CAJ | 학술논문

目的：探讨肝细胞癌（肝癌）破裂亚临床出血患者择期肝切除术后的预后。方法回顾性分析1997年1月至2010年12月在青岛大学医学院附属医院肝胆外科行择期肝切除术的614例肝癌患者临床资料。所有患者均签署知情同意书，符合医学伦理学规定。根据有否出现肝癌破裂亚临床出血，将患者分为破裂组和非破裂组。其中破裂组30例，男25例，女5例，年龄29～73岁，中位年龄55岁；非破裂组584例，男488例，女96例，年龄14～82岁，中位年龄55岁。所有患者均行肝切除术。观察破裂组与非破裂组患者的临床特征。患者术后均接受随访，观察患者存活情况、死亡原因。根据随访结果绘制Kaplan-Meier生存曲线，比较两组患者的存活情况。分析临床参数与破裂组患者预后的关系。两组临床参数比较采用χ2检验或Fisher确切概率法。组间多因素分析采用Logistic回归分析。生存分析和比较采用Kaplan-Meier法和Log-rank检验，预后危险因素分析采用Cox比例风险回归模型分析。结果破裂组中非完全切除、肝切除范围>1段、手术切缘<0.5 cm、术中输血、术中出血量≥1000 ml、肿瘤直径>5 cm和肿瘤组织学低分化者明显多于非破裂组（χ2=37.609，6.021，6.497，20.982，19.498，22.944，8.222；P<0.05）。进一步Logistic回归分析显示，非完全切除和肿瘤直径>5 cm是肝癌破裂亚临床出血的独立危险因素（OR=3.772，5.045；P<0.05）。随访期间破裂组死亡26例，非破裂组死亡316例。Kaplan-Meier分析显示，破裂组的中位生存期为9个月，非破裂组为56个月；破裂组患者肝切除术后的1、3、5年累积生存率分别为50.0%、22.2%、5.9%，非破裂组为86.0%、62.6%、48.9%，差异有统计学意义（χ2=38.879，P<0.05）。Cox比例风险回归模型分析显示，肿瘤组织学低分化是破裂组患者肝切除术后预后的独立危险因素（RR=3.736， P<0.05）。结论非完全切除和肿瘤直径>5 cm是肝癌破裂亚临床出血的独立危险因素。肝癌破裂亚临床出血患者择期肝切除术后预后仍较差，肿瘤组织学低分化是影响其预后的独立危险因素。目的：探討肝細胞癌（肝癌）破裂亞臨床齣血患者擇期肝切除術後的預後。方法迴顧性分析1997年1月至2010年12月在青島大學醫學院附屬醫院肝膽外科行擇期肝切除術的614例肝癌患者臨床資料。所有患者均籤署知情同意書，符閤醫學倫理學規定。根據有否齣現肝癌破裂亞臨床齣血，將患者分為破裂組和非破裂組。其中破裂組30例，男25例，女5例，年齡29～73歲，中位年齡55歲；非破裂組584例，男488例，女96例，年齡14～82歲，中位年齡55歲。所有患者均行肝切除術。觀察破裂組與非破裂組患者的臨床特徵。患者術後均接受隨訪，觀察患者存活情況、死亡原因。根據隨訪結果繪製Kaplan-Meier生存麯線，比較兩組患者的存活情況。分析臨床參數與破裂組患者預後的關繫。兩組臨床參數比較採用χ2檢驗或Fisher確切概率法。組間多因素分析採用Logistic迴歸分析。生存分析和比較採用Kaplan-Meier法和Log-rank檢驗，預後危險因素分析採用Cox比例風險迴歸模型分析。結果破裂組中非完全切除、肝切除範圍>1段、手術切緣<0.5 cm、術中輸血、術中齣血量≥1000 ml、腫瘤直徑>5 cm和腫瘤組織學低分化者明顯多于非破裂組（χ2=37.609，6.021，6.497，20.982，19.498，22.944，8.222；P<0.05）。進一步Logistic迴歸分析顯示，非完全切除和腫瘤直徑>5 cm是肝癌破裂亞臨床齣血的獨立危險因素（OR=3.772，5.045；P<0.05）。隨訪期間破裂組死亡26例，非破裂組死亡316例。Kaplan-Meier分析顯示，破裂組的中位生存期為9箇月，非破裂組為56箇月；破裂組患者肝切除術後的1、3、5年纍積生存率分彆為50.0%、22.2%、5.9%，非破裂組為86.0%、62.6%、48.9%，差異有統計學意義（χ2=38.879，P<0.05）。Cox比例風險迴歸模型分析顯示，腫瘤組織學低分化是破裂組患者肝切除術後預後的獨立危險因素（RR=3.736， P<0.05）。結論非完全切除和腫瘤直徑>5 cm是肝癌破裂亞臨床齣血的獨立危險因素。肝癌破裂亞臨床齣血患者擇期肝切除術後預後仍較差，腫瘤組織學低分化是影響其預後的獨立危險因素。
목적：탐토간세포암（간암）파렬아림상출혈환자택기간절제술후적예후。방법회고성분석1997년1월지2010년12월재청도대학의학원부속의원간담외과행택기간절제술적614례간암환자림상자료。소유환자균첨서지정동의서，부합의학윤리학규정。근거유부출현간암파렬아림상출혈，장환자분위파렬조화비파렬조。기중파렬조30례，남25례，녀5례，년령29～73세，중위년령55세；비파렬조584례，남488례，녀96례，년령14～82세，중위년령55세。소유환자균행간절제술。관찰파렬조여비파렬조환자적림상특정。환자술후균접수수방，관찰환자존활정황、사망원인。근거수방결과회제Kaplan-Meier생존곡선，비교량조환자적존활정황。분석림상삼수여파렬조환자예후적관계。량조림상삼수비교채용χ2검험혹Fisher학절개솔법。조간다인소분석채용Logistic회귀분석。생존분석화비교채용Kaplan-Meier법화Log-rank검험，예후위험인소분석채용Cox비례풍험회귀모형분석。결과파렬조중비완전절제、간절제범위>1단、수술절연<0.5 cm、술중수혈、술중출혈량≥1000 ml、종류직경>5 cm화종류조직학저분화자명현다우비파렬조（χ2=37.609，6.021，6.497，20.982，19.498，22.944，8.222；P<0.05）。진일보Logistic회귀분석현시，비완전절제화종류직경>5 cm시간암파렬아림상출혈적독립위험인소（OR=3.772，5.045；P<0.05）。수방기간파렬조사망26례，비파렬조사망316례。Kaplan-Meier분석현시，파렬조적중위생존기위9개월，비파렬조위56개월；파렬조환자간절제술후적1、3、5년루적생존솔분별위50.0%、22.2%、5.9%，비파렬조위86.0%、62.6%、48.9%，차이유통계학의의（χ2=38.879，P<0.05）。Cox비례풍험회귀모형분석현시，종류조직학저분화시파렬조환자간절제술후예후적독립위험인소（RR=3.736， P<0.05）。결론비완전절제화종류직경>5 cm시간암파렬아림상출혈적독립위험인소。간암파렬아림상출혈환자택기간절제술후예후잉교차，종류조직학저분화시영향기예후적독립위험인소。
