肝门部胆管癌大范围肝切除术前胆道引流作用的临床研究

Role of biliary drainage before major hepatectomy for hilar cholangiocarcinoma:a clinical study

目的评价大范围肝切除治疗伴有梗阻性黄疸的肝门部胆管癌术前胆道引流的作用。方法回顾性研究2005年6月至2011年4月在解放军总医院行大范围肝切除治疗的伴有梗阻性黄疸的肝门部胆管癌患者临床及术前影像学资料,测量预留肝体积,根据公式:余肝体积(RLV)/标准总肝体积(SLV)计算标准余肝率(standardizedremnant liver volume ratio,SRLVR)。根据术前胆道引流与否,分为两个亚组,比较两亚组术后近期结果。结果大范围肝切除治疗的伴有梗阻性黄疸的肝门部胆管癌共117例,所有病例均进行了肝体积测量,平均标准余肝率为52.3%,术后病死率为6.8%,总并发症发生率为41.9%,肝衰竭发生率为14.5%,感染性并发症发生率为9.7%,术后平均住院日数17.8 d(5～64 d)。多因素分析显示,SRLVR≤40%(OR:71.63,95%置信区间:8.07～635.96,P<0.001)和术前总胆红素>186.7μmol/L(OR:17.29,95%置信区间:1.97～151.92,P=0.01)为肝门部胆管癌术后肝衰竭的独立危险因素。SRLVR>40%时术前胆道引流亚组感染性并发症发生率显著高于非引流亚组,两亚组间术后病死率、总并发症发生率、肝衰竭发生率、术后住院日数差异无统计学意义,而SRLVR≤40%时,术前胆道引流亚组术后病死率、肝衰竭发生率、术后住院日数显著小于非引流亚组,两亚组间总并发症发生率、感染性并发症发生率差异无统计学意义。结论肝门部胆管癌伴有梗阻性黄疸患者肝切除术前,SRLVR≤40%时术前胆道引流显著降低术后病死率、肝衰竭发生率及术后住院日数,推荐常规使用术前胆道引流,而SRLVR>40%时术后感染性并发症发生率显著增加,选择性使用术前胆道引流更为合适。

[ Abstract] Objective To evaluate the role of biliary drainage before major hepatectomy for hilar cholangiocarcinoma （HCCA） accompanied by obstructive jaundice. Methods A retrospective analysis of clinical and imaging data was con- ducted among cases of HCCA accompanied by obstructive jaundice and undergone major hepatectomy in General Hospital of PLA between Jun 2005 and Apr 2011. Liver volumetry was conducted individually and the standardized remnant liver vol- ume ratio （SRLVR） was calculated accorcling to a formula： remnant liver volume （RLV）/ standard total liver volume （SLV）. According to whether biliary drainage was conducted or not, all cases were divided into two groups and short-term outcomes between the two groups were compared. Results Altogether, 117 cases of HCCA accompanied by obstructive jaundice underwent major hepatectomy and liver volumetry. The mean SRLVR was 52.3% , the postoperative mortality was 6.8%, the overall postoperative complication rate was 41.9%, the incidence of liver failure was 14.5%, the infectious complication rate was 9.7%, and the mean duration of postoperative hospital stay was 17.8 days （5 -64 days）. The multi- variate analysis showed that SRLVR ~〈40% （ OR：71.63,95 % C I 8.07 - 635.96, P 〈 0.001 ） and preoperative bilirubin 〉 186.7 tLmol/L （ OR ： 17.29, 95% CI 1.97 - 151.92, P = 0.01 ） were independent risk factors for postoperative liver fail- ure individually. Incases with SRLVR 〉 40%, the infectious complication rate in biliary drainage subgroup was significantly higher than that in non-drainage one, but the postoperative mortality, overall morbidity, incidence of liver failure and length of postoperative hospital stay between the two subgroups were not significantly different. In cases with SRLVR ~〈40%, how-ever, the postoperative mortality, incidence of liver failure and length of postoperative stay in biliary drainage subgroup were significantly lower than in non-drainage one, but the overall postoperative morbidity and infectious complication rate between the two subgroups were not significantly different. Conclusion In cases with SRLVR ~〈40%, the application of PBD before liver resection for patients with HCCA accompanied by obstructive jaundice could markedly reduce postoperative mortality, incidence of liver failure and length of postoperative stay. In cases with SRLVR ~ 40%, it can evidently increase the infectious complication rate, so the selective application of PBD in this setting is preferred.