预后控制外科:从理论到实践
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摘要
当前以互联网、大数据和人工智能为代表的信息技术的应用将外科实践提升到了智能化的新高度,以干预者经验为主导的传统医学和过度倚重干预手段的循证医学受到了新的冲击和挑战.为了更好地适应医学科技的飞速发展和医疗需求的不断提高,根据长期的肝胆胰外科临床实践,本文提出了预后控制外科理论.该理论以患者最优预后为根本目标,通过择优干预者、干预手段、干预时机的最佳组合来预控疾病风险.随着人工智能技术的逐渐兴起,本文提出了智能外科的概念,预控外科在其基础上,提倡应用医学影像识别与预测、三维重建与手术规划、术中导航和机器人手术系统为代表的人工智能等信息技术方法,促进外科诊疗的快速、均衡发展.在预控外科理论和方法的指导下,本研究团队创立了微创解剖性肝切除技术、个体化胰腺手术入路体系、模式化肝切除方法、单针全层胰肠吻合技术和胰腺端端吻合技术,提倡胰腺癌整块切除,并归纳总结出了外科四大核心策略:控血、入路、切除、重建,以最小损伤实现患者的最大获益.
Rapid advances of big data and artificial intelligence(AI) techniques have pushed the envelope of traditional surgery to intelligent surgery, which revolutionizes the traditional medicine model dominated by the experiences of interveners and evidence-based medicine. Intelligent surgery requires to judiciously integrate the clinical experience of interveners and medical evidences with the new AI techniques, so as to achieve the best therapeutic effect for patients through effective disease risk control. This paper puts forward a new theory of prognostic control surgery in the long-term clinical practice of hepato-pancreato-biliary surgery. Our theory takes the optimal prognosis of patients as the goal, and pre-controls the disease risk through the best combination of the optimal intervener, intervention methods and intervention timing to achieve the maximum clinical benefits of patients with minimal medical trauma. This theory also takes full advantage of information technologies such as neural networks, deep learning, big data and imaging system, and uses high-dimensional network decision making to replace the traditional two-dimensional decision making tree model.A main technical challenge in the theory is how to effectively exploit the AI techniques in to improve the production efficiency of large hospitals, enhance the service level of primary medical care, and improve the diagnosis, prediction,treatment of diseases. Prognostic control surgery advocates the exploitation of emerging information technology methods,such as medical image recognition and prediction, 3D reconstruction based surgical planning, intraoperative navigation,and remote intelligent robotic surgical system, to promote the rapid and balanced surgical diagnosis and treatment.Guided by the theory of prognosis control surgery, our team successfully established minimally invasive anatomic hepatectomy, individualized pancreatic surgical approaches, modular hepatectomy, single-layer continuous suture of pancreaticojejunostomy, and end-to-end pancreatic anastomosis and advocated en-bloc resection of pancreatic cancer. This paper also provides the details of four core surgical strategies proposed in our prognosis control surgery, namely, blood control technique, surgical approach selection, resection technique and reconstruction technique, by which to achieve the minimally invasive surgery regularization and the complex surgery simplification.
Rapid advances of big data and artificial intelligence(AI) techniques have pushed the envelope of traditional surgery to intelligent surgery, which revolutionizes the traditional medicine model dominated by the experiences of interveners and evidence-based medicine. Intelligent surgery requires to judiciously integrate the clinical experience of interveners and medical evidences with the new AI techniques, so as to achieve the best therapeutic effect for patients through effective disease risk control. This paper puts forward a new theory of prognostic control surgery in the long-term clinical practice of hepato-pancreato-biliary surgery. Our theory takes the optimal prognosis of patients as the goal, and pre-controls the disease risk through the best combination of the optimal intervener, intervention methods and intervention timing to achieve the maximum clinical benefits of patients with minimal medical trauma. This theory also takes full advantage of information technologies such as neural networks, deep learning, big data and imaging system, and uses high-dimensional network decision making to replace the traditional two-dimensional decision making tree model.A main technical challenge in the theory is how to effectively exploit the AI techniques in to improve the production efficiency of large hospitals, enhance the service level of primary medical care, and improve the diagnosis, prediction,treatment of diseases. Prognostic control surgery advocates the exploitation of emerging information technology methods,such as medical image recognition and prediction, 3D reconstruction based surgical planning, intraoperative navigation,and remote intelligent robotic surgical system, to promote the rapid and balanced surgical diagnosis and treatment.Guided by the theory of prognosis control surgery, our team successfully established minimally invasive anatomic hepatectomy, individualized pancreatic surgical approaches, modular hepatectomy, single-layer continuous suture of pancreaticojejunostomy, and end-to-end pancreatic anastomosis and advocated en-bloc resection of pancreatic cancer. This paper also provides the details of four core surgical strategies proposed in our prognosis control surgery, namely, blood control technique, surgical approach selection, resection technique and reconstruction technique, by which to achieve the minimally invasive surgery regularization and the complex surgery simplification.
