| Research backgroundPancreatic cancer is the most serious cancer with surgery difficult,poor prognosis, high case fatality rate. For its biological characteristics of onset conceals, early shift and so on, patients with clinical symptoms were often too late. Incomplete statistics, pancreatic tumor is the fourth in the malignant tumor mortality in whole worldwide. In our country, pancreatic tumor is also one of the ten malignant tumor whose mortality rates are the highest. The diagnosis of pancreatic tumors:At present, a lot of patients with clinical suspicion of pancreatic cancer using traditional diagnostic methods. For example, serum tumor marker(CA199), ultraphonic, CT, MRI and so on. Serological markers (CA199) and ultrasonic due to their own defects are often not as pancreatic tumor diagnosis.(CA199high sensitivity, but low specificity, additional diagnostic sensitivity low.) And In the diagnosis of pancreatic tumors, because of "lack of blood supply of pancreas itself biological characteristics, it make the traditional imaging method based on the technology of angiography, CT, MRI) on the sensitivity is not high. Often because the radiological characteristics of atypical, pancreatic vascular image reappearance defects and so on, pancreatic tumors are ignored or diagnosed of unrespectable malignant tumor by doctors. With literature statistics, because of the lack of effective method of early diagnosis, and high degree of malignant pancreatic cancer metastasis early easily happened, only10%of the patients in the diagnosis have operation conditions.The treatment of pancreatic tumor:Now the only way can effect a radical cure pancreatic tumors is surgical removal of the tumor. Since the first pancreatic tumor resection, pancreatic tumor resection has been extensively developed in the domestic each big hospital, and saves the lives of numerous patients. But the traditional operation method are combined resection of pancreas organs around, so make it a large abdominal surgical trauma, high risk, long course of treatment and complications of surgery.In nearly a decade, with the continuous development of various inspection techniques, Pancreatic cancer can possibly get early diagnosis and treatment. The surgery concept of "individualized","minimally invasive" were also successively put forward. According to different patients with different peripancreatic vascular contorts the proper procedure and reduce the surgical trauma has become an important issue. This research aims to obtain high quality individual data of pancreas and peripancreatic blood vessels, for pancreatic cancer patients with preoperative3-D reconstruction and simulation operation. We using the method of maximum density projection (MIP) reconstruction of pancreas and tumor blood supply artery and venous drainage directly, through the technique of reconstruction of individualization of pancreas and peripancreatic vascular and pancreatic tumor for all-round, three-dimensional observation. We can master the information of contorts the pancreatic vascularity, location, nature of pancreatic tumor, size, location and so on. To evaluate patients for preoperative diagnosis, satisfy individual difference operation method can be formulated, to achieve the purposes of reduce operation, reduce the operation risk, improve the resection rate. Objective1. Acquisition the data of pancreas and peripancreatic blood vessel and pancreatic tumor submillimeter high quality CT2. Explore a kind of technology based on MI-3DVS peripancreatic blood vessel and pancreatic tumor3-D reconstruction3. Research the clinical application value based on MI-3DVS peripancreatic vascular and pancreatic tumor preoperative surgery resectable evaluation and simulation procedureMethod1. Materials and data acquisition1.1Research instrument:(1)64slice spiral CT(Philips Brilliance);(2) MxLiteView DICOM Viewer13.0;(3)ACDSee9.0Message Center;(4) ACDSee image conversion software;(5) FreeForm Modeling System;(6) HP blade server1.2CT data collection:Patient in the supine position, cephalopod direction, By the diaphragm to the edge of the liver routine scan (according to the need can be appropriately increase the scan range). The condition of scanning is120kV,200-400nlAs. The0.625x64layer combination detector was used, layer thickness of5mm, interval of5mm, matrix512*512, pitch of0.984, ball swiveone week time is0.5s. Arterial scanning delay20-25S, venous phase scanning delay50to55s. Collect plain the data of scan and enhanced scan data (arterial and portal venous phase). It was spread to Mxview workstation for3-D reconstruction.1.3Pharmaceutical:Schering AG, Germany. Ultravist(300mg I/ml).2. Study subjectsWe