腹腔镜肝切除术难度评分系统临床实用性研究
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摘要
目的探讨BAN腹腔镜肝脏切除难度评分系统(DSS-B)及基于切除范围的腹腔镜肝脏切除难度评分系统(DSS-ER)的临床实用性。方法回顾我院肝胆胰外科2015年8月—2017年11月201例腹腔镜肝切除术病例。采用DSS-B及DSS-ER系统对151例肿瘤腹腔镜肝切除术进行难度分级,比较不同难度组围手术期资料的组间差异;50例肝内胆管结石(IHD)腹腔镜肝切除术按DSS-ER系统进行难度分级,比较不同难度组围手术期资料的组间差异;最后,对DSS-B及DSS-ER进行对比研究。结果 DSS-B不同难度腹腔镜肝切除组间手术时间、术中出血量、术中输血率、肝门阻断率、中转开腹率、术后住院天数比较,差异有显著性(P<0.05),总并发症率、严重并发症率比较,差异无显著性(P>0.05)。DSS-ER不同难度腹腔镜肝切除组手术时间、术中出血量、术中输血率、肝门阻断率、中转开腹率、总并发症率、术后住院天数比较,差异有显著意义(P<0.05);严重并发症率比较差异无显著性(P>0.05)。DSS-ER分组的50例IHD腹腔镜肝切除组手术时间、术中出血量、术中输血率、肝门阻断率比较,差异具有显著性(P<0.05);按DSS-ER分组的腹腔镜肝切除DSS-B评分组间比较,差异具有显著意义(P<0.01)。结论难度评分系统DSS-B和DSS-ER能够对腹腔镜肝切除术进行准确的难度分级,可以指导腹腔镜肝切除临床实践及培训学习;IHD腹腔镜肝切除术难度评分系统的建立值得进一步探讨。
Objective To investigate the clinical practicality of the difficulty scoring system for BAN laparoscopic hepatectomy( DSS-B) and the difficulty scoring system based on resection range for laparoscopic hepatectomy( DSS-ER). Methods A retrospective analysis was performed for the clinical data of 201 patients who underwent laparoscopic hepatectomy in the Department of Hepatopancreatobiliary Surgery in our hospital from August 2015 to November 2017. DSS-B and DSS-ER were used to determine the difficulty of laparoscopic hepatectomy in 151 patients with tumor,and the perioperative data were compared between different difficulty groups. DSS-ER was used to determine the difficulty of laparoscopic hepatectomy in 50 patients with intrahepatic bile duct stones,and the perioperative data were compared between different difficulty groups. A comparative analysis was performed for DSS-B and DSS-ER. Results Among the 151 patients with tumor,there were significant differences between diffe-rent DSS-B difficulty groups in the time of operation,intraoperative blood loss,rate of intraoperative blood transfusion,rate of hepatic portal occlusion,rate of conversion to laparotomy,and length of postoperative hospital stay( P<0.05),while there were no significant differences in the overall incidence of complications and incidence of serious complications( P>0.05); there were significant differences between different DSS-ER difficulty groups in the time of operation,intraoperative blood loss,rate of intraoperative blood transfusion,rate of hepatic portal occlusion,rate of conversion to laparotomy,overall incidence of complications,and length of postoperative hospital stay( P<0.05),while there was no significant difference in the incidence of serious complications( P>0.05). Among the 50 patients with intrahepatic bile duct stones,there were significant differences between different DSS-ER difficulty groups in the time of operation,intraoperative blood loss,rate of intraoperative blood transfusion,and rate of hepatic portal occlusion( P< 0.05).There was a significant difference in DSS-B score between the groups divided based on DSS-ER( P < 0.01). Conclusion DSS-B and DSS-ER difficulty scoring systems can accurately determine the difficulty of laparoscopic hepatectomy and thus guide the clinical practice and training of laparoscopic hepatectomy. Further studies are needed to establish a difficulty scoring system for laparoscopic hepatectomy in patients with intrahepatic bile duct stones.
