Chinese Medical Sciences Journal ›› 2020, Vol. 35 ›› Issue (2): 157-169.doi: 10.24920/003565
朱卫华,谢文勇,张哲栋,李澍(),张大方,刘以俊,朱继业,冷希圣
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
Zhu Weihua,Xie Wenyong,Zhang Zhedong,Li Shu(),Zhang Dafang,Liu Yijun,Zhu Jiye,Leng Xisheng
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。
Zhu Weihua,Xie Wenyong,Zhang Zhedong,Li Shu,Zhang Dafang,Liu Yijun,Zhu Jiye,Leng Xisheng. Postoperative Complications and Survival Analysis of Surgical Resection for Hilar Cholangiocarcinoma: A Retrospective Study of Fifty-Nine Consecutive Patients[J].Chinese Medical Sciences Journal, 2020, 35(2): 157-169.
"
Surgical procedures | Bismuth and Corlette type of HC | Sub-total | R0 resection rate(%) | ||||
---|---|---|---|---|---|---|---|
Type Ⅰ | Type Ⅱ | Type Ⅲa | Type Ⅲb | Type Ⅳ | |||
Hilar resection alone | 8 (8) | 7 (4) | 2 (1) | 3 (2) | 6 (1) | 26 (16) | 61.5 |
Hilar resection + MLR | 33 (19) | 57.6 | |||||
Left hemihepatectomy | 0 | 0 | 0 | 7 (7) | 6 (4) | 13 (11) | 84.6 |
Left trisectionectomy | 0 | 0 | 0 | 2 (1) | 5 (3) | 7 (4) | 57.1 |
Right hemihepatectomy | 0 | 0 | 4 (1) | 0 | 5 (0) | 9 (1) | 11.1 |
Right trisectionectomy | 0 | 0 | 1 (1) | 0 | 2 (2) | 3 (3) | 100.0 |
Central liver resection | 0 | 0 | 0 | 0 | 1 (0) | 1 (0) | 0 |
Total | 8 (8) | 7 (4) | 7 (3) | 12 (10) | 25 (10) | 59 (35) | 59.3 |
"
Postoperative outcomes | Hilar resection (n=26) | Hilar resection and MLR(n=33) | χ2 | P value |
---|---|---|---|---|
Mortality (n, %) | 1 (3.8 ) | 2 (6.1) | 0.703* | 0.145 |
Morbidity (n, %) | 6 (23.1) | 15 (45.5) | 3.893 | 0.048 |
Biliary leak | 1 (3.8) | 11 (33.3) | 7.804 | 0.005 |
Perihepatic abscess | 0 (0) | 2 (6.1) | 1.603* | 0.205 |
Liver failure | 0 (0) | 2 (6.1) | 1.603* | 0.205 |
Sepsis | 1 (3.8) | 2 (6.1) | 0.703* | 0.145 |
Pneumonia | 1 (3.8) | 2 (6.1) | 0.703* | 0.145 |
GI hemorrhage | 0 (0) | 1 (3.0) | 0.788* | 0.375 |
DEG | 2 (7.7) | 0 (0) | 2.583* | 0.108 |
Cardiac asthma | 1 (3.8) | 0 (0) | 1.269* | 0.260 |
Hepaticojejunostomy | 0 (0) | 2 (6.1) | 1.603* | 0.205 |
UG-TPPCD | 0 (0) | 6 (18.2 ) | 5.173* | 0.023 |
Reoperation | 0 (0) | 3 (9.1 ) | 2.448* | 0.118 |
"
Variables | 1-year survival rate (n=50) | P / χ2log-rank | 3-year survival rate (n=44) | P / χ2log-rank | 5-year survival rate (n=31) | P / χ2log-rank |
---|---|---|---|---|---|---|
Gender | 0.547/0.363 | 0.071/3.267# | 0.097/2.747# | |||
Male | 61.3% (31) | 31.3% (29) | 23.8%/(21) | |||
Female | 52.6% (19) | 6.7% (15) | 0 (10) | |||
Age (years) | 0.291/1.116 | 0.051/3.799# | 0.124/2.360# | |||
≥65 | 68.8% (16) | 6.3% (16) | 0 (9) | |||
<65 | 52.9% (34) | 32.1% (28) | 22.7% (22) | |||
