腹腔镜下肝切除术手术难度评分系统的建立与应用
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摘要
目的:建立腹腔镜下肝切除术手术难度评分系统,并初步应用。方法:对2014年1月—2017年5月重庆医科大学附属第一医院收治的83例行腹腔镜下肝切除术患者的临床资料进行回顾性分析,根据手术时间及是否中转开腹将患者分成简单组和困难组,对引起手术困难的因素行单因素与多因素Logistic回归分析,根据回归方程的系数建立预测手术难度的评分系统。对83例病例进行评分,通过受试者工作特征曲线(ROC)验证评分系统评价的效能。结果:单因素分析显示年龄、性别、病灶的直径、病灶的性质、病灶距下腔静脉的距离、病灶是否位于左外叶在简单组和困难组间差异有统计学差异(均P<0.05),多因素分析显示病灶直径(OR=7.034,P=0.043),病灶与下腔静脉的距离(OR=12.881,P=0.001),病灶是否位于左外叶(OR=26.774,P=0.001)为手术难度的独立影响因素。根据上述因素建立评分系统,效能检验显示,ROC曲线下面积为0.897(95%CI=0.826~0.968),截断值为4,患者评分≥4为手术困难。结论:手术难度评分系统对预测腹腔镜下肝切除术的难度有较好的指导意义。手术医生可以根据术前难度评分合理的选择手术方式。
Objective: To establish a difficulty scoring system to predict the difficulty of laparoscopic liver resection(LLR)and to make a preliminary application.Methods: The clinical data of 83 patients undergoing LLR between January 2014 and May 2017 in the First Affiliated Hospital of Chongqing Medical University were retrospectively analyzed. The patients were divided into simple group and difficult group according to the operative time and whether converted to open surgery or not. The factors for surgical difficulty were determined by univariate and multivariate Logistic regression analysis.Then, the scoring system for predicting the surgical difficulty was built based on the coefficient of the regression analysis. The 83 patients were scored and the validity of the scoring system was verified through receiver operatingcharacteristic curve(ROC).Results: The univariate analysis showed that there were significant differences in age, sex, lesion size, lesion traits,distance of the lesion from the inferior vena cava and whether the lesion was located in the left lateral lobe between simple group and difficult group(all P<0.05); multivariate analysis revealed that lesion size(OR=7.034, P=0.043),the distance between the lesion and the inferior vena cava(OR=12.881, P=0.001), and whether the lesion was located in the left lateral lobe(OR=26.774, P=0.001) were independent influential factors for surgical difficulty.The scoring system was established based on the above factors. Efficiency estimation showed that the area under the ROC curve was 0.897(95% CI=0.826–0.968) with a cut-off value of 4, so the score of a patient equal to or larger than 4 was regarded as surgical difficulty.Conclusion: Surgical difficulty scoring system has certain guiding significance for predicting surgical difficulty in LLR. Surgeons can choose the surgical procedure by referring to the preoperative difficulty score.
Objective: To establish a difficulty scoring system to predict the difficulty of laparoscopic liver resection(LLR)and to make a preliminary application.Methods: The clinical data of 83 patients undergoing LLR between January 2014 and May 2017 in the First Affiliated Hospital of Chongqing Medical University were retrospectively analyzed. The patients were divided into simple group and difficult group according to the operative time and whether converted to open surgery or not. The factors for surgical difficulty were determined by univariate and multivariate Logistic regression analysis.Then, the scoring system for predicting the surgical difficulty was built based on the coefficient of the regression analysis. The 83 patients were scored and the validity of the scoring system was verified through receiver operatingcharacteristic curve(ROC).Results: The univariate analysis showed that there were significant differences in age, sex, lesion size, lesion traits,distance of the lesion from the inferior vena cava and whether the lesion was located in the left lateral lobe between simple group and difficult group(all P<0.05); multivariate analysis revealed that lesion size(OR=7.034, P=0.043),the distance between the lesion and the inferior vena cava(OR=12.881, P=0.001), and whether the lesion was located in the left lateral lobe(OR=26.774, P=0.001) were independent influential factors for surgical difficulty.The scoring system was established based on the above factors. Efficiency estimation showed that the area under the ROC curve was 0.897(95% CI=0.826–0.968) with a cut-off value of 4, so the score of a patient equal to or larger than 4 was regarded as surgical difficulty.Conclusion: Surgical difficulty scoring system has certain guiding significance for predicting surgical difficulty in LLR. Surgeons can choose the surgical procedure by referring to the preoperative difficulty score.
