Application of 3D visualization and 3D printing in individualized precision surgery for Bismuth-Corlette type Ⅲ and Ⅳ hilar cholangiocarcinoma / 南方医科大学学报

OBJECTIVE@#To explore the application of 3D visualization and 3D printing in individualized precision surgical treatment of Bismuth-Corlette type Ⅲ and Ⅳ hilar cholangiocarcinoma.@*METHODS@#We retrospectively analyzed the data of 10 patients with hilar cholangiocarcinoma undergoing surgeries under the guidance of 3D visualization and 3D printing in the Department of Hepatobiliary Surgery, Zhujiang Hospital from May 2016 to March 2019. Thin-section CT data of the patients were collected for 3D reconstruction and 3D printing, and the 3D printed models were used for observing the 3D relationship of tumor with the intrahepatic bile duct, hepatic artery, portal vein and hepatic vein system and for performing preoperative simulated surgery and surgical planning. The 3D printed models were subsequently used for real-time intraoperative navigation to guide surgeries in the operating room.@*RESULTS@#3D visualization models were successfully reconstructed for all the 10 patients and printed into 3D models. The 3D visualization types in Bismuth-Corlette classification included type Ⅲa (4 cases), type Ⅲb (4 cases), and type Ⅳ (2 cases); 4 patients showed portal vein variation, 3 had hepatic artery variation, and 2 had both portal vein and hepatic artery variations. Two patients were found to have trifurcation type of portal vein variation, one had "I-shaped" variation, and one showed the absence of the right anterior branch of the portal vein; 3 patients had hepatic artery variations with the left hepatic artery originating from the left gastric artery (1 case) and the right hepatic artery originating from the superior mesenteric artery (2 cases). Four patients with type Ⅲb underwent left hepatectomy; 4 with type Ⅲa received right hepatectomy; 1 patient with of type Ⅳ received peripheral hepatic resection and another underwent left hepatectomy. The results of preoperative 3D reconstruction, 3D printed model and preoperative planning were consistent with the intraoperative findings. The operative time was 452±75.12 min with a mean intraoperative blood loss of 356±62.35 mL and a mean hospital stay of 15 ± 4.61 days in these cases. One patient had bile leakage and 3 patients had pleural effusion postoperatively, and they were discharged after drainage and medications. No liver failure or death occurred in these cases perioperatively.@*CONCLUSIONS@#3D visualization and 3D printing can facilitate accurate preoperative assessment, surgical planning and surgical procedure optimization for Bismuth-Corlette type Ⅲ and Ⅳ hilar cholangiocarcinoma to improve surgical safety and reduce surgical risks especially in cases of intrahepatic vascular variations.

Three-dimensional visual assessment and virtual reality study of centrally located hepatocellular carcinoma on the axis of blood vessels / 中华外科杂志

Objective@#To explore a novel method for preoperative precision assessment of centrally located hepatocellular carcinoma(HCC) with blood vessel as axis based on three-dimensional(3D) visualization and virtual reality(VR) technology and its application values.@*Methods@#High-quality thin-layer enhanced CT data were collected from 20 patients with centrally located HCC who treated at First Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University from March 2017 to August 2018 diagnosed by preoperative examination. There were 18 males and 2 females, aged 28 to 69 years, all of Child-Pugh grade A. First of all, 3D reconstruction was performed by a 3D visualization software; then, the reconstructed 3D image was imported into VR development engine for VR research; afterwards, the analysis and evaluation system with blood vessel as axis was established based on 3D visualization classification of centrally located HCC; therefore, the relationship of the tumor to its major peripheral blood vessels was accurately judged and the surgical planning was formulated. Two images were brought into the operating room for navigation in surgery. The assessments results of preoperative data (CT and (or) MRI) and three-dimensional visualization of blood vessels in VR environment were compared; the values of the preoperative and postoperative hemoglobin, serum albumin and bilirubin were recorded and compared. Chi-square test, t-test and non-parametric test were used for the analysis of counting data, continuous measurement data and non-normal distribution measurement data, respectively.@*Results@#3D visualization modeling was completed in all of the 20 patients with centrally located HCC. According to the results of 3D visualization classification of centrally located HCC, there were 3 cases of type Ⅰ,1 case of type Ⅱ,4 cases of type Ⅲ,7 cases of type Ⅳ and 5 cases of type Ⅴ; according to the assessment and classification based on blood vessel as the axis, there were 6 cases of type Ⅰa,2 cases of type Ⅰb,2 cases of type Ⅱa,9 cases of type Ⅱb and 1 case of type Ⅱc. All patients underwent successful resection of tumor under the guidance of 3D visualization and VR technology. There were 15 cases whose assessment results based on preoperative CT/MRI were consistent with intraoperative findings, with a coincidence rate of 75.0%(15/20); while in VR environment, the assessment results of 3D visualization with blood vessel as axis were all consistent with the intraoperative findings, with coincidence rate of 100%(20/20). There was a statistically significant difference between the groups (χ2=5.714, P=0.017). There was no red blood cell transfusion in all patients during the operation. The preoperative hemoglobin was (128.8±14.9)g/L, and it was (119.8±12.5)g/L on postoperative day 1. There was no significant difference between these two sets of data (t=2.07, P=0.054). No death during the perioperative period and no complications such as hepatic failure, hemorrhage and biliary fistula after operation occurred.@*Conclusion@#Preoperative evaluation based on 3D visualization and VR technology with blood vessel as the axis has significant clinical value for preoperative planning and surgical navigation of centrally located HCC.