prospectively collected the imaging data from64-slice spiral enhanced CT scans of the upper abdomen of60patients with pancreatic cancer who were conducted between February2010and December2012in our hospital and then utilized the3D visualization system of medical images (MI-3DVS) for the3D reconstruction of the abdominal organs. There were sixty patients (36M,24F), with a mean age of56.2(21-72years).The slice thickness of the enhanced abdominal CT image was1cm in all patients.3. The data of pancreas and peripancreatic vascular submillimeter with high quality.Patient in the supine position, cephalopod direction, By the diaphragm to the edge of the liver routine scan (according to the need can be appropriately increase the scan range). The condition of scanning is120kV,200-400nlAs. The0.625x64layer combination detector was used, layer thickness of5mm, interval of5mm, matrix512*512, pitch of0.984, ball swiveone week time is0.5s. Arterial scanning delay20-25S, venous phase scanning delay50to55s. Collect plain the data of scan and enhanced scan data (arterial and portal venous phase). It was spread to Mxview workstation for3-D reconstruction. This project is using0.625mm thin layer scanning, The threshold method (note tracking method) and the test injections (small dose pre injection) were combined. The scanning parameters of the two were comprehensive analyzed. The micro structure of the imaging characteristics were distinguished. Make the pancreas and peripancreatic blood vessels can be a good enhancement. After patients with64-row spiral CT on abdomen scan and arterial phase, pancreas period, venous phase enhancement scanning, in Mxview image post-processing workstation the four phase of image data, through the special line network transmission to digital medical research centre LinChuangBu HP blade server。 Disk data was exported to coexist.4.CT3-D reconstruction image dataTo individual patients with CT data import personal computer, using the DICOM viewer raw data format can be converted to JPG format. Use ACDSee software to adjust the picture size and converted into BMP format. Import the independent development of abdominal medical image3d visualization system (MI-3DVS) reconstruction program. Use MxliteViewDICOM Viewer to read64row CT scan data. Target organs (pancreas and peripancreatic arteriovenous) were adjusted with appropriate window width and window level. The above W, L the DICOM data were exported and translated to JPGE format and stored. And import the ACDSee9.0Massage Center into a BMP file. Import the imagines to MIPS after adjusting the image size, In turn, peripancreatic blood vessels, liver, pancreas and its tumor spleen and splenic arteriovenous structure division. Segmentation method using threshold segmentation and region growing method, and using the MIPS program for3-D reconstruction, Output in STL format and import the abdomen medical image3d visualization system (MI-3DVS) for automatic registration, color, smooth and modify such as post-processing, again will display various viscera model automatically on the space combination.4. So as to achieve celiac viscera, pancreatic cancer and3d reconstruction model peripancreatic blood vessels.5. The evaluation for3-D reconstruction of peripancreatic blood vessels, abdominal organs, and the diagnosis and differential diagnosis of pancreatic tumor excision.Preoperative CT data based on pancreatic cancer patients for individualized three-dimensional reconstruction, and establish the corresponding3d model. After3d reconstruction in patients with abdominal blood vessels, viscera and tumor model of free rotation, split, transparent, and so on, statisticed peripancreatic and retroperitoneal and contorts the display rate of the large blood vessels, presence of branch and structural variation, etc. According to the3d model reconstruction shows that the tumor and adjacent organs, peripancreatic blood vessels and the relationship between the celiac arteriovenous, three-dimensional observation of tumor and vascular morphology, for patients with pancreatic tumor excision can be determined. Specific assessment criteria can see the surgery of Chinese medical association branch of pancreas surgery group of the guide of diagnosis and treatment of pancreatic cancer.