肝切除联合血管切除重建治疗肝内胆管癌并血管侵犯疗效与安全性的多中心回顾性研究  

Analysis of the efficacy of hepatectomy combined with vascular resection and reconstruction in treatment of intrahepatic cholangiocarcinoma with vascular invasion:a multi-center retrospective analysis

作　　者：于小鹏 陈家璐 唐玥 陈晨[3] 邱应和 吴泓[5] 宋天强[6] 何宇 毛先海[8] 翟文龙[9] 程张军[10] 梁霄[11] 李敬东[12] 孙传东[13] 马凯[13] 耿智敏[3] 汤朝晖[1] 全志伟[1] YU Xiaopeng;CHEN Jialu;TANG Yue;CHEN Chen;QIU Yinghe;WU Hong;SONG Tianqiang;HE Yu;MAO Xianhai;ZHAI Wenlong;CHENG Zhangjun;LIANG Xiao;LI Jingdong;SUN Chuandong;MA Kai;GENG Zhimin;TANG Zhaohui;QUAN Zhiwei(Department of General Surgery,Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine,Shanghai 200092,China;Department of Oncology,Shanghai Sixth People's Hospital,Shanghai 200030,China;Department of Hepatobiliary Surgery,the First Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710061,China;Department of Biliary Surgery,Oriental Hepatobiliary Hospital Affiliated to Naval Medical University,Shanghai 200433,China;Department of Liver Surgery,West China Hospital of Sichuan University,Chengdu 610041,China;Department of Hepatobiliary Oncology,Tianjin Medical University Cancer Hospital,Tianjin 300060,China;Department of Hepatobiliary Surgery,the Southwest Hospital of Army Medical University,Chongqing 400038,China;Department of Hepatobiliary Surgery,Hunan Provincial People's Hospital,Changsha 410005,China;Department of Hepatopancreatobiliary and Liver Transplantation Surgery,the First Affiliated Hospital of Zhengzhou University,Zhengzhou 450052,China;Department of Hepatobiliary Surgery,Zhongda Hospital of Southeast University,Nanjing 210009,China;Department of Hepatobiliary and Pancreatic Surgery,Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine,Hangzhou 310020,China;Department of Hepatobiliary Surgery,Affiliated Hospital of North Sichuan Medical College,Nanchong,Sichuan 637000,China;Department of Hepatobiliary and Pancreatic Surgery,the Affiliated Hospital of Qingdao University,Qingdao,Shandong 266003,China)

机构地区：[1]上海交通大学医学院附属新华医院普通外科,上海200092 [2]上海市第六人民医院肿瘤科,上海200030 [3]西安交通大学第一附属医院肝胆外科,陕西西安710061 [4]中国人民解放军海军军医大学东方肝胆外科医院胆道外科,上海200433 [5]四川大学华西医院肝脏外科,四川成都610041 [6]天津医科大学肿瘤医院肝胆肿瘤科,天津300060 [7]中国人民解放军陆军军医大学西南医院肝胆外科,重庆400038 [8]湖南省人民医院肝胆外科,湖南长沙410005 [9]郑州大学附属第一医院肝胆胰与肝移植外科,河南郑州450052 [10]东南大学附属中大医院肝胆外科,江苏南京210009 [11]浙江大学医学院附属邵逸夫医院肝胆胰外科,浙江杭州310020 [12]川北医学院附属医院肝胆外科,四川南充637000 [13]青岛大学附属医院肝胆胰外科,山东青岛266003

