顺逆结合围肝门外科入路与传统手术入路治疗侵犯肝门胆囊癌对比研究
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摘要
目的评价顺逆结合围肝门外科入路治疗侵犯肝门部胆囊癌的疗效。方法收集2007年1月至2017年12月上海交通大学医学院附属仁济医院普外科与胆胰外科收治的侵犯肝门部胆囊癌手术共39例病人的临床资料,比较顺逆结合围肝门外科入路(围肝门入路组,20例)与传统手术入路(传统手术入路组,19例)两种手术入路术后R0切除率、术中出血量、并发症发生率和总体生存时间等。结果传统手术入路组采用CT和(或)MRI进行术前评估,围肝门入路组采用CT+MRI+三维重建评估。传统手术入路组可切除评估准确率为57.9%(11/19),围肝门入路组可切除评估准确率为90.0%(18/20),两者差异有统计学意义(P=0.031)。传统手术入路组和围肝门入路组比较,两组R0切除率分别为26.3%(5/19)和85.0%(17/20)(P=0.000)。两组行S4b,5+肝外胆管切除、S4b,5,6,7,8+肝外胆管切除、S4a,4b,5,6,7,8+肝外胆管切除、联合脏器切除术、胆囊切除+T管架桥胆肠内引流术或剖腹探查术分别为7例vs.8例、3例vs.6例、0 vs.1例、1例vs.3例、8例vs.2例(P=0.156)。两组术后30 d死亡例数为4例vs.0(P=0.047)。在肝切除病人中,传统手术入路组病人出血量显著大于围肝门入路组[(660.0±219.1)mL vs.(358.8±184.8)mL,P=0.006],传统手术入路组Clavien Ⅲ级以上并发症发生率显著高于围肝门入路组,其中Clavien Ⅲ级病人所占比例分别为72.7%vs. 27.8%(P=0.027),Clavien Ⅳ级病人所占比例分别为45.5%vs. 0(P=0.004),Clavien Ⅴ级27.3%vs. 0(P=0.045)。传统手术入路组与围肝门入路组1年存活率分别为21.1%(4/19)vs.61.1%(11/18)(P=0.020),总体生存时间围肝门入路组显著优于传统手术入路组(16.0个月vs 8.4个月,P=0.0005)。结论顺逆结合围肝门外科入路能提高R0切除率,减少术中出血量,降低围手术期病死率与严重并发症发生率,提高总体生存时间;CT+MRI+三维重建评估能提高术前可切除评估准确性,减少盲目手术探查。
Objective To evaluate the clinical efficacy of transhepatic hilar approach exposing porta hepatis for the treatment of gallbladder carcinoma invading porta hepatis. Methods The clinicopathological data of patients with gallbladder carcinoma invading porta hepatis who underwent surgical treatment at Department of General Surgery and Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University from January 2007 to December 2017 was collected. There were 39 patients enrolled in the study, including 19 patients in the conventional surgical approach group and 20 patients in the transhepatic hilar approach group. The R0 resection, intraoperative bleeding, postoperative complications and overall survival time were compared between the conventional approach group and the transhepatic hilar approach group. Results CT and/or MRI were used for preoperative evaluation in the conventional approach group, and CT + MRI + 3 D reconstruction were used in the transhepatic hilar approach group.The accuracy rate of preoperative resectable evaluation was 57.9%(11/19) in the conventional approach group, and 90.0%(18/20) in the transhepatic hilar approach group(P=0.031). The R0 resection rate of the conventional approach group was 26.3%(5/19), while the R0 resection rate of transhepatic hilar approach group was 85.0%(17/20)(P=0.000). The operations of the conventional approach group and the transhepatic hilar approach group were shown as follow: S4 b,5 + extrahepatic bile duct (7/8), S4 b,5,6,7,8 + extrahepatic bile duct (3/6), S4 a,4 b,5,6,7,8 +extrahepatic bile duct (0/1), extended resection(1/3) and others (8/2)(P= 0.156). The number of death within 30 days after surgery in the conventional approach group and the transhepatic hilar approach group was 4 and 0 respectively (P=0.047). Among the hepatectomy patients, the blood loss in the conventional approach group was significantly higher than that in the transhepatic hilar approach group [(660 ± 219.1)mL vs.(358.8 ± 184.8)m L,P=0.006]. The postoperative complication rate of Clavien Ⅲ to Clavien Ⅴwas significantly higher in the conventional approach group [Clavien Ⅲ was72.7% vs. 27.8% (P=0.027), Clavien Ⅳ was 45.5% vs. 0 (P=0.004), and Clavien Ⅴ was 27.3% vs. 0(P=0.045)]. The 1-year survival rate of the conventional approach group and the transhepatic hilar approach group was 21.1%(4/19) and61.1%(11/18)(P=0.020), respectively. The overall survival time of the transhepatic hilar approach group was significantly better than that of the conventional approach group(16.0 months vs. 8.4 months, P=0.0005). Conclusion The transhepatic hilar approach can improve the R0 resection rate, reduce intraoperative blood loss, perioperative mortality and serious complication rate, and improve the overall survival time. CT+MRI+3 D reconstruction can improve the accuracy of preoperative resectable evaluation and reduce unnecessary surgical exploration.
