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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_585_Библиотеки_им_академика_М_И_Перельмана.pdf
16 Digital Diagnosis andManagement ofCholangiocarcinoma
407
a
c
b
d
e
Fig. 16.54 The operation planning of portal vein variation under the guidance of 3D visualization. (a) Enhanced CT of the upper abdomen: the distal
bile ducts of the left and right hepatic ducts dilate; the conuence of the left
and right hepatic ducts, and the wall of the upper segment of the common
bile duct are thickened and enhanced. (b) The right hepatic artery originates
from the superior mesenteric vein. (c) A 3D reconstructed model of the rst
porta hepatis. (d) Comparison of the 3D reconstructed model and intraoperative condition of the rst porta hepatis. (e) Roux-en-Y anastomosis
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F. Shen et al.
16.3.7.2 Surgical Planning ofHepatic Artery
Variation Guided by 3D Visualization
The variation of the hepatic artery is common in hepatectomy for hilar cholangiocarcinoma, and its clinically common types include: the left hepatic artery starts from the left
gastric artery; the right hepatic artery originates from the
superior mesenteric artery; the common hepatic artery arises
from the superior mesenteric artery. It is also crucial to use a
3D visualization model to distinguish variation of the hepatic
artery and to prevent the intraoperative collateral injury.
Once the hepatic artery is damaged, it is often accompanied
by the obstruction of the blood supply of the bile duct, which
leads to severe complications such as ischemic biliary disease, ischemia of bilioenteric anastomosis, bile leakage, and
long-term bile duct stricture.
When applying 3D visualization technique to guide the
surgical treatment of hilar cholangiocarcinoma, attention
should be paid to the presence of hepatic artery variation and
the corresponding choice of surgical treatment.
• When it is found in the 3D visualization model that the
left hepatic artery [originated from the left gastric artery]
is not in the normal position and left hepatectomy is
required; the search for the variant left hepatic artery
along the left gastric artery should be considered in the
surgical planning.
• When the hepatic artery is from the superior mesenteric
artery in the 3D visualization model, and the clinical type
IIIb requires left hepatectomy to free hepatic hilum, care
should be taken to avoid damage to the variant right
hepatic artery.
• When the left hepatic artery is from the left gastric artery,
and the clinical type IIIa requires right hepatectomy, care
should be taken not to free the hepatic hilum too much, in
order to prevent injury to the variant left hepatic artery.
• When the proper hepatic artery originates from the supe-
rior mesenteric artery, care should be taken to avoid dam-
age to the variant hepatic artery when dissociating the rst
hepatic portal.
A case of hilar cholangiocarcinoma of hepatitis IIIb was
taken as an example. Preoperative imaging evaluation: CT
images showed that the wall of the hilar bile duct was thickened and signicantly enhanced, the lumen was narrowed,
the intrahepatic bile duct obstruction was diffuse and dilated.
The possibility of cholangiocarcinoma was considered, and
the multiple enlarged lymph nodes in the hilar region were
considered. MRI+MRCP suggested thickening and noticeable enhancement of the bile duct wall in the hilar area, local
narrowing of the lumen, and obvious diffuse expansion of
intrahepatic bile duct obstruction. The preoperative 3D visualization model was classied as Bismuth-Corlette IIIb. The
3D reconstruction model constructed successfully clearly
showed that the right hepatic artery originated from the superior mesenteric artery. The right hepatic artery from the superior mesenteric artery had to be protected to avoid injury
leading to postoperative liver failure during the intraoperative dissociation of the rst hepatic hilum.
16.3.7.3 Surgical Planning ofHepatic Vein
Variation Guided by 3D Visualization
The variation of hepatic vein is of great clinical signicance.
