节点文献
活体肝移植术后供、受者肝静脉淤血及肝再生的多层螺旋CT研究
Hepatic Venous Congestion and Liver Regeneration of Donor-recipients after Living Donor Liver Transplantation: Multi-slice Spiral CT Study
【作者】 季倩;
【导师】 祁吉;
【作者基本信息】 天津医科大学 , 影像医学与核医学, 2009, 博士
【摘要】 目的:评价利用多层螺旋CT(MSCT)测量活体肝移植(LDLT)供肝体积与术中实测体积和质量的关系,及MSCT测量肝体积的可重复性。利用MSCI平扫、增强及灌注检查评价LDLT术后供、受者肝静脉淤血(HVC)的原因、程度及预后。利用MSCI评价LDLT术后供、受者肝再生情况及不同因素的影响,得出术后不同时间段肝再生率(LRR)与其相关因素的回归方程。对象和方法:91例供者、153例及120例供、受者纳入本研究,同期纳入10例健康志愿者作为MSCT灌注检查的对照组。利用二维手动法进行肝体积测量,利用Pearson相关性检验和直线回归对LDLT术前MSCT所测右半肝体积与术中实测体积和质量之间、两名测量者所测右半肝体积之间进行相关及线性回归分析。记录肝静脉淤血在MSCT平扫和双期增强CT上的表现,判断其具体术式和淤血原因,利用配对t检验比较术前估计淤血区体积和术后实测淤血区体积之间的差异,记录并比较对照组、淤血区、非淤血区肝实质的肝血容量(BV)、血流量(BF)、平均通过时间(MTT)、表面通透性(PS)和肝动脉指数(HAF),记录并比较淤血组与无淤血组供、受者术后1~7天谷丙转氨酶(GPT)、谷草转氨酶(GOT)、总胆红素(TB)及凝血酶原时间(PT)。计算并比较LDLT术后不同时间段供、受者LRR以及不同因素的影响,利用线性逐步回归分析得出术后不同时间段LRR与其相关因素的回归方程。结果:LDLT术前MSCT所测全肝体积为1366.99±234.75cm3,右半肝体积(V术前)为862.73±175.94cm3,第二名测量者所测右半肝体积为843.15±171.39cm3,术中实测供肝体积(V术中)为654.46±151.23ml,质量(W术中)为710.70±150.25g,肝实质密度为1.09±0.09g/ml,误差率分别为33.69±19.63%和19.38±13.15%。V术前与V术中之间呈正相关(r=0.795,P=0.000),其回归方程为V术中=64.949+0.683×V术前。V术前与W术中之间亦呈正相关(r=0.858,P=0.000),其回归方程为W术中=78.609+0.733×V术前。两名测量者所测右半肝体积之间亦呈正相关(r=0.985,P=0.000)。MSCT平扫51.02%的肝静脉淤血区呈低密度;增强后动脉期可呈低密度(36.73%)、等密度(34.69%)或混杂密度(28.57%);门静脉期淤血区多呈混杂密度(63.27%)或高密度(34.69%)。增强后动脉期及门静脉期呈持续低密度者预后不良。常见HVC原因包括未保留MHV为主型引流通道且未行血管重建或搭桥,或搭桥血管变形、狭窄或梗阻。供者术前估计淤血区体积与术后实测淤血区体积之间差异没有统计学意义(t=-1.995,P=0.057),受者术前估计淤血区体积与术后实测淤血区体积之间差异有统计学意义(t=-8.986,P=0.000)。与对照组相比,淤血区肝实质BV、BF和HAF升高(P<0.05),MTT和PS差异没有统计学意义(P>0.05);非淤血区与对照组肝实质之间各项灌注参数差异均无统计学意义(P>0.05);淤血组与无淤血组非淤血区肝实质之间各指标差异均无统计学意义(P>0.05)。LDIT术后1~7天淤血组与无淤血组供、受者各项肝功能化验指标之间差异均无统计学意义(P>0.05)。术后各时间段受者LRR均高于供者,其中术后半月、1月及3月两组之间差异有统计学意义(P<0.05),术后6月两组之间差异没有统计学意义(P>0.05)。供者术后7天与1月、3月LRR之间差异有统计学意义(P<0.05),其余各时间段之间差异均无统计学意义(P>0.05)。受者术后半月、1月LRR与术后3月、6月之间差异有统计学意义(P<0.05),其余各时间段之间差异均无统计学意义(P>0.05)。供肝是否带MHV组供、受者LRR差异均无统计学意义(P>0.05);男性组与女性组供、受者LRR差异均无统计学意义(P>0.05);年龄<30岁组与年龄≥30岁组供者LRR差异没有统计学意义(P>0.05),供、受者年龄与术后不同时间段LRR之间均无相关性(P>0.05);术后半月不同Child-Pugh分级或MELD评分组之间LRR差异有统计学意义(P<0.05),其余各时间段之间差异均无统计学意义(P>0.05);残肝或供肝体积或质量与供、受者术后不同时间段LRR之间均呈负相关(P<0.05)。得到术后不同时间段供、受者LRR与其相关因素的回归方程。结论:MSCT测量肝体积可重复性好,根据回归方程可准确计算供肝实际体积和质量。健康供者肝实质密度大于1g/ml。应用MSCT评价HVC原因及程度准确性高,并可提示预后,血管重建或搭桥可显著改善HVC。LDLT术后供、受者肝再生模式不同,受者再生更明显、更快。供肝是否带MHV、性别和年龄对肝再生没有影响;受者术前肝功能状态对术后半月肝再生有影响,半月以后影响消失;残肝或供肝体积或质量与肝再生之间呈负相关;得到LDLT术后不同时间段供、受者肝再生率与其相关因素的回归方程。
【Abstract】 Objective To evaluate correlations between multi-slice spiral CT (MSCT)volumetric measurement and actual volume and weight of graft in living donor livertransplantation (LDLT), and the repeatability of MSCT volumetric measurement. Toevaluate the reasons, extent and prognosis of hepatic venous congestion (HVC) afterLDLT using MSCT. To evaluate the liver regeneration and the influencing factors atthe different stages after LDLT using MSCT.Materials and Methods 91 living donors, 153 and 120 living donor-recipientswere included in this study, 10 healthy volunteers were included as controls in CTperfusion examination. We did CT volumetric measurement of the liver by using thehand tracing method. Intraoperatively, the weight and volume of graft were recorded,correlation coefficient and linear regressions were calculated. Images were evaluatedfor hepatic attenuation difference and congestive reasons in areas of hepatic venouscongestion. Preoperative estimation of congestion volumes were correlated with theactual