中华消化内镜杂志
中華消化內鏡雜誌
중화소화내경잡지
CHINESE JOURNAL OF DIGESTIVE ENDOSCOPY
2012年
4期
188-193
,共6页
楼颂梅%阮凌翔%张啸%张筱凤
樓頌梅%阮凌翔%張嘯%張篠鳳
루송매%원릉상%장소%장소봉
螺旋CT%图像重建%内窥镜括约肌切开术%十二指肠乳头
螺鏇CT%圖像重建%內窺鏡括約肌切開術%十二指腸乳頭
라선CT%도상중건%내규경괄약기절개술%십이지장유두
Helical CT%Imaga reconstruction%Endoscopic sphiucterotomy%Duodenal papilla major
目的 探讨多层螺旋CT图像后处理技术对内镜乳头括约肌切开术(EST)前十二指肠乳头周围重要毗邻血管、胰胆管及实质空间关系的预测价值.方法 采用16层螺旋CT对30例正常十二指肠乳头周围结构进行28 s、68 s时相增强扫描,原始数据行减薄最大密度投影(TSMIP)或减薄平均密度投影(TSAIP)后处理,分别对胰胆管、十二指肠动脉、胰十二指肠毗邻结构进行重建,并对图像进行双盲法评价.统计两个时相重建图像上EST切开区域及周围血管、胆胰管等重要组织的数据并进行分析.结果 两个时相增强扫描后的胰十二指肠乳头周围结构重建图像结果稳定,双盲法阅片具有极好的一致性.十二指肠乳头周围相邻动脉的TSMIP图像评分在28 s增强时相高于68 s增强时相,两者差异具统计学意义；胰胆管及壶腹部周围实质结构显示的TSAIP图像评分68 s增强时相较高,其中胰管评分在两个时相存在统计学差异；局部血管结构TSMIP图像显示胰十二指肠上前动脉为93.3％、胰十二指肠上后动脉73.3％、胰十二指肠下动脉73.3％、十二指肠乳头动脉56.7％,胆管96.7％、胰管90.0％、胰肠实质100.0％；显示的十二指肠乳头动脉均发自胰十二指肠上后动脉起始处并向乳头下行,仅6.7％达到十二指肠乳头上缘,其余显示的动脉均于乳头上方平均12 mm处便明显变细；正常胆总管均可追踪至乳头开口水平；通过斜冠状位(EST切开方向)TSAIP重建,图像显示十二指肠乳头至胰十二指肠上部交界面下缘距离为(15.7±1.9)mm,至胰十二指肠交界处前缘的距离为(16.6±3.2)mm,至胰十二指肠后缘交界处距离为(1.7±0.4)mm,乳头部内缘至胰胆管共同部消失的距离(深度)为(8.0±1.7)mm.结论 多层螺旋CT增强扫描的三维重建图像能根据EST术式获得相应的血管、胰胆管及实质毗邻关系的高质量图像；根据十二指肠、胰腺的邻接情况、血管的分布及走向、胆管的显示情况可评价EST术中可能出现的大出血、穿孔风险以及回避方法,降低医疗风险.
目的 探討多層螺鏇CT圖像後處理技術對內鏡乳頭括約肌切開術(EST)前十二指腸乳頭週圍重要毗鄰血管、胰膽管及實質空間關繫的預測價值.方法 採用16層螺鏇CT對30例正常十二指腸乳頭週圍結構進行28 s、68 s時相增彊掃描,原始數據行減薄最大密度投影(TSMIP)或減薄平均密度投影(TSAIP)後處理,分彆對胰膽管、十二指腸動脈、胰十二指腸毗鄰結構進行重建,併對圖像進行雙盲法評價.統計兩箇時相重建圖像上EST切開區域及週圍血管、膽胰管等重要組織的數據併進行分析.結果 兩箇時相增彊掃描後的胰十二指腸乳頭週圍結構重建圖像結果穩定,雙盲法閱片具有極好的一緻性.十二指腸乳頭週圍相鄰動脈的TSMIP圖像評分在28 s增彊時相高于68 s增彊時相,兩者差異具統計學意義；胰膽管及壺腹部週圍實質結構顯示的TSAIP圖像評分68 s增彊時相較高,其中胰管評分在兩箇時相存在統計學差異；跼部血管結構TSMIP圖像顯示胰十二指腸上前動脈為93.3％、胰十二指腸上後動脈73.3％、胰十二指腸下動脈73.3％、十二指腸乳頭動脈56.7％,膽管96.7％、胰管90.0％、胰腸實質100.0％；顯示的十二指腸乳頭動脈均髮自胰十二指腸上後動脈起始處併嚮乳頭下行,僅6.7％達到十二指腸乳頭上緣,其餘顯示的動脈均于乳頭上方平均12 mm處便明顯變細；正常膽總管均可追蹤至乳頭開口水平；通過斜冠狀位(EST切開方嚮)TSAIP重建,圖像顯示十二指腸乳頭至胰十二指腸上部交界麵下緣距離為(15.7±1.9)mm,至胰十二指腸交界處前緣的距離為(16.6±3.2)mm,至胰十二指腸後緣交界處距離為(1.7±0.4)mm,乳頭部內緣至胰膽管共同部消失的距離(深度)為(8.0±1.7)mm.結論 多層螺鏇CT增彊掃描的三維重建圖像能根據EST術式穫得相應的血管、胰膽管及實質毗鄰關繫的高質量圖像；根據十二指腸、胰腺的鄰接情況、血管的分佈及走嚮、膽管的顯示情況可評價EST術中可能齣現的大齣血、穿孔風險以及迴避方法,降低醫療風險.
