CT血管造影在延期DIEP皮瓣乳房重建术中的应用研究

doi:10.19401/j.cnki.1007-3639.2022.02.004

摘要/Abstract

摘要：

背景与目的：乳房切除术后自体组织重建中,腹壁下动脉穿支（deep inferior epigastric perforator,DIEP）皮瓣越来越受到外科医师的关注,如何安全、有效地进行穿支血管定位、抉择、解剖是制备DIEP皮瓣最大的难点。探讨CT血管造影（computed tomographic angiography, CTA）在延期DIEP皮瓣修复乳腺癌术后乳房缺损中的应用价值。方法：选取2016年1月—2021年1月于上海交通大学医学院附属第九人民医院整复外科进行延期DIEP皮瓣乳房重建手术患者298例。将其中92例患者术前采用彩色多普勒超声检测进行皮瓣穿支评估设定为超声对照组（US组）,206例患者设定为观察组（CTA组）;术前采用CTA进行皮瓣穿支评估,将CTA数据导入HOROS软件分析,进行术前皮瓣优势穿支的选择,明确穿支血管直径、肌肉内走行方式及穿出点位置等解剖信息,从而指导手术。分析比较两组病例术前定位穿支数量、术中采用穿支数量、抉择穿支时间、穿支解剖时间、供区皮瓣获取时间、皮瓣重量、总手术时间,以及术后并发症发生率（腹部切口感染率、脂肪坏死率、二次手术探查率及皮瓣完全坏死率）,并进行两组病例影像手术一致率比较。结果：298例患者进行延期DIEP皮瓣乳房重建手术,皮瓣存活率为99.33%（296/298）。两组病例术前定位穿支数量[观察组（2.90±1.13）vs对照组（3.21±1.46）]差异有统计学意义（P<0.05）。供区皮瓣获取时间[（50.05±10.94）min vs（84.8±15.44）min] 差异有统计学意义（P<0.001）。两组病例在术后并发症发生率相比,差异无统计学意义（P>0.05）。在二次手术探查率的比较中,CTA组低于US组（P<0.001）。对于具有腹部手术史患者,CTA组穿支解剖时间、总手术时间优于US组（P<0.001）。两组病例影像手术符合率分别为97.09%和43.48%,差异有统计学意义（P<0.001）。结论：在延期DIEP皮瓣乳房重建术中,CTA可以明显地缩短术中皮瓣穿支抉择时间及解剖时间,降低二次手术探查风险,具有较高的影像手术一致率,可以有效地指导手术。

关键词: CT血管造影, 腹壁下动脉穿支皮瓣, 乳房重建, 延期, 乳腺癌

Abstract:

Background and purpose: Deep inferior epigastric perforator (DIEP) is attracting increasing attention in breast reconstruction surgery. How to safely and effectively locate, choose and anatomize perforating vessels is a huge challenge for the preparation of DIEP flaps. This study aimed to explore the value of computed tomographic angiography (CTA) in delayed DIEP reconstruction after breast cancer surgery. Methods: From January 2016 to January 2021, 298 patients underwent delayed DIEP flap breast reconstruction surgery in The Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Among them, 92 cases were set as the control group (US group), and the perforation of the flap was evaluated by ultrasound doppler before surgery. A total of 206 cases were selected as the observation group (CTA group). Preoperative perforation of the flap was evaluated by CTA, and the CTA data were imported into HOROS software for processing and analysis, so as to select the preoperatively dominant perforation of the flap and identify the anatomical information such as the diameter of perforation vessel, the way of intramural movement and the position of perforation point, for directing operation. The number of preoperative location perforations, number of intraoperative choice perforations, perforation choice time, perforation anatomy time, donor site flap acquisition time, flap weight, total operation time and incidence of postoperative complications (abdominal incision infection rate, fat necrosis rate, secondary surgical exploration rate and complete flap necrosis rate) were compared and analyzed between the two groups. And the consistency rate of imaging surgery was compared between the two groups. Results: All the 298 patients underwent delayed DIEP flap breast reconstruction, and the flap survival rate was 99.3% (296/298). The number of preoperative located perforations in the two groups was: CTA group (2.90±1.13) vs US group (3.21±1.46) (P<0.05). The acquisition time of donor flap was (50.05±10.94) min vs (84.8±15.44) min (P<0.001). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05). In the comparison of the second surgical exploration rate, the CTA group was lower than the US group (P<0.001). For patients with a history of abdominal surgery, the perforator anatomical time and total operation time in the CTA group were better compared with the US group (P<0.001). The coincidence rates of imaging surgery in the two groups were 97.09% and 43.48%, respectively, with statistical significance (P<0.001). Conclusion: In delayed DIEP flap breast reconstruction, CTA can significantly shorten the choice time of flap perforation and anatomy time, reduce the risk of secondary surgical exploration and has a high rate of image surgery consistency, which can effectively guide the operation.