Hypertension | 0.658/0.196 | 0.415/0.664# | 0.436/0.607# | |||
Yes | 62.5% (16) | 30.8% (13) | 25.0% (8) | |||
No | 55.9% (34) | 19.4% (31) | 13.0% (23) | |||
Diabetes Mellitus | 0.925/0.009# | 0.910/0.013# | 0.528/0.398# | |||
Yes | 60% (5) | 25% (4) | 0 (2) | |||
No | 57.8% (45) | 22.5% (40) | 17.2% (29) | |||
Chronic hepatitis | 0.093/2.819# | 0.839/0.041# | 0.661/0.192# | |||
Yes | 0 (2) | 0 (2) | 0 (1) | |||
No | 60.4% (48) | 23.8% (42) | 16.7% (30) | |||
T-Bil | 0.650/0.206# | 0.510/0.435# | 0.432/0.618# | |||
≥2 mg/dL | 66.7% (44) | 21.1% (38) | 17.9% (28) | |||
<2 mg/dL | 56.8% (6) | 33.3% (6) | 0 (3) | |||
Preoperative Ca19-9 | 0.001/18.252 | 0.040/4.216# | 0.124/2.360# | |||
≥1000 U/mL | 7.7% (13) | 0 (11) | 0 (9) | |||
<1000 U/mL | 75.7% (37) | 30.3% (33) | 22.7% (22) | |||
CEA | 0.015/5.884# | 0.336/0.925# | 0.432/0.618# | |||
≥4.7 ng/mL | 0 (4) | 0 (3) | 0 (3) | |||
<4.7 ng/mL | 63.0% (46) | 24.4% (41) | 17.9% (28) | |||
B&C type(1 st)* | 0.493/0.470# | 0.277/1.183# | 0.609/0.261# | |||
Ⅰ | 57.1% (7) | 33.3% (6) | 20.0% (5) | |||
Ⅱ | 85.7% (7) | 33.3% (6) | 33.3% (3) | |||
Ⅲ | 50% (14) | 23.1% (13) | 11.1% (9) | |||
Ⅳ | 54.5% (22) | 15.8% (19) | 14.3% (14) | |||
B&C type(2nd)* | 0.230/1.439 | 0.309/1.033# | 0.436/0.607# | |||
Ⅰ and Ⅱ | 71.45 (14) | 33.3% (12) | 25.0% (8) | |||
Ⅲ and Ⅳ | 52.8% (36) | 18.8% (32) | 13.1% (23) | |||
B&C type(3rd)* | 0.793/0.069# | 0.610/0.261# | 0.829/0.047# | |||
Ⅲ | 50.0% (14) | 23.1% (13) | 11.1% (9) | |||
Ⅳ | 54.5% (22) | 15.8% (19) | 14.3% (14) | |||
B&C type(4th)* | 0.298/1.083# | 0.626/0.238# | 0.264/1.250# | |||
Ⅲa | 33.3% (6) | 16.7% (6) | 0 (5) | |||
Ⅲb | 62.5% (8) | 28.6% (7) | 25.0% (4) | |||
Drainage | 0.314/1.012 | 0.280/1.167# | 0.969/0.002# | |||
Yes | 46.2% (13) | 10.0% (10) | 16.7% (6) | |||
No | 62.2% (37) | 26.5% (34) | 16.0% (25) | |||
Chemotherapy | 0.053/3.871# | 0.400/0.708# | 0.468/0.527# | |||
Yes | 90.0% (10) | 30.0% (10) | 25.0% (8) | |||
No | 50.0% (40) | 17.6% (34) | 13.6% (22) |
"
Variables | 1-year survival rate (n=50) | P / χ2log-rank | 3-year survival rate (n=44) | P / χ2log-rank | 5-year survival rate (n=31) | P / χ2log-rank |
---|---|---|---|---|---|---|
Hepatic ischemia | 0.738/0.112# | 0.910/0.013# | 0.402/0.703# | |||
Yes | 50.0% (4) | 25.0% (4) | 33.3% (3) | |||
No | 58.7% (46) | 22.5% (40) | 14.3% (28) | |||
Estimated blood loss | 0.724/0.124 | 0.681/0.169# | 0.562/0.337# | |||
≥2000 ml | 53.8% (13) | 18.2% (11) | 22.2% (9) | |||
<2000 ml | 59.5% (37) | 24.2% (33) | 13.6% (22) | |||
Transfusion (units) | 0.520/0.414# | 0.460/0.547# | 0.527/0.399# | |||
not applied | 61.3% (31) | 25.0% (28) | 10.0% (20) | |||
1 - 3 | 55.6% (9) | 28.6% (7) | 50.0% (4) | |||
