Studies On The Application Of The Medical Image 3D Visualization System Of Abdomen In Diagnosis And Treatment Of Pancreatic Tumor

BackgroundBecause of the special anatomy of the pancreas, complex blood supply, important physiological functions, the development of pancreatic surgery has lagged behind diseases of other abdomen organs in many aspects of research. The traditional studies of anatomy focus on fixed specimens without perfusion, therefore the vessels are collapsed, and anatomical relations of soft pancreas and visceral peritoneum has been changed. Anatomic information obtained by the specimens does not match with the living. In the actual clinical work, due to inaccurate understanding about the distribution of blood vessels and the resectability of tumors, blind exploration has been taken, resulting in complex operation, difficult decision and extending risk of complication.Modern imaging (CT, MRI, etc.) technological development has leaded pancreatic anatomy and tumor research to a new stage.64-spiral CT and more advanced ones are able to provide sub-millimeter image information, which has made it possible that the study of small pancreatic vessels variation, large vessels precise deformation and accurate assessment of tumor resectability. Currently, although CT three-dimensional reconstruction methods such as Maximum Intensity Projection (MIP) and Volume Rendering (VR) are common used in clinic, incorrect judgement has been making by experienced imaging physicians and pancreatic surgeons, that resectable tumors been underwent passive treatment.Part 1. The Research on Three-dimensional Reconstruction of Pancreatic Arteries and its Clinical SignificanceObjective1. To explore a fast three-dimensional reconstruction method for pancreatic arteries.2. To study the normal and variant types of pancreatic arteries and its clinical significance.3. To investigate the value of the individual digital pancreatic arteries model in abdominal surgery.Methods1. Materials:(1) PHILIPS BRILLIANCE 64-slice helical CT, Image process workstation; (2) binocular tube high pressure injector; (3)computer; (4) DICOM Viewer; (5) ACDSee; (6) Medical Image 3D Visualization System (MI-3DVS); (7) FreeForm Modeling System and PHANTOM.2. Examiners:63 physical examiners without abdominal disease included 45 men and 18 women with the mean age of 26 years.3. Collection of CT scan data:Pancreatic CTA during the arterial phase, pancreatic phase and portal venous phase were performed in all of the examiners, then the scan data was upload to dedicated database server and stored.4. Image Reconstruction:The original data was inputted into the personal computer and translated into JPG format through DICOM viewer; then the JPG format was translated into JPG format and the size of the images were adjusted from 512px×512px into 304px×304px by ACDSee.5. Image Segmentation:The adjusted images were imported into Medical Image 3D Visualization System (MI-3DVS) and underwent procedure segmentation and three-dimensional reconstruction. The reconstructed models were outputted to STL format; and then STL models were imported into FreeForm Modeling System to be smoothed, denoised and digital painting, etc. The result was not only able to shown as three-dimensional combined model but also independent vessel model.Results1. Digital pancreatic artery show effectThe 3D model of the pancreatic artery is clear, realistic, three dimensional sense. Indirectly supplying pancreatic arteries suchas celiac trunk, hepatic artery, splenic artery, gastroduodenal artery and related arteries suchse left gastric artery, the right gastroepiploic artery, hepatic artery are 100% shown. In all directly supplying pancreatic arteries, dorsal pancreatic artery were 71.4% shown(45 cases); anterior superior pancreaticoduodenal artery were 81.0% shown(51 cases); transverse pancreatic artery were 30.2% shown(19 cases); posterior superior pancreaticoduodenal artery were 68.3% shown(43 cases); great pancreatic artery were 58.7% shown(37 cases); anterior inferior pancreaticoduodenal artery were 25.4% shown(16 cases); posterior inferior pancreaticoduodenal artery were 57.1% shown(36cases); caudal pancreatic artery were 27% shown(17 cases).2. Statistics of normal and variant pancreatic arteryHepatic artery were classified according to Michels’ standards as typeⅠ: 65.1% (41 cases), typeⅡ:3.2% (2 cases), typeⅢ:1.6%(1 case), typeⅣ:3.2%(2 cases), typeⅤ:12.7%(8 cases), type VI:3.2% (2 cases), typeⅧ:1.6%(1 case), typeⅠⅩ:6.3%(4 cases), typeⅩ:1.6%(1 case), typeⅦ:not seen. A special variation type was 1.6%(1 case) seen which is not including in Michels’ types.1.6% (1 case) splenic artery was found originning from the superior mesenteric artery. 