| Research backgroundHepatolithiasis is a common disease of biliary surgery in our contury, especially in the Yangtze river basin, coastal area of south China, Taiwan province and so on.Under normal circumstances, the paitent with hepatolithiasis usually have the damage of hepatocyte and intrahepatic hepatic bile systems to varying degrees. Severe complications may occurre in the bile duct system and whole body. Hepatolithiasis is common reason of death among the nonmalignant disease in bile duct sytems. There are some patients with complicated hepatolithiasis among the patients with hepatolithiasis, the diagnosis and treatment procedure of them is more difficult. Some doctors of hepatic surgery now believe that except the patient’s systemic disease like heart disease, lung disease, kidney diseases, diabetes could be the risk factors to the bild duct surgery, if any of the below symptom occurred we think that it could be called complicated hepatolithiasis. (1) patients already had more than 1 time bile duct surgery because the calculus inside intrahepatic bile duct system, but there are still some residual calculus exist or recurrent cholangitis needed to perform the operation again. (2) patients already have performed some improper bile dcut surgery like all differents kinds of choledochojejunostomy, anastomotic stenosis occurred after the operation so that another suegery needed to be done. (3) there are permeating distributed calculus inside both lobes of the liver. (4) patients have hepatolithiasis with elevates biliary stricture or Caroli disease. (5) paitents have hepatolithiasis with biliary cirrhosis, portal hypertension and so on. (6) paitents have hepatolithiasis with intrahepatic cholangiocarcinoma. Patients with complicated hepatolithiasis ususlly cause serious complications like the syndrome of atrophy-hypertrophy in the liver, acute obstructive suppurative cholangitis, cholangiocellular carcinoma. The bacis pathologic change is the inhepatic bile systems have varying degrees of stenosis and dilate, usually combine with mechanical obstruction in the bile duct systems, giving rise to infection of biliary tract and the damage of liver parenchyma afterwards. Because of this pathologic change has substantial connection with the development of intrahepatic calculus and biliary stricture and would run through the whole procedure of the complicated hepatolithiasis. So, it is very important to set up a standard and rational system to deal with complicated hepatolithiasis.For the past few years, the recognition, diagnosis and treatment of complicated hepatolithiasis have already made an objective progress. Currently, the methods of diagnosis and treatment of complicated hepatolithiasis are B ultrasound, CT (computed tomography), MRI (magnetic resonance imaging), MRCP (magnetic resonance cholangiopancreatography), PTC (percutaneous transhepatic cholangiography), ERCP (endoscopic retrograde cholangiopancretography) and so on. These tradional imageological examinations have their respective advantages, but any of them has a certain amount of drawbacks. With the development of digital medicine, the three-dimensional visualization technique base on the sectional anatomical data like CT or MRI images had been brought to the attention of the hepatic and bile duct surgery experts and scholars. In later 1990s, he rapid developmented three-dimensional visualization technique has offered a new opportunity for the precisely diagnosis and treatment of hepatolithiasis. Although the three-dimensional visualization technique have already be applied to the are of the diagnosis and treatment of hepatopancreatobiliary disease, the application reports about complicated hepatolithiasis are seldom. Nowdays, the treatment concept of complicated hepatolithiasis transition from take temporary solution to effect a permanent cure, from merely symptomatic treatment to totally radical treatment. But due to the complicated pathogeny and pathophysiology change of complicated hepatolithiasis, it is an acid test to every single clinician of department of hepatobiliary surgery. Many years of clinical practices proved that it is impossible to choose a single treatment method to deal with all different types of complicated hepatolithiasis. In allusion to every patient with complicated hepatolithiasis, the surgeron should make a comprehensive assessment before the operation.Different kinds of surgical procedures should be gathered up the threads to deal with the particular disease. In order to achieve the final treatment aim of remove the pathogeny, take out of the calculus completely, disengage obstruction and implement unobstructed drainage.Based on the above the issues, the fisrt part of this research is to find out that on the basis of optimizing the CT image data collection method of patients with hepatolithiasis, applicatd the self-developed medical image three-dimensional visualization system(MI-3DVS,patent number:2008SR18798) to the diagnosis and treatment of complicated hepatolithiasis. We build a platform for the three dimensional visualization of hepatic imageology and virtual surgery to establish a three dimensional visualization model of hepatolithiasis. This three dimensional visualization model could used to zoom, hyalinized to show the abdominal organs and blood vessels from