术前肝硬度值对肝癌腹腔镜与开腹手术安全性的影响探究

doi:10.3877/cma.j.issn.1674-3946.2020.04.019

目的

探究术前肝硬度值对肝癌腹腔镜与开腹手术安全性的影响。

方法

回顾性分析2014年2月至2018年8月281例肝癌患者的临床资料，根据不同术式，将患者分为腹腔镜组(n＝68)和开腹组(n＝213)，分析不同肝硬度值对患者术后并发症发生风险的影响。研究数据使用SPSS 22.0进行分析，术后并发症等计数资料采用χ²检验；术中术后各项指标以(±s)表示，采用独立t检验；危险因素分析采用Logistic回归法，预测效能分析选用ROC曲线。以P<0.05为差异有统计学意义。

结果

腹腔镜组术中Pringle阻断率高于开腹组(P<0.05)。两组术前肝硬度值组间比较差异无统计学意义(P>0.05)，但肝硬度值>15.0 kPa者腹腔镜组术后并发症发生率高于开腹组(P<0.05)。Logistic多因素回归分析示，肝硬度值>15.0 kPa是肝癌术后并发症的独立危险因素(P<0.05)。以肝硬度值>15.0 kPa为截断值，预测肝癌患者术后并发症的曲线下面积(AUC)为0.759，其灵敏度、特异性分别为65.3%、83.9%。

结论

术前肝硬度值>15.0 kPa的肝癌患者有着更高的术后并发症发生风险，对于该类患者而言，应考虑实施开腹手术以提高手术安全性。

关键词: 癌，肝细胞, 硬度, 腹腔镜, 剖腹术, 安全

Objective

To explore the effect of preoperative liver hardness on the safety of laparoscopy and laparotomy for hepatocellular carcinoma.

Methods

The clinical data of 281 patients with liver cancer treated in our hospital from Feb 2014 to Aug 2018 were retrospectively analyzed, and the patients were divided into the laparoscopic group (n=68) and the laparotomy group (n=213) according to their treatment methods. The clinical data, preoperative liver hardness, postoperative recovery and complications of the two groups were compared, and the influence of different liver hardness values on the risk of postoperative complications was analyzed. SPSS 22.0 software was used for statistical analysis. Counting data were expressed as (n/%) and χ² was used for statistical analysis. Measuring data were expressed as (±s) and T test was used for risk factor analysis. Logistic regression method was used for risk factor analysis. ROC curve was used for predictive effectiveness analysis, with P<0.05 as the statistical difference.

Results

The intraoperative Pringle occlusion rate in the laparoscopic group was higher than that in the open group (P<0.05). There was no significant difference in preoperative liver stiffness between the two groups (P>0.05). The incidence of postoperative complications in the laparoscopic group (liver hardness value>15.0 kpa) was higher than that in the open group (P<0.05). Logistic multivariate regression analysis showed that liver hardness value >15.0 kpa was an independent risk factor for postoperative complications of liver cancer (P<0.05). Using the liver hardness value>15.0 kpa as the cut-off value, the area under the curve (AUC) for predicting postoperative complications in patients with liver cancer was 0.759, and its sensitivity and specificity were 65.3% and 83.9%, respectively.

Conclusion

The patients of liver cancer with preoperative liver hardness value>15.0 kpa have a higher risk of postoperative complications. For such patients, open surgery should be considered to improve surgical safety.

Key words: Carcinoma, hepatocellular, Hardness, Laparoscopes, Laparotomy, Safety

表1 281例肝癌患者不同术式两组患者基线临床资料比较[(±s)，例]

组别	例数	年龄(岁)	BMI (kg/m²)	肿瘤直径(cm)	性别	ASA分级	Child－pugh分级	肝切除范围
组别	例数	年龄(岁)	BMI (kg/m²)	肿瘤直径(cm)	男/女	Ⅰ/Ⅱ/Ⅲ	A级/B级	A/B/C /D
腹腔镜组	68	55.2±9.3	24.1±4.0	5.5±1.2	45/23	11/32/25	63/5	3/5/25/35
开腹组	213	54.7±9.3	24.1±3.7	5.6±1.1	132/81	36/93/84	201/12	18/13/72/110
t/χ²值	－	0.393	0.114	0.837	0.391	－	0.051	－
P值	－	0.347	0.455	0.202	0.532	－	0.822	－

表1 281例肝癌患者不同术式两组患者基线临床资料比较[(±s)，例]

组别	例数	年龄(岁)	BMI (kg/m²)	肿瘤直径(cm)	性别	ASA分级	Child－pugh分级	肝切除范围
组别	例数	年龄(岁)	BMI (kg/m²)	肿瘤直径(cm)	男/女	Ⅰ/Ⅱ/Ⅲ	A级/B级	A/B/C /D
腹腔镜组	68	55.2±9.3	24.1±4.0	5.5±1.2	45/23	11/32/25	63/5	3/5/25/35
开腹组	213	54.7±9.3	24.1±3.7	5.6±1.1	132/81	36/93/84	201/12	18/13/72/110
t/χ²值	－	0.393	0.114	0.837	0.391	－	0.051	－
P值	－	0.347	0.455	0.202	0.532	－	0.822	－

表2 281例肝癌患者不同术式两组患者手术情况比较[(±s),例(%)]

组别	例数	手术时间(min)	术中出血量(ml)	住院时间(d)
腹腔镜组	68	239.3±71.0	291.1±83.6	12.5±2.3
开腹组	213	225.8±66.5	280.4±81.9	12.9±2.6
t/χ²值	－	1.429	0.926	1.325
P值	－	0.077	0.178	0.093
组别	例数	Pringle阻断	术后并发症
腹腔镜组	68	42(61.8)	24(35.3)
开腹组	213	90(42.3)	54(25.4)
t/χ²值	－	7.878	2.541
P值	－	0.005	0.111

