目的 评价精准肝脏外科理念和技术对大范围肝切除围手术期安全性的影响.方法 回顾性分析1986年1月至2012年1月解放军总医院1250例行大范围肝切除(≥3个肝段)肝病患者的临床资料.按照收治的时间将患者分为传统手术组(459例,1986年1月至2006年12月)与精准手术组(791例,2007年1月至2012年1月).比较两组患者的围手术期状况,分析影响并发症发生率和病死率等危险因素.采用门诊、信件及电话随访,随访时间截至2012年12月.计量资料采用独立样本t检验,非正态分布的数据采用非参数Mann-Whitney U检验,计数资料采用x2检验.单因素分析采用x2检验,多因素分析采用二元Logistic回归分析.采用Kaplan-Meier法计算患者生存率,生存分析采用Log-rank检验.结果 传统手术组规则性肝切除术和不规则性肝切除术所占比例分别为62.31％ (286/459)和37.69％(173/459),精准手术组分别为85.59(677/791)和14.41％(114/791),两组比较,差异有统计学意义(x2=88.98,88.98,P＜0.05).传统手术组右半肝切除术、左半肝切除术、扩大左半肝切除术所占比例分别为18.52％(85/459)、29.85％(137/459)和3.05 (14/459),低于精准手术组的28.45％(225/791)、37.67％(298/791)和6.32％(50/791),两组比较,差异有统计学意义(x2=15.35,7.84,6.40,P＜0.05).传统手术组采用Pringle法入肝血流阻断和选择性血流阻断的比例分别为66.01％(303/459)和12.42％ (57/459),精准手术组分别为27.18％ (215/791)和31.73％(251/791),两组比较,差异有统计学意义(x2=180.49,58.35,P＜0.05).传统手术组手术时间、术中中位出血量、术中输血率、术后住院时间、术后并发症发生率和病死率分别为(291±124)min、750 ml、62.75％(288/459)、(18 ±14)d、26.36％(121/459)和3.49％(16/459),精准手术组分别为(337±142)min、550 ml、35.40％(280/791)、(14±9)d、20.73％(164/791)和1.52％(12/791),两组比较,差异有统计学意义(t=-5.74,Z=-2.01,x2=87.62,t=5.90,x2=5.23,5.14,P＜0.05).单因素分析结果显示:年龄＞60岁、肝硬化、入肝血流阻断、手术时间＞360 min、术中出血量＞800 ml、术中输血、血管重建、术前TBil＞ 17.1 μmol/L、术前Alb＜ 35 g/L与并发症的发生相关(x2=5.16,6.64,6.33,4.82,32.01,44.91,4.75,8.42,9.36,P＜0.05);肝硬化、术中出血量＞800 ml、术中输血及术前PLT＜ 100×109/L与病死率相关(x2=4.21,22.31,12.68,32,25,P＜0.05).多因素分析结果显示:术中出血量＞ 800 ml、术中输血、人肝血流阻断及术前Alb＜ 35 g/L是并发症发生的独立危险因素(OR=2.642,2.515,1.637,1.796,P＜0.05);术中出血量＞800 ml、术中输血及术前PLT＜ 100×109/L是影响病死率的独立危险因素(OR=1.325,1.682,3.742,P＜0.05).传统手术组345例与精准手术组651例患者获得随访,随访时间为11 ～ 96个月.传统手术组中肝细胞癌患者的1、3、5年生存率分别为83.5％、51.6％、42.0％,精准手术组中肝细胞癌患者的1、3年生存率分别为85.4％、63.8％,两组患者3年生存率比较,差异有统计学意义(x2=3.96,P＜0.05).传统手术组中肝门部胆管癌患者术后1、3、5年生存率分别为63.1％、31.4％、26.7％,精准手术组中肝门部胆管癌患者术后1、3年的生存率分别为71.3％、48.1％,两组患者3年生存率比较,差异有统计学意义(x2=3.95,P＜0.05).结论 精准肝脏外科理念和技术的应用,显著降低了大范围肝切除患者的围手术期并发症发生率及病死率,提高了手术安全性,具有重要的临床应用价值.