different all-dimensional and multi-angles. For patients with complicated hepatolithiasis, we could know the accurate position, size, morphology and number of inhepatic calculus, the location, length and degree of stenosised biliary duct, figure out if there is any lesion in the liver parenchyma, if there excit any syndrome of atrophy-hypertrophy inside the liver, the interrelationship among the hepatic dile duct sytems and surrounding tissues, clear-cut understand the blood supply pattern of liver and the variation type of hepatic artery and portal through the three dimensional visualization model. Perform the individualized liver segments, calculated the lvier volume, perform the individualized three dimensional visualization clinical typing of the hepatolithiasis. According to the individualized patients’practical situation, we come up with relevant surgical procedures aim at different patients guided by three dimensional visualization technology. During the operation, we combined the rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus to comprehensive deal with the patients with complicated hepatolithiasis. In the second part of this research, we mainly discussed the application value of laparoscope combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guiede by three dimensional visualization technique aim to individual patients with complicated hepatolithiasis. In order to provide the clinical evidence of the value of diagnosis and treatment of complicated hepatolithiasis which is guided by three dimensional visualization technique.Part I The application research of different surgical methods combine with rigid choledochoscope in the treatment of complicated hepatolithiasis guided by three dimensional visualization techniqueObjective1. To study the diagnostic value of MI-3DVS in complicated hepatolithiasis.2. Whether using different surgical procedures combined with rigid choledochoscope to treat the complicated hepatolithiasis based on three dimensional visualization technique could enhance the effectiveness, reduce the rate of residual stone, recurrence, reoperation and operative complications.Materials and Methods1. Research objectRetrospective analysis of 39 complicated hepatolithiasis patients in our hospital between June 2012 and October 2013. All the patients had underwent different kinds of surgical methods combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guided by the three dimensional visualization technique based on the CT image data. The ethics committee in our hospital approve to this retrospective study. Every patient or their guardian informs consent form of three dimensional reconstruction, analysis of three dimensional visualization technique and the surgery.2. Equipment and instruments3. The acquisition and storage of CT dataFirstly, taking advantage of the 64/256 layer spiral CT which was made by the PHILIPS company from Netherlands to scan patients with hepatolith for arterial and portal venous phase. The parameters of CT settings and scan method are in reference Secondly, using CT machine own workstation for the third phase of data processing in order to acquire high quality of submillimeter thin layer CT data. Finally, through hospital internal network transmission system to transfer CT data to the HP blade server from the clinical engineering and technological research center of digital medicine of Guangdong Province. The concrete operation process can be found in the references.4. Three dimensional reconstruction based on CT images and three dimensional visualization analysisExport the quality submillimeter thin layer CT data of patients from the data center (the digital medical clinical engineering technology research center of Guangdong province), and then using the MI-3 DVS complete individual patient CT images segmentation and 3D visualization display and analysis. Figure out the distribution, size and shape of hepatolith, and the length of the bile duct stricture, the scope and extent, and the trend and distribution of hepatic artery and portal vein and their possible variation, and 3D visualization individualized liver segmentation and volume calculation, the distribution of the clear stones liver segment. Next, through a kind of force feedback tools (PHANTOM) to operate the virtual surgery before a real one which could help surgeons to design several different operation method and repeat them over and over in order to choose the best method of optimal operation for actual surgery and provide complete information as soon as possible.5. The implementation of the actual operationIn three dimensional visualization technology group, intraoperative using of biliary hard mirror find other intrahepatic bile duct stones rapidly and accurately. Through the biliary hard mirror using the lithotomy forceps or reticular basket to take out the bile duct stones. A combination of pneumatic ballistic lithotripsy would be used to crush large and hard stone if necessary. After disintegration, the stones would be cleaned through high pressure flushing and reticular basket taking out, and clean up the biliary system at the same time. For patients with severe biliary stricture of intrahepatic bile ducts cannot be treated by choledochoscope. Patients with lobe atrophy or clinical suspicion of bile duct carcinama must be treated under the