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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 3  |  Issue : 4  |  Page : 164-169

Three-dimensional visualization technology in the diagnosis and treatment of malignant tumor in the hilar bile duct to the upper segment of common bile duct


1 Department of General Surgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi Province, China
2 Department of Emergency, Taiyuan City Center Hospital, Taiyuan, Shanxi Province, China

Date of Web Publication26-Mar-2018

Correspondence Address:
Weidong Di
Department of General Surgery, Shanxi Provincial People's Hospital, Taiyuan, Shanxi Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/digm.digm_43_17

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  Abstract 


Background and Objectives: The aim of this study is to investigate the application of three-dimensional (3D) visualization technique in the surgical treatment of malignant tumors of the hilar and common bile ducts. Materials and Methods: A total of 23 patients admitted from January 2015 to April 2017 for surgical treatment were analyzed, of whom 13 patients underwent medical image 3D visualization system (treatment group) while 10 underwent surgery alone (control group). Indicators to the treatment effects were recorded and compared between the two groups, including the operation time, intraoperative bleeding volume, postoperative hospitalization time, the number of dissected lymph nodes, the incidence of all postoperative complications, and the alanine transaminase (ALT), albumin (ALB), and total bilirubin (TBIL) monitored on days 1, 3, 5, and 7 after the operation. Results: In the treatment group and control group, the operation time was 194.66 ± 13.79 and 230.81 ± 27.07 min (t = 3.857, P = 0.002), the intraoperative bleeding volume was 274.28 ± 44.57 and 320.69 ± 35.90 mL (t = 2.686, P = 0.014), the postoperative hospitalization time was 11.15 ± 1.25 and 15.25 ± 1.75d (t = 6.557, P = 0.000), the number of dissected lymph nodes 10.46 ± 1.71 and 7.40 ± 0.97 (t = 5.050, P = 0.000), and the incidence of all postoperative complications 7.69% and 60% (χ2 = 7.304, P = 0.019), respectively. The level of ALT and TBIL was significantly higher in the treatment group than in the control group, whereas the level of ALB was significantly lower in the treatment group than in the control group on days 3, 5, and 7 (P < 0.05). The recovery of liver function was better in the treatment group than in the control group. In addition, no perioperative deaths were found in either group. Conclusions: In the surgical treatment of malignant tumors occurring in the hilar to the common bile duct, 3D visualization technology can reduce the operation injury and intraoperative bleeding, decrease the incidence of postoperative complications, improve the safety and effectiveness of the operation, and promote the recovery of liver function, thus demonstrating promising short-term efficacy.

Keywords: Hilar cholangiocarcinoma, simulated operation, three-dimensional visualization technology, vascular variation


How to cite this article:
He Y, Di W, Zhang Y, Li J. Three-dimensional visualization technology in the diagnosis and treatment of malignant tumor in the hilar bile duct to the upper segment of common bile duct. Digit Med 2017;3:164-9

How to cite this URL:
He Y, Di W, Zhang Y, Li J. Three-dimensional visualization technology in the diagnosis and treatment of malignant tumor in the hilar bile duct to the upper segment of common bile duct. Digit Med [serial online] 2017 [cited 2018 Sep 19];3:164-9. Available from: http://www.digitmedicine.com/text.asp?2017/3/4/164/228668




  Introduction Top


Malignant tumors of in the bile duct have long been considered a focus and difficulty in the field of hepatobiliary surgery. Hilar cholangiocarcinoma, in particular, is difficult to detect at early stages due to its insidious onset and special location. A large percent of patients have lost the chance of surgery when showing symptoms, leading to a high mortality rate. Therefore, it is in urgent need to improve the diagnosis and treatment of this disease. In recent years, computed tomography (CT) scanning with ultrathin sections has been used to collect the data of the lesion, and the data can be imported into a three-dimensional (3D) visualization software (Yorktal Digital Medical Imaging Technology Co., Ltd., Shenzhen, China) to be processed and synthesized into a clear 3D simulation image of the lesion, thus significantly improving the diagnosis and treatment of the bile duct tumors.