目的 評價精準肝髒外科理唸和技術對大範圍肝切除圍手術期安全性的影響.方法 迴顧性分析1986年1月至2012年1月解放軍總醫院1250例行大範圍肝切除(≥3箇肝段)肝病患者的臨床資料.按照收治的時間將患者分為傳統手術組(459例,1986年1月至2006年12月)與精準手術組(791例,2007年1月至2012年1月).比較兩組患者的圍手術期狀況,分析影響併髮癥髮生率和病死率等危險因素.採用門診、信件及電話隨訪,隨訪時間截至2012年12月.計量資料採用獨立樣本t檢驗,非正態分佈的數據採用非參數Mann-Whitney U檢驗,計數資料採用x2檢驗.單因素分析採用x2檢驗,多因素分析採用二元Logistic迴歸分析.採用Kaplan-Meier法計算患者生存率,生存分析採用Log-rank檢驗.結果 傳統手術組規則性肝切除術和不規則性肝切除術所佔比例分彆為62.31％ (286/459)和37.69％(173/459),精準手術組分彆為85.59(677/791)和14.41％(114/791),兩組比較,差異有統計學意義(x2=88.98,88.98,P＜0.05).傳統手術組右半肝切除術、左半肝切除術、擴大左半肝切除術所佔比例分彆為18.52％(85/459)、29.85％(137/459)和3.05 (14/459),低于精準手術組的28.45％(225/791)、37.67％(298/791)和6.32％(50/791),兩組比較,差異有統計學意義(x2=15.35,7.84,6.40,P＜0.05).傳統手術組採用Pringle法入肝血流阻斷和選擇性血流阻斷的比例分彆為66.01％(303/459)和12.42％ (57/459),精準手術組分彆為27.18％ (215/791)和31.73％(251/791),兩組比較,差異有統計學意義(x2=180.49,58.35,P＜0.05).傳統手術組手術時間、術中中位齣血量、術中輸血率、術後住院時間、術後併髮癥髮生率和病死率分彆為(291±124)min、750 ml、62.75％(288/459)、(18 ±14)d、26.36％(121/459)和3.49％(16/459),精準手術組分彆為(337±142)min、550 ml、35.40％(280/791)、(14±9)d、20.73％(164/791)和1.52％(12/791),兩組比較,差異有統計學意義(t=-5.74,Z=-2.01,x2=87.62,t=5.90,x2=5.23,5.14,P＜0.05).單因素分析結果顯示:年齡＞60歲、肝硬化、入肝血流阻斷、手術時間＞360 min、術中齣血量＞800 ml、術中輸血、血管重建、術前TBil＞ 17.1 μmol/L、術前Alb＜ 35 g/L與併髮癥的髮生相關(x2=5.16,6.64,6.33,4.82,32.01,44.91,4.75,8.42,9.36,P＜0.05);肝硬化、術中齣血量＞800 ml、術中輸血及術前PLT＜ 100×109/L與病死率相關(x2=4.21,22.31,12.68,32,25,P＜0.05).多因素分析結果顯示:術中齣血量＞ 800 ml、術中輸血、人肝血流阻斷及術前Alb＜ 35 g/L是併髮癥髮生的獨立危險因素(OR=2.642,2.515,1.637,1.796,P＜0.05);術中齣血量＞800 ml、術中輸血及術前PLT＜ 100×109/L是影響病死率的獨立危險因素(OR=1.325,1.682,3.742,P＜0.05).傳統手術組345例與精準手術組651例患者穫得隨訪,隨訪時間為11 ～ 96箇月.傳統手術組中肝細胞癌患者的1、3、5年生存率分彆為83.5％、51.6％、42.0％,精準手術組中肝細胞癌患者的1、3年生存率分彆為85.4％、63.8％,兩組患者3年生存率比較,差異有統計學意義(x2=3.96,P＜0.05).傳統手術組中肝門部膽管癌患者術後1、3、5年生存率分彆為63.1％、31.4％、26.7％,精準手術組中肝門部膽管癌患者術後1、3年的生存率分彆為71.3％、48.1％,兩組患者3年生存率比較,差異有統計學意義(x2=3.95,P＜0.05).結論 精準肝髒外科理唸和技術的應用,顯著降低瞭大範圍肝切除患者的圍手術期併髮癥髮生率及病死率,提高瞭手術安全性,具有重要的臨床應用價值.
