康莹丽，鲍海华，栗海龙
(*青海大学附属医院影像中心,青海 西宁 810001）

【摘要】 目的 本研究采用MRI评价肝泡型包虫病胆道侵犯的特点，为肝泡型包虫病临床精准外科切除提供依据。方法 收集青海大学附属医院肝胆外科2016年6月-2018年6月140例经临床及病理证实的HAE患者的MRI常规扫描、磁共振胰胆管水成像及胆道重建的影像资料，评价病灶位置、大小及类型对胆道侵犯的特点。结果 肝左叶病灶以胆管受压为主，发生率为37.5%；肝右叶以胆管受压和截断为主，发生率均为26.1%；肝门部以胆管梗阻性扩张为主，发生率为44.9%；病灶平均直径约11.79cm±0.54cm，直径大于10cm和15cm患者，以胆管截断为主，发生率为48.1%、58.7%；左肝管、右肝管、肝总管、肝左右管侵犯率为74.1%、85.5%、100.0%、84.6%（P<0.05），肝总管侵犯率大于肝左管侵犯率（P<0.0083）；肝总管与肝右管、肝左右管胆管侵犯率之间无显著差异(P>0.0083)；胆瘘发生率占21.3%,病灶直径>10cm，胆瘘发生率为62.7%,病灶类型为液化坏死型，胆瘘发生率为52.5%,病灶直径、类型与胆瘘发生具有相关性（P<0.05）,病灶部位与胆瘘发生无相关性(P>0.05)。结论 MRI可精确评估术前病灶对胆管侵犯特点，对临床精准治疗具有重要的指导意义。
【关键词】肝泡型包虫病；磁共振；磁共振胰胆管水成像；胆管侵犯
基金项目：远程影像诊断技术在青海省农村牧区的推广应用（2017-SF-158）

Evaluation of bile duct damage in hepatic alveolar echinococcosis by MRI【Abstract】 Objective To evaluate the characteristics of biliary invasion of hepatic alveolar echinococcosis by MRI, and to provide evidence for clinical precision surgical resection of hepatic alveolar echinococcosis. Methods The MRI routine scan, magnetic resonance cholangiopancreatography and biliary reconstruction of 140 patients with HAE who were clinically and pathologically confirmed by the Department of Hepatobiliary Surgery, Affiliated Hospital of Qinghai University from June 2016 to June 18, 2016 were collected to evaluate the location and size of the lesion. And the characteristics of the type of biliary invasion. Results The left hepatic lobe lesions were mainly bile duct compression, with an incidence of 37.5%. The right hepatic lobe was treated with bile duct. Pressure and truncation were dominant, the incidence rate was 26.1%; The hepatic portal area was mainly biliary obstructive expansion, the incidence rate was 44.9%; The average diameter of the lesion was about 11.79cm±0.54cm, and the diameter was greater than 10cm and 15cm, the bile duct was cut off. Mainly, the incidence rate was 48.1%, 58.7%; the left hepatic duct, right hepatic duct, hepatic portal, and left and right hepatic duct invasion rate were 74.1%, 85.5%, 100.0%, 84.6% (P<0.05), total hepatic duct invasion rate. It was greater than the left hepatic duct invasion rate (P<0.0083); there was no significant difference between the common hepatic duct and the right hepatic duct and the left and right duct bile duct invasion rate (P>0.0083); The incidence of biliary fistula was 21.3%, and the lesion diameter was >10cm. The incidence of delirium was 62.7%, the type of lesion was liquefied necrosis, the incidence of biliary fistula was 52.5%, the diameter and type of lesions were correlated with the occurrence of biliary fistula (P<0.05), and the lesion site was not associated with biliary fistula (P<0.05). Conclusion MRI can accurately evaluate the characteristics of preoperative lesions on bile duct invasion, and has important guiding significance for clinical precision treatment.
【Key words】 hepatic alveolar echinococcosis; magnetic resonance; magnetic resonance cholangiopancreatography; bile duct invasion
Fund Project: Popularization and Application of Remote Image Diagnosis Technology in Rural Pastoral Areas of Qinghai Province (2017-SF-158)
青海省是目前国内包虫病高发区，省内多种类型棘球绦虫混合感染，缺乏有效包虫病治疗手段，病人预后效果较差。随着近些年肝泡型包虫病(Hepatic Alveolar Echincoccosis HAE)诊治病例增加,大量的临床工作总结发现HAE患者术后胆道并发症发生率较高，尤其是胆瘘[1-2],是造成患者低生活质量及预后较差的重要原因。因而研究HAE胆道侵犯特点对于泡型包虫病外科精准切除及一定程度上预防术后胆瘘的发生有重要意义，然而目前国内外关于该方向的文献还鲜有报道。
近年来，磁共振胆胰管造影 (MR cholangiopancreatograp MRCP)对于胆道相关疾病的诊断及评价与直接胆胰管造影价值相当[3]。MRCP通过360°旋转和3D成像技术多角度、全方位地显示病灶与肝内胆管的关系以及肝内胆管的走形，为临床手术精准切除方案的制定提供参考。因此综合MRCP在多种胆道疾病中应用的优越性，将其应用于泡型包虫病胆道侵犯评价中，旨在归纳总结出泡型包虫病胆道侵犯特点及规律，为临床肝胆外科精确切除包虫病灶及预防术后胆瘘提供影像学依据。
1 资料与方法
1.1临床资料
收集青海大学附属医院肝胆外科2016年6月-2018年6月明确诊断为肝泡型包虫病患者140例，且术前均行MRI常规扫描及MRCP检查，资料完整。所有患者均签署知情同意书。
1.2影像检查
MRI常规扫描采用Philips 1.5T超导型磁共振成像仪，选用腹部线圈同时利用呼吸门控技术进行扫描。扫描序列为T１WI、T2WI-SPAIR及DWI序列（ｂ值=800ｓ/ｍｍ２）。扫描参数：TR-2741ms，TE（37.4ms-71.2ms），间距 2mm，层厚6mm，FOV172mm～350mm，128×128 矩阵，NEX1，b 值选用 800s/mm2。
MRCP在FSE扫描后，经过MIP后处理重建胆道影像，扫描序列：快速自旋回波序列（FSE），单次激发（Single-shot）成像；扫描参数：TR/TE=1204/650，观察野38cm，层厚80mm，重建矩阵256×205，单层扫描时间2s。
1.3资料分析
所有结果均由两名经验丰富的影像科医师认真鉴定,分析及归纳病灶的生长部位、直径、类型及对肝内胆道系统的侵犯特点。
1.4统计分析
应用SPSS18.0统计学软件对数据进行分析处理，计量资料统计描述以均数±标准差表示；计数资料统计描述以百分位数（%）表示，差异性检验采用卡方检验，相关性检验采用趋势卡方检验，检验水准a=0.05,以P<0.05表示差异有统计学意义。