Application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma / 中华消化外科杂志

Objective To explore the application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma (ICC).Methods The retrospective descriptive study was conducted.The clinicopathological data of 11 patients with ICC who were admitted to Zhujiang Hospital of Southern Medical University between January and September 2018 were collected.There were 5 males and 6 females,aged (55 ± 12)years,with a range from 30 to 74 years.The data of contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with gadoxetate disodium (Gd-EOB-DTPA) of the upper abdomen were respectively collected,and three-dimensional(3D) model of liver was constructed based on CT-MRI fusion images.The preoperative evaluation and surgical planning were carried out based on the different modal imaging examination technologies.The indocyanine green (ICG) molecular fluorescence imaging system and augmented reality navigation system were used to guide hepatectomy.Observation indicators:(1) preoperative evaluation;(2) intraoperative situations;(3) comparison between surgical planning based on the different model imaging technologies and actual surgical method;(4) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to November 2018.Measurement data with normal distribution were represented as Mean ± SD,measurement data with skewed distribution were represented as M (range).Count data were described as absolute number or percentage and comparisons were analyzed using the paired chi-square test.Results (1) Preoperative evaluation:the proportions of grade 3 and above branch vessels of the portal vein and hepatic vein system and tumor margin by enhanced CT examination and enhanced MRI examination were respectively 11/11,4/11 and 5/11,11/11,with statistically significant differences in above indicators (x2 =4.16,5.14,P＜0.05).The enhanced CT showed 11 liver cancer lesions and enhanced MRI showed 13 lesions (including 2 lesions not demonstrated by enhanced CT,with a maximum diameter ≤ 10 mm).The 3D model of liver based on CT-MRI fusion image:location,number,infiltrating range (tumor boundary),intrahepatic vascular distribution,variation and its spatial relationship with lesions could be stereoscopically,intuitively and comprehensively displayed.(2) Intraoperative situations:of 11 patients,11 lesions were explored with naked eyes;13 lesions were detected by ICG molecular fluorescence imaging system,including 2 lesions showing low uptake lesions in liver and gallbladder specific period by preoperative MRI examinations and intrahepatic metastasis cancer by pathologic examination.Of 11 patients,6 had naked-eye ischemia boundaries around related vessels of hepatic portal ligation;10 with anatomical hepatectomy had hepatic segments or hemihepatic boundary by ICG molecular fluorescence imaging system,including 2 using positive staining and 8 using anti-staining.Among 11 patients,3 (1 combined with local resection of hepatic segment Ⅷ metastases),2,2,1,1,1 and 1 underwent respectively left hepatectomy,left lateral lobectomy of liver,right hepatectomy,extended right hepatectomy,right lobectomy of liver,resection of partial hepatic segment Ⅷ and mesohepatectomy.Seven of 11 patients received regional lymph node dissection and 4 received simple lymph node biopsy.Of 11 patients,1 diagnosed as with bile leakage of liver section underwent suture and ligation treatment with 4-0 Prolene;10 didn't occurred bile leakage.The surgical margin of 11 patients was negative.The operation time,volume of intraoperative blood loss and duration of hospital stay were (240± 118)minutes,(275±249)mL and (13 ± 8) days,respectively.There was no blood transfusion in the perioperative period.(3) Comparison between surgical planning based on the different model imaging technologies and actual surgical method:surgical planning of 3D model based on CT,MRI and CT-MRI fusion image in 6,9 and 11 patients was respectively consistent with actual surgical method.(4) Follow-up:11 patients were followed up for 2-10 months,with a median time of 6 months.Three patients had postoperative complications,2 of which were found in Clavien-Dindo Ⅰ and Ⅱ,including 1 with pleural effusion + peritoneal effusion and 1 with pleural effusion,they were improved after conservative treatment;1 with complication of Clavien-Dindo Ⅲ (postoperative intra-abdominal bleeding) was improved by selective arterial embolization using percutaneous femoral artery puncture.There was no postoperative bile leakage,hepatic failure and death.Conclusion Multimodal image fusion technique is helpful to optimize the preoperative surgical planning,which can assist the recognition of important vessels and real-time navigation of hepatectomy during operation,and improve the safety of operation.

