| Background of studyHepatolithiasis is frequent and common not only in the south of the Yangtze River, coastal area, southwest area, especially in the vast rural areas in China but also in Southeast Asia and Japan. The disease is characterized by the disease resistance, high recurrence rate and susceptibility of severve complications. Currently, the solution to it points to hepatectomy. However, the structures of liver and its internal tract themselves have many variations. Meantime hepatolithiasis sets on frequently with deformation, translocation, and intrahepatic vascular and bile duct variations. Moreover, the extensively distributed intrahepatic bile duct stones together with uncertain location of bile duct stenosis, often undermine the curative effect of hepatectomy which may come out with the narrow bile duct and residual stones in spite of hopefully removing the lesions which lead to postoperative recurrence and re-operation of hepatolithiasis.In recent years, the applications of duodenoscopy, choledochoscopy and laparoscopy has resulted in the decrease of the laparotomy rate. To surgeons’ annoyance, all these approaches go weak in lowering the current stone recurrence rate, which is as high as32.6%. Although the choledochoscopy is reported to be effective in the stones clearance at a rate of80%, the fiber choledochoscopy is still difficult to solve the serious bile duct stenosis. For most of the patients with repeated operations, the changed normal anatomical channels of the biliary tract and intestines make the duodenoscopy unable. The percutaneous transhepatic cholangioscopy (PTCS) and its advantages are reported by the Japanese Takata (1972) and Nimura (1981). The PTCS shows its superiority in the treatment of hepatolithiasis and is introduced by Professor Zhang Baoshan (1985). But the traditional PTCS method has its shortcomings like long treatment duration, susceptibility to bleeding, bile leakage, biliary tract infection, peritonitis and other complications so that it is difficult to be accepted by surgeons and patients.Diagnostically, hepatolithiasis is also problematic in that so far the sophisticated instruments including B-ultrasound, CT, MRI, MRCP, and ERCP are not all specific in that they all are limited in demonstrations of the size and location of stones, the location, length and degree of bile duct stenosis, and the3D anatomies of bile duct system and intrahepatic vasculature. As a result, this bottleneck makes it difficult to plan a rational operation and reach an accurate treatment of hepatolithiasis operation.In recent decades, the digital medical technologies have shown their important application value in the diagnosis and treatment of liver diseases. Since1990, the rapidly-developed three-dimensional visualization technology allows surgeons to simulate the surgical approaches on a virtual model so as to optimize an ideal one directing the real surgical manipulation. In this study, the three-dimensional visualization system of abdominal medical images (MI-3DVS)(software Patent No.:2008SR18798) was applied in the digital biliary tract anatomy of hepatolithiasis to diagnose hepatolithiasis by typing and guiding the design of individual operation as well. At the same time, the operation process of percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) was simulated and optimized to further improve the preoperative diagnosis rate of hepatolithiasis and the accuracy of PTCSL operation treatment, thereby reducing the postoperative residual stone rate, recurrence rate and complications and improving the clinical efficacy of patients with hepatolithiasis.I. The application of MI-3DVS technology in bile duct anatomy, hepatolith liver segmentation, clinical typing and PTCSL channel construction Objective:1. To study the digital three-dimensional reconstruction of biliary anatomy by using spiral CT with image post-processing workstation and abdominal medical image three-dimensional visualization system (MI-3DVS), to make the3D reconstruction of the liver, biliary tract system, intrahepatic vasculature and stones of patients with hepatolithiasis, and to realize the anatomical digitization of hepatobiliary system;2. To study the biliary tracts of live human hepatolithiasis by MI-3DVS based on the3D reconstruction of biliary system to anatomize and improve the traditional channel construction of percutaneous transhepatic cholangioscopy (PTCS), choose the best rigid choledochoscope biliary surgical approach and optimize the channel construction time of PTCSL.Methods:1.1Subjects:39patients with hepatolithiasis admitted to the Department of Hepatobiliary Surgery of Zhujiang Hospital, the First People’s Hospital of Shunde, Southern Medical University and the First affiliated Hospital of Guangzhou Medical University1from January2007to September2013were recruited in the