목적 탐토다층라선CT도상후처리기술대내경유두괄약기절개술(EST)전십이지장유두주위중요비린혈관、이담관급실질공간관계적예측개치.방법 채용16층라선CT대30례정상십이지장유두주위결구진행28 s、68 s시상증강소묘,원시수거행감박최대밀도투영(TSMIP)혹감박평균밀도투영(TSAIP)후처리,분별대이담관、십이지장동맥、이십이지장비린결구진행중건,병대도상진행쌍맹법평개.통계량개시상중건도상상EST절개구역급주위혈관、담이관등중요조직적수거병진행분석.결과 량개시상증강소묘후적이십이지장유두주위결구중건도상결과은정,쌍맹법열편구유겁호적일치성.십이지장유두주위상린동맥적TSMIP도상평분재28 s증강시상고우68 s증강시상,량자차이구통계학의의；이담관급호복부주위실질결구현시적TSAIP도상평분68 s증강시상교고,기중이관평분재량개시상존재통계학차이；국부혈관결구TSMIP도상현시이십이지장상전동맥위93.3％、이십이지장상후동맥73.3％、이십이지장하동맥73.3％、십이지장유두동맥56.7％,담관96.7％、이관90.0％、이장실질100.0％；현시적십이지장유두동맥균발자이십이지장상후동맥기시처병향유두하행,부6.7％체도십이지장유두상연,기여현시적동맥균우유두상방평균12 mm처편명현변세；정상담총관균가추종지유두개구수평；통과사관상위(EST절개방향)TSAIP중건,도상현시십이지장유두지이십이지장상부교계면하연거리위(15.7±1.9)mm,지이십이지장교계처전연적거리위(16.6±3.2)mm,지이십이지장후연교계처거리위(1.7±0.4)mm,유두부내연지이담관공동부소실적거리(심도)위(8.0±1.7)mm.결론 다층라선CT증강소묘적삼유중건도상능근거EST술식획득상응적혈관、이담관급실질비린관계적고질량도상；근거십이지장、이선적린접정황、혈관적분포급주향、담관적현시정황가평개EST술중가능출현적대출혈、천공풍험이급회피방법,강저의료풍험.
Objective To study the predetermination value of multi-slice spiral CT for showing the major blood vessels,bile and pancreatic ducts around normal duodenal papilla before EST.Methods A 16-slice spiral CT was used to perform 28s and 68s enhanced scan for normal structures surrounding duodenal papilla in 30 subjects.Post-processing was done to the raw data with thin-slice maximum intensity projection (TSMIP) and thin-slice average intensity projection (TSAIP),and then the structure of bile and pancreatic ducts,duodenal artery and pancreatic-duodenal conjunction were reconstructed.The reconstructed images were double-blind evaluated.Distances between papilla and upper,front,and behind edge of the pancreatic-duodenal conjunction,situation of the duodenal papilla artery and the distance from the papilla artery end to the papilla were recorded.Results After dual-phase enhanced scan,the post-processing results for the images of the surrounding structure of pancreatic and duodenal papilla were stable and the results of double-blind evaluation were consistent.Image scores of the arteries surrounding duodenal papilla and pancreatic duct at 28th second were significantly higher than those of 68th second,whereas bile duct and the ampulla structure image scores of 68th second were higher.TSMIP of local vascular structure could display anterior-superior pancreatic-duodenal artery (ASPDA) in 93.3％ of the subjects,posterior-superior pancreatic-duodenal artery (PSPDA) in 73.3％,inferior pancreatic-duodenal artery (IPDA) in 73.3％,duodenal-papillary artery (DPA) in 56.7％,bile duct in 96.7％,pancreatic duct in 90.0％ aud pancreatic and duodenal parenchima in 100.0％.The DPAs all started from PSPDA origin and down to papilla,with only 2 cases of 30 (6.7％) reached the upper edge of the duodenal papilla.Others showed arteries turned thin obviously at 12 mm above the papilla; the normal common bile duct can be tracked to the opening of the papilla.The Coronal Oblique TSAIP imaging showed the distance from the duodenal papilla-bile duct ending to the lower edge of the pancreatic-duodeual upper conjunction was 15.7±1.9 mm.Distance from papilla to the front edge of pancreatic-duodenal conjunction was 16.6±3.2 mm and to the behind edge was 1.7±0.4 mm.Distance (depth) from the inner edge of the papilla to the bile-pancreatic conjunction was 8.0±1.7 mm.Conclusion The 3D reconstruction of the Multi-slice spiral enhancement CT Imaging can providc high quality images of relative vascular,bile-pancreatic and obvious surrounding structures to the forthcoming operation.Massive hemorrhage and perforation risks of EST can be evaluated based on the vascular distribution and directions around duodenum and pancreas and the bile duct imaging.
