1、D0I.10.39794X.202308.013Clinicalresearch:临床研究792介人放射学杂志2 0 2 3年8 月第32 卷第8 期J Intervent Radiol 2023,Vol.32,No.8CT、M R三维重建在恶性肿瘤致梗阻性黄疽穿刺定位中的应用价值刘金，周周胜利，魏宁，曹刚，张根山，吉廷举【摘要】目的探讨CT、M R三维重建在恶性肿瘤致梗阻性黄疽穿刺定位中的应用价值。方法选择2 0 18 年2 月至2 0 2 1年12 月江苏省连云港市第一人民医院因恶性肿瘤致梗阻性黄疽行经皮肝穿刺胆道引流（PTBD)和（或）胆道支架植人患者154例，分为研究组8 1例，对照组
2、7 3例。研究组术前行胆道系统CT、M R三维重建，根据重建图像明确胆道穿刺皮肤穿刺点、穿刺深度、穿刺水平及穿刺角度后在DSA下行胆道穿刺；对照组选用经典DSA引导下穿刺。比较两组首针穿刺成功率、总体穿刺成功率、穿刺次数、穿刺成功后手术完成率及穿刺并发症发生率，分析三维重建辅助下穿刺定位价值。结果研究组首针穿刺成功率为9 0.9 1%，高于对照组的7 8.7 9%；穿刺次数为（1.2 6 0.54），少于对照组的（1.8 6 1.11），差异有统计学意义（P0.05)。两组间总体穿刺成功率和穿刺成功后手术完成率差异无统计学意义。36 例(2 3.38%)出现穿刺并发症，主要为出血、腹痛、气胸和
3、感染等。研究组穿刺并发症发生率为13.58%,低于对照组的34.2 5%,差异有统计学意义（P0.05）。结论CT、M R三维重建技术辅助胆道系统穿刺，可提高首针穿刺的成功率，降低反复穿刺次数和穿刺并发症的发生率，在各级医院和不同年资术者中具有一定的普及意义。【关键词】CT、M R三维重建；梗阻性黄疽；恶性肿瘤；胆道穿刺中图分类号：R730.5文献标志码：B文章编号：10 0 8-7 9 4X(2023)-08-0792-04Application value of three dimensional reconstruction of CT and MR imaging in punctur
4、e positioningof obstructive jaundice caused by malignant tumors LIU Jin,ZHOU Shengli,WEI Ning,CAO Gang,ZHANG Genshan,JI Tingju.Department of Interventional Radiology,Lianyungang Municipal First PeoplesHospital,Lianyungang,Jiangsu Province 222000,ChinaCorresponding author:ZHOU Shengli,E-mail:Abstract
5、 Objective To investigate the application value of three dimensional(3D)reconstruction ofCT and MR imaging in puncture positioning of obstructive jaundice caused by malignant tumors.Methods Theclinical data of 154 patients with obstructive jaundice caused by malignant tumor,who underwent PTBD and/or
6、 biliary stent implantation at the Lianyungang Municipal First Peoples Hospital of China between February2018 and December 2021,were retrospectively analyzed.The patients were divided into study group(n=81)andcontrol group(n=73).For the patients of the study group,preoperative CT and MRI 3D reconstr
7、uction of biliarysystem was performed,based on the reconstructed images the skin puncture point,puncture depth,puncturelevel and puncture angle of biliary tract were determined,then the biliary puncture was carried out underDSA guidance.For the patients of the control group,the classical DSA-guided
8、puncture of biliary tract wasemployed.The success rate of initial needle puncture,the overall puncture success rate,the number ofpuncture times,the surgical completion rate after a successful puncturing,and the puncture complicationswere compared between the two groups,and the value of 3D reconstruc
