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10THE ROLE OF THREE-DIMENSIONAL MODELING IN PLANNING OPERATIONS IN PATIENTS
WITH PORTAL HYPERTENSION SYNDROME
Zelter P.
Ph.D., assistant, Chair of Radiology and Radiation Therapy with a course of medical informatics, Samara state medical university, Samara, Russia
Chaplygin S.
Ph.D., associate professor, Chair of Operative Surgery and Topographic Anatomy with a course of innovative technology, Samara state medical university, Samara, Russia
Kapishnikov A.
Ph.D., Head, Chair of Radiology and Radiation Therapy with a course of medical informatics Samara state medical university, Samara, Russia
Abstract
Purpose: to evaluate the experience of using abdominal CT with 3D modeling in preoperative planning in patients with portal hypertension syndrome. 40 patients were examined. All patients underwent abdominal CT with a modified protocol. CT data was segmented and 3D modeled. CT allows you to: identify the cause and level of the block in the portal system; identify characteristic changes in the liver and spleen; visualize collateral in patients with portal hypertension syndrome. Using the system for modeling and combining the phases of the study allows you to choose the best method of surgical intervention for decompression of the portal system.
Keywords: portal hypertension, preoperative 3-D modelling, CT.
Portal hypertension - increased pressure in the portal vein of any etiology over 12 mmHg or 160 mm. water st .. Traditionally, portal hypertension is classified into four groups: 1. The suprahepatic form - with thrombosis or stenosis of the hepatic veins, inferior vena cava, right ventricular failure 2. The intrahepatic form - for various causes of damage to the liver parenchyma 3. The subhepatic form - with portal vein thrombosis or branches, squeezing them from the outside 4. Hyperdynamic form - with various variants of arteriovenous fistulas [1].
In Russia, the largest number of patients with portal hypertension are patients with cirrhosis. Portal hypertension causes life-threatening complications: in 90% of patients with cirrhosis, varicose veins of the esophagus occur, which in 30% of cases is manifested by bleeding. Such bleeding even after the first episode in 30-50% of cases ends fatally [2].
Computed tomography with bolus contrast is one of the leading places in assessing the pathology of the abdominal organs, [3].
Computer simulation based on MSCT data is a technique that allows you to combine all four phases of visualization with volumetric transformation on a single integrated image that provides information about the anatomical features of the abdominal organs along with the features of arterial and venous blood supply [2]. Segmentation is the division of the image into areas for which a certain uniformity criterion is fulfilled [4].
The question of choosing the optimal tactics of palliative surgery for decompression of the portal system is still open [5]. Thus, the endovascular TIPS operation to create an intrahepatic anastomosis between the hepatic vein and portal portal vein, despite its relative effectiveness, is contraindicated in hepatic encephalopathy due to a sharp decrease in hepatic blood flow. According to the literature, TIPS is technically feasible in 97.3% of cases. The most common causes of failure to create a shunt are portal vein thrombosis, damage and
hepatic vein thrombosis, liver fibrosis, as well as severe ascites. The frequency of lethal complications averages 1.4-3.0%, depending on the size of the sample [6].
Purpose: to evaluate the experience of using abdominal CT with subsequent segmentation and 3D modeling in preoperative planning in patients with portal hypertension syndrome.
We studied data from 40 patients with presumed portal hypertension syndrome. All patients underwent abdominal CT scan with bolus contrast enhancement. The arterial phase was performed for 10 s after reaching the threshold density level (120-150 HU) in the aorta. The difference in the technique was the execution of the venous phase at 55 seconds after reaching the threshold (approximately 70 seconds from the start of administration of the contrast medium, on average 20 seconds later than the standard venous phase). This approach is somewhat different from the technique described by A. Kudryavtseva [7], in which the study was carried out at 60 and 120 seconds from the start of the administration of the contrast mediu
The delayed phase scan was carried out for 6 minutes. Next, segmentation, modeling and analysis of a three-dimensional model were carried out in the Avtoplan system.
Avtoplan is a hardware-software complex that was developed for preoperative planning and intraoperative navigation [8]. After loading the data in the DICOM format into the system, semi-automatic segmentation of parenchymal organs was carried out on the basis of "medium" models, segmentation of arteries and veins by installing one point in the lumen and further threshold processing.