1.6%(1 case) gastroduodenal artery was found originning from the superior mesenteric artery.In all directly supplying pancreatic arteries,2%(1 case) of anterior superior pancreaticoduodenal artery were found variation that originning from common hepatic artery; 4.7%(2 cases) of posterior superior pancreaticoduodenal artery were found variation that originning from common hepatic artery; 50% (7 cases) of anterior inferior and posterior inferior pancreaticoduodenal artery were found that divided originning from superior mesenteric artery or its braches; the other 50% (7 cases) were found in joint origin as inferior pancreaticoduodenal artery, which was come from superior mesenteric artery or its branch such as the first jejunal artery.Conclusions1. Reconstructed by Medical Image 3D Visualization System (MI-3DVS), based on 64-slice helical CT pancreatic tri-phase dynamic contrast scanning data, the pancreatic artery model is clear, realistic, three-dimensional.2. The variation that hepatic artery originates from the superior mesenteric artery should be taken into account in pancreatic surgery; Three-dimensional digital reconstruction of individual is able to provide instructive information.3. Thers are many variations of the supplying for the pancreatic head, that should be taken into account in pancreatic and hepatic surgical procedures. Three-dimensional digital reconstruction of individual is able to provide instructive information. Part 2. Application of the Medical Image 3D Visualization System of Abdomen in Diagnosis and Evaluating Resectability of Pancreatic TumorsObjective1. To explore a fast three-dimensional reconstruction method for pancreatic tumor.2. To investigate the value of this system for diagnosis and respectability appraisal of pancreatic tumors.Methods1. Materials:same as the first past.2. Examiners:9 patients of pancreatic tumors including 6 men and 3 women with the mean age of 36 years. The tumors included 5 pancreas-pseudopapillary tumors,3 pancreatic serous cystadenomas,1 pancreas cyst(ductal epithelial papillary hyperplasia). During the patients,2 persons were assessmented unresectable by other hospitals.3. Collection of CT scan data:same as the first part.4. Diagnosis and tumor resectability assessment:before surgery, the patients were diagnosed by experienced pancreatic surgeons combining with individual three-dimensional disease model and disease history; the tumor resectability was assessmented by the condition of great vessels, tumors and organs.5. Comparison of actual surgical contents:the actual results were compared with the preoperative diagnosis and the assessment of resectability.Results1. Digital display of individual pancreatic tumors:three-dimensional model of tumor was clear realistic and stereo. Those organs, such as pancreas, tumor, liver, extrahepatic bile ducts, expansion of pancreatic duct, gall bladder, spleen, kidney and portal vein, have shown good. The relationship between tumor shape, scope and adjacent large blood vessels was clear and legible.2. The resectability assessment of pancreatic tumor:Based on the tumor and vascular models, all cases of tumor could to be cut, including 2 being assessed by other hospitals as "unresectable".3. The contradistinction between tumor surgical and pathological findings and the preoperative evaluation:the 9 cases assessed as resectable were successfully removed and intraoperative findings consistent with the preoperative three-dimensional reconstruction, no perioperative deaths. So far Follow-up had not found recurrence in situ ater resection.Conclusions1. The three-dimensional reconstruction models of the pancreas tumor were clear, realistic and stereo. The three-dimensional reconstruction based on 64-slice spiral CT angiography of pancreatic triphasic abdominal scan data set and three-dimensional medical image visualization system MI-3DVS. The reconstruction anatomical structure reflected the living conditions inside the human body abdomen, and it could be used for anatomy, clinical teaching, preoperative diagnosis and surgical decision-making, etc. The value was higher.2. The three-dimensional reconstruction could accurately reflect the relationships between pancreatic tumors and mesenteric vein, inferior vena cava, celiac trunk, abdominal aorta, hepatic artery, splenic vein, renal vein, other large vessels. The tumor resectability assessment was high accuracy. Part 3. Application of the Medical Image 3D Visualization System of Abdomen in Diagnosis and Evaluating Resectability of Pancreatic and Periampullary CancerObjective1. To explore a fast three-dimensional reconstruction method for pancreatic and periampullary cancer.2. To investigate the value of this system for diagnosis and respectability