In a national study, 200 cases of individualized 3D visualization classications of the hepatic veins were analyzed. The
left hepatic vein, the middle hepatic vein, and the right
hepatic vein showed 25%, 22%, and 18% variations, respectively; the occurrence rate of the right posterior inferior
hepatic vein was 25.5%, especially that of segment IV vein,
which was as high as 46.5% (Fang etal. 2012). Special attention should be paid to the presence of segment IV hepatic
vein in preoperative 3D reconstruction, especially in the
right hepatectomy combined with middle hepatic vein resection. During the operation, attention should be paid to avoiding injury to segment IV hepatic veins. Once the injury
occurs, the blood of liver tissue in segment IV cannot be
returned to inferior vena cava normally, resulting in complications such as liver congestion, necrosis, and liver failure.
Therefore, we should pay attention before the operation, to
the variation of the hepatic vein and the choice of surgical
treatment when applying 3D visualization technology to
guide the surgical treatment of hilar cholangiocarcinoma.
16.3.7.4 Surgical Planning ofBiliary Tract
Variation Guided by 3D Visualization
The signicance of using 3D visualization models to distinguish the classication characteristics and variation of bile
duct before the operation is as follows: (A) Determining the
diseased bile duct to be resected and clearing the bile drainage pathway of residual liver tissue reconstructed after
blocking the main pathway of bile ow. For example, when
the patient’s clinical classication is type IIIb, it should be
noted whether the bile duct in the caudate lobe is dilated or
not, and observe whether it is invaded or not; when the caudate lobe bile duct opens to the left hepatic duct, left hemihepatectomy + caudate lobe resection should be performed
to prevent cholestasis caused by postoperative residual caudate lobe; (B) Among the common bile duct variations, the
bile duct of many hepatic segments can be directly opened at
the conuence of the left and right hepatic tubes. After the
resection of the hilar tumor, multiple bile duct openings will
appear on the liver section. The more the number of bile duct
openings requiring anastomosis, the greater the difculty of
the surgical anastomosis, and the higher the possibility of
surgical complications. The application of 3D visualization
technology can clarify the number, size, and shape of bile
duct openings in the liver section in advance, as well as the
16 Digital Diagnosis andManagement ofCholangiocarcinoma
classication and attribution of these bile ducts, to plan the
ways of choledochoplasty and choledochoenteric anastomosis in advance, avoid the omission of small bile ducts, and
prevent the occurrence of bile leakage after surgery; (C) The
relationship between the bile duct and adjacent blood vessels, especially the variant bile duct and blood vessels can be
clearly distinguished. In the treatment of hilar cholangiocarcinoma, adjacent blood vessels should be carefully managed
to reduce the risk of intraoperative blood vessel injury and
reduce intraoperative blood loss.
Above all, the 3D visualization model can be rotated
360°, and the overlapping bile ducts can be separated through
different perspectives; the course, involvement, and variation
of bile ducts, as well as their relationship with adjacent blood
vessels, can be clearly identied. The number, size, and
shape of bile duct openings on the residual liver section were
predicted, and a reasonable bile drainage scheme was
designed to ensure the unobstructed drainage path after
reconstruction, avoiding the omission of small, variant bile
ducts, the side injury of adjacent blood vessels, and complications such as cholestasis, bile leakage, or bleeding.
409
Fig. 16.55 3D printed model of hilar cholangiocarcinoma clearly displays points U and P
16.3.8 3D Printing ofHilar
Cholangiocarcinoma
3D printing of the liver in patients with hilar cholangiocarcinoma was used for intraoperative indirect navigation to guide
precise surgical resection (Fig.16.56). See Chap. 5 on application of 3D printing in biliary surgery for details.
3D printing technology has been applied in complex surgery for hilar cholangiocarcinoma, realizing a leap-forward
transition from 3D screen images to 3D solid models. 3D
printing technology has made possible a great leap forward,
transforming from screen three-dimensional images to solid
three-dimensional models suitable for complex hilar cholangiocarcinoma surgery. 3D printing can be performed for
patients with types III and IV hilar cholangiocarcinoma before
operation, and 3D proportional models can be checked repeatedly before and during operation. Especially for patients with
vascular variation. Accurate preoperative diagnosis, localization, and planning of operation can be performed to guide precise operation. It contributes toward improved success rates
and reduces the risk of operation (Fig.16.55).