  Materials and Methods Top


A retrospective analysis was performed on 23 cases of surgical patients admitted to our hospital during January 2015–April 2017, who had a malignant tumor in the hilar bile duct and the upper segment of the common bile duct. All these patients received enhanced spiral CT scanning, among whom 13 patients were examined using medical image 3D visualization system (MI-3VDS) after a new ultrathin CT scanning and then were set as an experimental group. The average age in the experimental group (8 males, 5 females) was 58.6 ± 6.8 years (range 44–73 years). Examinations showed that three patients had hypertension, two patients had type II diabetes mellitus, one patient had coronary atherosclerotic heart disease (CHD), and 1 patient had both hypertension and coronary heart disease. The other ten patients who were not treated with MI-3VDS were set as control group. The average age in the control group (4 males, 6 females) was 60 ± 5.6 years (range 47–68 years). Among them, there were 3 cases of hypertension, 1 case of type II diabetes mellitus, and 1 case of both hypertension and coronary heart disease.

All patients underwent a preoperative laboratory examination of blood cell, blood coagulation, liver function, renal function, tumor markers, infectious diseases, blood type, urine, and stool. Electrocardiography, chest X-ray radiography, abdominal ultrasound and nuclear magnetism were performed as auxiliary examination. Some patients also underwent other examinations such as cardiac ultrasonography and pulmonary function test. Those with a total bilirubin (TBIL) level more than 250 μmol/l underwent percutaneous transhepatic puncture drainage and liver protection therapy to keep the TBIL level <200 μmol/L, the alanine transaminase (ALT) and aspartate transaminase <300 IU, and albumin (ALB) level >35 g/l. The evaluation 1 day before operation showed that the liver function was child–pugh A grade. The preoperative CT of all patients were analyzed; the 3D visualized image and the ordinary CT of the experimental group were compared, with three types of results: invaded, uninvaded and uncertain, based on the relationship between tumor and blood vessel (including portal veins, left and right branches of portal vein, hepatic artery, left liver, and right hepatic artery). The final result was determined through the operation. The CT and 3D visualization were analyzed to find out whether they were consistent with those seen during the operation. In addition, a surgical simulation was performed in the experimental group based on the 3D imaging to analyze the tumor volume, liver resection volume, residual liver volume, functional liver volume, and the percentage of residual liver volume to functional liver volume in patients who need to receive partial hepatectomy.[1] The variation of the hepatic artery, portal vein, and its branches were analyzed according to 3D visualization image. The operation time, intraoperative bleeding, duration of postoperative hospitalization, number of lymph node dissection, the total incidence of postoperative complication, postoperative mortality, and ALT, TBIL, and ALB on day 1, 3, 5, and 7 after operation were compared in the two groups. In the experimental group, there were 5 cases of carcinoma in the upper segment of common bile duct and 4 cases of Bismuth–Corlette type II, treated with radical resection of extrahepatic bile duct; 1 case of gallbladder duct carcinoma invasion and confluence of cystic duct and common hepatic duct, treated with radical cholecystectomy and resection of extrahepatic bile duct; 2 cases of Bismuth–Corlette type II, accompanied with invasion in the left branch of portal vein, treated with radical resection of extrahepatic bile duct and the left hemihepatectomy; 1 case of Bismuth–Corlette type II, treated with hepaticojejunostomy after resection of the extrahepatic bile duct and partial caudate lobe. The pathologic analysis showed biliary papillary adenocarcinoma in 5 cases, well-differentiated adenocarcinoma in 2 cases, poorly-differentiated adenocarcinoma in 2 cases, squamous cell carcinoma in 2 cases, undifferentiated carcinoma in 1 case, and poorly-differentiated adenocarcinoma of gallbladder in 1 case. In the control group, there were 4 cases of carcinoma in the upper segment of common bile duct and 3 cases of Bismuth–Corlette type II, treated with radical resection of extrahepatic bile duct; 1 case of gallbladder duct carcinoma invasion and confluence of cystic duct and common hepatic duct, treated with radical cholecystectomy and resection of extrahepatic bile duct; 2 cases of Bismuth–Corlette type II, treated with radical resection of extrahepatic bile duct and the left hemihepatectomy. The pathologic analysis showed biliary papillary adenocarcinoma in 4 cases, well-differentiated adenocarcinoma in 2 cases, poorly-differentiated adenocarcinoma in 1 case, squamous cell carcinoma in 1 case, and well-differentiated adenocarcinoma of the gallbladder in 1 case.