出　　处：《中国普通外科杂志》2023年第8期1146-1155,共10页China Journal of General Surgery

基　　金：上海交通大学医学院附属新华医院院级临床研究培育基金资助项目(17CSK06);上海交通大学医学院多中心临床研究基金资助项目(DLY201807)。

摘　　要：背景与目的:在过去,大血管(门静脉、下腔静脉等)侵犯被认为是肝内胆管癌(ICC)根治性切除的禁忌证,随着手术技术的进步,目前肝切除联合血管切除重建的安全性逐渐被认可,但其疗效如何尚无定论。因此,本研究通过国内多中心数据探讨ICC并血管侵犯患者肝切除联合血管切除重建的安全性和疗效,以及术后辅助治疗的价值。方法:回顾性收集2010年1月—2021年6月国内12家三甲医院收治的1040例行根治性切除术的ICC患者临床病理资料,包括未发生血管侵犯872例,血管侵犯168例(其中行联合血管切除重建35例,行常规ICC根治术未行血管切除133例)。分析全组及不同类型患者的总生存(OS)时间;在血管侵犯的患者中,分析血管切除重建对患者的主要临床指标与OS时间的影响,以及术后辅助治疗对患者OS时间的影响。结果:全组患者中位OS时间为18(9.4~30.6)个月,无血管侵犯患者中位OS时间为18.51(10~32)个月,血管侵犯患者中,未血管切除患者中位OS时间为16.3(9.4~28)个月,血管切除患者中位OS时间为10(5.5~21.6)个月。生存分析结果显示,血管侵犯患者无论是否行血管切除,OS时间均低于无血管侵犯患者(均P<0.05),血管切除重建对血管侵犯患者的OS无明显改善作用(P=0.662);两两1∶1倾向评分匹配后分析显示,血管侵犯患者无论是否行血管切除,中位OS时间均低于无血管侵犯患者,但差异无统计学意义(无血管侵犯vs.血管切除:26个月vs.21.8个月,P=0.087;无血管侵犯vs.未血管切除:27个月vs.16个月,P=0.068),血管切除重建对血管侵犯患者的OS无明显改善作用(P=0.293)。在血管侵犯的患者中,血管切除重建患者手术时间及术后住院时间均长于未血管切除患者(均P<0.05),而术后并发症等其他临床指标均无明显差异(均P>0.05);同种类型血管侵犯患者的亚组分析结果显示,血管切除重建对不同类型的血管侵犯患者的OS均无改善�Background and Aims:In the past,the invasion of major vessels(such as the portal vein and inferior vena cava)was considered a contraindication for radical resection of intrahepatic cholangiocarcinoma(ICC).With advancements in surgical techniques,the safety of liver resection combined with vascular resection and reconstruction is gradually being recognized,but its efficacy remains inconclusive.Therefore,this study was conducted to investigate the safety and efficacy of liver resection with vascular resection and reconstruction for ICC patients with vascular invasion and the value of postoperative adjuvant therapy using multi-center data from domestic institutions.Methods:The clinicopathologic data of 1040 ICC patients who underwent radical resection between January 2010 and June 2021 in 12 grade A tertiary hospitals in China were retrospectively collected.This cohort included 872 patients without vascular invasion and 168 patients with vascular invasion(among whom 35 underwent combined vascular resection and reconstruction,and 133 underwent conventional radical ICC resection without vascular resection).Overall survival(OS)was analyzed for the entire cohort and patient subgroups.The impact of vascular resection and reconstruction on major clinical variables and OS of patients with vascular invasion and the influence of postoperative adjuvant therapy on OS were analyzed.Results:The median OS for the entire cohort was 18(9.4-30.6)months.The median OS for patients without vascular invasion was 18.51(10-32)months,while for patients with vascular invasion,the median OS was 16.3(9.4-28)months for those without vascular resection and 10(5.5-21.6)months for those with vascular resection and reconstruction.Survival analysis indicated that patients with vascular invasion had lower OS than those without vascular invasion,regardless of whether vascular resection was performed(all P<0.05).Vascular resection and reconstruction did not significantly improve OS for patients with vascular invasion(P=0.662).After 1∶1 propensity sc

关 键 词：胆管肿瘤 胆管 肝内 血管侵犯 血管切除 辅助治疗 

分 类 号：R735.8[医药卫生—肿瘤]