Objective To discuss the prognosis of ruptured hepatocellular carcinoma (HCC) patients with subclinical bleeding after elective hepatectomy. Methods Clinical data of 614 patients with HCC who underwent elective hepatectomy in Department of Hepatobiliary Surgery, the Afifliated Hospital of Medical College, Qingdao University from January 1997 to December 2010 were analyzed retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. According to whether the patients had subclinical bleeding following ruptured HCC or not, they were devided into ruptured group (n=30;25 males, 5 females;29 to 73 of age, 55 of median age) and non-ruptured group (n=584;488 males, 96 females;14 to 82 of age, 55 of median age). All the patients underwent hepatectomy. Clinical characters of patients in ruptured group and non-ruptured group were observed. All the patients received follow-up after operations, the survival and causes of death were observed. The Kaplan-Meier survival curves were drawn according to the results of follow-up, and the survival of 2 groups was compared. The relation between the clinical parameters and the prognosis of patients in ruptured group was analyzed. The clinical parameters in 2 groups were compared using Chi-square test or Fisher’s exact probability method. Multiple factors analysis between groups was conducted using Logistic regression analysis. Survival analysis and comparison were conducted using Kaplan-Meier method and Log-rank test. Prognostic risk factor analysis was conducted using Cox proportional hazards regression model analysis. Results The patients with non-radical resection, liver resection range > 1 segment, surgical margin < 0.5 cm, intraoperative transfusion, intraoperative blood loss≥1 000 ml, tumor diameter>5 cm and poorly differentiated tumor in ruptured group were signiifcantly more than those in non-ruptured group (χ2=37.609, 6.021, 6.497, 20.982, 19.498, 22.944, 8.222; P<0.05). Further Logistic regression analysis showed that non-radical resection and tumor diameter>5 cm were the independent risk factors for ruptured HCC with subclinical bleeding (OR=3.772, 5.045;P<0.05). There were 26 deaths in ruptured group and 316 deaths in non-ruptured group during the follow-up. Kaplan-Meier analysis showed that the median survival time was 9 months in ruptured group and 56 months in non-ruptured group. The 1-, 3-, 5-year accumulative survival rate were 50.0%, 22.2%, 5.9%in ruptured group and 86.0%, 62.6%, 48.9%in non-ruptured group respectively, where signiifcant difference was observed (χ2=38.879, P<0.05). Cox proportional hazards regression model analysis showed that poorly differentiated tumor was an independent risk factor for patients in ruptured group after hepatectomy (RR=3.736, P<0.05). Conclusions Non-radical resection and tumor diameter>5 cm are the independent risk factors for ruptured HCC with subclinical bleeding. The prognosis of ruptured HCC patients with subclinical bleeding after elective hepatectomy is still poor, and poorly differentiated tumor is an independent risk factor for it.