[5]. According to the results of3d reconstruction we choose suitable individual pancreatic cancer radical prostatectomy for patients. In order to achieve the purpose of reducing operation, reducing the operation risk, improving the resection rate.6. Preoperative simulation surgeryTo restore the patient’s abdominal viscera and pancreatic tumor model import FreeForm Modeling the System and its own PHANTOM equipment. Using interactive force feedback devices the PHANTOM and the team developed the design of the virtual simulation surgical instruments in FreeForm Modeling System in patients with preoperative3d reconstruction model simulation exercise, the whole process of pancreatic tumor resection was imitated, successful completion of the operation cut, suture and ligation operation. Through a variety of simulation surgery simulation and comparison to determine the final solution, achieve the purpose of anatomical digitalization, visualization operation, and minimize actual risk of intraoperative and postoperative complications.7. The actual operationAll tumors can be removed and all evaluated may resection by experienced surgeon surgical exploration and resection of pancreas, the whole operation process with whole video, and record of actual situation. According to the results of preoperative3d reconstruction resected pancreatic tumor resection, intranperative cutting edge were send to frozen section examination, and postoperation samples were sented to pathological examination..8. Data processingSurgical specimen was sent to pathological examination. The actual operation results and the preoperative diagnosis of patients with resectable evaluation results were compared, and satisficed average age, operation time, blood loss, hospital stay, tumor maximum cross-sectional area, the incidence of postoperative complications (pancreatic fistula, anastomotic fistula, abdominal cavity hemorrhage, abdominal abscess, etc.).Compared to the same cases of without three-dimensional reconstruction and simulation procedure. SPSS13.0was adopted to statistical analysis for the data. Statistical inference was adopted to matching chi-square test. Difference was statistically significant (P<0.05).Results1. Abdominal viscera, peripancreatic blood vessels and pancreatic tumor submillimeter CT data collection with high qualityAll89patients with pancreatic cancer are successful completion of the upper abdomen thin layer CT multiphase enhancement scanning, and then thin layers of processing. Layer thickness is0.625mm. There were sixty patients (36M,24F), with a mean age of56.2(21-72years). CT images showed46cases of pancreatic head tumor,31cases of ampulla tumor around,12cases of body tail of pancreas tumor.2. Acquisition of the CT image data could be clear to display peripancreatic major arteriovenous, abdominal large vascular and pancreatic tumor.Compared with traditional single CT scan images were more clear and accurate. It met the requirements of the pancreas and peripancreatic vascular remodeling. The detection effect of the individualized reconstruction of the pancreas, pancreas space-occupying lesions, peripancreatic vessels, and major abdominal vessels The detection rate of the pancreas, major peripancreatic vessels (CTA, CHA, PHA, SA, GDA, RGEA, SMA, PV, SV, and SMV), and lesions from the MI-3DVS reconstruction was100%. The display on the3D model was vivid and clear, with a strong stereoscopic effect that facilitated a clear view of the morphology and range of the pancreatic head vessels, pancreatic tumors, and the surrounding normal tissues and the spatial relationship between the peripancreatic and major abdominal vessels.3. Individualized reconstruction of the peripancreatic arteries and any anatomical variations.The reconstruction of the arteries of60pancreatic tumor patients. For some patients, the peripancreatic arteries were clearly shown, and the complete arterial arch near the pancreatic head was shown in24patients. The blood flow of the arterial arch is the confluence of the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery, and the blood to the pancreatic head is mainly supplied from the arterial arch. A malformation of the right hepatic artery was seen in some patients. An early bifurcation of the right hepatic artery was seen in1patient, where the right hepatic artery was branching from the common hepatic artery. The3D reconstruction showed both the anterior-superior pancreaticoduodenal artery and the posterior-superior pancreaticoduodenal artery in46patients (76.6%). In17patients (36.9%), both the anterior-superior pancreaticoduodenal artery and the posterior-superior pancreaticoduodenal artery were branched from the gastroduodenal artery. In29patients (63.1%), the anterior-superior pancreaticoduodenal artery and the posterior-superior pancreaticoduodenal artery had different origins. In addition, the3D reconstruction showed both the anterior-inferior pancreaticoduodenal artery and the posterior-inferior pancreaticoduodenal artery in36patients (60%), and in11patients (30.5%), the anterior-inferior pancreaticoduodenal artery and the posterior-inferior