CAJ | 학술논문

目的探讨肝癌伴胆管癌栓术后肝功能衰竭的危险因素,建立术后肝功能衰竭的风险评估模型.方法回顾性分析第二军医大学附属东方肝胆外科医院2002年3月至2011年2月收治的107例接受肝癌切除术的肝癌伴胆管癌栓患者的临床资料.根据术后是否发生肝功能衰竭,将患者分为无肝功能衰竭组(98例)和肝功能衰竭组(9例)进行队列研究.对围手术期可能与肝功能衰竭发生相关的多种因素进行分析,筛选肝癌伴胆管癌栓术后肝功能衰竭的危险因素,并建立肝功能衰竭的风险预测模型.单因素分析采用Logistic二元回归模型,筛选获得有统计学意义的指标纳入Logistic多元回归模型进行多因素分析.结果 107例患者中105例行肝癌切除+胆总管切开取栓术,2例行肝癌切除+肝外胆管切除+胆肠吻合术；手术时间为2.0～5.5 h；术中出血量为200 ～ 3500 ml.无肝功能衰竭组患者中,胸、腹腔积液5例,胆道出血3例,切口感染2例,胆道感染、胆汁漏、上消化道应激性溃疡、胸椎硬膜外血肿各1例.胸椎硬膜外血肿患者经胸椎减压止血治疗后出血停止,但遗留截瘫；其余患者经过对症、支持治疗后痊愈.肝功能衰竭组患者中,2例因术后急性肝功能衰竭抢救无效死亡,7例因术后亚急性肝功能衰竭死亡(排除因肿瘤复发或药物因素死亡).单因素分析结果表明:术前TBil、Alb、Pre-Alb、白球比值(A/G),癌栓分布及术中出血量和术后剩余肝脏体积占全肝体积比与肝癌伴胆管癌栓患者术后发生肝功能衰竭相关(OR=3.017,0.191,0.248,2.681,9.048,4.759,13.714,P＜0.05).多因素分析结果显示:术前TBil＞ 256.5 μmol./L、术前A/G≤1.3和术后剩余肝脏体积占全肝体积比＜50％是肝癌伴胆管癌栓患者术后发生肝功能衰竭的独立危险因素(OR=5.537,11.107,172.450,P＜0.05).术后肝功能衰竭风险预测模型为Z=1.711 ×(术前TBil)+2.408×(术前A/G)+5.150×(术后剩余肝脏体积占全肝体积比)-17.288,Z值越大,术后发生肝功能衰竭的预期风险越高；Z值＞0时,术后发生肝功能衰竭的预期风险＞50％.结论术前TBil＞256.5 μmol/L、术前A/G≤1.3、术后剩余肝脏体积占全肝体积比＜50％是肝癌伴胆管癌栓患者术后发生肝功能衰竭的独立危险因素.采用肝功能衰竭风险预测模型对肝癌伴胆管癌栓患者进行有效的筛选,可降低术后肝功能衰竭的发生率. 目的探討肝癌伴膽管癌栓術後肝功能衰竭的危險因素,建立術後肝功能衰竭的風險評估模型.方法迴顧性分析第二軍醫大學附屬東方肝膽外科醫院2002年3月至2011年2月收治的107例接受肝癌切除術的肝癌伴膽管癌栓患者的臨床資料.根據術後是否髮生肝功能衰竭,將患者分為無肝功能衰竭組(98例)和肝功能衰竭組(9例)進行隊列研究.對圍手術期可能與肝功能衰竭髮生相關的多種因素進行分析,篩選肝癌伴膽管癌栓術後肝功能衰竭的危險因素,併建立肝功能衰竭的風險預測模型.單因素分析採用Logistic二元迴歸模型,篩選穫得有統計學意義的指標納入Logistic多元迴歸模型進行多因素分析.結果 107例患者中105例行肝癌切除+膽總管切開取栓術,2例行肝癌切除+肝外膽管切除+膽腸吻閤術；手術時間為2.0～5.5 h；術中齣血量為200 ～ 3500 ml.無肝功能衰竭組患者中,胸、腹腔積液5例,膽道齣血3例,切口感染2例,膽道感染、膽汁漏、上消化道應激性潰瘍、胸椎硬膜外血腫各1例.胸椎硬膜外血腫患者經胸椎減壓止血治療後齣血停止,但遺留截癱；其餘患者經過對癥、支持治療後痊愈.肝功能衰竭組患者中,2例因術後急性肝功能衰竭搶救無效死亡,7例因術後亞急性肝功能衰竭死亡(排除因腫瘤複髮或藥物因素死亡).單因素分析結果錶明:術前TBil、Alb、Pre-Alb、白毬比值(A/G),癌栓分佈及術中齣血量和術後剩餘肝髒體積佔全肝體積比與肝癌伴膽管癌栓患者術後髮生肝功能衰竭相關(OR=3.017,0.191,0.248,2.681,9.048,4.759,13.714,P＜0.05).多因素分析結果顯示:術前TBil＞ 256.5 μmol./L、術前A/G≤1.3和術後剩餘肝髒體積佔全肝體積比＜50％是肝癌伴膽管癌栓患者術後髮生肝功能衰竭的獨立危險因素(OR=5.537,11.107,172.450,P＜0.05).術後肝功能衰竭風險預測模型為Z=1.711 ×(術前TBil)+2.408×(術前A/G)+5.150×(術後剩餘肝髒體積佔全肝體積比)-17.288,Z值越大,術後髮生肝功能衰竭的預期風險越高；Z值＞0時,術後髮生肝功能衰竭的預期風險＞50％.結論術前TBil＞256.5 μmol/L、術前A/G≤1.3、術後剩餘肝髒體積佔全肝體積比＜50％是肝癌伴膽管癌栓患者術後髮生肝功能衰竭的獨立危險因素.採用肝功能衰竭風險預測模型對肝癌伴膽管癌栓患者進行有效的篩選,可降低術後肝功能衰竭的髮生率.
