| Puzzle and argument always existed in the therapy of portal hypertension(PHT),because of complicated pathogenetic condition,more high risk factor,complicatedoperative procedure and masses of operative methodes.Extensive and complicatedcompensatory circulation of PHT is crucial clinical significance to the nosogenesisand progress of variceal bleeding of esophago and fundus gastricus and hepaticencephalopathy.Accordingly,it is crucial to determin therapeutic regimen exactly thatdoctor ascertained completely anatomic form of portal system,positioning ofcompensatory circulation and changing of haemodynamics.Successful surgical therapy was based on compact connection of surgerg andmodern imageology.Three dimensional imaging based on lamellar reconstructedcame to be true by Multiple-slice computed tomographic portography (MSCTP) thatrealized long range of volume scanning during of short time and that obtain morehigh-quality reconstructed image of blood vessel by lamellar reconstructed ofdifferent layer and spacing. Above all, 64-detector row helical CT was applied toclinic for the past few years,that provided optimizing scanning range and spaceresolution simultaneously adopting with high speed deuto-millimeter lamellarscanning,and that provided limpid three dimensional stereopicture of portal system with image reconstruction of multiple planes and methodes utilizing powerfulpostprocessing workstation according to different process and objective. Accordinglythere is extensive prospect of application in the diagnosis and treatment of portalhypertension with the use of 64-detector row helical CT.According to data of eikonic and clinical data,we study application of threedimensional imaging with 64-detector row helical CT on portal hypertension,whichwas supported from the national high technological project of investigation anddevelopment (project of 863,2006AA02Z346) and the team project of naturalscientific foundation in Guangdong province (the fifth official document of 2006).Objective1 Study normal and pathological eikonic character of branch and compensatorycirculation of portal system with 64-detector row helical CT portography.2 Study application of three dimensional imaging with 64-detector row helicalCT portography in the diagnosis and treatment of portal hypertension.Materials and methods1 Clinical data: 72 cases were examined by 64-detector row helical CT inZhujiang hospital from November 2005 to February 2007. Normal group: 39caes,PHT group:33 cases,Portal hypertension was final diagnosed through patienthistory,hepatic function and gastroscope.26 cases were done surgical therapy:21 caseswere done selective operation and 5 cases were done emergency operation.2 Method of examine:(1)Instrument: 64-detector row helical CT (PhilipsBrilliance, Holland);High pressure injector: Medrad double barrelled high pressureinjector (USA);workstation of image postprocessing: Maxview workstation.(2)Contrast agent: Dianbile 370 (370mg I/ml), produced by the ShanghaiBolaikexinyi limited liability company of pharmaceutical industry.(3)Plain scan:Scanning with most wide range from furcation department of trachea to pubis union;scanning parameter: by using a section thickness of 5mm, interval of 5mm, apitch of 0.984, the voltage of 120 kV, the electric current of 250mA and per rotationof 0.5 second.(4)portal venography: The nonionic iodinated contrast agent ,that wasinserted into the cubital vein,was intravenously administered 20 ml in a rate of the5ml/s.To start the same layer dynamic scanning after 35s; time and density curve ofthe same plane with portal vein was obtained to get peak time of portal venography(pre-injection method by small dosage). Then the nonionic iodinated contrast agentwas intravenously administered 70～120 ml in a dosage of the 1.5ml/kg. Based on thetime to peak portal vein enhancement, the starting scan time of artery phase was50-55s.The starting scan time of arterial phase was the time to 21-25S and advancedstage of arterial phase was the time to 30-35S (experiential method) .The time ofevery phase kept 6-8S.The scope of scanning was coincident with plain scan.3 Three dimensional reconstruction and analysis:(1) reconstruction of thin layerto scanning data: the primitive image data of portal vein were reconstructed withminimum slice: thickness of 0.67 mm,interval of 0.33 mm; minimum slice imageswere passed on to the Maxview workstation.(2) Three dimensional reconstruction:thin layer images of portal vein were carried on to the three dimensionalreconstruction in the Maxview workstation;the main method including: maximumintensity projection (MIP) ,multiplanar reformation(MPR), volume rendering, (VR),shaded surface display(SSD).Portal system and compensatory circulation weredemonstrated separately and completely.(3) Measurements of different calibre inportal vein system: The main portal vein (MPV) was measured from 2 cm aboveconverge of splenic vein (SPV) and superior mesenteric vein (SMV) ; SPV was takenits middle point as a measuring point; SMV was measured from 1 cm under portalvein; Left gastric vein was measured from 1 cm under portalvein.All survey weredone by two doctors separately.4 Statistical treatment: Analysis was carried on by using the SPSS 13.0; Variousdata of the portal vein system were indicated by the mean value±standard deviation ((?)