食管癌合并肝硬化的外科治疗策略
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摘要
目的探讨食管癌合并肝硬化的外科治疗策略。方法回顾本中心2012-2018年,29例食管癌合并肝硬化患者的治疗情况,观测平均手术时间,平均术中失血量,术后放置胸管时间,胸腔引流液量,血清白蛋白,肝脏相关并发症,肺相关并发症,吻合口瘘,术后90 d死亡率等指标,使用Child-Turcotte-Pugh(CTP)评分及Model for End Stage Liver Disease(MELD)评分,分析术后相关并发症、吻合口瘘和死亡患者与血清白蛋白浓度变化之间的关系及死亡患者与术前评分的关系。结果在18例接受手术的食管癌合并肝硬化患者中,有8例术后出现了肝脏相关并发症;6例发生肺相关并发症;4例吻合口瘘;4例死亡。65.3%的患者术前血清白蛋白<35 g/L。食管癌合并肝硬化术后死亡患者组和发生吻合口瘘组较未死亡组,术后血清白蛋白水平均有显著降低(P <0.05)。食管癌合并肝硬化死亡组患者的MELD评分显著高于未死亡组(P <0.001)。结论对食管癌合并肝硬化患者采用Child分级与MELD评分相结合的方式预测患者面对手术的风险,可以更加优化手术患者的选择,减少患者术后并发症的发生。肝硬化不是食管癌手术的绝对禁忌症,精准的评估以及合理的并发症治疗是最大限度提高患者生存获益的关键。
Objective To investigate the surgical treatment strategy of esophageal cancer patientswith liver cirrhosis. Methods The treatment of 29 patients with esophageal cancer complicated with liver cirrhosis from2012 to 2018 were reviewed. Average operation time and intraoperative blood loss,postoperative chest tube time,chest drainage volume,serum albumin,liver related complications,lung-related complications,anastomotic leakage and 90-day mortality after surgery were observed. Child-Turcotte-Pugh(CTP)score and Model for End Stage Liver Disease(MELD)scores were used to analyzethe relationship of postoperative complications,anastomotic leakage and death with serum albumin concentration and the relationship between death and preoperative score.Results Of the 18 patients who underwent surgery,8 had postoperative liver-related complications;6 pulmonary-related complications;4 anastomotic leakage and 4 died. Of the total,65.3% of the patients had preoperative serum albumin < 35 g/L. Serum albumin levels were significantly lower in dead patients and in patients with anastomotic leakage when compared with those survived(P < 0.05). MELD scores of dead patients were significantly higher than those survived(P < 0.001). Conclusion For esophageal cancer patients with liver cirrhosis,the combination of CTP and MELD score can predict the risk of surgery,which can optimize the choice of patients and reduce postoperative complications. Cirrhosis is not an absolute contraindication to esophageal cancer surgery. Accurate assessment and reasonable treatment for complications are the key to maximizethe survival of patients.
Objective To investigate the surgical treatment strategy of esophageal cancer patientswith liver cirrhosis. Methods The treatment of 29 patients with esophageal cancer complicated with liver cirrhosis from2012 to 2018 were reviewed. Average operation time and intraoperative blood loss,postoperative chest tube time,chest drainage volume,serum albumin,liver related complications,lung-related complications,anastomotic leakage and 90-day mortality after surgery were observed. Child-Turcotte-Pugh(CTP)score and Model for End Stage Liver Disease(MELD)scores were used to analyzethe relationship of postoperative complications,anastomotic leakage and death with serum albumin concentration and the relationship between death and preoperative score.Results Of the 18 patients who underwent surgery,8 had postoperative liver-related complications;6 pulmonary-related complications;4 anastomotic leakage and 4 died. Of the total,65.3% of the patients had preoperative serum albumin < 35 g/L. Serum albumin levels were significantly lower in dead patients and in patients with anastomotic leakage when compared with those survived(P < 0.05). MELD scores of dead patients were significantly higher than those survived(P < 0.001). Conclusion For esophageal cancer patients with liver cirrhosis,the combination of CTP and MELD score can predict the risk of surgery,which can optimize the choice of patients and reduce postoperative complications. Cirrhosis is not an absolute contraindication to esophageal cancer surgery. Accurate assessment and reasonable treatment for complications are the key to maximizethe survival of patients.
引文
[1]曹小琴,孙喜斌.食管癌发病水平及变化趋势[J].中国肿瘤临床,2016,43(21):932-936.
[2]TRIVIN F,BOUCHER E,VAULEON E,et al.Management of esophageal carcinoma associated with cirrhosis:A retrospective case-control analysis[J].J Oncol,2009,2009:173421.
[3]VALMASONIM,PIEROBONES,DE PASQUALCA,et al.Esophageal cancer surgery for patients with concomitant liver cirrhosis:A single-center matched-cohort study[J].Ann Surg Oncol,2017,24(3):763-769.
[4]VALMASONI M,PIEROBON E S,DE PASQUAL C A,et al.Esophageal cancer surgery for patients with concomitant liver cirrhosis:A single-center matched-cohort study[J].Ann Surg Oncol,2017,24(3):763-769.
[5]章燕虹,李游,陈龙,等.2890例住院的肝硬化患者病因和并发症分析[J]实用肝脏病杂志,2018,34(3):344-347.
