摘要目的 探讨三维可视化技术在肝脏恶性肿瘤治疗规划中的作用.方法 回顾性分析2016年1月至2017年1月在第二军医大学东方肝胆外科医院肝外三科就诊的300例肝脏恶性肿瘤患者的临床资料,男性221例,女性89例,中位年龄54岁(7～76岁),中位身高168 cm(115～183 cm),中位体重65 kg(20～105 kg),中位肿瘤体积142 ml(23～2493 ml).所有患者术前均采用三维可视化技术进行肝脏三维图像重建,并通过二维和三维的方法进行术前评估和制定治疗方案.观察三维评估对二维评估治疗方案的改变,以及手术时间、肝血流阻断时间、术中出血量、术中输红细胞量、术后并发症等情况.结果 应用三维可视化技术评估后,300例患者中75例(25.0％)改变了治疗方案.25例患者扩大了肝切除范围,其中因肝静脉变异、相应引流范围增大而扩大切除范围7例,因切除门静脉后肝实质缺乏血流灌注而扩大切除范围4例,因增加切缘而扩大切除范围14例.8例患者缩小了肝切除范围,其中因肝静脉变异缩小切除范围4例,因剩余肝脏体积不足缩小切除范围4例.300例患者中,278例患者完成了手术切除,其中257例进行了直接手术治疗(左半肝切除24例,右半肝切除33例,左三区切除12例,右三区切除11例,尾状叶切除10例,左外区切除18例,右前区切除7例,右后区切除25例,中肝切除18例,肝段切除99例).36例患者改行二步肝切除(联合肝脏分隔和门静脉结扎的二步肝切除术11例、门静脉栓塞25例)策略.中位手术时间130 min(90～360 min)、中位入肝血流阻断时间20 min(0～75 min)、中位术中出血量200 ml(20～1600 ml).278例手术患者中,术中输血37例,平均红细胞悬液输血量(4.4±1.7)个单位(0～8个单位)、中位肝切除体积530 ml(30～2600 ml).患者术后出现胸腔积液117例,其中需胸腔穿刺处理的胸腔积液3例;腹腔积液23例,其中需行腹部穿刺处理的6例;胆瘘30例;术后腹腔肝创面渗血8例,需输血处理6例,行剖腹探查止血4例;出现术后肺部感染3例;出现术后胆道梗阻3例;下肢深静脉血栓2例,门静脉血栓4例.本组观察患者术后均未发生肝功能衰竭和死亡.结论 三维可视化技术可以优化肝脏恶性肿瘤患者的治疗策略,提高手术安全性.

abstractsObjective To discuss the application of three dimentional ( 3D ) visualization technologies in treatment plan of hepatic malignant tumor. Methods The clinical data of 300 patients with liver malignant tumor who received treatment from January 2016 to January 2017 in the Third Department of Hepatic Surgery of Eastern Hepatobiliary Surgery Hospital was retrospectively analyzed in this study, including 221 male and 79 female patients aged from 7 to 76 years with median age of 54 years. The median height was 168 cm ( 115-183 cm ) , the median weight was 65 kg ( 20-105 kg ) and the median tumor volume was 142 ml ( 23-2493 ml) . Three-dimensional visualization technology was used in all patients to reconstruct liver three-dimensional graphics. Also, two and three-dimensional methods were taken respectively to evaluate patients and develop treatment strategy. The change of treatment strategy caused by 3D evaluation,actual surgical plan,operation time,time of hepatic vascular occlusion,intraoperative blood loss,volumes of blood transfusion and postoperative complications was observed. Results After three-dimensional visualization technology was applied,75(25％) of 300 patients′ treatment strategies had been changed. The range of hepatectomy was extended in 25 patients. And 7 of them were due to hepatic venous variation,which resulted in increasing drainage area. In other 4 patients,liver resections were extended due to lack of perfusion of the liver parenchyma after the removal of portal vein. And hepatectomy was expanded in 14 patients in order to increase the surgical margin. The range of hepatectomy was reduced in 8 patients, 4 of which were due to hepatic venous variation,such as hepatic vein of segment 4 or lower right posterior hepatic vein. The remaining 4 cases were because of insufficient residual liver volume. The surgical resection was performed in 278 cases,257 of which received operation directly. Left hepatectomy was performed in 24 patients and right hepatectomy was performed in 33 patients. Left trisectionectomy was carried out in 12 patients and right trisectionectomy was carried out in 11 patients. Caudate lobectomy was applied in 10 patients. There were 18 cases of left lateral sectionectomy, 7 cases of right anterior sectionectomy, 25 cases of right posterior sectionectomy and 18 cases of mesohepatectomy. Single or multi segment resection was performed in 99 patients. The treatment strategy of thirty-six patients was converted to staged hepatectomy (ALPPS 11 cases and portal vein embolization 25 cases) . The median operation time was 130 minutes ( 90-360 minutes) and the median inflow blood occlusion time was 20 minutes ( 0-75 minutes) . Median blood loss volume was 200 ml ( 20-1600 ml) . Thirty-seven of 278 patients received transfusions, and the average red blood transfusion volume was (4. 4±1. 7)units (0-8 units). Median hepatic resection volume was 530 ml ( 30-2600 ml ) . There were 117 cases of pleural effusion after operation, including 3 patients needing invasive therapy. Ascites occurred in 23 patients, 6 of whom needed invasive therapy. Biliary leakage was observed in 30 patients. Eight patients occurred hepatic cutting surface hemorrhage,6 of whom received blood transfusion,and 4 of whom underwent laparotomy to stop bleeding. Three patients had pulmonary infection after surgery and 3 patients appeared biliary obstruction. Deep vein thrombosis took place in 2 patients and portal vein thrombosis was observed in 4 patients. No postoperative liver failure and death ever happened in our study group. Conclusion Three-dimensional visualization technique can optimize the treatment strategy of patients with liver malignant tumor,improve surgical safety.