Objective To evaluate the clinical efficacy of transhepatic hilar approach exposing porta hepatis for the treatment of gallbladder carcinoma invading porta hepatis. Methods The clinicopathological data of patients with gallbladder carcinoma invading porta hepatis who underwent surgical treatment at Department of General Surgery and Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University from January 2007 to December 2017 was collected. There were 39 patients enrolled in the study, including 19 patients in the conventional surgical approach group and 20 patients in the transhepatic hilar approach group. The R0 resection, intraoperative bleeding, postoperative complications and overall survival time were compared between the conventional approach group and the transhepatic hilar approach group. Results CT and/or MRI were used for preoperative evaluation in the conventional approach group, and CT + MRI + 3 D reconstruction were used in the transhepatic hilar approach group.The accuracy rate of preoperative resectable evaluation was 57.9%(11/19) in the conventional approach group, and 90.0%(18/20) in the transhepatic hilar approach group(P=0.031). The R0 resection rate of the conventional approach group was 26.3%(5/19), while the R0 resection rate of transhepatic hilar approach group was 85.0%(17/20)(P=0.000). The operations of the conventional approach group and the transhepatic hilar approach group were shown as follow: S4 b,5 + extrahepatic bile duct (7/8), S4 b,5,6,7,8 + extrahepatic bile duct (3/6), S4 a,4 b,5,6,7,8 +extrahepatic bile duct (0/1), extended resection(1/3) and others (8/2)(P= 0.156). The number of death within 30 days after surgery in the conventional approach group and the transhepatic hilar approach group was 4 and 0 respectively (P=0.047). Among the hepatectomy patients, the blood loss in the conventional approach group was significantly higher than that in the transhepatic hilar approach group [(660 ± 219.1)mL vs.(358.8 ± 184.8)m L,P=0.006]. The postoperative complication rate of Clavien Ⅲ to Clavien Ⅴwas significantly higher in the conventional approach group [Clavien Ⅲ was72.7% vs. 27.8% (P=0.027), Clavien Ⅳ was 45.5% vs. 0 (P=0.004), and Clavien Ⅴ was 27.3% vs. 0(P=0.045)]. The 1-year survival rate of the conventional approach group and the transhepatic hilar approach group was 21.1%(4/19) and61.1%(11/18)(P=0.020), respectively. The overall survival time of the transhepatic hilar approach group was significantly better than that of the conventional approach group(16.0 months vs. 8.4 months, P=0.0005). Conclusion The transhepatic hilar approach can improve the R0 resection rate, reduce intraoperative blood loss, perioperative mortality and serious complication rate, and improve the overall survival time. CT+MRI+3 D reconstruction can improve the accuracy of preoperative resectable evaluation and reduce unnecessary surgical exploration.
引文
[1]Kanthan R,Senger JL,Ahmed S,et al.Gallbladder Cancer in the21st Century[J].J Oncol,2015,2015:967472.
[2]中华医学会外科学分会胰腺外科学组,中国研究型医院学会胰腺病专业委员会,中华外科杂志编辑部.胰腺术后外科常见并发症诊治及预防的专家共识(2017)[J].中华外科杂志,2017,55(5):328-334.
[3]Clavien P A,Barkun J,Oliveira MLD,et al.The Clavien-Dindo classification of surgical complications:five-year experience[J].Ann Surg,2009,250(2):187-196.
[4]中华医学会数字医学分会,中华医学会外科学分会胆道外科学组,中国研究型医院学会数字医学临床外科专业委员会.胆囊癌三维可视化诊治专家共识(2018版)[J].中国实用外科杂志,2018,38(12):1339-1346.
[5]中华医学会外科学分会胆道外科学组.胆囊癌诊断和治疗指南(2015版)[J].中华消化外科杂志,2015,14(11):881-890.
[6]Kokudo N,Makuuchi M,Natori T,et al.Strategies for surgical treatment of gallbladder carcinoma based on information available before resection[J].Arch Surg,2003,138(7):741-750.
[7]Shimizu H,Kimura F,Yoshidome H,et al.Aggressive surgical approach for stage IV gallbladder carcinoma based on Japanese Society of Biliary Surgery classification[J].J Hepatobiliary Pancreat Surg,2007,14(4):358-365.
[8]Ong SL,Garcea G,Thomasset SC,et al.Ten-year experience in the management of gallbladder cancer from a single hepatobiliary and pancreatic centre with review of the literature[J].HPB(Oxford),2008,10(6):446-458.