[6]KALAITZAKISE,GUNNARSDOTTIR S A,JOSEFSSON A,et al.Increased risk for malignant neoplasms among patients with cirrhosis[J].Clin Gastroenterol Hepatol,2011,9(2):168-174.
[7]FEKETE F,BELGHITI J,CHERQUID,et al.Results of esophagogastrectomy for carcinoma in cirrhotic patients.A series of 23 consecutive patients[J].Ann Surg,1987,206(1):74-78.
[8]WANG Z Q,DENG H Y,YANG Y S,et al.Can oesophagectomy be performed for patients with oesophageal carcinoma and concomitant liver cirrhosis?A retrospective study based on a propensity-matched cohort[J].Interact Cardiovasc Thorac Surg,2017,25(3):442-447.
[9]TSOU Y K,LIU C Y,FU K I,et al.Endoscopic submucosal dissection of superficial esophageal neoplasms is feasible and not riskier for patients with liver cirrhosis[J].Dig Dis Sci,2016,61(12):3565-3571.
[10]SOZZIM,SIBONI S,ASTI E,et al.Short-term outcomes of minimally invasive esophagectomy for carcinoma in patients with liver cirrhosis[J]J Laparoendosc Adv Surg Tech A,2017,27(6):592-596.
[11]骆文君,郑媛钰,叶秋,等.肝硬化患者并发肺部感染92例临床分析[J]中华肺部疾病杂志(电子版),2017,10(3):337-339.
[12]桑海威,朱珉,王家宁,等,食管癌术后吻合口延迟愈合对机体免疫及预后的影响[J]实用医学杂志,2015,31(4):592-595.
[13]闵庭明,王启斌.食管癌术后吻合口瘘35例治疗体会[J]实用临床医药杂志,2018,22(11):126-127,132.
[14]田烨,周凌霄,任光国.1208例食管癌患者术后吻合口瘘风险因素分析[J].重庆医学,2014,15(15):1924-1927.
[15]VAN DAELE E,VAN DE PUTTE D,CEELEN W,et al.Risk factors and consequences of anastomotic leakage after Ivor Lewis oesophagectomydagger[J].Interact Cardiovasc Thorac Surg,2016,22(1):32-37.
[2]TRIVIN F,BOUCHER E,VAULEON E,et al.Management of esophageal carcinoma associated with cirrhosis:A retrospective case-control analysis[J].J Oncol,2009,2009:173421.
[3]VALMASONIM,PIEROBONES,DE PASQUALCA,et al.Esophageal cancer surgery for patients with concomitant liver cirrhosis:A single-center matched-cohort study[J].Ann Surg Oncol,2017,24(3):763-769.
[4]VALMASONI M,PIEROBON E S,DE PASQUAL C A,et al.Esophageal cancer surgery for patients with concomitant liver cirrhosis:A single-center matched-cohort study[J].Ann Surg Oncol,2017,24(3):763-769.
[5]章燕虹,李游,陈龙,等.2890例住院的肝硬化患者病因和并发症分析[J]实用肝脏病杂志,2018,34(3):344-347.
[6]KALAITZAKISE,GUNNARSDOTTIR S A,JOSEFSSON A,et al.Increased risk for malignant neoplasms among patients with cirrhosis[J].Clin Gastroenterol Hepatol,2011,9(2):168-174.
[7]FEKETE F,BELGHITI J,CHERQUID,et al.Results of esophagogastrectomy for carcinoma in cirrhotic patients.A series of 23 consecutive patients[J].Ann Surg,1987,206(1):74-78.
[8]WANG Z Q,DENG H Y,YANG Y S,et al.Can oesophagectomy be performed for patients with oesophageal carcinoma and concomitant liver cirrhosis?A retrospective study based on a propensity-matched cohort[J].Interact Cardiovasc Thorac Surg,2017,25(3):442-447.
[9]TSOU Y K,LIU C Y,FU K I,et al.Endoscopic submucosal dissection of superficial esophageal neoplasms is feasible and not riskier for patients with liver cirrhosis[J].Dig Dis Sci,2016,61(12):3565-3571.
[10]SOZZIM,SIBONI S,ASTI E,et al.Short-term outcomes of minimally invasive esophagectomy for carcinoma in patients with liver cirrhosis[J]J Laparoendosc Adv Surg Tech A,2017,27(6):592-596.
[11]骆文君,郑媛钰,叶秋,等.肝硬化患者并发肺部感染92例临床分析[J]中华肺部疾病杂志(电子版),2017,10(3):337-339.
[12]桑海威,朱珉,王家宁,等,食管癌术后吻合口延迟愈合对机体免疫及预后的影响[J]实用医学杂志,2015,31(4):592-595.
[13]闵庭明,王启斌.食管癌术后吻合口瘘35例治疗体会[J]实用临床医药杂志,2018,22(11):126-127,132.
[14]田烨,周凌霄,任光国.1208例食管癌患者术后吻合口瘘风险因素分析[J].重庆医学,2014,15(15):1924-1927.
[15]VAN DAELE E,VAN DE PUTTE D,CEELEN W,et al.Risk factors and consequences of anastomotic leakage after Ivor Lewis oesophagectomydagger[J].Interact Cardiovasc Thorac Surg,2016,22(1):32-37.