congestion volume after LDLT. Blood volume (BV), blood flow (BF), meantransit time (MTT), permeability surface (PS) and hepatic arterial fraction (HAF) ofcontrols, congestive areas and non-congestive areas were recorded, respectively.Gutamic pyruvic transaminase (GPT), glutamic oxalacetic transaminase (GOT), totalbilirubin (TB) and prothrombin time (PT) of 1 to 7 days after LDLT betweencongestion group and non-congestion group were recorded and compared. The liverregenerative ratio (LRR) of different stages of donor-recipients after LDLT werecalculated and compared, correlation coefficient and linear regressions werecalculated.Results Preoperative measurement of total liver and grafts resulted in a meanvolume of 1366.99±234.75cm3 (standard deviation) and 862.73±175.94cm3 (Vpreop),respectively, and the volume of grafts was measured by the second gauger was843.15±171.39cm3. Intraoperative mean weight and volume of the grafts were710.70±150.25g (Wintraop) and 654.46±151.23m1 (Vintraop), respectively. Allcorresponding pre- and intraoperative data correlated significantly with each other.Vintraop and Wintraop can be calculated with the equations Vintraop =64.949+(0.683× Vpreop) ml and Wintraop=78.609+(0.733×Vpreop)g, respectively. HVC often appear ashypoattenuation on plain CT scan (51.02%) and arterial phase (36.73%), mixed(63.27%) or hyperattenuation (34.69%) on portal vein phase. Persistenthypoattenuation on arterial phase and portal vein phase indicated severe HVC. Therewas no significantly difference between preoperative estimation of congestionvolumes and the actual congestion volume in donors (P>0.05). Compared withcontrols, BV, BF and HAF of congestive areas were significantly increased (P<0.05).There were no significantly difference of GPT, GOT, TB and PT after LDLT betweencongestion group and non-congestion group (P>0.05). There were significantlydifference of LRRs between different stages of donors and recipients (P<0.05). Thefollowing factors, included whether the graft contain MHV or not, age and sex ofdonor-recipients, had no significant influence on LRR after LDLT (P>0.05). Thestatus of liver function of recipients preoperatively had significant influence on LRRof early stage after LDLT (P<0.05). There were significantly negative correlationbetween the residual or graft volume and LRRs of donor-recipients at different stagesafter LDLT.Conclusion The repeatability of MSCT volumetric measurement are good. Byusing two equations, expected intraoperative weight and volume can properly bedetermined. It is accurate to evaluate the reasons, extent and prognosis of HVC byusing MSCT. Reconstruction of blood vessel can significantly improve HVC. It issignificantly faster and reach a higher peak of LRRs in recipients than in donors. Thefollowing factors, included whether the graft contain MHV or not, age and sex ofdonor-recipients, have no significant influence on LRR after LDLT. The status ofliver function of recipients preoperatively has significant influence on LRR of earlystage after LDLT. The residual or graft volume has significant influence on LRR afterLDLT. At different stages, we get different regression equations to evaluate LRR andthe influence fractors in donor-recipients.
【Key words】 living donor liver transplantation; tomography; X-ray computed; volumetric measurement; hepatic venous congestion; perfusion imaging; liver regeneration;