16.3.9 Intraoperative Consultation forClinical
Classication ofHilar
Cholangiocarcinoma
3D visualization models need to be constructed by hepatobiliary surgeons who have specialist lm reading knowledge;
nevertheless, there are still some sources of error, such as the
quality of CT data and artifacts, which will affect the quality
of 3D visualization models. Therefore, the use of pathological examination in combination with the B-ultrasound examination performed before the operation is essential to verify
the consistency of the preoperative 3D visualization model
with the clinical observation and whether the original operation plan is feasible; adjusting it if necessary, to determine
the nal surgical plan.
One case of hilar cholangiocarcinoma was reported.
Preoperative imaging evaluation: CT imaging suggested
410
F. Shen et al.
“soft rattan” expansion in the intrahepatic bile duct, with
uneven thickening of the junction of the left and right hepatic
ducts to the wall of the upper common bile duct. After
strengthening, noticeable enhancement was observed, and
the gallbladder volume was signicantly reduced, showing
soft tissue density shadow. MRI+MRCP indicated visible
dilatation of the intrahepatic bile duct, uniform thickening,
and obvious enhancement of the wall of the left and right
liver, common hepatic duct, upper segment of the common
bile duct, and stenosis of the lumen. The preoperative 3D
visualization model was classied as Bismuth-Corlette type
IIIa or IV (Fig.16.56).
The 3D visualization and the 3D printed model showed
variation of the portal vein with P point moving forward to
the rst hilus. Therefore, the rst hilus was dissociated rst
during the operation. The right hepatic artery left hepatic
artery, middle hepatic artery and main trunk, the right anterior branch and left branch of the portal vein were protected,
respectively. The right hepatic duct, caudate lobe bile duct,
and left bile duct were examined by intraoperative pathology
after successful perihepatic portal resection. If the pathology
of the right bile duct was positive, the right hemihepatectomy should be performed, and if that of the left bile duct
was positive, the left hemihepatectomy/left trisectionectomy
should be performed. The pathology of the patient’s three
stumps was negative; thus, the preoperative three- dimensional
visualization classication was adjusted to Bismuth-Corlette
type II and only perihepatic portal hepatectomy was scheduled (Fig.16.57).
16.3.10 Other Comprehensive Treatment
It is suggested that chemotherapy such as radiofrequency
ablation or gemcitabine combined with platinum anticancer
drugs, or palliative therapy such as chemotherapy combined
with radiotherapy should be used postoperatively for patients
with 3D visualized V-type who cannot undergo radical resection or simple internal and external biliary drainage, or those
with positive pathological margin (R1) or local residual
lesions (R2) under the microscope.
16.3.11 Other Perioperative Management
Other perioperative management of hilar cholangiocarcinoma includes preoperative reduction of bilirubin level and
anti-inammation, liver protection, and nutritional support.
16.3.11.1 Preoperative Reduction ofBilirubin
Level
Obstructive jaundice can cause severe pathophysiological
changes in the organism and even inhibit liver regeneration.
Some scholars believe that preoperative reduction of bilirubin levels can reduce the incidence of surgical complications, while the other considers it will not lead to expected
survival benets but increased postoperative complications
and mortality instead. Therefore, it has been controversial
whether preoperative reduction of bilirubin levels should be
performed. In China, patients with hilar cholangiocarcinoma
are often associated with hyperbilirubinemia, most of which
also suffer from diabetes, hypertension, renal insufciency,
and viral hepatitis; for these high-risk patients, it may be
safer to perform PTCD to decrease bilirubin level signicantly prior to hepatectomy. Although there is not enough
evidence-based medical evidence to support this, the clinical
results suggest that the advantages outweigh the
disadvantages.