guidance of the three dimensional visualization technology to operate a liver resection. Postoperatively, all patients bile total tube need indwelling a T tube according to the conventional method. Before discharge patients with T tube, biliary imaging is needed in order to found the postoperative residual stones and any narrow may exists. If the residual stones or narrow are not found in intrahepatic bile ducts, patients could detach the T tube in 2 months through surgeons help. If there are still residual calculi detected, so the secondary biliary lithotomy hard surgery should be operated after six weeks. Through biliary imaging, biliary endoscopy or both at the same time check can evaluate whether the stones were removed completely.6. Effectiveness evaluation of surgery:time of operation, blood loss and transfusion during the operation, clearance and recurrence rate of stones, occurrence rate of complications and death rate during the perioperative period.7. Statistical processingThis study only involves statistical description and don’t refer to statistical analysis.8. Postoperative follow-upThe Postoperative follow-ups were carried on for patients with different treatment. Postoperative follow-up examination include abdominal CT scan, T tube biliary imaging, ultrasound examination, laboratory examination (hemoglobin, white blood cell count, bilirubin, alanine aminotransferase, aspertate aminotransferase, bilirubin, urea nitrogen, CEA, CA-199 and so on). Patients with liver and gallbladder surgery should have surgery outpatient follow-up on a regular basis. If stones were found after 3 months treatment we considerate it calculi recurrence cases.The average follow-up time was 13 months, range of fluctuations in 5～23 months.Results1. The organization structures in or out of the liver, position and degree of the confined bile duct, and the location, size, shape and number of stones were clearly showed in the 3D visualization image model. By enlarging, rotatingand hyalinizing the 3D visualization image model, all these architectural features would be clearly observed from entire angular range and different levels. These would provide some key information of choosing surgical methods and setting up a best path for rigid choledochoscope.2. These could make sure more precise diagnosis before the surgery and help to make a safe and reasonable surgical plan by simulation surgery. So, unnecessary surgical exploration could be avoided and it will help to reduce the clearance rate of stones, reoperation rate and incidence of surgical complications. So, the therapeutic effect could be ensured.ConclusionDifferent surgical procedure under the guidance of 3D visualization technology (like liver resection and PTCSL) which were used to treat the complicated hepatolithiasis could help to make clearly and straightforward preoperative diagnosis. The clearance rate of stones was high and the surgical complications was little and slight. In conclusion, based on CT 3D visualization technology to guide different operation method combined with biliary mirror pneumatic ballistic lithotripsy to take stone surgery may be a safe and effective treatment for complex intrahepatic biliary calculi disease patterns.Part II Clinical analysis about the value of laparoscope combined with ri gid choledochoscope assisted with ureterorenoscopy lithotripsy to take out t he calculus guiede by three dimensional visualization techniqueObjectiveTo discuss the diagnosis and treatment application value in individual patients who underwent three dimensional visualization technology guided laparoscopy combined with allistic lithoclasty and nephrolithotomy to treat complicated hepatolithiasis.Materials and Methods1. Research objectResearch Data of 45 patients who underwent laparoscope combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guiede by three dimensional visualization technique to treat complicated hepatolithiasis from October 2012 to October 2015 were selected. The cases of men were 31, women 14, and women the proportion of men and women were 2.21:1, the range of age were from 22 to 83 years old, average age were 53.0 years old, course of the disease were from 1 month to 10 years. Clinical manifestation:7 cases (15.6%) were without symptoms and exposed through physical examination,38 cases (84.4%) had calculi irritation, characterized by abdominal pain, bloating, etc; 15 cases (33.3%) had mild jaundice. Medical history:12 cases (26.7%) had 1-3 times biliary tract surgery history.2 cases (4.4%) were combined with merger diabetes,1 case (2.2%) biliary cirrhosis. Preoperative Child-Pugh classification:41 cases (91.1%) were class A,4 cases (8.9%) were B. All patients signed the informed consent, ethics committee of this study was approved from zhujiang hospital, southern medical university.2. Equipment and instrumentsthe same as the first part.3. Acquisition and storage of CT data the same as the first part.4. Three dimensional reconstruction, clinical classification and surgical planning for hepatolithiasis.Import patients CT data acquired from data center to MI-3DVS, then reconstruct three dimension visualization model of liver, bile duct system, stones, vascular system. Get detailed knowledge of the following content:(1) the number, size and distribution of stones; (2) whether the liver parenchyma with stone have atrophy. (3) The region, degree and length of stricture bile duct. (4) Whether there were tumor in liver and biliary system.