表2 281例肝癌患者不同术式两组患者手术情况比较[(±s),例(%)]

组别	例数	手术时间(min)	术中出血量(ml)	住院时间(d)
腹腔镜组	68	239.3±71.0	291.1±83.6	12.5±2.3
开腹组	213	225.8±66.5	280.4±81.9	12.9±2.6
t/χ²值	－	1.429	0.926	1.325
P值	－	0.077	0.178	0.093
组别	例数	Pringle阻断	术后并发症
腹腔镜组	68	42(61.8)	24(35.3)
开腹组	213	90(42.3)	54(25.4)
t/χ²值	－	7.878	2.541
P值	－	0.005	0.111

表3 281例肝癌患者不同术式两组患者肝硬度值与术后并发症的关系分析

组别	例数	肝硬度值	例数	并发症	发生率(%)
腹腔镜组	68	<10.0 kPa	22	3	13.6
		10.1～15.0 kPa	16	5	31.3
		15.1～25.0 kPa	15	9	60.0
		>25.0 kPa	15	9	60.0
开腹组	213	<10.0 kPa	63	9	14.3
		10.1～15.0 kPa	54	15	27.8
		15.1～25.0 kPa	39	12	30.8^a
		>25.0 kPa	57	18	31.6^a

表3 281例肝癌患者不同术式两组患者肝硬度值与术后并发症的关系分析

组别	例数	肝硬度值	例数	并发症	发生率(%)
腹腔镜组	68	<10.0 kPa	22	3	13.6
		10.1～15.0 kPa	16	5	31.3
		15.1～25.0 kPa	15	9	60.0
		>25.0 kPa	15	9	60.0
开腹组	213	<10.0 kPa	63	9	14.3
		10.1～15.0 kPa	54	15	27.8
		15.1～25.0 kPa	39	12	30.8^a
		>25.0 kPa	57	18	31.6^a

图1 281例肝癌患者不同术式肝硬度值预测肝癌术后并发症的ROC曲线

[1]	Golse N, El Bouyousfi A, Marques F，et al.Large hepatocellular carcinoma: Does fibrosis really impact prognosis after resection？[J]．Journal of Visceral Surgery，2018，155(4): 265-273.
[2]	李始亮，张清秀．肝细胞肝癌合并门静脉高压症的诊疗进展[J]．现代医药卫生，2016，32(8): 1203-1205.
[3]	Braunwarth E, St？ttner S, Fodor M，et al.Surgical techniques and strategies for the treatment of primary liver tumours: hepatocellular and cholangiocellular carcinoma[J]．Eur Surg，2018，50(3): 100-112.
[4]	Kim EY, Hong TH.Initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for left－sided pancreatic cancer in a single institution: technical aspects and oncological outcomes[J]．BMC Surg，2017，17(1): 2.
[5]	nal E, Akata D, Karcaaltincaba M．Liver function assessment by magnetic resonance imaging[J]．Semin Ultrasound CT MR，2016，37(6): 549-560.
[6]	Ratti F, Cipriani F, Catena M，et al.Approach to hepatocaval confluence during laparoscopic right hepatectomy: three variations on a theme[J]．Surg Endosc，2017，31(2): 949.
[7]	Lee JH, Han DH, Jang DS，et al.Robotic extrahepatic Glissonean pedicle approach for anatomic liver resection in the right liver: techniques and perioperative outcomes[J]．Surg Endosc，2016，30(9): 3882-3888.
[8]	Leong WQ, Ganpathi IS, Kow AWC，et al.Comparative study and systematic review of laparoscopic liver resection for hepatocellular carcinoma[J]．World J Hepatol，2015，7(27): 2765-2773.
[9]	陈孝平，裴有亮，张万广．腹腔镜肝癌根治术的热点与未来发展[J/CD]．中华普外科手术学杂志(电子版)，2019，13(3): 217-219.
[10]	李鸿飞，黄庆录，蔡小勇．腹腔镜肝叶切除术治疗原发性肝癌的疗效及技巧探讨[J]．实用临床医药杂志，2015，19(9): 112-113.
[11]	Kim J, Nakajima Y, Kobayashi K．A Suction－Fixing, Stiffness－Tunable Liver Manipulator for Laparoscopic Surgeries[J]．IEEE/ASME Transactions on Mechatronics，2018，23(1): 262-273.
[12]	Sato N, Kenjo A, Kimura T，et al.Prediction of major complications after hepatectomy using liver stiffness values determined by magnetic resonance elastography[J]．Br J Surg，2018，105(9): 1192-1199.
[13]	陈熙，彭永海，胡朝辉，等．肝硬度值预测肝癌肝切除术后并发症的应用价值[J]．中华消化外科杂志，2018，17(5): 466-473.
[14]	Dimitri M, Staderini F, Brancadoro M，et al.A new microwave applicator for laparoscopic and robotic liver resection[J]．Int J Hyperthermia，2019，36(1): 75-86.
[15]	张浩，董科，俞小炯，等．完全腹腔镜和开腹肝切除手术治疗原发性肝细胞肝癌的近期和远期疗效比较[J]．实用医学杂志，2017，33(12): 1943-1948.
[16]	Nishio T, Taura K, Koyama Y，et al.Prediction of posthepatectomy liver failure based on liver stiffness measurement in patients with hepatocellular carcinoma[J]．Surgery，2016，159(2): 399-408.

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Study on the effect of preoperative liver hardness on the safety of laparoscopy and laparotomy for hepatocellular carcinoma

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Study on the effect of preoperative liver hardness on the safety of laparoscopy and laparotomy for hepatocellular carcinoma