肝脏第Ⅵ段肝硬化肝细胞癌患者行不同手术方式的预后比较

Different surgical modalities for hepatocellular carcinoma confined to the Couinaud segment Ⅵ in cirrhotic patients:comparison of the outcomes

目的比较位于肝脏第Ⅵ段肝硬化肝细胞癌患者的不同手术治疗方式的预后情况。方法回顾性分析了从2008年12月至2016年12月行肝切除治疗的2 450位肝硬化肝细胞癌患者,其中有210位于肝脏第Ⅵ段的肝硬化肝细胞癌患者纳入了本研究。纳入病人分为楔形切除组,Ⅵ段切除组,右后叶切除组和右半肝切除4个小组,同时又分为局部切除组(包括楔形切除组和Ⅵ段切除组)和扩大切除组(右后叶切除组和右半肝切除)两个大组。本文分析比较了不同手术方式的围手术期结果,以及1. 3. 5年总体生存率(OS)和无病生存率(DFS)。结果楔形切除组、Ⅵ段切除组、右后叶切除组和右半肝切除组所占的比例分别是22. 4%(47)、44. 3%(93)、19. 5%(41)、13. 8%(29)。局部切除组的手术时间、术中出血量、平均住院日、术后并发症及手术切缘均少于扩大切除组(P <0. 05)。楔形切除组和Ⅵ段切除组就术中出血量、平均住院日及术后并发症方面没有统计学差异(P> 0. 05)。楔形切除组的1、3、年OS和DFS均低于第Ⅵ段切除组,右后叶切除组和右半肝切除组(P <0. 05)。Ⅵ段切除组,右后叶切除组和右半肝切除组1、3、5年OS和DFS无明显差异(P> 0. 05).围术期没有患者出现死亡。Cox多因素回归分析显示Ⅵ段肝切除(0S:HR=0. 56,P=0. 028. DFS:HR=0. 68,P=0. 018),右后叶肝切除(0S:HR=0. 63,P=0. 015,DFS:HR=0. 48,P=0. 029),右半肝切除(0S:HR=0. 61,P=0. 018. DFS:HR=0. 54,P=0. 031)能提高肝癌患者总体生存率和无病生存率,楔形肝切除(0S:HR=1. 36,P=0. 032. DFS:HR=1. 69,P=0. 014),肿瘤数目(≥2)(0S:HR=1. 48,P=0. 026. DFS:HR=1. 61,P=0. 022),肿瘤直径(≥5 cm)(0S:HR=1. 73,P=0. 014. DFS:HR=1. 89,P=0. 013)能降低肝癌患者总体生存率和无病生存率。结论对于肿瘤位于肝脏第Ⅵ段的肝硬化肝细胞癌患者来说,解剖性Ⅵ段切除是一种有效可行的手术治疗方式,不仅能做到肿瘤学根治并且能保存大部分有功能的肝组织。手术切除方式、肿瘤数目(≥2)、肿瘤直径(≥5 cm)是肝癌患者预后影响因素。

Objective To compare the outcomes of cirrhotic patients with hepatocellular carcinoma (HCC) confined to the Couinaud segment Ⅵ undergoing different surgical modalities for tumor resection. Methods We retrospectively reviewed the data of 2450 patients undergoing hepatectomy for HCC during the period from December, 2008 to December, 2016, and 210 cirrhotic patients with HCC in the Couinaud segment Ⅵ were enrolled in this study. The enrolled patients underwent local resection [wedge resection (WR) or segmentectomy of the segment VI] or extensive resection [right posterior sectionectomy (RPS) or right hepatectomy (RH)]. We compared the perioperative outcomes, disease-free survival (DFS) and overall survival (OS) rates at 1, 3 and 5 years between the patients receiving local and extensive resection and also among the 4 subgroups treated with different surgical modalities. Results Of the total of 210 patients, 47 (22.4%) underwent WR, 93 (44.3%) received segmentectomy, 41 (19.5%) had RPS and 29 (13.8%) had RH. Compared with extensive resection, local resection of the tumor was associated with a shorter operation time, shorter hospital stay, less blood loss, lower postoperative morbidity and narrower surgical margins (P<0.05). No significant difference was found in the hospital stay, blood loss or postoperative morbidity between the patients receiving WR and segmentectomy (P>0.05). Among the 4 surgical modalities, WR was associated with the poorest DFS and OS rates at 1, 3 and 5 years (P<0.05), and these rates did not differ significantly among the other 3 modalities (P>0.05). No perioperative mortality occurred in the overall patients. Multivariate Cox regression analysis suggested that segmentectomy (OS: HR=0.56, P=0.028; DFS: HR=0.68, P=0.018), RPS (OS: HR=0.63, P=0.015; DFS: HR=0.48, P=0.029) and RH (OS: HR=0.61, P=0.018; DFS: HR=0.54, P=0.031) improved the OS and DFS of the patients, while WR (OS: HR=1.36, P=0.032; DFS: HR=1.69, P=0.014), a tumor number ≥2(OS: HR=1.48, P=0.026; DFS: HR=1.61, P=0.022) and a tumor diameter ≥5cm (OS: HR=1.73, P=0.014; DFS: HR=1.89, P=0.013) were associated with lowered OS and DFS of the patients. Conclusion For cirrhotic patients with HCC confined to the segment Ⅵ, anatomic segmentectomy of the segment Ⅵ can be an effective surgical modality that not only achieves oncologically radical tumor resection but also preserves the functional parenchyma. The surgical approaches, tumor number (≥2) and tumor diameter (≥5 cm)are all factors affecting the prognosis of the patients.