study, male20cases, female19; aged31to84years, averaged (50.6±11.5) years old.1.2CT date and Equipments In accordance to those from12. Individualized liver segmentation and typing of hepatolithiasis based on MI-3DVSUsing the3D reconstructions of portal vein, hepatic vein, bile duct and hepatic artery of liver, the liver was divided into four segments along the three intrahepatic major hepatic veins, each containing a portal vein branch, and further into sub-segments using vena cava as a center which were then named segments I-VIII counterclockwise. Finally, the digital typing of hepatolithiasis was conducted based on the above results combined with2011China Hepatolith Disease Diagnosis and Treatment Guidelines, Nakayama Parting and Tsunoda Classification.3. Optimization of PTCSL channel construction timeThe traditional PTCS channel construction time isl week for the percutaneous transhepatic biliary drainage (PTBD). Thereafter, distention is performed for2-3times a week,2F each time until the fistula tract is extended by16～18F. After2-3weeks prepartion, the lithotomy is performed by use of fiber choledochoscope. In this study, two kinds of optimized PTCSL channel construction were used:PTBD was directly performed based on the MI-3DVS.5-7d after PTBD, percutaneous transhepatic fistulization was made to18-20F and a PTCSL channel was constructed in built-in protective sheath of fistula. At the same time, lithotrity and stage II lithotomy were performed using rigid choledochoscope. Under precise guidance of the MI-3DVS system, for the other method, the target bile duct sinus was punctured and expanded directly to16-18F via B ultrasound, and C arm machine positioning, a PTCSL channel was constructed in built-in protective sheath of fistula and meanwhile lithotrity and stage I lithotomy were performed.4. PTCSL precise surgical approach guided by MI-3DVS MI-3DVS software adaptive region growing algorithm was used for precise segmentation of the biliary system. The3D reconstructed biliary system displayed the biliary arbors as a whole, clearly positioning the distributions, forms, sizes and number of stones and at the same time accurately presenting the spatical positions of the bile duct and blood vessels. In the practical PTCSL,an accurate puncturation into bile duct was done and the major vessels like hepatic vein and portal veins, and abdominal and thoracic cavity viscera could be protected.Results:1. Three-dimensional reconstruction of the liver and intra/extra-hepatic vascular system.The constructed3D models of the blood supply of liver and intra/extra-biliary was vivid in stereoscopic view and rotatable freely in multiple directions so as to reflect the actual volume and anatomical structure of liver and clearly present the sources and distributions of blood supply of intra/extra-biliary. Importantly, it showed clearly the main portal vein, left and right main portal vein as well as branches of each lobe and segment of portal vein system via adjusting the transparency of the liver. Meanwhile, it clearly displayed the distributions of branches of three main hepatic veins within the liver, and the spatial anatomic structure of hepatic veins entering to supra-and inferior-hepatic vena cava as well as the abdominal aorta, celiac trunk and its branches structure.2. The3D reconstruction of biliary system and stonesThe image segmentation was performed for the data of each phase of biliary system by using MI-3DVS technique, and the specific information contained in each phase was integrated into a complete3D image of biliary tract by using the automatic registration function of the system. Digital bile duct anatomy system reflected really the stereo shape of intrahepatic biliary tree, the length and diameter of bile duct stenosis or distention, and the location, size, number of stones, and even the stereo anatomical structural relationship between bile duct system and intrahepatic three vascular systems. Based on the reconstructed model, intrahepatic bile duct stenoses:were calculated among the subjects in the study:(1)19cases contracted bile duct stenosis (48.7%,19/39),95%CI ranged between36.4%-60.5%;(2)20cases did not contract bile duct stenosis (51.3%,40/77),95%CI ranged between39.5%-63.6%.3. The individualized segmentation and precise localization of calculi and lesions in the bile ducts based on MI-2DVS. The digital typing diagnosis of hepatolithiasis was made according to localizations of diseased bile duct and stones, stenosis of the bile duct, distention of bile duct, cirrhosis and cirrhosis based on the MI-3DVS. For example, hepatolith with the various types of LⅡ, Ⅵ,Ⅶ, SⅡ, Ⅵ, Ⅶ, DⅡ3, Ⅶ3.and C indicated hepatic stones with type Ⅱ,Ⅵ and Ⅶ, severe stenosis at the stages of Ⅱ, Ⅵ and Ⅶ, severe stenosisat the stages of Ⅱ, Ⅵ and Ⅶ, distal expansion of bile duct and even hepatic cirrhosis.4. Time