목적 평개정준간장외과이념화기술대대범위간절제위수술기안전성적영향.방법 회고성분석1986년1월지2012년1월해방군총의원1250례행대범위간절제(≥3개간단)간병환자적림상자료.안조수치적시간장환자분위전통수술조(459례,1986년1월지2006년12월)여정준수술조(791례,2007년1월지2012년1월).비교량조환자적위수술기상황,분석영향병발증발생솔화병사솔등위험인소.채용문진、신건급전화수방,수방시간절지2012년12월.계량자료채용독립양본t검험,비정태분포적수거채용비삼수Mann-Whitney U검험,계수자료채용x2검험.단인소분석채용x2검험,다인소분석채용이원Logistic회귀분석.채용Kaplan-Meier법계산환자생존솔,생존분석채용Log-rank검험.결과 전통수술조규칙성간절제술화불규칙성간절제술소점비례분별위62.31％ (286/459)화37.69％(173/459),정준수술조분별위85.59(677/791)화14.41％(114/791),량조비교,차이유통계학의의(x2=88.98,88.98,P＜0.05).전통수술조우반간절제술、좌반간절제술、확대좌반간절제술소점비례분별위18.52％(85/459)、29.85％(137/459)화3.05 (14/459),저우정준수술조적28.45％(225/791)、37.67％(298/791)화6.32％(50/791),량조비교,차이유통계학의의(x2=15.35,7.84,6.40,P＜0.05).전통수술조채용Pringle법입간혈류조단화선택성혈류조단적비례분별위66.01％(303/459)화12.42％ (57/459),정준수술조분별위27.18％ (215/791)화31.73％(251/791),량조비교,차이유통계학의의(x2=180.49,58.35,P＜0.05).전통수술조수술시간、술중중위출혈량、술중수혈솔、술후주원시간、술후병발증발생솔화병사솔분별위(291±124)min、750 ml、62.75％(288/459)、(18 ±14)d、26.36％(121/459)화3.49％(16/459),정준수술조분별위(337±142)min、550 ml、35.40％(280/791)、(14±9)d、20.73％(164/791)화1.52％(12/791),량조비교,차이유통계학의의(t=-5.74,Z=-2.01,x2=87.62,t=5.90,x2=5.23,5.14,P＜0.05).단인소분석결과현시:년령＞60세、간경화、입간혈류조단、수술시간＞360 min、술중출혈량＞800 ml、술중수혈、혈관중건、술전TBil＞ 17.1 μmol/L、술전Alb＜ 35 g/L여병발증적발생상관(x2=5.16,6.64,6.33,4.82,32.01,44.91,4.75,8.42,9.36,P＜0.05);간경화、술중출혈량＞800 ml、술중수혈급술전PLT＜ 100×109/L여병사솔상관(x2=4.21,22.31,12.68,32,25,P＜0.05).다인소분석결과현시:술중출혈량＞ 800 ml、술중수혈、인간혈류조단급술전Alb＜ 35 g/L시병발증발생적독립위험인소(OR=2.642,2.515,1.637,1.796,P＜0.05);술중출혈량＞800 ml、술중수혈급술전PLT＜ 100×109/L시영향병사솔적독립위험인소(OR=1.325,1.682,3.742,P＜0.05).전통수술조345례여정준수술조651례환자획득수방,수방시간위11 ～ 96개월.전통수술조중간세포암환자적1、3、5년생존솔분별위83.5％、51.6％、42.0％,정준수술조중간세포암환자적1、3년생존솔분별위85.4％、63.8％,량조환자3년생존솔비교,차이유통계학의의(x2=3.96,P＜0.05).전통수술조중간문부담관암환자술후1、3、5년생존솔분별위63.1％、31.4％、26.7％,정준수술조중간문부담관암환자술후1、3년적생존솔분별위71.3％、48.1％,량조환자3년생존솔비교,차이유통계학의의(x2=3.95,P＜0.05).결론 정준간장외과이념화기술적응용,현저강저료대범위간절제환자적위수술기병발증발생솔급병사솔,제고료수술안전성,구유중요적림상응용개치.