>3 | 50.0% (10) | 11.1% (9) | 14.3% (7) | |||
Type of resection | 0.111/2.538 | 0.819/0.052# | 0.803/0.062# | |||
Hilar resection+MLR | 67.9% (28) | 24.0% (25) | 17.6% (17) | |||
Hilar resection | 45.5% (22) | 21.1% (19) | 14.3% (14) | |||
Vascular resection | 0.817/0.054# | 0.438/0.602# | NA | |||
Yes | 50.0% (2) | 0 (2) | 0 (0) | |||
No | 53.3% (48) | 23.8% (42) | 16.1% (31) | |||
Surgical margin status | 0.059/3.577# | 0.104/2.702# | 0.036/4.375# | |||
R0 | 65.5% (29) | 30.8% (26) | 31.3% (16) | |||
R1 | 60.0% (15) | 14.3% (14) | 0 (11) | |||
R2 | 16.7% (6) | 0 (4) | 0 (4) |
"
Variables | 1-year survival rate (n=50) | P / χ2log-rank | 3-year survival rate (n=44) | P / χ2log-rank | 5-year survival rate (n=31) | P / χ2log-rank |
---|---|---|---|---|---|---|
Histopathologic grade | 0.925/0.009# | 0.010/6.690# | 0.014/6.069# | |||
Well | 60.0% (5) | 75.0% (4) | 66.7% (3) | |||
Moderate & poor | 57.8% (45) | 17.5% (40) | 11.5% (26) | |||
Perineural invasion | 0.726/0.123 | 0.290/1.144# | 0.592/0.287# | |||
Yes | 55.0% (20) | 13.3% (15) | 12.5% (8) | |||
No | 60.0% (30) | 27.6% (29) | 17.4% (23) | |||
Hepatic invasion | 0.084/2.993 | 0.290/1.144# | 0.889/0.020# | |||
Yes | 41.2% (17) | 13.3% (15) | 16.7% (12) | |||
No | 66.7% (33) | 27.6% (29) | 15.8% (19) | |||
Microvascular invasion | 0.738/0.112 | 0.051/3.799# | 0.437/0.604# | |||
Yes | 61.1% (18) | 6.3% (16) | 9.1% (11) | |||
No | 56.3% (32) | 32.1% (28) | 20.0% (20) | |||
Lymph node metastases | 0.075/3.178 | 0.025/4.998# | 0.272/1.209# | |||
Yes | 42.1% (19) | 5.6% (18) | 6.7% (15) | |||
No | 67.7% (31) | 34.6% (26) | 25.0% (16) | |||
AJCC staging | 0.003/8.981# | 0.024/5.807# | 0.312/1.022# | |||
Ⅰ | 78.6% (14) | 38.5% (13) | 22.2% (9) | |||
Ⅱ | 66.7% (9) | 37.5% (8) | 25.0% (4) | |||
Ⅲ | 63.2% (19) | 11.8% (17) | 15.4% (13) | |||
Ⅳ | 0 (8) | 0 (6) | 0 (5) |
"
Factors | P value | Wald χ2 | Hazard ratio | 95% CI |
---|---|---|---|---|
Preoperative Ca19-9 (<1000 U/mL vs. ≥1000 U/mL) | <0.001 | 17.255 | 7.039 | 2.803-17.678 |
Histopathologic grade (well vs. moderate / poor) | 0.044 | 4.068 | 4.964 | 1.046-23.552 |
Surgical margins (R0) | 0.031 | 6.939 | Reference | - |
(R1) | 0.292 | 1.113 | 2.051 | 0.254-1.509 |
(R2) | 0.033 | 4.529 | 3.190 | 1.096-9.287 |
AJCC staging (Ⅰ) | 0.015 | 10.459 | Reference | - |
(Ⅱ) | 0.984 | <0.001 | 0.988 | 0.314-3.113 |
(Ⅲ) | 0.105 | 2.634 | 2.463 | 0.829-7.315 |
(Ⅳ) | 0.004 | 8.239 | 7.091 | 1.861-27.017 |
CEA (<4.7 ng/mL vs. ≥4.7 ng/mL) | 0.609 | 0.262 | 0.700 | 0.179-2.736 |
Lymph node metastasis (negative vs. positive) | 0.862 | 0.030 | 1.078 | 0.464-2.505 |
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