pancreaticoduodenal artery were branched from different parts of the inferior pancreaticoduodenal arteries. However, in25patients (69.5%), the anterior-inferior pancreaticoduodenal artery and the posterior-inferior pancreaticoduodenal artery shared a common origin. In5patients (8.3%), the arterial arch near the pancreatic head was distant from the descending duodenum and entered the pancreas in the right margin of the pancreatic neck. In55patients (91.7%), the dorsal pancreatic artery was shown and was branched from the splenic artery or the celiac trunk branch to feed the pancreatic body. In1patient (1.67%), the common hepatic artery and its branches originated from the superior mesenteric artery. In3patients (5%), the gastroduodenal artery originated from the superior mesenteric artery, and the anterior-superior pancreaticoduodenal artery and the posterior-superior pancreaticoduodenal artery originated from the common hepatic artery. In1patient (1.67%), the posterior-superior pancreaticoduodenal artery originated from the common hepatic artery. In addition, in32patients (53.3%), the superior marginal arterial branch of the pancreatic head was shown along the superior margin of the pancreas and was branched from the gastroduodenal artery and then extended left to connect to the dorsal pancreatic artery.4. Individualized reconstruction of the peripancreatic veins and any anatomical variationsThe3D reconstructions of the peripancreatic veins of the60patients were rotated and observed in three dimensions. The reconstruction showed that the peripancreatic veins detected were mainly the anastomosis of the anterior-superior pancreaticoduodenal artery (detection rate of61.6%,37patients) and the anterior-inferior pancreaticoduodenal artery (55.0%,33patients) of the right gastroepiploic vein, the posterior-superior pancreaticoduodenal artery (43.3%,26patients), and the posterior-inferior pancreaticoduodenal artery of the superior mesenteric vein trunk (51.6%,31patients). The3D reconstruction showed that in1patient, a number of innominate veins from the upper and lower margins of the pancreatic head entered the right and posterior margin of the superior mesenteric vein. Some peripancreatic veins were extensions of the pancreatic venous arch anastomosis. In some patients with pancreatic cancer, the compression of the peripancreatic veins by the tumor led to poor venous return by the peripancreatic veins and extensive dilation of the right gastroepiploic vein, splenic vein, and small splenic flexure veins5. For three-dimensional reconstruction of pancreatic cancer surgery simulationIn FreeForm Modeling System, by force feedback devices the PHANTOM and the virtual surgical instruments surgeons can easily make for reconstruction surgery on the various types of simulation model, including pancreatic resection of duodenum, pancreas resection, resection of pancreatic body tail and so on. Visual simulation could observe the relationships of tumor surgery and main portal vein, splenic vein and superior mesenteric vein anatomy, so avoid the damage in real operation. Understood contorts the gastroduodenal artery, celiac artery variation patients avoid intraoperative hepatic artery injury.3-D reconstruction can also be for an enlarged lymph node assessments standardized lymph node cleaning,.Through multiple surgery scheme optimization surgeons selected to determine the best solution.6. Operation resultIn89patients,62underwent surgery, and43cases of3-D reconstruction group,19cases of conventional treatment group,42cases in standard Whipple procedure,16cases in body tail of pancreas tumor resection,4cases in middle of pancreas resection. The age, tumor size of two groups, there was no statistically significant difference (P>0.05).3-D reconstruction group of intraoperative blood loss and operation time obviously were less than the conventional group.(P<0.05, P<0.01). Length of hospital stay and postoperative complications were slightly more than normal group, but two groups there were no statistically significant difference. Conclusions1. Successful completion the data collection of the pancreas and peripancreatic blood vessels and submillimeter pancreatic cancer patients high quality image.2. Peripancreatic vascular remodeling can display normal contorts the peripancreatic vascular morphological changes, and changes. Compared with conventional CT is more intuitive, accurate, and reliable. It is assistance to choose the pancreas tumor resection operation3. Based on MI-3DVS simulation surgery for pancreatic cancer surgery can effectively reduce the operation risk, improve the resection rate... |
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