  Results Top


Statistical analyses were performed using SPSS statistical software (SPSS 21.0, SPSS Inc., IBM, USA). The measurement data were presented using mean ± standard deviation (±s) and were compared with t-test; the enumeration data were presented using utilization rate and were analyzed using Chi-square statistics. A P< 0.05 was considered statistically significant. In the experimental group, we found two patients with variation of donor hepatic artery branches, one patient with S4 artery directly originating from the bifurcation of the left and right hepatic arteries, one patient with left hepatic lateral artery originating from the common hepatic artery using 3D visualization technology. The CT and 3D visualization imaging in this group were analyzed. The CT of the relationship between tumor and blood vessels found 4 invaded cases, 5 uninvaded cases and 4 uncertain cases. Among the uncertain 4 cases, 1 case was confirmed as invaded and 3 cases as uninvaded during the operation. MI-3VDS found that 5 cases were invaded and 8 cases were uninvaded, which was consistent with the results observed in operation [Figure 1]. In the two cases receiving left hepatectomy, the percentage of residual hepatic volume in the functional liver volume was both >60%, enabling the liver to function normally. The operation on all the patients in the experimental group, which was successfully performed following the predetermined operation method, obtained consistent results with those of the preoperative simulated operation. In the two groups of patients, The operation time, intraoperative bleeding, duration of postoperative hospitalization, and number of lymph node dissection [Table 1], the incidence of total postoperative complications [Table 2], AlT, TBIL, ALB on day 1, 3, 5, and 7 after operation were analyzed respectively in the two groups [Table 3], [Table 4], [Table 5], with the value of P < 0.05, which was considered statistically significant. No death resulted from serious complication was found after operation.
Figure 1: (1) Tumor of hilar bile duct, (2) variant S4 hepatic artery, (3) tumor invasion of the outer membrane of the left branch of the portal vein

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Table 1: Comparison of the surgical results in the two groups

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Table 2: Comparison of the incidence of postoperative complications in the two groups

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Table 3: Comparison of postoperative alanine transaminase in the two groups (IU)

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Table 4: Comparison of postoperative albumin in the two groups (g/L)

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Table 5: Comparison of postoperative total bilirubin in the two groups (µmol/L)

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  Discussion Top


Hilar cholangiocarcinoma and cancer in the upper segment of the common bile duct are still malignant tumors that are associated with high mortality, and are difficult to diagnose and treat. Hilar cholangiocarcinoma in particular, because of its special anatomy, is difficult to detect at early stages. Therefore, delayed treatment is common. The tumor was first described in 1965 by Klatskin, and was called Klatskin tumor.[2] In recent years, great progress has been made in the medical field, and the 3D visualization technology also facilitates the diagnosis and treatment of malignant tumors in this area. Through Multi-slice spiral CT volume scanning, a thin layer image of 1 mm can be obtained, and after multiplanar reconstruction (MPR), it is clear that the tumor can invade into 80.9% of the surrounding tissue, and that 100% length of the bile duct can be affected. The 3D visualization technology makes it possible to observe the lesion from a 3D perspective after 3D reconstruction of data which are collected from CT scan and then processed by software. Images obtained by 3D visualization are more stereoscopic, vivid, and intuitive than those of MPR, in terms of tumor location, size, growth, surrounding invasion, relationship between tumor and vessels, vascular and bile duct variability, possible tendency of lymphatic metastasis. Therefore, these images are easier to be received by the brain. At the same time, the 3D visualization technology can be used to perform surgical simulation, and according to the simulated surgical resection, the residual liver function can be calculated to see if it meets the demand, which can inform the decision-making in surgery. This is a great advantage of this technology, which cannot be matched by common CT scan.[3] In the experimental group, there was one female patient, aged 64, and with type Bismuth–Corlette. 3D visualization technology showed that the tumor invaded into the openings of bilateral primary bile duct and proximal secondary bile duct above the bifurcation, indicating a high tumor location, and the close spatial relationship between the tumor and the left branch of portal vein. Through a 360° rotation comparison, the blood vessel wall was considered to be invaded. In addition, it was found that the hepatic artery supplying segment IV was originated from the starting bifurcation of the left and right hepatic artery, which was a variation of the artery. After preoperative surgical simulation, multiple sets of surgery plans were prepared. If the invaded left branch of the portal vein cannot be separated from the tumor, the resection will be extended to the left half of the liver. Intraoperative exploration revealed that the hepatic artery was divided into three arterial vessels at the hilar region, and the further dissection of bile duct tumor was blocked by the central artery, which was a major obstacle to the operation. As the preoperative 3D visualization provides a clear image that shows the middle artery as the hepatic artery supplying segment, the artery was severed decisively. In the subsequent dissection of the tumor, if the tumor invaded into in the outer membrane of the left branch of the portal vein, the tumor was successfully separated from the vein through the patient, careful and discreet dissection, avoiding the enlargement of the resection of the left half liver. Although it is difficult, the operation is basically performed according to the simulation process. After resection of the lesion, there were 5 bile duct stump openings, consistent with the preoperative plan. The anastomosis was accomplished in a meticulous and precise way, and did not omit any anastomosis of the bile duct or result in postoperative bile leakage. The patient was discharged after a short-term rehabilitation.