목적 탐토간암반담관암전술후간공능쇠갈적위험인소,건립술후간공능쇠갈적풍험평고모형.방법 회고성분석제이군의대학부속동방간담외과의원2002년3월지2011년2월수치적107례접수간암절제술적간암반담관암전환자적림상자료.근거술후시부발생간공능쇠갈,장환자분위무간공능쇠갈조(98례)화간공능쇠갈조(9례)진행대렬연구.대위수술기가능여간공능쇠갈발생상관적다충인소진행분석,사선간암반담관암전술후간공능쇠갈적위험인소,병건립간공능쇠갈적풍험예측모형.단인소분석채용Logistic이원회귀모형,사선획득유통계학의의적지표납입Logistic다원회귀모형진행다인소분석.결과 107례환자중105례행간암절제+담총관절개취전술,2례행간암절제+간외담관절제+담장문합술；수술시간위2.0～5.5 h；술중출혈량위200 ～ 3500 ml.무간공능쇠갈조환자중,흉、복강적액5례,담도출혈3례,절구감염2례,담도감염、담즙루、상소화도응격성궤양、흉추경막외혈종각1례.흉추경막외혈종환자경흉추감압지혈치료후출혈정지,단유류절탄；기여환자경과대증、지지치료후전유.간공능쇠갈조환자중,2례인술후급성간공능쇠갈창구무효사망,7례인술후아급성간공능쇠갈사망(배제인종류복발혹약물인소사망).단인소분석결과표명:술전TBil、Alb、Pre-Alb、백구비치(A/G),암전분포급술중출혈량화술후잉여간장체적점전간체적비여간암반담관암전환자술후발생간공능쇠갈상관(OR=3.017,0.191,0.248,2.681,9.048,4.759,13.714,P＜0.05).다인소분석결과현시:술전TBil＞ 256.5 μmol./L、술전A/G≤1.3화술후잉여간장체적점전간체적비＜50％시간암반담관암전환자술후발생간공능쇠갈적독립위험인소(OR=5.537,11.107,172.450,P＜0.05).술후간공능쇠갈풍험예측모형위Z=1.711 ×(술전TBil)+2.408×(술전A/G)+5.150×(술후잉여간장체적점전간체적비)-17.288,Z치월대,술후발생간공능쇠갈적예기풍험월고；Z치＞0시,술후발생간공능쇠갈적예기풍험＞50％.결론 술전TBil＞256.5 μmol/L、술전A/G≤1.3、술후잉여간장체적점전간체적비＜50％시간암반담관암전환자술후발생간공능쇠갈적독립위험인소.채용간공능쇠갈풍험예측모형대간암반담관암전환자진행유효적사선,가강저술후간공능쇠갈적발생솔.
Objective To investigate the risk factors for postoperative liver failure of patients with hepatocellular carcinoma (HCC) and bile duct tumor thrombus through a risk evaluation model.Methods The clinical data of 107 patients with HCC and bile duct tumor thrombus who received hepatic resection at the Eastern Hepatobiliary Surgery Hospital from March 2002 to February 2011 were retrospectively analyzed.All patients were divided into the non-liver failure group (98 patients) and liver failure group (9 patients).Risk factors associated with liver failure were analyzed and a risk evaluation model was established.All data were analyzed using the bivariate regression model,and factors with significance were further analyzed using the multivariate regression model.Results Of the 107 patients,105 received hepatic resection + choledochotomy + thrombectomy and 2 received hepatic resection + extrahepatic bile duct resection + cholangiojejunostomy.The operation time was 2.0-5.5 hours,and the intraoperative blood loss was 200-3500 ml.In the non-liver failure group,5 patients had pleural and peritoneal effusion,3 had biliary bleeding,2 had incisional infection,1 had biliary infection,1 had bile leakage,1 had stress-induced ulcer of upper digestive tract and 1 had thoracic epidural hematoma.The bleeding of the patients with thoracic epidural hematoma was stopped after thoracic spinal decompression,but subsequent paraplegia occurred.In the liver failure group,2 patients died of postoperative acute liver failure,and 7 patients died of postoperative subacute liver failure (death caused by tumor recurrence or medicine was excluded).The results of univariate analysis showed that preoperative total bilirubin,albumin,pre-albumin,albumin/globulin ratio,distribution of tumor thrombus,operative blood loss and ratio of postoperative residual liver volume to the total liver volume were correlated with the postoperative liver failure in patients with HCC and bile duct tumor thrombus (OR =3.017,0.191,0.248,2.681,9.048,4.759,13.714,P ＜ 0.05).The results of multivariate analysis showed that preoperative total bilirubin ＞ 256.5 μmol/L,albumin/globulin ratio ≤ 1.3 and postoperative residual liver volume ＜ 50％ were the independent risk factors of postoperative liver failure (OR =5.537,11.107,172.450,P ＜ 0.05).The risk evaluation model was Z =1.77 × preoperative total bilirubin + 2.408 × preoperative albumin/globulin ratio + 5.150 × ratio of postoperative residual liver volume to the total liver volume-17.288.The risk of postoperative liver failure increased as the increase of Z value.The risk of postoperative liver failure ＞ 50％ when the Z value ＞ 0.Conclusions Preoperative total bilirubin ＞ 256.5μmol/L,albumin/globulin ratio ≤ 1.3 and postoperative residual liver volume ＜ 50％ were the independent risk factors of postoperative liver failure.Risk evaluation model is helpful in screening the risk factors so as to decrease the incidence of postoperative liver failure.