引文
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5 Liu R.Opportunities and challenges of intelligent surgery(in Chinese).Chin J Laparo Surg(Electr Ed),2017,10:327-329[刘荣.智能外科的机遇与挑战.中华腔镜外科杂志(电子版),2017,10:327-329]
6 Liu H.On the prognosis(in Chinese).Med Philos,2002,4-8[刘虹.论预后.医学与哲学,2002,4-8]
7 Liu R,Liu Q.Intraoperative risk precontrol and minimally invasive hepato-pancreato-biliary surgery(in Chinese).Chin J Laparo Surg(Electr Ed),2017,10:65-67[刘荣,刘渠.术中风险预控与肝胆胰微创外科.中华腔镜外科杂志(电子版),2017,10:65-67]
8 Chen W,Ji H,Feng J,et al.Classification of pancreatic cystic neoplasms based on multimodality images.Mach learn med imaging,2018,11046:161-169
9 Ackerman M J.The visible human project:A resource for education.Acad Med,1999,74:667-670
10 Mezger U,Jendrewski C,Bartels M.Navigation in surgery.Langenbecks Arch Surg.2013,398:501-514
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2 Liu R.Medical intervention should focus on prognosis:Dynamic prognosis-control in medicine(in Chinese).Acad J Chin PLA Med Sch,2018,39:931-933[刘荣.医疗干预应聚焦预后--医学中的动态预后控制.解放军医学院学报,2018,39:931-933]
3 Liu R.The transformation of doctors in the era of intelligent medicine(in Chinese).J Laparo Surg,2018,23:1-3[刘荣.智能医学时代医生的转型.腹腔镜外科杂志,2018,23:1-3]
4 Liu R.Enter the new era of intelligent medicine(in Chinese).Chin J Laparo Surg(Electr Ed),2018,11:65-67[刘荣.走进智能医学新时代.中华腔镜外科杂志(电子版),2018,11:65-67]
5 Liu R.Opportunities and challenges of intelligent surgery(in Chinese).Chin J Laparo Surg(Electr Ed),2017,10:327-329[刘荣.智能外科的机遇与挑战.中华腔镜外科杂志(电子版),2017,10:327-329]
6 Liu H.On the prognosis(in Chinese).Med Philos,2002,4-8[刘虹.论预后.医学与哲学,2002,4-8]
7 Liu R,Liu Q.Intraoperative risk precontrol and minimally invasive hepato-pancreato-biliary surgery(in Chinese).Chin J Laparo Surg(Electr Ed),2017,10:65-67[刘荣,刘渠.术中风险预控与肝胆胰微创外科.中华腔镜外科杂志(电子版),2017,10:65-67]
8 Chen W,Ji H,Feng J,et al.Classification of pancreatic cystic neoplasms based on multimodality images.Mach learn med imaging,2018,11046:161-169
9 Ackerman M J.The visible human project:A resource for education.Acad Med,1999,74:667-670
10 Mezger U,Jendrewski C,Bartels M.Navigation in surgery.Langenbecks Arch Surg.2013,398:501-514
11 Zhang W Q,Dai K R,Wang C T.The present state and development of navigation system for orthopedic surgery(in Chinese).J Med Biomech,2004,19:51-55[张文强,戴尅戎,王成焘.外科手术导航系统的研究现状及进展.医用生物力学,2004,19:51-55]
12 Schicho K,Figl M,Donat M,et al.Stability of miniature electromagnetic tracking systems.Phys Med Biol,2005,50:2089-2098
13 Qi S T,Liu T B.Surgical robot system and its clinical applications(in Chinese).Chin Med Dev,2011,26:56-59[戚仕涛,刘铁兵.外科手术机器人系统及其临床应用.中国医疗设备,2011,26:56-59]
14 Liu R.Establishment and technical optimization of LR robotic pancreaticoduodenectomy(in Chinese).Chin J Laparo Surg(Electr Ed),2016,9:193-195[刘荣.LR式机器人胰十二指肠切除术手术方法建立和技术优化.中华腔镜外科杂志(电子版),2016,9:193-195]
15 Liu R.Tunnel construction strategy in minimally invasive pancreatic surgery(in Chinese).Chin J Laparo Surg(Electr Ed),2018,11:193-195[刘荣.胰腺手术中的“隧道构建”策略.中华腔镜外科杂志(电子版),2018,11:193-195]
16 Liu R,Zhao G D,Ma X,et al.The first case of robotic retroperitoneal laparoscopic pancreatic surgery(in Chinese).Chin J Laparo Surg(Electr Ed),2016,9:59-60[刘荣,赵国栋,马鑫,等.机器人后腹腔镜胰腺手术首例报道.中华腔镜外科杂志(电子版),2016,9:59-60]
17 Liu R,Zhao G D,Yin Z Z,et al.A case report of robotic pancreatic tumor enucleation combined with main pancreatic duct bridge repair(in Chinese).Chin J Laparo Surg(Electr Ed),2016,9:373-374[刘荣,赵国栋,尹注增,等.机器人胰腺肿瘤剜除联合主胰管架桥修复术个案报道.中华腔镜外科杂志(电子版),2016,9:373-374]
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