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《中华消化外科杂志》2018年5月第17卷第5期论著

腹腔镜超声联合三维可视化技术引导门静脉穿刺吲哚菁绿荧光染色在精准解剖性肝段切除术中的应用

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引用本文:
王晓颖,高强,朱晓东,等.腹腔镜超声联合三维可视化技术引导门静脉穿刺吲哚菁绿荧光染色在精准解剖性肝段切除术中的应用[J].中华消化外科杂志,2018,17(5):452-458.DOI:10.3760/cma.j.issn.1673-9752.2018.05.008.
【摘要】

目的:探讨腹腔镜超声联合三维可视化技术引导门静脉穿刺吲哚菁绿(ICG)荧光染色在精准解剖性肝段切除术中应用的可行性和安全性。
方法:采用回顾性横断面研究方法。2016年12月至2018年4月复旦大学附属中山医院运用腹腔镜超声联合三维可视化技术引导门静脉穿刺ICG荧光染色行解剖性肝段切除术患者26例,收集并分析上述患者的临床资料。术前三维可视化重建及门静脉分支流域分析;术中腹腔镜超声定位肿瘤及目标肝段门静脉; 腹腔镜超声结合三维可视化图像引导下门静脉穿刺染色; 腹腔镜解剖性肝段切除术。观察指标:(1)术中情况:门静脉穿刺成功率、目标肝段、染色效果、术中并发症、手术时间、术中出血量、输血、中转开腹情况、肿瘤直径和距肿瘤最小切缘。(2)术后情况:术后并发症情况(以Clavien-Dindo分级为标准)、住院时间。(3)随访情况:获得随访的患者例数,随访时间,患者术后肿瘤复发情况。采用门诊和电话方式进行随访,了解患者术后肿瘤复发情况。随访时间截至2018年4月。正态分布的计量资料以平均数(范围)表示,计数资料以百分率表示。
结果:(1)术中情况:26例患者采用腹腔镜超声联合三维可视化技术引导门静脉穿刺成功率达100.0%(26/26),穿刺肝段S8段7例、S7段6例、S2段4例、S3段3例、S6段3例、S5段2例、S4段1例。26例患者门静脉注射ICG荧光染色效果:22例ICG荧光染色效果满意,满意度为84.6%(22/26);4例未达到预期效果,染色不均匀2例,目标肝段部分区域未覆盖1例,相邻肝段染色致无法确定边界1例。26例患者术中注射ICG无过敏等并发症发生,平均手术时间为184 min(60~315 min),平均术中出血量为97 mL(10~400 mL),无术中输血和中转开腹患者。26例患者平均肿瘤直径为3.2 cm(1.2~10.0 cm),平均距肿瘤最小切缘为1.5 cm(0.4~3.0 cm)。(2)术后情况:26例患者中,2例发生Clavien-Dindo Ⅰ~Ⅱ级并发症(下肢深静脉血栓1例、胸腔积液1例)均经药物治疗好转;无Ⅲ级以上严重并发症,无胆汁漏、感染、肝功能不全等并发症发生,无围术期死亡患者。26例患者术后平均住院时间为6.9 d(5.0~14.0 d)。(3)随访情况:26例患者术后均获得随访,随访时间为0.3~17.0个月,中位随访时间为6.0个月;随访期间1例肝细胞癌发生肾上腺转移,25例无瘤生存。
结论:腹腔镜超声联合三维可视化技术引导门静脉穿刺ICG荧光染色,运用于腹腔镜解剖性肝段切除术安全可行,尤其适用于后、上肝段等困难部位的精准腹腔镜解剖性肝段切除术。

【Abstract】

Objective:To investigate the feasibility and safty of indocyanine green (ICG) fluorescence staining by laparoscopic ultrasound and three-dimensional (3D) visualization guided portal branch puncture approach in anatomical segmentectomy.
Methods:The retrospective cross-sectional study was conducted. The clinical data of 26 patients who underwent anatomical segmentectomy using ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in the Zhongshan Hospital of Fudan University between December 2016 and April 2018 were collected. The preoperative 3D visualization reconstruction and areas of portal branch perfusion were analyzed, laparoscopic ultrasound localization was intraoperatively applied to tumor and portal vein of targeted hepatic segment, and then portal branch puncture and staining were done under laparoscopic ultrasound and 3D visualization, finally laparoscopic anatomical segmentectomy was performed. Observation indicators: (1) intraoperative situations: success rate of portal vein puncture, targeted hepatic segment, effect of ICG fluorescence staining, intraoperative complications, operation time, volume of intraoperative blood loss, blood transfusion, conversion to open surgery, tumor diameter, the minimum resection margin to tumor; (2) postoperative situations: postoperative complications (Clavien-Dindo classification as a criteria) and duration of hospital stay; (3) follow-up situations: cases with follow-up, follow-up time and postoperative tumor recurrence. Follow-up using outpatient examination and telephone interview was performed to detect postoperative tumor recurrence up to April 2018. Measurement data with normal distribution and count data were respectively described as average (range) and percentage.
Results:(1) Intraoperative situations: a success rate of laparoscopic ultrasound and 3D visualization guided portal branch puncture in 26 patients was 100.0%(26/26), and punctures in S8, S7, S2, S3, S6, S5 and S4 of the liver were respectively performed to 7, 6, 4, 3, 3, 2 and 1 patients. Of 26 patients, 22 achieved expected effect of ICG fluorescence staining, with a statisfaction of 84.6%(22/26) and 4 failed to get expected effect, including 2 with uneven dying, 1 with staining-uncovered partial areas of targeted liver segment and 1 with adjacent hepatic segmental staining induced to unclear boundary. All the 26 patients were not complicated with ICG injection induced to allergy. Average operation time and volume of intraoperative blood loss were 184 minutes (range, 60-315 minutes) and 97 mL (range, 10-400 mL), without intraoperative blood transfusion and conversion to open surgery. Average tumor diameter and average minimum resection margin to tumor in 26 patients were respectively 3.2 cm (range, 1.2-10.0 cm) and 1.5 cm (range, 0.4-3.0 cm). (2) Postoperative situations: of 26 patients, 2 with gradeⅠ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 1 with pleural effusion), no patient had grade Ⅲ and above complications, and there was no bile leakage, infection and hepatic dysfunction. Average duration of hospital stay in 26 patients was 6.9 days (range, 5.0-14.0 days). (3) Follow-up situations: 26 patients were followed up for 0.3-17.0 months, with a median time of 6.0 months. During the follow-up, 1 patient with hepatocellular carcinoma had adrenal metastasis and 25 had tumor-free survival.
Conclusions:Laparoscopic anatomical segmentectomy with ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach is safe and feasible, especially suitable in posterosuperior liver segments.

DOI:10.3760/cma.j.issn.1673-9752.2018.05.008
基金项目:国家科技重大专项(2017ZX10203208-004)
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