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多层螺旋CT图像后处理对内镜乳头括约肌切开区域周围结构的预测

(2014-10-22 12:25:43)

    【摘要】
    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。

    【关键词】螺旋CT;图像重建;内窥镜括约肌切开术;十二指肠乳头


    Predetermination of structure surrounding duodenal papilla before EST by multi-slice spiral CT
    LOU Song-mei*, RUAN Ling-xiang, ZHANG Xiao, ZHANG Xiao-feng. *Department of Gastroenterology, The First People′s Hospital of Hangzhou, Hangzhou 310006, China
    Corresponding author: LOU Song-mei
    【Abstract】
    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% and 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-duodenal 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 provide 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.
    【Key words】Helical CT;Imaga reconstruction;Endoscopic sphincterotomy;Duodenal papilla major                        

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    张筱凤 单位:杭州市第一人民医院
    所属科室:
    出生:1976-03-17
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