for PTCSL channel constructionFor the39cases of hepatolithiasis, the time span for constructing PTCSL channel under the guidance of MI-3DVS was significantly shorter than the traditional PTCS channel construction.In the study, PTCSL was suitable for16cases undergoing stage Ⅰ lithotomy and23cases underdoing stage Ⅱ lithotomy.5. PTCSL precise surgical approach:For39patients with hepatolith, the times for lithotomy by PTCSL included:1-time lithotomy for14times; twice lithotomy for18times,3-times lithotomy for4times;4-times lithotomy for2times and5-times lithotomy for once. Puncturation approaches included:(1) the left lateral puncturation in24cases, taking up61.5%(24/39),95%CI ranging between48.8%-72.4%. The stone clearance was done in19cases, and residual calculi happened in5cases, with a clearance rate of79.1%(19/24),95%CI ranged between34.9%-59.0%;(2) right approaches in8cases, taking up20.5%(14/39),95%CI ranged between11.4%-31.1%, with a clearance rate of37.5%(3/8);(3) left external/right approaches in7cases, taking up17.9%(7/39),95%CI ranged between8.0%and33%, wich a clearance in5cases and residual stones ini2cases.Conclusions:1. Based on the three-dimensional reconstruction of MI-3DVS of the biliary tract digital anatomy, the liver and its adjacent organs, abdomen blood vessels, and intrahepatic tract system were observed from a stereo perspective so that a precise preoperative diagnosis could be made for hepatolithiasis.2. Based on MI-3DVS individualization of segmented anatomical characteristics of liver in patients with hepatolith and combined with digital disease classification, the time for optimizing PTCSL channel was significantly shortened, the frequency for distention was reduced and the complications such as bile leakage, bleeding, false way formation were refrained from. Clinically, it is of great value to make precise the PTCSL surgical approachII. Application of MI-3DVS in PTCSL for individualized treatment of hepatolithObjective:1. To study the value of MI-3DVS in decision of treatment plans for PTCSL.2. To compare clinical effects MI-3DVS-aided PTCSL with those of traditional hepatectomy for treating hepatolith.Method:1. The subjects::The clinical data of81patients with hepatolithiasis admitted at the Department of Hepatobiliary Surgery of Zhujiang Hospital, the First People’s Hospital of Shunde, Southern Medical University and the First Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. Of all the patients, 39(20male, female19cases, aged56.2±13.8years, with a course of3months to10years) receiving MI-3DVS-aided PTCSL were assigned as group A, and the other42(male:21, female:21; aged49.9±11.5years; with a course of4months to9.5years) receiving traditional hepatectomy guided by MI-3DVS. There were statistically insignificant differences between the two groups in terms of gender, age, preoperative liver function, location of lesions, intrahepatic bile duct stenosis and hepatic atrophy (P>0.05).2. The equipment and parameters used for CT data acquisition,, data segmentation, and the3D reconstruction of the liver and its vasculatures were the same as in the section1.2.3. Virtual PTCSL for hepatolithiasisIn FreeForm Modeling System, the3D reconstruction hepatobiliary model was zoomed, rotated, transparentized to observe the pathological changes of bile duct or details of each structure. Based on the data, then, virtual PTCSL was performed using PHANTOM and self-developed PTCSL instruments to make a best PTCSL scheme.4. PTCSL in group ABefore PTCSL, an accurate approach was chosen for biliary puncturation under the direction of MI-3DVS system. Then PTCSL was performed in two ways:1) Stage II lithoclasty and lithotomy:Puncturation of biliary duct was performed under the guidance of US, C arm X-ray machine and CT, followed by intubation of8F for drainage. After a week, the duct was dilated to16-18F along the fistulous tract for drainage using the dilators of16-18F series under intravenous or epidural anesthesia. Finally the shealth for16F or18F dilator was used to allow a rigid choledochoscope for stage II lithotripsy and lithotomy.2) Stage I lithoclasty and lithotomy:After successful puncturation of biliary duct, a fistulous tract in the duct was made and dilated directly to16-18F and then the shealth for16F or18F dilator was used to allow a rigidcholedochoscope for stage I lithoclasty and lithotomy. After operation, postoperative biliary imaging was done to check if there were residue stones and extubation time was specified.5. Open hepatectomy in group BCT data of patients with hepatolith conducted by MI-3DVS can clearly show stone size, position, shape, and a three-dimensional position; It also can accurately show the relationshap between stones and hepatic vein, portal vein and hepatic artery and inferior vena cava and the abdominal blood vessels, thus to