Objective To investigate the clinical practicality of the difficulty scoring system for BAN laparoscopic hepatectomy( DSS-B) and the difficulty scoring system based on resection range for laparoscopic hepatectomy( DSS-ER). Methods A retrospective analysis was performed for the clinical data of 201 patients who underwent laparoscopic hepatectomy in the Department of Hepatopancreatobiliary Surgery in our hospital from August 2015 to November 2017. DSS-B and DSS-ER were used to determine the difficulty of laparoscopic hepatectomy in 151 patients with tumor,and the perioperative data were compared between different difficulty groups. DSS-ER was used to determine the difficulty of laparoscopic hepatectomy in 50 patients with intrahepatic bile duct stones,and the perioperative data were compared between different difficulty groups. A comparative analysis was performed for DSS-B and DSS-ER. Results Among the 151 patients with tumor,there were significant differences between diffe-rent DSS-B difficulty groups in the time of operation,intraoperative blood loss,rate of intraoperative blood transfusion,rate of hepatic portal occlusion,rate of conversion to laparotomy,and length of postoperative hospital stay( P<0.05),while there were no significant differences in the overall incidence of complications and incidence of serious complications( P>0.05); there were significant differences between different DSS-ER difficulty groups in the time of operation,intraoperative blood loss,rate of intraoperative blood transfusion,rate of hepatic portal occlusion,rate of conversion to laparotomy,overall incidence of complications,and length of postoperative hospital stay( P<0.05),while there was no significant difference in the incidence of serious complications( P>0.05). Among the 50 patients with intrahepatic bile duct stones,there were significant differences between different DSS-ER difficulty groups in the time of operation,intraoperative blood loss,rate of intraoperative blood transfusion,and rate of hepatic portal occlusion( P< 0.05).There was a significant difference in DSS-B score between the groups divided based on DSS-ER( P < 0.01). Conclusion DSS-B and DSS-ER difficulty scoring systems can accurately determine the difficulty of laparoscopic hepatectomy and thus guide the clinical practice and training of laparoscopic hepatectomy. Further studies are needed to establish a difficulty scoring system for laparoscopic hepatectomy in patients with intrahepatic bile duct stones.
引文
[1]OTSUKA Y,KATAGIRI T,ISHII J,et al.Gas embolism in laparoscopic hepatectomy:what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy[J]?J Hepatobiliary Pancreat Sci,2013,20(2):137-140.
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[3]DAGHER I,O’ROURKE N,GELLERr D A,et al.Laparoscopic major hepatectomy:An evolution in standard of care[J].Ann Surg,2009,250(5):856-860.
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[5]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.
[6]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.e241.
[7]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.
[8]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.
[9]YAN Y,CAI X A,GELLER D A.Laparoscopic liver resection:Areview of current status[J].J Laparoendosc Adv Surg Tech A,2017,27(5):481-486.
[10]DINDO D,DEMARTINES N,CLAVIEN P A.Classification of surgical complications:A new proposal with evaluation in a cohort of 6336 patients and results of a survey[J].Ann Surg,2004,240(2):205-213.
[11]CAUCHY F,FUKS D,NOMI T,et al.Risk factors and consequences of conversion in laparoscopic major liver resection[J].Br J Surg,2015,102(7):785-795.
[12]UCHIDA H,IWASHIT Y,SAGA K,et al.Clinical utility of the difficulty scoring system for predicting surgical time of laparoscopic liver resection[J].J Laparoendosc Adv Surg Tech A,2016,26(9):702-706.
[13]HAN H S,CHO J Y,YOON Y S.Techniques for performing laparoscopic liver resection in various hepatic locations[J].J Hepatobiliary Pancreat Surg,2009,16(4):427-432.
[14]YOON Y S,HAN H S,SHIN S H,et al.Laparoscopic treatment for intrahepatic duct stones in the era of laparoscopy:Laparoscopic intrahepatic duct exploration and laparoscopic hepatectomy[J].Ann Surg,2009,249(2):286-291.
[15]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.
[16]HASEGAWA Y,NITTA H,TAKAHARA T,et al.Safely extending the indications of laparoscopic liver resection:When should we start laparoscopic major hepatectomy[J]?Surg Endosc,2017,31(1):309-316.
[17]WAKABAYASHI G,CHERQUI D,GELLER D A,et al.Recommendations for laparoscopic liver resection:A report from the second international consensus conference held in Morioka[J].Ann Surg,2015,261(4):619-629.