Overall, the characteristics of 3D visualization technology are mainly embodied in the following aspects. First, the understanding of the tumor lesions is more comprehensive and intuitive. MI-3VDS images apply different color configuration for different organs, tumors, blood vessels, and lymph nodes, which makes it easier to identify them. At the same time, they provide a 360°rotating image for multi-angle and 3D observation. It is even easier to realize an ideal information analysis by selectively displaying tumors and associated tissues while hiding other tissue organs, which cannot be achieved by CT. Due to the above technical advantages, we can have a clear understanding of the location, size, length of the bile duct, the surrounding invasion and range, the metastasis of viscera and the invasion of related vessels. Thus, we can analyze the opportunity of surgery for the patients, and have a more accurate evaluation of whether the radical resection can be implemented or the patients should receive palliative treatment. As a result, we can have a clear and reasonable evaluation of the overall treatment for the patient. Second, the anatomical structure of hilar is complex, and the variation of arteries, portal veins and bile ducts is more common. For variant hepatic arteries, CTA plays an important role in examination and is valued by surgeons. However, the 3D visualization technology can provide comparable image information. A hospital in China reported that for the hepatic artery and branch vessels above the second level, the variation can be fully displayed. Due to its smaller trauma, it has gradually been approved by the clinicians, and the clear and continuous image of the branch is superior to the two-dimensional CT and magnetic resonance imaging.[4] By taking advantage of the course of the variant vessels, we can determine whether they can be cutoff or retained. At the same time, many problems can be resolved, including unclear anatomical structure caused by vascular variation, blind operation, and vascular injury caused by excessive exploration, which may result in blood transfusion in surgery, difficulties in postoperative recovery and other problems. Shimizu et al.[5] found that for patients with hilar cholangiocarcinoma who need joint resection of the right liver, if there is a variation of the left hepatic artery, the surgery will be more difficult because variant arteries are susceptible to invasion and therefore need to be resected and reconstructed. The bile duct is hideous, where the cancer is always closely associated with the surrounding tissues and vessels, which has always been a headache for surgeons. The 3D visualization technology can clearly display the course of the blood vessels, and the specific anatomic site and length of the affected vessels. In addition, through rotational, multi-directional, and multi-angle observation, it can provide sound guidance for the operation. The bleeding volume of the patients in the experimental group was significantly different from that in the control group, which confirms that the 3D visualization technology can improve the operation technology and reduce intraoperative bleeding. Third, the MI-3VDS images of experimental group clearly indicate the region of suspicious lymph node metastasis, and even can suggest that there may be distant lymph node metastasis. In addition to standard lymph node dissection, we can perform more meticulous, patient, and precise lymphatic dissection at key regions or even at a wider area. Therefore, compared with the control group, the number of dissected lymph nodes is larger, and the difference is statistically significant. This is of great value to the prognosis of patients and may prolong the survival. Finally, for patients who need partial hepatectomy, through the surgical simulation, we can not only select the surgical method or the resection plane but also calculate whether the residual liver volume can ensure adequate liver function for the patients, and formulate ideal surgical plan to meet the requirements of precise excision. In addition, according to the accurate image analysis, we can have a more accurate typing of Hilar Cholangiocarcinoma according to Bismuth–corlette and conduct further staging before operation.[6] According to the staging, we can determine whether R0 excision can be performed. Kondo used U and P points as the surgical resection boundary. The U point refers to the corner of the horizontal part of the left branch of the portal vein and the sagittal part. The P point refers to the bifurcation of the right anterior branch and the right posterior branch of the right portal vein. 3D visualization technology can accurately display these two points [7] and guide the decision-making of resection. In addition, after the simulated resection, the opening position, number and variations of the stump of the branch bile duct can be revealed on the resection plane, which can guide the anastomosis after resection, avoiding the omission of small bile duct in anastomosis, which might cause severe bile leakage after operation, and affect the postoperative rehabilitation and even result in death of patients.