individualized liver segmentation, computing the liver volume, resection of liver volume and residual liver volume; have hepatolith lob lesions off.6. Inclusion standardsThe standard for3D reconstruction included presence of dilated intrahepatic bile ducts. Standards for hepatectomy:(1) cholangiolithiasis combined with liver fibrosis and atrophy;(2) cholangiolithiasis with severe biliary stenosis and liver cancer;(3) diseased bile duct combined with hepatic abscess. Exclusion criteria: cholangiolithiasis combined with other serious diseases, not suitable for the treatment in the study. Finally, our study included81cases of patients.7. Observation indexesThe indexes include operation-related data (including time for operation, intraoperative blood loss, and intraoperative blood transfusion volume), hospital stay, postoperative residual intrahepatic bile duct stricture rate, mortality and complication rate, and preoperative and postoperative laboratory test results. The postoperative follow-ups were done by telephone calls or outpatient visits.8. Statistical treatment:the application of statistical software SPSS19.0, measurement data using t test, Chi-square analysis, P<0.05was statistically significant.Results:1. Three-dimensional anatomical structure of3D reconstructed intrahepatic biliary system and cardiovascular system3D reconstructed liver, biliary and cardiovascular system of39patients were vivid anatomically and suitable for the typing of cholangiolithiasis as well as simulated PTCSL.2. Operative resultsThe duration of hospital stay was the same generally between the two groups. The intraoperative blood transfusion volume and intraoperative blood loss in group A were both significantly less than in group B, the difference was statistically significant (0vs.195.7±205.7ml;20.6±25.9vs.256.1±155.8ml, P<0.05). The operation time in group A was significantly shorter than in group B(127.8±78.7vs.213.2±50.9min, P<0.05), as shown in Table3. In39patients of group A,6cases belonged to type I,5cases type Ha,1case type Ⅱb,1case type IIc,and26cases type E, which all accorded with the types verified in the reconstructed model. Only2patients were excluded for PTCSL due to hepatobiliary deformations. The simulated operative schemes coincided with the actual schemes for hepatectomy by95%(37/30). In the42patients of group B,7cases belonged to type I,2cases type Ha,2cases type Ⅱb, type1Ⅱc case and30cases type E.3. The postoperative outcomesThere were significant differences between the two groups in the calculi residual rate (2.6%vs.18.6%, P<0.05), the final residual rate (5.3%vs.23.8%, P<0.05) and the intrahepatic bile duct stricture retention rate (1.8%vs.14.3%, P<0.05)..A total of22patients came out with complications,(10cases (25.6%) in group A and12cases (28.6%) in group B). Postoperative laboratory examinations in Table6showed no significant differences in terms of the levels of serum transaminase, serum bilirubin, serum albumin as well as the thrombin time between the two groups. But the hemoglobin level was significantly higher than that of group B (116.3±16.0vs.108.0±13.9/L, P<0.05).4. Follow-up resultsPatients were followed up for2-85months with a mean of31.1months, and the follow-up rate was100%(81/81).15patients came out with recurrence of cholangiolithiasis (2cases in group A and10in group B). There was no statistically significant difference between the two groups in the rate of cholangiolithiasis recurrence (12.8%vs.23.8%, P>0.05). All calculis at the recurrence were located in the right lobe:one in the right posterior hepatobiliary duct and another in right anterior hepatobiliary duct. The recurrence rate of cholangitis in group A was lower than that in group B (5.1%vs.23.8%, P<0.05). In group A,1patient contracted bile duct carcinoma combined with intestinal anastomotic stone and died of tumor metastasis with MODS13months after operation. With the exception, no other patients died until data analysis was done.Conclusion:In comparison with the open hepatectomy, PTCSL based on3D reconstruction technology is more advantageous for its shorter operation duration, lower rate of caculi residuals as well as identical rate of calculi recurrence. Therefore, it allows us to have a more reasonable access to the cure of cholangiolithiasis by using digital minimally invasive technology, even though its curative effect in lithotomy as well as in the treatment of cholangiolithiasis combined with hepatic lobe atrophy was not remarkable. III. Application of rigid choledochoscope guided by MI-3DVS in the treatment of cholangiolithiasisObjective:To study the effect of MI-3DVS on PTCSL for the treatment of cholangiolithiasis.Method:1. Subjects of study:77patients with hepatolithiasis admitted in the Department of Hepatobiliary Surgery of Zhujiang Hospital, the First People’s Hospital of Shunde, Southern