Key words: Computed tomographic angiography, Deep inferior epigastric perforator, Breast reconstruction, Delayed, Breast cancer

中图分类号:

R737.9

徐华, 刘莺, 张亦, 王庭亮, 王涛, 何金光, 罗杰, 董莉萍, 王海蓉, 董佳生, 徐元兵. CT血管造影在延期DIEP皮瓣乳房重建术中的应用研究[J]. 中国癌症杂志, 2022, 32(2): 125-133.

XU Hua, LIU Ying, ZHANG Yi, WANG Tingliang, WANG Tao, HE Jinguang, LUO Jie, DONG Liping, WANG Hairong, DONG Jiasheng, XU Yuanbing. Application of CT angiography in delayed DIEP flap breast reconstruction[J]. China Oncology, 2022, 32(2): 125-133.

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Factors	CTA group	US group	F/χ²	P value
Age/year	41.78±9.06	40.94±8.61	1.25	0.27
BMI	24.34±3.20	24.21±2.86	0.71	0.40
Basic disease			0.098	0.754
With	25	10
Without	181	82
Chemotherapy			0.281	0.596
With	158	69
Without	48	23
Chest-wall radiotherapy			0.001	0.977
With	72	32
Without	134	60
Abdominal surgery			0.264	0.608
With	82	36
Without	124	56
Smoking			0.017	0.895
Yes	4	2
No	202	90
Blood supply of flap			0.128	0.720
Unipedicle	85	40
Bipedicle	121	52

Indicators	CTA group	US group	F/χ²	P value
Number of preoperative location perforations	2.90±1.13	3.21±1.46	6.460	0.012
Number of intraoperative choice perforations	2.26±0.92	2.49±0.96	0.907	0.342
Perforation choice time t/min	9.14±3.38	26.73±6.54	49.420	<0.001
Perforation anatomy time t/min	40.92±9.98	58.11±14.44	19.640	<0.001
Donor site flap acquisition time t/min	50.05±10.94	84.80±15.44	15.560	<0.001
Flap weight m/g	730.62±127.31	718.25±129.36	0.005	0.942
Total operation time t/min	294.20±68.51	328.74±68.69	0.058	0.809
Abdominal incision infection			0.199	0.656
Yes	3	2
No	203	90
Fat necrosis			0.404	0.525
Yes	6	4
No	200	88
Secondary surgical exploration			11.501	<0.001
Yes	6	12
No	200	80
Complete flap necrosis
Yes	0	2		0.095
No	206	90

Groups	Perforation anatomy time t/min	P value	Total operation time t/min	P value
① CTA+NAS	32.06±7.96	0.023^a	288.46±58.34	0.040^e
② CTA+AS	42.36±10.06	<0.001^b	300.06±60.29	0.018^f
③ US+NAS	50.98±13.02	<0.001^c	304.78±64.58	0.248^g
④ US+AS	68.30±15.08	0.012^d	332.03±70.28	0.014^h