±SD); The sample information of the non-cirrhosis patients was notparticipated to statistical processing. P＜0.05 is standard to display the significantdifference: (1) Independent sample T-test was done to the data of portal vein systembetween liver cirrhosis group and normal group. (2) Liver cirrhosis group wasseparated to three groups according to the graduation of Child-pugh, and one-wayANOVA was done among portal vein, splenic vein, cranial mesenteric vein and leftgastric vein of different groups. (3) The correlation analysis was done between leftgastric vein and splenic vein to decide relation of the two phases in forming ofPortal hypertension. (4) Independent sample T-test was done between two groupswhether spleen/stomach-kidney split existed or not. (5) Kappa check was done todisplaying of phlebeurysma of esophago and fundus gastricus between 64-detectorrow helical CT and gastroscopy.5 Surgical comparison: 26 cases were carryed on surgery according to threedimensional data which based on 64-detector row helical CT ; Clinical situation. Theresult of operative exploration and data of imageology were carried on to becontrasted, analyzed and summarized to estimate the value of 64-detector rowhelical CT portography in the diagnosis and treatment of portal hypertension.Results1 Etiological diagnosis of imageology: Portal vein of normal group,39 cases,wasshown to be clear,smooth and glossy,natural course and branch of portal vein above 5grade was displayed to ratio of 97.4%.The main portal vein, left or right branch ofportal vein and splenic vein in hepatic cirrhosis group,27 cases, were shownthickening ,stiff and twist courses obviously. The intrahepatic branch of portal veincould only be displayed the third or fourth grade. Primary hepatic carcinoma in 5cases, cancerous epistomium of the portal vein in 2 cases.Non-cirrhosis group in 6cases: pancreatic sinistral portal hypertension in 3 cases, cavernous transformation of portal vein in 2 cases (one case was congenital intrahepatic cavernous transformationof portal vein), and idiopathic portal hypertension in 1 case.70 cases were shownclear graphs of portal vein while other 2 cases showed congenital cavernoustransformation or thrombus in portal vein.2 The eikonic anatomy of 64-detector row helical CT to portal system andcompensatory circulation: (1) Portal system of 27 cases were shown vary degreeexpansion: diameter of main portal vein(MPV), splenic vein (SPV),and superiormesenteric vein (SMV) was measured for (1.37±0.13)cm, (1.17±0.14)cm, and(1.09±0.14)cm separately and 1 case was shown variation of SPV. (2) Compensatorycirculation in 33 cases were displayed well: The vein of hypomere of esophago andfundus gastricus,vena epigastrica, superior rectal veins,spontaneous gastro-renal orspleno-renal shunt,left gonadal vein and retroperitoneal communicans,were accountedfor the proportion of 72.7%,24.2%,21.2%,21.2%,18.2%,12.1%.Spleno-leftovarial vein diverges, 1 case, was infrequent fairly.3 Result of statistical treatment (liver cirrhosis group): (1) It was significantdeviation between the sick group and normal group that calibers of portal system(main portal vein, splenic vein, superior mesenteric vein) were contrasted(P=0.000)(2)It was not nsignificant deviation among different hepatic function that calibers ofmain portal vein, splenic vein, superior mesenteric vein and left gastric vein werecontrasted(P=0.343,0.778,0.367,0.370). (3) It was significant deviation betweengastro-renal or spleno-renal shunt and no gastro-renal or spleno-renal shunt cases thatcalibers of main portal vein were contrasted(P=0.000). The width of portal vein wasinfluenced by congenital shunt.(4)It was positive correlation that calibers of splenicvein and left gastric vein were contrasted(r=0.653,P=0.000);Both shared thepressure of portal vein and participate high pressure of the stomach and spleen regionsimultaneouly. (5) It is high uniformity between 64-detector row helical CT and the gastroscope that phlebeurysma of esophago and fundus gastricus were diagnosed;The value of Kappa was equal to 0.832.4 Operative compare:23 cases were carryed on surgery according of the threedimensional data based on 64-detector row helical CT and clinical situation. Thesplenectomy in 4 cases,disconnection to peripheral vesselsa round preventriculus in15 cases,splenocaval shunt in 2 cases,hepatic carcinectomy combined withSplenectomy in 3 cases,and hepatic carcinectomy in 2 cases. The data by 64-detectorrow helical CT were coincident with exploration of operation and surgery was carriedon to realize satisfactory curative effect according to anticipated plan.Conclusions1 Portal system and compensatory circulation were displayed no-create, clearly,tridimensionally by 64-detector row helical CT which realized the visualization of CT;The resolution of three dimensional reconstruction based on the two-dimensionalimage by 64-detector row,that had the superiority which traditional multi-layerscrew CT was unable to compare with, was coincident with others by DSA.2 Etiological diagnosis of portal hypertension was carried on accurately by64-detector row helical CT,and the non-liver cirrhosis cause of disease was diagnosedexactly,which was great useful to chooses correct treatmentplan for clinicist.3 Portal system was displayed clearly by 64-detector row helical CT, which wasextremely useful to understood the transform of portal system, easy and smooth ofblood vessels, the compensatory circulation as well as hepatic haemodynamics forpatients of liver cirrhosis. Accordingly there was extensive prospect of application inthe evaluation to pathogenetic condition and individualized treatment of portalhypertension with the use of 64-detector row helical CT.4 Three dimensional image formation of portal vein was obtained beforeoperation to determin overview of normal portal system and pathological anatomy, and to appraise condition of blood vessels, by which blind operation wasrefrained,surgical traumathe was reduced,and there was important value of instructionto make the surgical operation plan.
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