appraisal of pancreas and periampullary cancer.3. To set up a new standard classification assessment based on MI-3DVS to evaluate the respectability of the blood vessels of pancreatic and periampullary cancer.Methods1. Materials:same as the first past.2. Examiners:11 patients of pancreatic and periampullary cancer including 8 men and 3 women with the mean age of 62 years. During the patients,1 persons were assessmented unresectable by other hospitals, and 3 persons were benign lesion by endoscopic biopsy.3. Collection of CT scan data and three-dimensional reconstruction:same as the second part.4. Diagnosis and cancer resectability assessment:before surgery, the examiners grouped by individual three-dimensional model of vascular disease manifestations.Ⅰ:large gap exsited between great vessels and cancer, no deformation of the lumen;Ⅱ:there was no obvious space between great vessels and cancer, vascular cavity was smooth;Ⅲ:there was no space between great vessels and cancer, lumen of blood vessel was rough and vermiculata;Ⅳ:the primary tumor completely surrounded the great vessels;Ⅴ:large vascular discontinue and/or significant expansion of veinlet around pancreas.Ⅰ-type assessment of tumor resectability;Ⅱ-type assessment for the tumor may be removed, or may be removed in the case of combined vascular resection or reconstruction;Ⅲ,Ⅳ,Ⅴ-type assessment can not be removed.5. Comparison of actual surgical contents:the actual results were compared with the preoperative diagnosis and the assessment of resectability.Results1. Digital display of individual pancreatic and periampullary cancer: three-dimensional model of tumor was clear realistic and stereo. Those organs, such as pancreas, tumor, liver, extrahepatic bile ducts, expansion of pancreatic duct, gall bladder, spleen, kidney and portal vein, have shown good. The relationship between tumor shape, scope and adjacent large blood vessels was clear and legible.2. Pancreatic and periampullary cancer treatment results:According to preoperative 3D reconstruction and diagnosis, of which 7 cases had surgical exploration and pancreatoduodenectomy; the remaining four cases of proven violations of the great vessels can not be removed.Ⅰtype 3 cases,Ⅱtype 3 cases,Ⅲtype 2 cases,Ⅳtype 1 case,Ⅴtype 1 case.Conclusions1. MI-3DVS three-dimensional reconstruction can be more accurate reflection the relationship among the pancreas and periampullary cancer, mesenteric vein, inferior vena cava, celiac trunk, abdominal aorta, hepatic artery, splenic vein, renal vein and other large vessels, and accurate reproduction of tumor’s shape and growth extent, there was high value in the tumor resectability assessment. 2. Based on MI-3DVS three-dimensional reconstruction of blood vessel classification standards had practical value in the pancreas and periampullary cancer resectability assessment.3. Based on multi-slice spiral CT of the MI-3DVS three-dimensional reconstruction can display partial or full expansion of the bile duct and pancreatic duct. Compared with ERCP and endoscopic biopsy, this system was non-invasive, no complications and lower cost, it could be supplement or even substituted ERCP in the diagnosis of periampullary tumors.Part 4. Individualization Visual Simulation Surgery of Bulky Caput Pancreatis TumorObjective1. To explore clinical value of the system of individualization visual simulation surgery of bulky caput pancreatis tumorMethods1. Materials:same as the first past;2. Examiners:bulky pancreatic head cancer patient. Preoperative clinical diagnosis:unknown origin of pancreatic occupying lesions. Data acquisition and image reconstruction with the second part;3. Simulation Surgery:According to routine Pancreaticoduodenectomy, the simulation surgery platformed on the FreeForm Modeling System and its owned PHANToM force feedback device;5. The actual surgical contents contrast:Results were compared with the real surgery.Results1. Individual pancreatic digital display of massive tumor:Three-dimensional model of tumor disease was clear, realistic, three-dimensional sense. It showed good the orgins of pancreas, tumor, liver, gallbladder, spleen, kidney, artery, vein and portal vein.2. The actual surgical contents contrast:The actual operation went smoothly, the simulation procedure for each step fit with realistic surgical procedure, the movements of cutting and sewing were realistic, and a basic sense of force feedback.Conclusions1. massive pancreatic cancer surgery individual visual simulation, which based on MI-3DVS three-dimensional reconstruction and surgical simulation system, was more fidelity, and it could provide a good platform for preoperative planning, surgical rehearsal, patient communication and learning, and had good prospects...