引文
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[16]Lee MK 4th,Gao F,Strasberg SM.Perceived complexity of various liver resections:results of a survey of experts with development of a complexity score and classification[J].J Am Coll Surg,2015,220(1):64–69.doi:10.1016/j.jamcollsurg.2014.09.017.
[17]Halls MC,Cherqui D,Taylor MA,et al.Are the current difficulty scores for laparoscopic liver surgery telling the whole story?An international survey and recommendations for the future[J].HPB(Oxford),2017,pii:S1365–182X(17)30926–7.doi:10.1016/j.hpb.2017.08.028.[Epub ahead of print]
[18]刘荣,赵国栋.肝左外叶切除"金标准"术式:腹腔镜肝左外叶切除术[J].中华腔镜外科杂志:电子版,2010,3(6):474–478.doi:10.3877/cma.j.issn.1674–6899.2010.06.002.Liu R,Zhao GD.A"gold standard"procedure of left lateral segment liver resection:laparoscopic left lateral segment liver resection[J].Chinese Journal of Laparoscopic Surgery:Electronic Edition,2010,3(6):474–478.doi:10.3877/cma.j.issn.1674–6899.2010.06.002.
[19]陈求赞.腹腔镜和开腹肝左外叶切除术62例对比分析[J].中华普外科手术学杂志:电子版,2016,10(2):174–176.doi:10.3877/cma.j.issn.1674–3946.2016.02.029.Chen QZ.Open and laparoscopic hepatic left lateral lobectomy for62 patients[J].Chinese Journal of Operative Procedures of General Surgery:Electronic Version,2016,10(2):174–176.doi:10.3877/cma.j.issn.1674–3946.2016.02.029.
[20]Tanaka S,Kubo S,Kanazawa A,et al.Validation of a Difficulty Scoring System for Laparoscopic Liver Resection:A Multicenter Analysis by the Endoscopic Liver Surgery Study Group in Japan[J].J Am Coll Surg,2017,225(2):249–258.doi:10.1016/j.jamcollsurg.2017.03.016.
[21]Zhao H,Chen C,Gu S,et al.Anatomical versus non-anatomical resection for solitary hepatocellular carcinoma without macroscopic vascular invasion:A propensity score matching analysis[J].J Gastroenterol Hepatol,2017,32(4):870–878.doi:10.1111/jgh.13603.
[22]Marubashi S,Gotoh K,Akita H,et al.Analysis of Recurrence Patterns After Anatomical or Non-anatomical Resection for Hepatocellular Carcinoma[J].Ann Surg Oncol,2015,22(7):2243–2252.doi:10.1245/s10434–014–4214–4.
[23]Shindoh J,Makuuchi M,Matsuyama Y,et al.Complete removal of the tumor-bearing portal territory decreases local tumorrecurrence and improves disease-specific survival of patients with hepatocellular carcinoma[J].J Hepatol,2016,64(3):594–600.doi:10.1016/j.jhep.2015.10.015.
[24]Cucchetti A,Cescon M,Ercolani G,et al.A comprehensive metaregression analysis on outcome of anatomic resection versus nonanatomic resection for hepatocellular carcinoma[J].Ann Surg Oncol,2012,19(12):3697–3705.doi:10.1245/s10434–012–2450-z.
[25]Li SQ,Huang T,Shen SL,et al.Anatomical versus non-anatomical liver resection for hepatocellular carcinoma exceeding Milan criteria[J].Br J Surg,2017,104(1):118–127.doi:10.1002/bjs.10311.