Medical University and the First affiliated Hospital of Guangzhou Medical University from January2007to September2013, male24cases,female14cases, aged30-75years old, average (53.2-13.8) years. Among them,20patients underwent biliary surgery for once,10for twice, and5for3times; another10patients underwent biliary-intestinal anastomosis. Besides,3patients had biliary tumors and another3biliary obstruction.2. The equipment and parameters used for CT data acquisition,, data segmentation, and the3D reconstruction of the liver and its vasculatures were the same as in the section1.2.3. The use of virtual rigid choledochoscope and built-in protective sheath for the treatment of cholangiolithiasis:According to calculi distribution and biliary lesions in the3D reconstruction model, four operative modes were made:open surgery, laparoscopy on bile duct, lithotomy by percutaneous hepatocholangiostomy, and The stone with biliary fistula. Among them, The stone with biliary fistula was the most reasonable for the virtual rigid choledochoscope and built-in protective sheath based on PHANTOM for the simulation lithotripsy.4. The effect of lithotomy aided by virtual rigid choledochoscopeBefore real lithotomy, the3D models of cholangiolithiasis on the imaging data of the77patients were constructed to visually investigate the distributions and sizes of hepatolith, and the stereo vision of bile duct and intrahepatic vascular system in details. Based on the individual characteristics of each case, an optimal operative scheme was chosen and manipulated. The rate for removing stones, the recurrence rate of cholangiolithiasis and complications were investigated.Results:1. The3D anatomic structures of intrahepatic biliary system and cardiovascular system in MI-3DVSThe3D reconstructed liver, biliary and cardiovascular system of77patients were vivid anatomically in the3D reconstructed models. When transparentized, the models presented the size, number, location, scope and degree of bile duct stenosis, distribution of hepatolith and even relationship between the lesions in bile duct system and the adjacent tissues and organs. The bile duct stenosis rate was31.2%(24/77,95%CI为18.1%-49.2%).2. PTCSL aided by virtual rigid choledochoscope and built-in protective sheath In the3D models, the distributions of intrahepatic calculi, the connection of biliary system to the adjacent organs and the change of the intrahepatic vascular tree were sharply demonstrated. In this way, an optimal surgical scheme was decided upon the data from the manipulation of3D models. Among the77patients in this study, as a result,8underwent lithotripsy guided with3D virtual rigid choledochoscope by open operation;13lithotripsy using laparoscope and rigid choledochoscope guided by the3D reconstructed models.39PTCSL lithotripsy under the guidance of3D reconstructed model,17The stone with biliary fistula lithotripsy aided by protective sheath under the3D reconstructed model.3.Effect of3D visualization technology on lithotomy or lithotripsy aided by rigid choledochoscope and built-in protective sheath Before actual operation, repeated rehearsals of simulation operation were enforced according to the3D videos and screenshots so as to optimize the individual operative schemes. Among the77patients, as a result,3of them were excluded from lithotripsy aided by protective sheath and rigid choledochoscope because of hepatic duct variations and all others were included. The results showed the simulation operative schemes coincided with the actual operative plans by95%(73/77), with95%CI between90.4%-100.0%. The intraoperative blood loss was (18.47±1.27)ml, with95%CI between15.94-21.00ml. The residual stone rate was31.8%(21/66), with95%CI between20.6%-43.1%. Postoperative complication rate was10.6%(7/66), with95%CI betwen3.2%-18.0%.1patients contracted chest bile leak, another pleural effusion, the two cured by thoracic intubation for drainage.1patients contracted chronic cholangitis and two patients wound infections.2patient had hemorrhage, with an incidence of postoperative bleeding3%(2/66), with95%CI between0.0%-7.2%(The bleeding volumes were400ml and1500ml, respectively) and they were cured by perfusion with noradrenalin saline. The average stay was14.7±4.3D.1patient contracted bile duct carcinoma combined with intestinal anastomotic stone and died of tumor metastasis complicated with MODS13months after operation.Conclusion:3D visualization technology provides reliable references for optimizing operation schemes for typing of hepatolithiasis, open surgery, laparoscopic bile duct exploration, percutaneous colostomy lithotomy, and The stone with biliary fistula so as to achieve individualized therapies for hepatolithiasis and reduce the residual stone rate, stones recurrence rate and postoperative complications to the largest extent. |
PDF Full Text Request