Objective To evaluate the effects of concept and techniques of precision hepatic surgery on the perioperative safety of patients who received major hepatectomy.Methods The clinical data of 1250 patients with hepatic diseases who received major hepatectomy at the Chinese PLA General Hospital from January 1986 to January 2012 were retrospectively analyzed.All the patients were divided into 2 groups,459 patients who were admitted from January 1986 to December 2006 were in the traditional surgery group,and 791 patients who were admitted from January 2007 to January 2012 were in the precision surgery group.The perioperative conditions of the patients in the 2 groups were compared,and the risk factors of morbidity and mortality were analyzed.The patients were followed up via out-patient examination,mail or telephone till December 2012.The measurement data,non-normal data and count data were analyzed using independent sample t test,non-parametric MannWhitney U test and chi-square test,respectively.The univariate and multivariate analysis were done using the chisquare test and bivariate Logistic regression analysis,respectively.The survival rates were calculated by using the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results The ratios of anatomical hepatectomy and unanatomical hepatectomy were 62.31％ (286/459) and 37.69％ (173/459) in the traditional surgery group,and 85.59％ (677/791) and 14.41％ (114/791) in the precision surgery group,with significant difference between the 2 groups (x2 =88.98,88.98,P ＜ 0.05).The ratios of right hemihepatectomy,left hemihepatectomy and extended left hemihepatectomy were 18.52％ (85/459),29.85％ (137/459) and 3.05％ (14/459)in the traditional surgery group,which were significantly lower than 28.45 ％ (225/791),37.67 ％ (298/791) and 6.32％ (50/791) in the precision surgery group (x2=15.35,7.84,6.40,P ＜ 0.05).The ratios of hepatic inflow occlusion with Pringle maneuver and selective inflow occlusion were 66.01％ (303/459) and 12.42％ (57/459)in the traditional surgery group,27.18％ (215/791) and 31.73％ (251/791) in the precision surgery group,with significant difference between the 2 groups (x2=180.49,58.35,P ＜ 0.05).The operation time,median volume of intraoperative blood loss,ratio of intraoperative blood transfusion,duration of postoperative hospital stay,morbidity and mortality were (291 ± 124)minutes,750 ml,62.75％ (288/459),(18± 14)days,26.36％ (121/459)and 3.49％ (16/459) in the traditional surgery group,and (337 ± 142) minutes,550 ml,35.40％ (280/791),(14±9) days,20.73％ (164/791) and 1.52％ (12/791) in the precision surgery group,with significant difference between the 2 groups (t =-5.74,Z =-2.01,x2 =87.62,t =5.90,x2 =5.23,5.14,P ＜ 0.05).The results of univariate analysis showed that age ＞ 60 years,hepatic cirrhosis,hepatic inflow occlusion,operation time ＞360 minutes,volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion,vessel reconstruction,preoperative total bilirubin ＞ 17.1 μmol/L,preoperative albumin ＜35 g/L were correlated with the morbidity (x2=5.16,6.64,6.33,4.82,32.01,44.91,4.75,8.42,9.36,P ＜ 0.05) ; hepatic cirrhosis,volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion and preoperative platelet ＜ 100 × 109/L were correlated with the mortality (x2=4.21,22.31,12.68,32.25,P ＜ 0.05).The results of multivariate analysis showed that volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion,hepatic inflow occlusion and preoperative albumin ＜ 35 g/L were the independent risk factors of morbidity (odds ratio =2.642,2.515,1.637,1.796,P ＜ 0.05) ; volume of intraoperative blood loss ＞ 800 ml,intraoperative blood transfusion and preoperative platelet ＜ 100 x 109/L were the independent risk factors of mortality (odds ratio =1.325,1.682,3.742,P ＜ 0.05).A total of 345 patients in the traditional surgery group and 651 patients in the precision surgery group were followed up for 11-96 months.The 1-,3-,5-year survival rates of patients with primary liver cancer in the traditional surgery group were 83.5％,51.6％,42.0％,and the 1-,3-year survival rates of patients with primary liver cancer of the precision surgery group were 85.4％ and 63.8％.There was a significant difference in the 3-year survival rate between the 2 groups (x2 =3.96,P ＜ 0.05).The 1-,3-,5-year survival rates of patients with hilar cholangiocarcinoma of the traditional surgery group were 63.1％,31.4％ and 26.7％,and the 1-,3-year survival rates of patients with hilar cholangiocarcinoma of the precision surgery group were 71.3％ and 48.1％.There was a significant difference in the 3-year survival rate between the 2 groups (x2 =3.95,P ＜ 0.05).Conclusion Application of the concept and techniques of precision hepatic surgery significantly decreases the perioperative morbidity and mortality,increase the safety and improves the long-term efficacy of treatment.