Three-dimensional visualization evaluation and VR study of giant liver cancer with blood vessels as the axis / 中华普通外科杂志

Objective To explore the clinical application value of three-dimensional visualization of blood vessels as the axis and virtual reality technology in giant liver cancer.Methods Thin-layer CT image data of 13 patients who were diagnosed as giant primary liver cancer were collected for three-dimensional reconstruction,and then transformed into VR model.The anatomical relationship between the tumor and its surrounding important structures was analyzed.The preoperative evaluation,classification and surgical planning based on blood vessels as the axis were carried out to guide intraoperative navigation.The consistency was verified by the intraoperative rapid pathological examination.Results 13 patients successfully achieved 3D reconstruction and VR model transformation.According to the 3D visualization classification of blood vessels as the axis.There were three cases of type Ⅰ a grade 1,two cases of type Ⅰa grade 2;one case of type Ⅱ a grade 2;one case of type Ⅱ b grade 3;two cases of type Ⅱ c grade 3;four cases of type Ⅱ a grade 3.Conclusions Three-dimensional visualization and VR technology can provide comprehensive information on the anatomical structure of liver cancer lesions and blood vessels,which is of great value in the application of giant liver cancer surgery.

Three-dimensional visual assessment and VR study of hilar cholangiocarcinoma with portal vein as the axis / 中华肝胆外科杂志

Objective To explore the application value of three-dimensional visual (3DV) assessment and virtual reality (VR) study of type Ⅲ and Ⅳ hilar cholangiocarcinoma with portal vein as the axis.Methods The CT image data of 10 patients who were diagnosed as Bismuth type Ⅲ and Ⅳ hilar cholangiocarcinoma by B-ultrasound and CT in Zhujiang Hospital,Southern Medical University were imported into 3D visualization system (3DVS) for 3D image reconstruction,and the portal vein was used as the axis for 3DV analysis and evaluation.The 3D data were then imported into the VR development engine to perform VR research,so as to help the operation planning.Both of the image data were taken into the operation room for intraoperative navigation.Results 10 patients completed 3D visualization reconstruction and VR model transformation.According to the 3D visualization of hepatic hilar hepatocarcinoma,there were 1 case of type Ⅱ,2 cases of type Ⅲa,5 cases of type Ⅲb,1 case of type Ⅳa and 1 case of type Ⅳb.The portal vein was classified according to Cheng type:6 cases of type Ⅰ,3 cases of type Ⅱ,and 1 case of type Ⅲ.The hepatic artery was classified according to Michels type:5 cases of type Ⅰ,1 case of type Ⅱ,3 cases of type Ⅲ,and 1 case of type Ⅸ.The 3DV assessment and VR study were almost consistent with the intraoperative findings.No liver failure or death occurred during the perioperative period.Conclusion The 3DV assessment and VR study with the portal vein as the axis have potential application for the surgical treatment of type Ⅲ and Ⅳ hilar cholangiocarcinoma.

Three-dimensional visualization combined with indocyanine green fluorescence imaging in diagnosis and treatment of primary hepatocellular carcinoma / 南方医科大学学报

OBJECTIVE@#To explore the value of three-dimensional visualization technology (3DVT) combined with indocyanine green (ICG) fluorescence imaging in the diagnosis and treatment of primary hepatocellular carcinoma (HCC).@*METHODS@#We retrospectively analyzed the clinical data of 154 patients with HCC admitted to the Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University between January, 2016 and November, 2018. In 57 of the patients (3DVT group), preoperative CT and Gd-EOB-DTPA-enhanced MRI were performed and 3D visualization and surgical planning was carried out before the operation; intraoperative ICG florescence imaging was performed for real-time detection of the tumor location and demarcation, intrahepatic satellite lesions and metastases. According to the intraoperative fluorescent signals and 3D visualization-based surgical planning, the final surgical plan was determined. In the other 97 patients (control group), conventional surgical assessment and surgical resection of the tumor was carried out. The preoperative imaging findings, intraoperative tumor detection, postoperative laboratory results, pathological reports, and follow-up data of the patients were analyzed.@*RESULTS@#In 3DVT group, 63 and 70 lesions were detected by preoperative CT and MRI, respectively; compared with CT examination, intraoperative ICG florescence imaging revealed additional 17 lesions, among which 10 were pathologically confirmed as HCC and 7 as cirrhosis nodules. The median volume of bleeding was 300 mL in 3DVT group, significantly less than that in the control group (400 mL; Z=2.291, =0.022). In both groups, serious complications or perioperative death occurred in none of the patients. The incidence of postoperative complications was significantly lowed in 3DVT group than in the control group [21% (12/57) 48.4% (47/97); =11.406, =0.001]. The overall disease-free survival rate at 2 years after the operation was significantly higher in 3DVT group than in the control group (74.9% 28.9%, =0.022).@*CONCLUSIONS@#3DVT combined with ICG fluorescence imaging allows precise preoperative diagnosis, surgical planning and implementation, intraoperative detection of small liver cancers and precise navigation for HCC treatment, thereby helping to reduce postoperative complications and improve the disease-free survival rate of the patients.