(5)Referring the Hepatolithiasis diagnosis and treatment guidelines, complete three dimension visualization, clinical classification for individualized hepatolith disease; Rehearse the simulation operation and ultimately determine the optimal surgical approach5. The operation equipment and operating equipment(1) the German KARL STORZ 2D/3 D laparoscopic system. (2) the German Wolf F8/9.8 cm rigid choledochoscope. (3) the air pressure ballistic lithotriptor (JML6), adjustable voltage lose water pump. (4) Japan Olympus electronic choledochoscope. (5) other:lithotomy forceps, Cook top, biliary balloon expander,14-22 f sheath pipe,8-16 f dilator, etc. 6.The actual surgical procedurePatients with supine position, head higher than foot, choose endotracheal intubation general anesthesia. (1) firstly establish pneumoperitoneum, surgeon, surgeon assistant instrument nurses are wearing 3D glasses. Place laparoscope through the puncture hole under navel, Palce puncture outfit under the xiphoid, left and right sides of collarbone midline under costal margin. (2) Dissect gallbladder, open common bile duct, take out the stones by the common bile duct exploration, observe Oddi sphincter function through laparoscopy, then saturate the underneath of common duct with gauze temporarily. (3)Pull out under puncture under xiphoid process, snake hard glass into sheath pipe through the original puncture arrived in bile duct, hard mirror link adjustable voltage pump (0.9% warm saline rinses), then arrive in bile duct. Place pneumatic ballistic lithotripsy instrument under the guidance of Rigid-Choledochoscopy, pneumatic lithotripsy was feasible for the stones which diameter were less thanlcm,air pressure size usually set in the range of 0.2-0.4 MPa, and automaticly adjusted by the pump. (4) before the end of surgery, remove the gauze in the lower common bile duct, then detect intra-and extrahepatic bile duct again to eliminate bleeding and residual calculi. (5) after operation, routinely put T tube and abdominal cavity drainage tube.7. The operation evaluation index(l)Operation time, intraoperative blood loss, blood transfusion amount, stone clearance rate, the rate of postoperative residual stone, stone recurrence rate, complication rates, and perioperative mortality.(2)Whether the actual operation conforms to preoperative planning the situation. (3) Whether actual operation and hepatolith distribution is consistent with the 3D visualization image model.8. Postoperative treatment and follow-upUsing a CT scan or biliary imaging directly understand hepatolith residual stone rate and recurrence rate. Have T pipe or bile duct imaging 2weeks after the operation, then determine the extubation time. If placed T pipe or bile supporting duct at staging surgery, extubation time should be determined according to the need of the staging surgery. Bile duct supporting tube should be placed 3-6 months at narrdw section. Have row CT scan and 3 d visualization analysis regularly in out-patient clinic.9. Statistical processingThis section does not involve statistical analysis, just statistical description is needed.Result1. Perioperative resultsAll 45 patients in this group successfully underwent laparoscope combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guiede by three dimensional visualization technique to treat complicated hepatolithiasis. What we saw in operation all accord with 3D visualization imaging model, the actual operation method are consistent with preoperative planning.39 cases (86.7%) was confirmed no residue by choledochoscope. Operation time wasl38.0+45.7 mins (90-250), intraoperative bleeding was 41.8±25.4 (10～100) ml, no perioperative death, no blood transfusion and no bleeding. Bile duct injury in 1 case, recovered after conservative treatment.2. The postoperative follow-up resultsAll patients were followed up, follow-up time was18.7±8.8 (2-38)months. Six cases didn’t eliminate the stone clearly in the stage 1 operation, then remove the stone clearly through the sinus approach for 1-3 times. Calculi recurrence in 11 patients, they all underwent surgical treatment again.Conclusion1.3D visualization technology provides a new method that can make precise preoperative diagnosis for hepatolithiasis.2. Laparoscope combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guiede by three dimensional visualization technique to treat complicated hepatolithiasis provides a new choice for patients with hepatolith disease.3. laparoscope combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guiede by three dimensional visualization technique to treat complicated hepatolithiasis is in accordance with the hepatolith treatment principle "removal of lesion,eliminate stones, rectify narrow, damage obstruction, prevent and cure recurrence, protect function".4. Laparoscope combined with rigid choledochoscope assisted with ureterorenoscopy lithotripsy to take out the calculus guiede by three dimensional visualization technique to treat complicated hepatolithiasis provides a safe and effective way for the treatment of complex hepatolith,and is a important operation method in hepatolith digital minimally invasive surgical treatment... |
PDF Full Text Request