[18]HIBI T,CHERQUI D,GELLER D A,et al.International survey on technical aspects of laparoscopic liver resection:A web-based study on the global diffusion of laparoscopic liver surgery prior to the 2nd International Consensus Conference on Laparoscopic Liver Resection in Iwate,Japan[J].J Hepatobi-liary Pancreat Sci,2014,21(10):737-744.
[19]NOMI T,FUKS D,KAWAGUCHI Y,et al.Learning curve for laparoscopic major hepatectomy[J].Br J Surg,2015,102(7):796-804.
[20]BROWN K M,GELLER D A.What is the learning curve for laparoscopic major hepatectomy[J]?J Gastrointest Surg,2016,20(5):1-7.
[21]KLUGER M D,VIGANO L,BARROSO R,et al.The lear-ning curve in laparoscopic major liver resection[J].Ann Surg,2009,250(5):772.
[22]LEE W,WOO J W,LEE J K,et al.Comparison of learning curves for major and minor laparoscopic liver resection[J].J Laparoendosc Adv Surg Tech A,2016,26(6):457-464.
[23]BAN D,KUDO A,ITO H,et al.The difficulty of laparoscopic liver resection[J].Updates in Surgery,2015,67(2):123.
[24]MAJOR I V,GAO F,STRASBERG S M.Perceived comple-xity 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.
[25]MUANGKAEW P,CHO J Y,HAN H S,et al.Defining surgical difficulty according to the perceived complexity of liver resection:Validation of a complexity classification in patients with hepatocellular carcinoma[J].Ann Surg Oncol,2016,23(8):2602-2609.
[26]LIU X,MIAO X,LIU X,et al.Laparoscopic left hemihepatectomy for treatment of left intrahepatic duct stones[J].Am Surg,2014,80(12):E350-351.
[27]JEONG C Y,KIM K J,HONG S C,et al.Laparoscopic left hemihepatectomy for left intrahepatic duct stones[J].J Korean Surg Soc,2012,83(3):149-154.
[28]IM C,CHO J Y,HAN H S,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.
[29]WAKABAYASHI G,KANEKO H.Can major laparoscopic liver and pancreas surgery become standard practices[J]?J Hepatobiliary Pancreat Sci,2016,23(2):89-91.
[30]HALLET J,BEYFUSS K,MEMEO R,et al.Short and long-term outcomes of laparoscopic compared to open liver resection for colorectal liver metastases[J].Hepatobiliary Surg Nutr,2016,5(4):300-310.
[31]TAKAHARA T,WAKABAYASHI G,BEPPU T,et al.Longterm and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching:A multi-institutional Japanese study[J].J Hepatobiliary Pancreat Sci,2015,22(10):721-727.
[32]CHEN X,YANG J,PENG J,et al.Case-rematched analysis of combined thoracoscopic-laparoscopic versus on open escophagectomy for esophageal squamous cell carcinoma[J].Int J Clin Exp Med,2015,8(8):13516-13532.
[2]NITTA H,SASAKI A,OTSUKA Y,et al.Impact of hybrid techniques on laparoscopic major hepatectomies[J].J Hepatobiliary Pancreat Sci,2013,20(2):111-113.
[3]DAGHER I,O’ROURKE N,GELLERr D A,et al.Laparoscopic major hepatectomy:An evolution in standard of care[J].Ann Surg,2009,250(5):856-860.
[4]陈孝平.腹腔镜肝切除术专家共识(2013版)[J].中国肿瘤临床,2013,40(6):303-307.
[5]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.
[6]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.e241.
[7]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.
[8]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.
[9]YAN Y,CAI X A,GELLER D A.Laparoscopic liver resection:Areview of current status[J].J Laparoendosc Adv Surg Tech A,2017,27(5):481-486.
[10]DINDO D,DEMARTINES N,CLAVIEN P A.Classification of surgical complications:A new proposal with evaluation in a cohort of 6336 patients and results of a survey[J].Ann Surg,2004,240(2):205-213.
[11]CAUCHY F,FUKS D,NOMI T,et al.Risk factors and consequences of conversion in laparoscopic major liver resection[J].Br J Surg,2015,102(7):785-795.