[2]郑树国,田驹.腹腔镜肝切除术适应证再探讨[J].中国普外基础与临床杂志,2013,20(4):352–355.Zheng SG,Tian J.Further Discussion of Indications for Laparoscopic Hepatectomy[J].Chinese Journal of Bases and Clinics In General Surgery,2013,20(4):352–355.
[3]Komorowski AL,Mitu?JW,Wysocki WM,et al.Laparoscopic and open liver resection-a literature review with meta-analysis[J].Arch Med Sci,2017,13(3):525–532.doi:10.5114/aoms.2015.55545.
[4]佟庆,丁伟,晏冬,等.腹腔镜与开腹肝切除术治疗肝癌疗效的Meta分析[J].中国普通外科杂志,2015,24(1):27–33.doi:10.3978/j.issn.1005–6947.2015.01.006.Tong Q,Ding W,Yan D,et al.Meta-analysis of efficacy of laparoscopic versus open liver resection for liver cancer[J].Chinese Journal of General Surgery,2015,24(1):27–33.doi:10.3978/j.issn.1005–6947.2015.01.006.
[5]Vigano L,Laurent A,Tayar C,et al.The learning curve in laparoscopic liver resection:improved feasibility and reproducibility[J].Ann Surg,2009,250(5):772–782.doi:10.1097/SLA.0b013e3181bd93b2.
[6]中华医学会外科学分会肝脏外科学组.腹腔镜肝切除术专家共识和手术操作指南(2013版)[J].中华外科杂志,2013,51(4):289–292.doi:10.3760/cma.j.issn.0529–5815.2013.04.001.Liver Surgery Group of Surgery Society of Chinese Medical Association.Expert consensus on and operation instructions for laparoscopic liver resection(2013 edition)[J].Chinese Journal of Surgery,2013,51(4):289–292.doi:10.3760/cma.j.issn.0529–5815.2013.04.001.
[7]晏益核,卢榜裕,蔡小勇,等.腹腔镜肝切除术中两种选择性入肝血流阻断方法的比较[J].中国普通外科杂志,2012,21(7):859–863.Yan YH,Lu BY,Cai XY,et al.Comparison of two methods of selective hepatic vascular exclusion for laparoscopic hepatectomy[J].Chinese Journal of General Surgery,2012,21(7):859–863.
[8]Ban D,Tanabe M,Ito H,et al.A novel difficulty scoring system for laparoscopic liver resection[J].J Hepatobiliary Pancreat Sci,2014,21(10):745–753.doi:10.1002/jhbp.166.
[9]Kawaguchi Y,Fuks D,Kokudo N,et al.Difficulty of Laparoscopic Liver Resection:Proposal for a New Classification[J].Ann Surg,2018,267(1):13–17.doi:10.1097/SLA.0000000000002176.
[10]Periyasamy M,Cho JY,Ahn S,et al.Prediction of surgical outcomes of laparoscopic liver resections for hepatocellular carcinoma by defining surgical difficulty[J].Surg Endosc,2017,31(12):5209–5218.doi:10.1007/s00464–017–5589–7.
[11]陈章彬,许丁伟,许宁,等.腹腔镜下肝切除术中转开腹的相关因素初步分析[J].腹腔镜外科杂志,2016,21(12):894–898.doi:10.13499/j.cnki.fqjwkzz.2016.12.894.Chen ZB,Xu DW,Xu N,et al.The preliminary analysis of relative factors for laparo scopic hepatectomy converted to open surgery[J].Journal of Laparoscopic Surgery,2016,21(12):894–898.doi:10.13499/j.cnki.fqjwkzz.2016.12.894.
[12]Hasegawa Y,Wakabayashi G,Nitta H,et al.A novel model for prediction of pure laparoscopic liver resection surgical difficulty[J].Surg Endosc,2017,31(12):5356–5363.doi:10.1007/s00464–017–5616–8.