Fig. 16.57 Intraoperative contrast of the right liver section
16.3.11.2 Postoperative Follow-Up
The postoperative treatment and follow-up are determined
based on the specic conditions of intraoperative and pathological examination. For patients with radical resection (R0),
contrast-enhanced CT of the upper abdomen should be
reviewed within 2–3 months and regularly reviewed for
2 years; for those with a microscopically positive cutting
edge (R1) or local residual lesion (R2), a monthly review
should be performed after surgery; for those with elevated
16 Digital Diagnosis andManagement ofCholangiocarcinoma
411
CA19-9, the level of CA19-9 should be followed up regularly to detected promptly after surgery; the contrastenhanced CT of the upper abdomen is reviewed every
2~3months for 2years. Further follow-up should be long
term, recurrence has been observed in 79% of patients at
5years (Tabrizian etal. 2015).
16.4 Digitalized Surgical Diagnosis
andTreatment ofPeriampullary
Carcinoma
Periampullary carcinoma is a general term involving the
tumor that grows in the ampulla, duodenal papilla, lower
common bile duct, the opening of the pancreatic duct, and
medial wall of the duodenum, all of which possess these
common characteristics: obstruction of the common bile
duct and main pancreatic duct [can be caused at an early
stage of cancer], so in these patients jaundice occurs early.
The age of onset is 40–70years old, mostly male. Currently,
surface US, MSCT, MRCP, ERCP, and duodenoscopic
biopsy are mainly used for diagnosis.
With the promotion of MSCT with more than 64 layers,
the resolution of CT has been improved to the sub-millimeter
level, which provides a favorable foundation for the application of three-dimensional reconstruction technology in the
diagnosis and treatment of lesions in this area. The MI-3DVS
system is used to set an independent growth point for biliary
and pancreatic ducts, which are lled with bile and pancreatic juice, and these tubes can be segmented by adjusting the
threshold without enhancement. The reconstructed model
can reect the course, the degree of dilatation, the location of
the obstruction, and the shape of the tube wall of gallbladder
and pancreas duct, which is helpful to distinguish the benign
and malignant tumors of the ampulla, and to decide the mode
of operation and the scope of resection. Compared with other
imaging methods, such as MSCT with MIP (maximum
intensity projection) or VR (volume rendering), MI-3DVS
images can display the curved morphology of large vessels,
dilated bile ducts, and pancreatic ducts in full three dimensions, overcoming the disadvantage that MIP can only display a section of the pipeline. MI-3DVS uses the region of
interest (ROI) growth algorithm, which is better than VR in
the reconstruction of small vascular branches. It also has distinct advantages for the pancreas with poor enhancement
effect and tumors with uneven density.
The process of data acquisition, post-processing of scanning data, data format conversion, image segmentation, and
3D reconstruction are as described above.
In the FreeForm Modeling System, a force feedback
device (PHANTOM) is used in the established virtual surgery environment to conduct various types of simulated
operations on the reconstruction model through the manipulation of simulated surgical instruments such as scalpels, surgical scissors, surgical forceps, and sewing needle and
thread. The anatomical relationship between the tumor and
main portal vein, splenic vein and the superior mesenteric
vein was observed by visual simulation surgery to avoid
injury during real surgery. Simulated surgery can also help to
understand the course of the gastroduodenal artery in patients
with celiac artery variation in case of intraoperative arterial
injury; it can guide standardized lymph node dissection
through evaluation of 3D reconstruction of the enlarged
lymph nodes and determine the best surgical scheme through
optimal screening.