[12]UCHIDA H,IWASHIT Y,SAGA K,et al.Clinical utility of the difficulty scoring system for predicting surgical time of laparoscopic liver resection[J].J Laparoendosc Adv Surg Tech A,2016,26(9):702-706.
[13]HAN H S,CHO J Y,YOON Y S.Techniques for performing laparoscopic liver resection in various hepatic locations[J].J Hepatobiliary Pancreat Surg,2009,16(4):427-432.
[14]YOON Y S,HAN H S,SHIN S H,et al.Laparoscopic treatment for intrahepatic duct stones in the era of laparoscopy:Laparoscopic intrahepatic duct exploration and laparoscopic hepatectomy[J].Ann Surg,2009,249(2):286-291.
[15]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.
[16]HASEGAWA Y,NITTA H,TAKAHARA T,et al.Safely extending the indications of laparoscopic liver resection:When should we start laparoscopic major hepatectomy[J]?Surg Endosc,2017,31(1):309-316.
[17]WAKABAYASHI G,CHERQUI D,GELLER D A,et al.Recommendations for laparoscopic liver resection:A report from the second international consensus conference held in Morioka[J].Ann Surg,2015,261(4):619-629.
[18]HIBI T,CHERQUI D,GELLER D A,et al.International survey on technical aspects of laparoscopic liver resection:A web-based study on the global diffusion of laparoscopic liver surgery prior to the 2nd International Consensus Conference on Laparoscopic Liver Resection in Iwate,Japan[J].J Hepatobi-liary Pancreat Sci,2014,21(10):737-744.
[19]NOMI T,FUKS D,KAWAGUCHI Y,et al.Learning curve for laparoscopic major hepatectomy[J].Br J Surg,2015,102(7):796-804.
[20]BROWN K M,GELLER D A.What is the learning curve for laparoscopic major hepatectomy[J]?J Gastrointest Surg,2016,20(5):1-7.
[21]KLUGER M D,VIGANO L,BARROSO R,et al.The lear-ning curve in laparoscopic major liver resection[J].Ann Surg,2009,250(5):772.
[22]LEE W,WOO J W,LEE J K,et al.Comparison of learning curves for major and minor laparoscopic liver resection[J].J Laparoendosc Adv Surg Tech A,2016,26(6):457-464.
[23]BAN D,KUDO A,ITO H,et al.The difficulty of laparoscopic liver resection[J].Updates in Surgery,2015,67(2):123.
[24]MAJOR I V,GAO F,STRASBERG S M.Perceived comple-xity 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.
[25]MUANGKAEW P,CHO J Y,HAN H S,et al.Defining surgical difficulty according to the perceived complexity of liver resection:Validation of a complexity classification in patients with hepatocellular carcinoma[J].Ann Surg Oncol,2016,23(8):2602-2609.
[26]LIU X,MIAO X,LIU X,et al.Laparoscopic left hemihepatectomy for treatment of left intrahepatic duct stones[J].Am Surg,2014,80(12):E350-351.
[27]JEONG C Y,KIM K J,HONG S C,et al.Laparoscopic left hemihepatectomy for left intrahepatic duct stones[J].J Korean Surg Soc,2012,83(3):149-154.
[28]IM C,CHO J Y,HAN H S,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.
[29]WAKABAYASHI G,KANEKO H.Can major laparoscopic liver and pancreas surgery become standard practices[J]?J Hepatobiliary Pancreat Sci,2016,23(2):89-91.
[30]HALLET J,BEYFUSS K,MEMEO R,et al.Short and long-term outcomes of laparoscopic compared to open liver resection for colorectal liver metastases[J].Hepatobiliary Surg Nutr,2016,5(4):300-310.
[31]TAKAHARA T,WAKABAYASHI G,BEPPU T,et al.Longterm and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching:A multi-institutional Japanese study[J].J Hepatobiliary Pancreat Sci,2015,22(10):721-727.
[32]CHEN X,YANG J,PENG J,et al.Case-rematched analysis of combined thoracoscopic-laparoscopic versus on open escophagectomy for esophageal squamous cell carcinoma[J].Int J Clin Exp Med,2015,8(8):13516-13532.