[13]Im C,Cho JY,Han HS,et al.Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy[J].Surg Endosc,2017,31(1):430–436.doi:10.1007/s00464–016–4994–7.
[14]Couinaud C.Contribution of anatomical research to liver surgery[J].Fr Med,1956,19(5):5–12.
[15]Lee MK 4th,Gao F,Strasberg SM.Completion of a Liver Surgery Complexity Score and Classification Based on an International Survey of Experts[J].J Am Coll Surg,2016,223(2):332–342.doi:10.1016/j.jamcollsurg.2016.03.039.
[16]Lee MK 4th,Gao F,Strasberg SM.Perceived complexity of various liver resections:results of a survey of experts with development of a complexity score and classification[J].J Am Coll Surg,2015,220(1):64–69.doi:10.1016/j.jamcollsurg.2014.09.017.
[17]Halls MC,Cherqui D,Taylor MA,et al.Are the current difficulty scores for laparoscopic liver surgery telling the whole story?An international survey and recommendations for the future[J].HPB(Oxford),2017,pii:S1365–182X(17)30926–7.doi:10.1016/j.hpb.2017.08.028.[Epub ahead of print]
[18]刘荣,赵国栋.肝左外叶切除"金标准"术式:腹腔镜肝左外叶切除术[J].中华腔镜外科杂志:电子版,2010,3(6):474–478.doi:10.3877/cma.j.issn.1674–6899.2010.06.002.Liu R,Zhao GD.A"gold standard"procedure of left lateral segment liver resection:laparoscopic left lateral segment liver resection[J].Chinese Journal of Laparoscopic Surgery:Electronic Edition,2010,3(6):474–478.doi:10.3877/cma.j.issn.1674–6899.2010.06.002.
[19]陈求赞.腹腔镜和开腹肝左外叶切除术62例对比分析[J].中华普外科手术学杂志:电子版,2016,10(2):174–176.doi:10.3877/cma.j.issn.1674–3946.2016.02.029.Chen QZ.Open and laparoscopic hepatic left lateral lobectomy for62 patients[J].Chinese Journal of Operative Procedures of General Surgery:Electronic Version,2016,10(2):174–176.doi:10.3877/cma.j.issn.1674–3946.2016.02.029.
[20]Tanaka S,Kubo S,Kanazawa A,et al.Validation of a Difficulty Scoring System for Laparoscopic Liver Resection:A Multicenter Analysis by the Endoscopic Liver Surgery Study Group in Japan[J].J Am Coll Surg,2017,225(2):249–258.doi:10.1016/j.jamcollsurg.2017.03.016.
[21]Zhao H,Chen C,Gu S,et al.Anatomical versus non-anatomical resection for solitary hepatocellular carcinoma without macroscopic vascular invasion:A propensity score matching analysis[J].J Gastroenterol Hepatol,2017,32(4):870–878.doi:10.1111/jgh.13603.
[22]Marubashi S,Gotoh K,Akita H,et al.Analysis of Recurrence Patterns After Anatomical or Non-anatomical Resection for Hepatocellular Carcinoma[J].Ann Surg Oncol,2015,22(7):2243–2252.doi:10.1245/s10434–014–4214–4.
[23]Shindoh J,Makuuchi M,Matsuyama Y,et al.Complete removal of the tumor-bearing portal territory decreases local tumorrecurrence and improves disease-specific survival of patients with hepatocellular carcinoma[J].J Hepatol,2016,64(3):594–600.doi:10.1016/j.jhep.2015.10.015.
[24]Cucchetti A,Cescon M,Ercolani G,et al.A comprehensive metaregression analysis on outcome of anatomic resection versus nonanatomic resection for hepatocellular carcinoma[J].Ann Surg Oncol,2012,19(12):3697–3705.doi:10.1245/s10434–012–2450-z.
[25]Li SQ,Huang T,Shen SL,et al.Anatomical versus non-anatomical liver resection for hepatocellular carcinoma exceeding Milan criteria[J].Br J Surg,2017,104(1):118–127.doi:10.1002/bjs.10311.