Clinical efficacy of three-dimensional visualization technique combined with enhanced recovery after surgery in the treatment of hepatolithiasis / 中华消化外科杂志

Objective To investigate the clinical efficacy of three-dimensional visualization technique (3DVT) combined with enhanced recovery after surgery (ERAS) in the treatment of hepatolithiasis.Methods The retrospective cohort study was conducted.The clinicopathological data of 64 patients with hepatolithiasis who were admitted to Zhujiang Hospital of Southern Medical University from November 2015 to August 2018 were collected.There were 17 males and 47 females,aged from 30 to 82 years,with a median age of 55 years.Of the 64 patients,23 who completed preoperative assessment and planning using 3DVT,and furthermore received ERAS for perioperative management were divided into 3DVT + ERAS group,and 41 who received preoperative assessment merely under the guidance of 3DVT,combined with conventional perioperative management were divided into 3DVT + conventional group.Observation indicators:(1) preoperative CT and 3DVT assessment;(2) perioperative conditions;(3) follow-up.The follow-up was conducted by outpatient service,e-mail or telephone interview to detect the postoperative recurrence of hepatolithiasis up to March 2019.The measurement data with normal distribution were expressed as Mean±SD,and the t test was used for comparison between groups.The measurement data with skewed distribution were expressed as M (P25,P75),and the Mann-Whitney U test was used for comparison between groups.The count data were expressed as absolute numbers or percentages,and the comparison between groups was pedormed using the chi-square test or Fisher exact probability.Results (1) Preoperative CT and 3DVT assessment:23 patients in the 3DVT + ERAS group underwent preoperative CT examination and 3DVT assessment,the consistency between CT results and intraoperative findings was 91.3％ (21/23),and the consistency between 3DVT results and intraoperative findings was 95.7％(22/23).Fourty-one patients in the 3DVT + conventional group underwent preoperative CT examination and 3DVT assessment,the consistency between CT results and intraoperative findings was 90.2％ (37/41),and the consistency between 3DVT results and intraoperative findings was 95.1％ (39/41).(2) Perioperative conditions:the volume of intraoperative blood loss,duration of postoperative hospital stay,postoperative total bilirubin,postoperative direct bilirubin,postoperative albumin,postoperative alanine aminotransferase,postoperative aspartate aminotransferase and postoperative hemoglobin were 50 mL (10 mL,100 mL),8 days (7 days,9 days),12 μmol/L (9 μmol/L,16 μmoL/L),6 μmol/L (4 μmoL/L,8 μmol/L),(37±4)g/L,44 U/L (18 U/L,85 U/L),32 U/L (20 U/L,65 U/L),(117±18)g/L in the 3DVT + ERAS group,and 100 mL (50 mL,300 mL),13 days (10 days,16 days),17 μmol/L (12 μmoL/L,33 μmoL/L),11 μmoL/L (7 μmoL/L,21 μmol/L),(29±6)g/L,78 U/L (43 U/L,122 U/L),121 U/L (72 U/L,176 U/L),(106±13)g/L in the 3DVT + conventional group,respectively;there were significant differences between two groups (Z =-3.084,-4.827,-2.953,-3.632,t =5.261,Z=-2.960,-4.625,t =2.773,P＜0.05).Two patients had pulmonary infection and 2 had pleural effusion in the 3DVT + ERAS group,and all the 4 patients were cured after treatment.One case of biliary fistula,4 cases of pulmonary infection and 5 cases of pleural effusion occurred in the 3DVT + conventional group,and these patients were cured by adequate abdominal drainage,antibiotic therapy and thoracocentesis,respectively.There was no perioperative death in either group.(3) Follow-up:64 patients were followed up for 6-36 months,with a median time of 23 months.During the follow-up,no recurrent hepatolithiasis in the 3DVT + ERAS group,and 1 case of recurrent hepatolithiasis was confirmed by ultrasound in the 3DVT + conventional group.No cholangiocarcinoma occurred in either group.Conclusion The combination of 3DVT and ERAS is effective,safe and feasible in the management of hepatolithiasis,which can accelerate the postoperative recovery of liver function,thus enhancing perioperative recovery and improving the prognosis of patients simultaneously.