[9]Shimada K,Nara S,Esaki M,et al.Extended right hemihepatectomy for gallbladder carcinoma involving the hepatic hilum[J].Br J Surg.2011,98(1):117-123.
[10]Singh SK,Talwar R,Kannan N,et al.Aggressive surgical approach for gallbladder cancer:a single-center experience from Northern India[J].J Gastrointest Cancer,2015,46(4):399-407.
[11]Pottakkat B,Kapoor A,Prakash A,et al.Evaluation of a prospective surgical strategy of extended resection to achieve R0status in gall bladder cancer[J].J Gastrointest Cancer,201344(1):33-40.
[12]Hundal R,Shaffer EA.Gallbladder cancer:epidemiology and outcome[J].Clin Epidemiol,2014,6:99-109.
[13]Yamamoto Y,Sugiura T,Ashida R,et al.Indications for major hepatectomy and combined procedures for advanced gallbladder cancer[J].Br J Surg,2017,104(3):257-266.
[14]Sirohi B,Mitra A,Jagannath P,et al.Neoadjuvant chemotherapy in patients with locally advanced gallbladder cancer[J].Future Oncol,2015,11(10):1501-1509.
[15]Engineer R,Goel M,Chopra S,et al.Neoadjuvant chemoradiation followed by surgery for locally advanced gallbladder cancers:a new paradigm[J].Ann Surg Oncol,2016,23(9):3009-3015.
[16]王坚,陈炜.围肝门外科技术在胆道外科的应用[J].中华消化外科杂志,2015,14(4):284-287.
[17]王坚.围肝门外科技术处理围肝门胆道肿瘤[J].中华外科杂志,2018,56(5):332-337.
[2]中华医学会外科学分会胰腺外科学组,中国研究型医院学会胰腺病专业委员会,中华外科杂志编辑部.胰腺术后外科常见并发症诊治及预防的专家共识(2017)[J].中华外科杂志,2017,55(5):328-334.
[3]Clavien P A,Barkun J,Oliveira MLD,et al.The Clavien-Dindo classification of surgical complications:five-year experience[J].Ann Surg,2009,250(2):187-196.
[4]中华医学会数字医学分会,中华医学会外科学分会胆道外科学组,中国研究型医院学会数字医学临床外科专业委员会.胆囊癌三维可视化诊治专家共识(2018版)[J].中国实用外科杂志,2018,38(12):1339-1346.
[5]中华医学会外科学分会胆道外科学组.胆囊癌诊断和治疗指南(2015版)[J].中华消化外科杂志,2015,14(11):881-890.
[6]Kokudo N,Makuuchi M,Natori T,et al.Strategies for surgical treatment of gallbladder carcinoma based on information available before resection[J].Arch Surg,2003,138(7):741-750.
[7]Shimizu H,Kimura F,Yoshidome H,et al.Aggressive surgical approach for stage IV gallbladder carcinoma based on Japanese Society of Biliary Surgery classification[J].J Hepatobiliary Pancreat Surg,2007,14(4):358-365.
[8]Ong SL,Garcea G,Thomasset SC,et al.Ten-year experience in the management of gallbladder cancer from a single hepatobiliary and pancreatic centre with review of the literature[J].HPB(Oxford),2008,10(6):446-458.
[9]Shimada K,Nara S,Esaki M,et al.Extended right hemihepatectomy for gallbladder carcinoma involving the hepatic hilum[J].Br J Surg.2011,98(1):117-123.
[10]Singh SK,Talwar R,Kannan N,et al.Aggressive surgical approach for gallbladder cancer:a single-center experience from Northern India[J].J Gastrointest Cancer,2015,46(4):399-407.
[11]Pottakkat B,Kapoor A,Prakash A,et al.Evaluation of a prospective surgical strategy of extended resection to achieve R0status in gall bladder cancer[J].J Gastrointest Cancer,201344(1):33-40.
[12]Hundal R,Shaffer EA.Gallbladder cancer:epidemiology and outcome[J].Clin Epidemiol,2014,6:99-109.
[13]Yamamoto Y,Sugiura T,Ashida R,et al.Indications for major hepatectomy and combined procedures for advanced gallbladder cancer[J].Br J Surg,2017,104(3):257-266.
[14]Sirohi B,Mitra A,Jagannath P,et al.Neoadjuvant chemotherapy in patients with locally advanced gallbladder cancer[J].Future Oncol,2015,11(10):1501-1509.
[15]Engineer R,Goel M,Chopra S,et al.Neoadjuvant chemoradiation followed by surgery for locally advanced gallbladder cancers:a new paradigm[J].Ann Surg Oncol,2016,23(9):3009-3015.
[16]王坚,陈炜.围肝门外科技术在胆道外科的应用[J].中华消化外科杂志,2015,14(4):284-287.
[17]王坚.围肝门外科技术处理围肝门胆道肿瘤[J].中华外科杂志,2018,56(5):332-337.