Results and discussion.
In the study group of patients, various changes in abdominal CT scan were identified that are the cause or manifestation of portal hypertension syndrome. Their list and frequency of detection are presented in table 1.
Table 1
Signs detected during CT in patients of the study group
Sign %
Portal vein enlargement 90
Splenal vein enlargement 60
Cirrhosis 25
Ascites 30
Splenomegaly 65
Hypervascular lesion 7,5
Splenorenal anastomosis 7,5
Portacaval anastomosis 10
Caput medusa 10
Portal vein thrombosis 12,5
Splenal vein thrombosis 7,5
Mesentheric vein thrombosis 10
Hepatic vein thrombosis 7,5
Esophageal vein enlargement 20
Cavernoma of portal vein 17,5
In most cases, the study allowed not only to suggest the presence of portal hypertension, to determine its forms, but also to speak out about its causes. The most common cause of the intrahepatic form was liver cirrhosis, which was manifested by a decrease in the size of the liver, a change in its configuration (sickle shape or hypertrophy of 1 segment) with a bumpy outline. With the subhepatic form, various causes of the block were revealed: portal vein thrombosis, compression from the outside with pseudocysts, calcifications in the structure of the pancreatic head, and lymph nodes.
After segmentation in the Avtoplan system, polygonal models were obtained, on which structures accumulating contrast medium at different phases of the study were visualized on one image. Such a model made it possible to evaluate the area of the proposed intervention.
When planning the application of an H-shaped splenorenal anastomosis, it was necessary to evaluate the distance between the left renal and splenic veins, their course and tortuosity, the presence of large arterial trunks and the tail of the pancreas between them (Fig. 1).
which is an indication for choosing the tactics of applying an H-shaped splenorenal anastomosis.
Planning for such an operation was carried out in 10 patients. A favorable variant of topographic relationships was revealed in 5 patients. In two cases, the simulation allowed to abandon the H-shaped anastomosis due to the close location of the veins. They were
hemmed directly to each other. In three cases, the proximal overlap of the splenorenal anastomosis was chosen due to the significant distance between the vessels and the location of the pancreatic tail.
Conclusions.
1. CT with bolus contrast enhancement is effective in detecting signs of portal hypertension, its shape, and evaluating portacaval anastomoses.
2. In patients with suspected portal hypertension, it is necessary to change the protocol for conducting multiphase scanning due to a slowdown in blood flow. If necessary, supplement the standard phases with a late venous phase.
3. Using the system for modeling and combining the phases of the study allows you to choose the best method of surgical intervention for decompression of the portal system;
4. After surgery, CT with modeling allows you to visually assess the patency of shunts and anastomoses
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SYSTEM OF MEDICAL-PSYCHOLOGICAL SUPPORT OF THE FAMILY WHERE A PATIENT WITH ENDOGENOUS MENTAL DISORDER LIVES
Kaminska A.
MD, PhD, Associated professor
Department of Medical Psychology and Psychiatry with the Course of Postgraduate Education of
National Pirogov Memorial University, Vinnytsya, Ukraine
Abstract
Family, where a patient with endogenous mental disorder lives, experiences deep psychosocial stress; changes in patients behavior and social losses, caused by the disorder, lead to the disruption of inter-family interaction and increased emotional tension; attitude of the family to the disease and their perception of the patient depend on clinical and psychopathological features of mental disorder, which determines the type of family response to the diagnosis and affect its ability to cope with stress; self-stigmatization of family, social isolation, lack of psychological support increase disadaptation of family.
Family caregivers of patients with endogenous mental disorder often lack adequate information about mental disorders, as well as appropriate medical-psychological support services.
Taking into consideration above listed, there are four aspects of family interventions included into complex medical-psychological support system:
1) psychoeducation;
2) stress management and development of adaptive coping behavior;
3) mastering effective communication skills;
4) activation of resource components and adaptive potential of individuals.
The work model, described in this article, is based on interactive thematic groups, using integrative approach, combining the following methods:
- cognitive-behavioral psychotherapy;
- mindfulness-oriented cognitive therapy;
- psychotraining;
- art therapy.
Keywords: medical-psychological support system, psychoeducation, family caregivers, endogenous mental disorders, family burden.
