肝切除术治疗合并肝门静脉高压的肝细胞癌患者的疗效与安全性

Liver resection for patients with hepatocellular carcinoma and portal hypertension

背景与目的:肝细胞癌(hepatocellular carcinoma,HCC)患者肝硬化伴有肝门静脉高压的比例很高,肝门静脉高压明显增加肝切除术治疗中出血和术后肝功能衰竭的风险。本文旨在评价肝切除术治疗合并肝门静脉高压HCC患者的疗效、安全性,以及肝门静脉高压患者的肝切除术的适应证。方法:回顾性分析2006年1月—2010年12月接受肝切除术治疗的564例肝功能为Child-Pugh A级的HCC患者临床资料,其中486例患者无肝门静脉高压,剩余78例患者合并肝门静脉高压。经倾向性分析校正组间资料平衡后,按1:1比例对患者进行配对。比较两组接受肝切除术患者术后并发症、术后30和90 d死亡率、总生存率和复发率。根据巴塞罗那临床肝癌分期标准(Barcelona Clinic Liver Cancer Staging Classification,BCLC)和手术范围大小行亚组分析。结果:肝门静脉高压组患者的术后并发症、术后30和90 d死亡率均显著高于非肝门静脉高压组(P<0.05)。经随访(平均32.1个月),肝门静脉高压组和非肝门静脉高压组患者术后1、3、5年总生存率分别为75%、45%、32%和90%、66%、48%,差异有统计学意义(P<0.001);复发率分别为31%、57%、73%和26%、53%、67%,差异无统计学意义(P=0.53)。倾向性分析匹配后,两组患者总生存率和复发率相比,差异均无统计学意义(P>0.05)。亚组分析结果显示,在BCLC-A期和接受小范围肝切除术的两组患者中,总生存率的比较差异无统计学意义(P>0.05)。结论:肝门静脉高压并非HCC患者行肝切除术治疗的绝对禁忌证。在合并肝门静脉高压的HCC患者中,BCLC-A期和预计行小范围肝切除术的患者可选择相应肝切除术。

Background and purpose： The proportion of hepatocellular carcinoma （HCC） patients with cirrhosis and portal hypertension （PHT） is high. PHT may increase the risk of hemorrhage and liver failure. The aim of this study was to evaluate the safety and efifcacy of liver resection （LR） for patients with HCC and PHT. Methods：From 2006 to 2010, a total of 564 HCC patients with Child-Pugh A liver function and with （78） or without PHT （486） were retrospective analyzed. Complications after surgry, 30 and 90-day mortality, overall survival （OS）, and recurrence rates were compared between the two groups. Propensity score analysis was also conducted to reduce confounding bias between the groups. Moreover, subgroup analysis based on tumor stage and the range of resection was carried out. Results：The complications after surgry, 30 and 90-day mortality of patients with PHT were signiifcantly higher than those without PHT, before and after propensity analysis （P〈0.05）. After an average follow-up of 32.1 months, the 1-, 3-, 5-year OS of patients with PHT （75%, 45%and 32%） were signiifcantly worse than those without PHT （90%, 66%and 48%;P〈0.001）. However, the 1-, 3-, and 5-year recurrence rates were similar between PHT group （31%, 57%, and 73%） and without PHT group （26%, 53%, and 67%;P=0.53）. Moreover, the OS of the two groups were similar after propensity analysis, and for patients with early stage HCC and those who underwent minor hepatectomy （all P〉0.05）. Conclusion： PHT is not the contraindication of LR for patients with HCC. Those with early stage HCC and who underwent minor hepatectomy are the best candidates to LR therapy.