Chinese Medical Sciences Journal ›› 2020, Vol. 35 ›› Issue (2): 157-169.doi: 10.24920/003565

• 论著 • 上一篇    下一篇

59例肝门部胆管癌切除术后并发症和生存率分析

朱卫华,谢文勇,张哲栋,李澍(),张大方,刘以俊,朱继业,冷希圣   

  1. 北京大学人民医院 肝胆外科,北京,100044 中国
  • 收稿日期:2019-01-25 接受日期:2019-12-23 出版日期:2020-06-30 发布日期:2020-06-22
  • 通讯作者: 李澍 E-mail:lishu@medmail.com.cn

Postoperative Complications and Survival Analysis of Surgical Resection for Hilar Cholangiocarcinoma: A Retrospective Study of Fifty-Nine Consecutive Patients

Zhu Weihua,Xie Wenyong,Zhang Zhedong,Li Shu(),Zhang Dafang,Liu Yijun,Zhu Jiye,Leng Xisheng   

  1. Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing 100044, China
  • Received:2019-01-25 Accepted:2019-12-23 Published:2020-06-30 Online:2020-06-22
  • Contact: Li Shu E-mail:lishu@medmail.com.cn

摘要: 目的 肝门部胆管癌(HC)非手术治疗基本上是不可治愈的。本研究旨在明确HC手术切除的安全性和术后生存率,并且研究影响切除术后生存率的预后因素。 方法 以2009年2月至2017年2月完成的59例手术切除的HC病人为研究对象,出院后每隔3-6个月对病人进行随访,明确术后并发症和总体生存率,并通过单因素和Cox回归分析,研究患者临床、病理和手术因素中与总体生存率相关的预后因素。 结果 59例外科治疗的HC病人中,33例(55.9%)Bismuth & Corlette(B & C)Ⅲ型(n=19)和Ⅳ型(n=25)采用肝门部切除联合大部肝切除(MLR)治疗,其余11例Ⅲ-Ⅳ型HC病人与Ⅰ型(n=8)和Ⅱ型(n=7)HC病人均采用肝门切除术。本组HC病人的死亡率为5.1%,手术并发症发生率为35.6%。肝门切除+MLR组的死亡率(6.1%)与肝门部切除的死亡率(3.8%)之间无统计学差异(Χ 2=0.703,P=0.145)。本组病人中位随访期为18个月(1-94个月),1、3、5年生存率分别为59.3%、36.5%和17.7%,总生存期为18个月。在Ⅲ型和Ⅳ型HC病人中,行肝门切除+MLR的中位生存期为23个月,而行肝门切除术的中位生存期为8个月;前者的1、3、5年累积生存率分别为63.9%、23.3%和15.5%,而后者1、3、5年累积生存率分别为11.1%、0和0,在两种术式间存在显著差异(HR,9.902;95% CI,2.636-19.571,P=0.001)。与术后生存率相关的四个独立预后因素分别为:术前血清Ca19-9水平(HR,7.039;95% CI,2.803-17.678,P<0.001),组织病理学分级(HR,4.964;95% CI,1.046-23.552,P<0.05),手术切缘(P<0.05)和AJCC分期(P<0.05)。 结论 R0切除是HC外科治疗的有效方法。MLR结合尾状叶切除可以增加Ⅲ型和Ⅳ型HC病人R0切除的机会,并提高术后生存率。对合适的HC病人行胆道引流的术前准备,可以确保绝大多数病人安全的接受MLR。应研究新的辅助疗法以改善具有不良预后因素的HC病人的生存率。

关键词: 发病率, 死亡, 预后, 肝门部胆管癌, 肝切除术

Abstract:

Objective Hilar cholangiocarcinoma (HC) is invariably fatal without surgical resection. The primary aim of the current study was to determine the safety of variable surgical resections for patient with HC and their survival after surgical resection. In addition, prognostic factor for the overall survival was also evaluated. Methods The study included 59 consecutive patients who were newly diagnosed with HC and underwent surgical resections with curative intend between February 2009 and February 2017. Patients were followed up at 3-6 months intervals after hospital discharge. Postoperative complications and overall survival were determined. Associations of clinicopathologic and surgeon-related factors with overall survival were evaluated through univariate analysis and Cox regression analysis. Results Of patients with Bismuth and Corlette (B & C) type Ⅲ (n=19) and Ⅳ (n=25) HC lesions, 33 (55.9%) were treated with hilar resection combined with major liver resection (MLR), while the other 11 patients with type Ⅲ and Ⅳ, and those with type Ⅰ (n=8) and Ⅱ (n=7) HC lesions were treated with hilar resection. The overall surgical mortality was 5.1% and surgical morbidity was 35.6%. There was no statistical difference in the mortality between MLR group and hilar resection group (6.1% vs. 3.8%; X2=0.703, P=0.145). The median follow-up period was 18 months (range, 1-94 months). The 1-, 3-, 5-year survival rate was 59.3%, 36.5%, and 17.7%, respectively. The overall survival after resections was 18 months. In HC patients with B & C type Ⅲ and Ⅳ lesions, the median survival was 23 months for hilar resection with MLR and 8 months for hilar resection alone; the 1-, 3-, 5-year cumulative survival rate was 63.9%, 23.3%, and 15.5%, respectively for hilar resection with MLR, and 11.1%, 0, and 0, respectively for hilar resection alone, with significant differene observed (HR, 9.902; 95% CI, 2.636-19.571, P=0.001). Four factors were independently associated with overall survival: preoperative serum Ca19-9 (HR, 7.039; 95% CI, 2.803-17.678, P<0.001), histopathologic grade (HR, 4.964; 95% CI, 1.046-23.552, P=0.044), surgical margins (P=0.031), and AJCC staging (P=0.015). Conclusions R0 resection is efficacious in surgical treatment of HC. MLR in combination with caudate lobe resection may increase the chance of R0 resection and improve survival of HC patients with B & C type Ⅲ and Ⅳ lesions. Preoperatively prepared for biliary drainage may ensure the safety of MLR in most HC patients. Novel adjuvant therapies are needed to improve the survival of HC patients with poor prognostic factors.

Key words: morbidity, mortality, prognosis, hilar cholangiocarcinoma, hepatectomy

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