9、tion of CT and MR imaging inpuncture positioning was evaluated.Results In the study group,the success rate of initial needle puncture was90.91%,which was higher than 78.79%in the control group;the mean number of puncture times was(1.260.54),which was less than(1.861.11)in the control group,the dffer
10、ence between the two groups was statisticallysignificant(P0.05).No statistically significant differences in the overall puncture success rate and the surgical作者单位：2 2 2 0 0 0 江苏连云港连云港市第一人民医院介人放射科(刘J金、曹冈刚、张根山）;徐州医科大学附属医院(魏宁)；连云港灌南县第一人民医院(周胜利、吉廷举)通信作者：周胜利E-mail：52 2 9 6 9 9 9 8 q q.c o m793-介人放射学杂志2 0
11、 2 3年8 月第32 卷第8 期J Intervent Radiol 2023,Vol.32,No.8completion rate after a successful puncturing existed between the two groups.Puncture-related complicationsoccurred in 36 patients(23.38%),mainly including bleeding,abdominal pain,pneumothorax and infection.Thepuncture complication rate in the stud
12、y group was 13.58%,which was lower than 34.25%in the control group,the difference between the two groups was statistically significant(P0.05).Conclusion The CT/MRI 3Dreconstruction-assisted biliary tract puncture can improve the success rate of initial needle puncture,reducethe number of puncture ti
13、mes,and decrease the incidence of puncture complications.This technique has acertain popularity value in different level hospitals and in surgeons with different seniority.(J InterventRadiol,2023,32:792-795)Key words three dimensional reconstruction of CT and MRI;obstructive jaundice;malignant tumor
14、;biliary puncture恶性梗阻性黄疽由胰头癌、胆管癌等恶性肿瘤所致胆道梗阻引起，持续性恶性胆道梗阻可导致黄疽、凝血及肝肾功能障碍。因此,姑息性手术是患者的唯一选择。经皮肝穿刺胆道引流(percutaneoustranshepaticbiliarydrainage,PTBD)联合胆道支架植人术操作简单，缓解黄疽梗阻效果好，术后有机会恢复生源性胆道引流，对组织器官损伤小，术后恢复快，已成为治疗恶性肿瘤梗阻性黄疽的主要方法14。在PTBD或胆道支架植人操作中，常规采用DSA透视引导盲穿胆道5-6 。本研究探讨应用CT、M R三维定位结合DSA透视对胆道系统进行穿刺的效果。1#材料与方法1
15、.1临床资料选择2 0 18 年2 月至2 0 2 1年12 月江苏省连云港市第一人民医院收治因恶性肿瘤致梗阻性黄疽行PTBD和（或）胆道支架植人患者154例，其中男84例，女7 0 例，年龄为（6 7.2 11.0)岁。纳人标准：存在消化系统恶性肿瘤，经影像学检查明确诊断为梗阻性黄疽，有明确的PTBD和(或）胆道支架植人治疗适应证7 ；均在DSA透视引导下行PTBD和（或)胆道支架植人；所有穿刺均为右侧人路。将患者分为研究组8 1例,对照组7 3例,研究组术前行胆道系统CT、M R三维重建，并根据重建图像计算穿刺路径后在DSA下行胆道穿刺；对照组根据经典方法在DSA下行胆道穿刺。术前患者本人
16、或患者直系亲属均签署手术知情同意书。1.2经典胆道穿刺患者仰卧位或左卧位，右上肢展开，2%利多卡因局部麻醉穿刺点（腋中线7 9 肋间隙），自皮下直至肝被膜下，采用2 2 G胆道穿刺针，在DSA透视下选择下位肋骨上缘进针，穿刺针指向第10 11胸椎椎体下缘，针尾保持水平，针径靠近脊柱约2 cm。平静呼吸状态下，缓慢拔出针芯，待有胆汁流出，注入少量稀释的对比剂即可见典型的胆管形态显示。1.3CT、M R三维重建标记采用6 4排12 8 层CT增强或3.0 T超导磁共振扫描仪，行胆道系统三维重建，冠状位上明确肝内最佳胆道穿刺点为D点，该层面为最佳穿刺水平，做一条通过D点的水平线，其与皮肤交点为BO点，并根据肋间隙情况调整BO点到D点穿刺角度，寻找合适的肋间隙（通常选择靠足侧肋骨上缘肋间隙），确定皮肤穿刺点为B1点，同时在定位片上明确B1点所对应椎体的水平位置。矢状位做通过D点水平线，与皮肤交点为E点。横断位图像上找到B1点水平线，在前胸与后背分别做一条与其平行的皮肤最凸点的切线，沿B1点做一条与三条平行线垂直的直线，其与前胸线交点为A点，与后背线交点为C点,B1A表示体表穿刺点与前胸壁之间的
