Radiologic evaluation of vasculobiliary anatomy in the umbilical fissure.
Radiologic evaluation of vasculobiliary anatomy in the umbilical fissure.
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DOI：
10.1016/j.jss.2017.03.027
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发表时间：
2017-06
期刊：
影响因子：
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通讯作者：
G. Ji;F. Zhu;Ke Wang;Yong-xiang Xia;C. Jiao;Zi-cheng Shao;Xiang-Cheng Li
中科院分区：
文献类型：
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作者：
G. Ji;F. Zhu;Ke Wang;Yong-xiang Xia;C. Jiao;Zi-cheng Shao;Xiang-Cheng Li
研究背景术前评估脐裂（U点）的血管-胆道解剖是肝门周围胆管癌（PCCA）行右肝切除术的关键。本研究的目的是回顾性研究血管睫状体解剖在U点使用三维（3D）重建技术，调查的诊断能力的2D扫描，以评估解剖变异，并讨论其手术implications.MethodsA回顾性研究159例患者的BispelletypeI，II，和IIIa型PCCA，2012年11月至2016年9月在我院接受手术的患者。由一名肝胆外科医生使用多探测器计算机断层扫描（MDCT）评估解剖结构，而3D图像由独立的放射科医生重建。左胆系正常合流类型定义为左内段胆管（B4）与II段（B2）和III段（B3）胆管共同干汇合，而异常合流类型分为3种类型：I型，B2、B3和B4三重合流; II型，B2汇入B3和B4共同干; III型，其他类型。根据B4与肝汇合部的关系，将其分为中央型、周围型和混合型。在3D图像上测量Spiegel叶（B11）胆管分支至B4开口及B2、B3交界处的长度。结果3D重建显示71.1%（113/159）的肝左胆管系统正常汇合，变异型为I型11.9%（19/159），II型12.6%（20/159），I型11.9%（19/159），II型12.6%（20/159）。Ⅲ型占4.4%（7/159）。Ⅰ型变异B11至B2、B3交界处的长度为12.1 ± 3.1mm，明显短于正常构型（30.0 ± 6.8mm，P< 0.001），而明显长于Ⅱ型变异（9.6 ± 3.4mm，P= 0.019）。B4的手术解剖：周围型最常见（74.2%，118/159），其次为中央型（15.7%，25/159）和混合型（10.1%，16/159）。中央型和联合型B11与B4的距离（8.4 ± 2.4）mm明显短于周围型（14.5 ± 4.1）mm（P< 0.001）。分别有6例（3.8%）和9例（5.7%）患者存在来自胃左动脉的替代或辅助LHA。LHA沿U点左尾侧沿着143例（89.9%），沿U点右颅侧沿着9例（5.7%），联合位置7例（4.4%）。两种成像方式在胆管合流模式中的观察者间一致性几乎完美（kappa = 0.90; 95%置信区间：0.79-1.00），在B4的手术解剖结构中显著（kappa = 0.74; 95%置信区间：0.62-0.86），完美的LHA结论深入了解U-型颈椎病外科解剖的影像学特点，2D重建技术可为晚期PCCA患者提供详细的肝脏解剖结构和个性化的手术计划。
BackgroundPreoperative evaluation of vasculobiliary anatomy in the umbilical fissure (U-point) is pivotal for perihilar cholangiocarcinoma (PCCA) applied to right-sided hepatectomy. The purpose of our study was to review the vasculobiliary anatomy in the U-point using three-dimensional (3D) reconstruction technique, to investigate the diagnostic ability of 2D scans to evaluate anatomic variations, and to discuss its surgical implications.MethodsA retrospective study of 159 patients with Bismuth type I, II, and IIIa PCCA, who received surgery at our institution from November 2012 to September 2016, was conducted. Anatomic structures were assessed using multidetector computed tomography (MDCT) by one hepatobiliary surgeon, whereas 3D images were reconstructed by an independent radiologist. Normal confluence pattern of left biliary system was defined as the left medial segmental bile duct (B4) joining the common trunk of segment II (B2) and segment III (B3) ducts, whereas aberrant confluence patterns were classified into 3 types: type I, triple confluence of B2, B3, and B4; type II, B2 draining into the common trunk of B3 and B4; type III, other patterns. Surgical anatomy of B4 was classified into the central, peripheral, and combined type according to its relation to the hepatic confluence. The lengths from the bile duct branch of Spiegel's lobe (B1l) to the orifice of B4 and the junction of B2 and B3 were measured on 3D images. The anatomy of left hepatic artery (LHA) was classified according to different origins and the spatial relationship related to the U-point.Results3D reconstruction revealed that normal confluence pattern of left biliary system was observed in 71.1% (113/159) of all patients, and variant patterns were type I in 11.9% (19/159), type II in 12.6% (20/159), and type III in 4.4% (7/159). The length from B1l to the junction of B2 and B3 was 12.1 ± 3.1 mm in type I variation, which was significantly shorter than that in normal configuration (30.0 ± 6.8 mm,P< 0.001) but significantly longer than that in type II variation (9.6 ± 3.4 mm,P= 0.019). Surgical anatomy of B4: the peripheral type was most commonly seen (74.2%, 118/159), followed by central type (15.7%, 25/159) and combined type (10.1%, 16/159). The distance between the B1l and B4 was 8.4 ± 2.4 mm in central and combined type, which was significantly shorter than that in peripheral type (14.5 ± 4.1 mm,P< 0.001). A replaced or accessory LHA from the left gastric artery was present in 6 (3.8%) and 9 (5.7%) patients, respectively. LHA running along the left caudal position of U-point was present in 143 cases (89.9%), along the right cranial position of U-point in nine cases (5.7 %), and combined position in seven cases (4.4%). Interobserver agreement of two imaging modalities was almost perfect in biliary confluence pattern (kappa = 0.90; 95% confidence interval: 0.79-1.00), substantial in surgical anatomy of B4 (kappa = 0.74; 95% confidence interval: 0.62-0.86), and perfect in LHA (kappa = 1.00).ConclusionsThoroughly understanding the imaging characters of surgical anatomy in the U-point may be benefit for preoperative evaluation of PCCA by successive review of 2D images alone, whereas 3D reconstruction technique allows detailed hepatic anatomy and individualized surgical planning for advanced cases.