脾切除对病毒性肝炎肝硬化合并门静脉高压症患者肝癌发生影响的多中心队列研究  

Effect of splenectomy on the risk of hepatocellular carcinoma development among patients with liver cirrhosis and portal hypertension:a multi-institutional cohort study

作　　者：张谞丰[1] 刘阳[2] 李建辉[3] 雷鹏[4] 张兴元 万真[6] 雷霆 张楠[1] 武晓宁 龙志达 李宗芳[2] 王博[1] 刘学民[1] 仵正[1] 陈熹[2] 王健雄[3] 袁鹏[4] 李勇[6] 周军 Pawlik Timothy M. 吕毅[1] Zhang Xufeng;Liu Yang;Li Jianhui;Lei Peng;Zhang Xingyuan;Wan Zhen;Lei Ting;Zhang Nan;Wu Xiaoning;Long Zhida;Li Zongfang;Wang Bo;Liu Xuemin;Wu Zheng;Chen Xi;Wang Jianxiong;Yuan Peng;Li Yong;Zhou Jun;Pawlik Timothy M.;Lyu Yi(Department of Hepatobiliary Surgery,the First Affiliated Hospital of Xi′an Jiaotong University Institute of Advanced Surgical Technology and Engineering,Xi′an Jiaotong University National-Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine,Xi′an 710061,China;Department of General Surgery,the Second Affiliated Hospital of Xi′an Jiaotong University,Xi′an 710004,China;Department of Surgical Oncology,Shaanxi Provincial People′s Hospital Institute of Advanced Surgical Technology and Engineering,Xi′an Jiaotong University National-Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine,Xi′an 710068,China;Department of Hepatobiliary Surgery,General Hospital of Ningxia Medical University,Yinchuan 750003,China;Department of Hepatobiliary Surgery,Binzhou Medical University Hospital,Binzhou 256603,Shandong Province,China;Department of General Surgery,the First Affiliated Hospital of Nanchang University,Nanchang 330006,China;Department of Hepabobiliary Surgery,the Affiliated Hospital of Shanxi University of Chinese Medicine,Xianyang 710077,Shanxi Province,China;Department of General Surgery,Jingzhou Hospital of Tongji Medical College,Huazhong University of Science and Technology Institute of Advanced Surgical Technology and Engineering,Xi′an Jiaotong University National-Local Joint Engineering Research Center for Precision Surgery and Regenerative Medicine,Jingzhou 434022,Hubei Province,China;Department of Surgery,the Ohio State University,Columbus 15213,Ohio,USA)

机构地区：[1]西安交通大学第一附属医院肝胆外科,西安交通大学先进外科技术与工程中心,精准外科与再生医学国家地方联合工程中心,710061 [2]西安交通大学第二附属医院普通外科,710004 [3]陕西省人民医院肿瘤外科,西安交通大学先进外科技术与工程中心,精准外科与再生医学国家地方联合工程中心,710068 [4]宁夏医科大学总医院肝胆外科,银川750003 [5]滨州医科大学附属医院肝胆外科,山东省滨州市256603 [6]南昌大学第一附属医院肝胆外科,330006 [7]陕西省中医药大学第一附属医院肝胆外科,陕西省咸阳市710077 [8]华中科技大学同济医学院附属荆州市医院,西安交通大学先进外科技术与工程中心,精准外科与再生医学国家地方联合工程中心,湖北省荆州市434022 [9]美国俄亥俄州立大学肿瘤外科,美国俄亥俄州哥伦布市15213

出　　处：《中华外科杂志》2021年第10期821-828,共8页Chinese Journal of Surgery

摘　　要：目的探讨脾切除术对肝硬化合并门静脉高压症患者发生肝细胞癌(HCC)的影响。方法回顾性收集2008年1月至2012年12月中国7所三级医院收治的因肝硬化和门静脉高压症继发脾功能亢进行脾切除术的407例患者的病例资料,纳入脾切除组;将同期因肝硬化和门静脉高压症接受药物治疗的464例患者的病例资料纳入非脾切除组。脾切除术中采用开腹或腹腔镜联合或不联合贲门血管离断术。非脾切除组中所有患者均在HCC发生前保守治疗肝硬化和门静脉高压症,未进行经颈静脉肝内门体分流术、脾切除或肝移植术。两组患者均采用相同的HCC监测方案。每3~6个月常规进行腹部超声检查、肝功能检查和甲胎蛋白检查。使用倾向性评分匹配(PSM)对脾切除组和非脾切除组的患者资料进行匹配。采用Kaplan-Meier法计算总体生存率和肝癌累积发生率,采用对数秩和检验比较两组患者的生存率。采用单因素和Cox比例风险回归模型分析影响肝癌发生的相关因素。结果PSM后,两组各233例患者。49例(12.0%)脾切除患者和75例(16.2%)非脾切除患者在随访期间发生了HCC。脾切除组患者1、3、5、7年HCC的累积发生率分别为1%、6%、7%、15%,显著低于非脾切除组1%、6%、15%、23%(HR=0.53,95%CI:0.31~0.91,P=0.028)。多因素分析结果显示,年龄≤40岁、男性、有脾切除史是HCC发生的独立相关因素(HR=0.55,95%CI:0.32~0.95,P=0.031)。脾切除组1、3、5、7年累积生存率分别为100%、97%、91%、86%,而非脾切除组为100%、97%、92%、84%,差异无统计学意义(P=0.899)。与非脾切除组的HCC患者相比,脾切除组发生HCC患者接受肝切除的比例更低(12.2%比33.3%,χ^(2)=7.029,P=0.008)。结论脾切除术可能降低肝硬化合并门静脉高压症患者HCC的发病风险。Objective To identify whether splenectomy for treatment of hypersplenism has any impact on development of hepatocellular carcinoma(HCC)among patients with liver cirrhosis and hepatitis.Methods Patients who underwent splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension between January 2008 and December 2012 were included from seven hospitals in China,whereas patients receiving medication treatments for liver cirrhosis and portal hypertension(non-splenectomy)at the same time period among the seven hospitals were included as control groups.In the splenectomy group,all the patients received open or laparoscopic splenectomy with or without pericardial devascularization.In contrast,patients in the control group were treated conservatively for liver cirrhosis and portal hypertension with medicines(non-splenectomy)with no invasive treatments,such as transjugular intrahepatic portosystemic shunt,splenectomy or liver transplantation before HCC development.All the patients were routinely screened for HCC development with abdominal ultrasound,liver function and alpha-fetoprotein every 3 to 6 months.To minimize the selection bias,propensity score matching(PSM)was used to match the baseline data of patients among splenectomy versus non-splenectomy groups.The Kaplan-Meier method was used to calculate the overall survival and cumulative incidence of HCC development,and the Log-rank test was used to compare the survival or disease rates between the two groups.Univariate and Cox proportional hazard regression models were used to analyze the potential risk factors associated with development of HCC.Results A total of 871 patients with liver cirrhosis and hypertension were included synchronously from 7 tertiary hospitals.Among them,407 patients had a history of splenectomy for hypersplenism(splenectomy group),whereas 464 patients who received medical treatment but not splenectomy(non-splenectomy group).After PSM,233 pairs of patients were matched in adjusted cohorts.The cumulative incidence of HCC diagn

关 键 词：脾切除术 肝硬化 肝细胞癌 门静脉高压症 脾功能亢进 

分 类 号：R512.6[医药卫生—内科学] R575.2[医药卫生—临床医学] R657.6