16.4.1 Simulated Pancreatoduodenectomy
forPeriampullary Cancer (Fig.16.58)
16.4.2 Simulated Pancreatoduodenectomy
forDuodenal Papillary Carcinoma
(Fig.16.59)
16.4.3 Application of3D Visualization inDistal
Cholangiocarcinoma
A 63-year-old male was admitted to the hospital for one year
due to recurrent right upper abdominal pain accompanied by
skin and sclera yellowing. CA19-9 = 505 U/ml; 64-slice
enhanced CT showed that the lower end of common bile duct
obstruction and dilatation of intrahepatic and extrahepatic
bile duct were caused by ampullary mass (Fig.16.60a, b).
3D reconstruction of MI-3DVS showed that the tumors originated from the ampulla, with extensive dilatation of intrahepatic and extrahepatic bile ducts, and lymph nodes about
3cm x 4cm in size were visible behind the portal vein. The
tumor was far from the surrounding vessels (Fig.16.60c, d,
e). Including results from other examinations, no signs of
distal metastasis were found. According to the MI-3DVS
evaluation criteria, the tumor was classied as Grade I, which
was resectable. A virtual pancreaticoduodenectomy was performed before operation, and the surgical scheme was
rehearsed. The morphology of the tumor, the anatomical
relationship of related organs and vessels, the morphology of
the mesenteric artery and vein, and the adjacent relationship
with the tumor were consistent with the preoperative 3D
reconstruction (Fig.16.60f, g). The postoperative pathology
suggested moderately differentiated adenocarcinoma of the
duodenal papilla, with no tumor tissue at the margin of the
incision. No recurrence was found at 12months after operation (Fig.16.60h, i, j).
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F. Shen et al.
a
c
b
d
e
Fig. 16.58 Simulated surgery of pancreaticoduodenectomy for periampullary carcinoma. (a) General exploration: The retroperitoneum of
the descending duodenal segment is explored and separated. (b)
Resectable exploration: The surface of the inferior neck of the pancreas,
superior mesenteric vein, and portal vein are explored. (c) The bile duct
is traversed. (d) The gastroduodenal artery is ligated and severed. (e) An
f
electric knife cuts the neck of the pancreas. (f) Suture the pancreatic
stump. (g) Explore and separate the posterior portal vein space. (h)
End-to-end pancreaticojejunostomy. (i) An end-to-side anastomosis
between the stomach and jejunum. (j) Reconstruction of the digestive
tract
16 Digital Diagnosis andManagement ofCholangiocarcinoma
413
g
i
h
j
Fig. 16.58 (continued)
414
ab
cd
F. Shen et al.
Fig. 16.59 Simulated pancreatoduodenectomy for duodenal papillary
carcinoma. (a) The surface of the inferior vein of the neck of the pancreas, superior mesenteric vein and portal vein are explored. (b)
Cholecystectomy. (c) Cut off the bile duct. (d) The gastroduodenal
artery is ligated and severed. (e) An electric knife cuts the neck of the
pancreas. (f) The superior pancreaticoduodenal vein is ligated and severed. (g) Explore and separate the posterior lymph nodes of the portal
vein. (h) The alimentary canal was reconstructed by Child’s method
gh
16 Digital Diagnosis andManagement ofCholangiocarcinoma
415
e
f
Fig. 16.59 (continued)
416
ef
F. Shen et al.
a
c
b
d
Fig. 16.60 Application of 3D visualization in distal cholangiocarcinoma. (a) The CT image shows that the tumor is located in the ampulla.
(b) The CT image shows the posterior portal lymph nodes. (c)
Abdominal organs and blood vessels are observed as a whole in
MI-3DVS. (d) The relationship between tumor, biliary tract, and artery
is observed by MI-3DVS. (e) The relationship between tumor and bili-
ary tract and portal vein is observed by MI-3DVS. (f) The gastroduodenal artery is severed in the simulated surgery. (g) The gastroduodenal
artery is transected during the operation. (h) The superior pancreaticoduodenal vein is ligated and severed. (i) Transect the small vein between
portal vein and head of pancreas. (j) 3D reconstruction result at review
6months postoperatively