At the same time, the residual tumors and bile leakage on liver section can be detected sensitively.It has certain practical value in the operation navigation of liver tumor.
【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R735.7

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