  Conclusion Top


In summary, 3D visualization technology has high clinical value in the surgical treatment of malignant tumor of hilar bile duct to the upper segment of the common bile duct by reducing injury of blood vessel and bile duct during operation, and then reducing intraoperative bleeding, shortening operation time and postoperative hospitalization time, and preventing postoperative severe complication. It can further improve the skills of the surgeons, and meet the requirements of R0 resection. The correlative monitoring analysis of AlT, ALB and TBIL of two groups shows P < 0.05, which was statistically significant, demonstrating that the recovery of liver function in the experimental group was better than that in the control group, which can be attributed to the use of the 3D visualization technology. Compared with the two-dimensional CT, the advantages of 3D visualization technology are obvious.[8],[9] Therefore, we should make better use of the platform provided by 3D visualization technology, and strive to improve the diagnosis and treatment of malignant tumor in the hilar bile duct to the upper segment of the common bile duct, to bring more benefits to the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chihua F, Shijian F, Yingfang F, Susu B, Shizhen Z, Jian Y, et al. Application of three-dimensional visualization technique in evaluation the volume of remnant liver and guiding hepatectomy. J Hepatobiliary Sur 2012;20:95-8.  Back to cited text no. 1
    
2.
Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis. An unusual tumor with distinctive clinical and pathological features. Am J Med 1965;38:241-56.  Back to cited text no. 2
    
3.
Endo I, Shimada H, Sugita M, Fujii Y, Morioka D, Takeda K, et al. Role of three-dimensional imaging in operative planning for hilar cholangiocarcinoma. Surgery 2007;142:666-75.  Back to cited text no. 3
    
4.
Yang J, Fang C, Fan Y, Xiang N, Wang H, Bao S, et al. Application of three-dimensional visualization technology in pancreaticoduodenctomy for patients with variant hepatic artery. Zhonghua Wai Ke Za Zhi 2014;52:55-9.  Back to cited text no. 4
    
5.
Shimizu H, Hosokawa I, Ohtsuka M, Kato A, Yoshitomi H, Miyazaki M. Clinical significance of Anatomical Variant of the left hepatic artery for perihilar cholangiocarcinoma applied to right-sided hepatectomy. World J Surg 2014;38:3210-4.  Back to cited text no. 5
    
6.
van Gulik TM, Gouma DJ. Changing perspectives in the assessment of resectability of hilar cholangiocarcinoma. Ann Surg Oncol 2007;14:1969-71.  Back to cited text no. 6
    
7.
Hirano S, Tanaka E, Shichinohe T, Suzuki O, Hazama K, Kitagami H, et al. Treatment strategy for hilar cholangiocarcinoma, with special reference to the limits of ductal resection in right-sided hepatectomies. J Hepatobiliary Pancreat Surg 2007;14:429-33.  Back to cited text no. 7
    
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Sasaki R, Kondo T, Oda T, Murata S, Wakabayashi G, Ohkohchi N. Impact of three-dimensional analysis of multidetector row computed tomography cholangioportography in operative planning for hilar cholangiocarcinoma. Am J Surg 2011;202:441-8.  Back to cited text no. 8
    
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Yijun Z, Xiaoping G. Effect of three-dimensional visualization technique on surgical decision-making of hilar cholangiocarcinoma. J Hepatobiliary Surg 2015;23:73-4.  Back to cited text no. 9
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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