98例复杂性肝多房棘球蚴病外科治疗方案的比较分析

Treatment of complicated hepatic alveolar echinococcosis: our experience of 98 cases

目的探讨复杂性肝多房棘球蚴病的临床治疗策略,总结治疗经验。方法回顾性分析2015年10月至2017年10月青海大学附属医院收治的复杂性多房棘球蚴病患者资料,根据病灶分布情况,将中晚期或晚期患者纳入本研究,排除肝细粒棘球蚴病患者、早期肝多房棘球蚴病患者、仅行阿苯达唑药物治疗的患者。按照治疗方式分为准根治性切除组、姑息性切除组、肝移植组,分析患者的手术时间、术中出血量、术后并发症及复发随访情况。应用SPSS 20.0统计学软件对数据进行统计分析。结果符合纳入标准的患者98例,其中男40例,女58例,男女性别比1∶1.45;患者年龄5～72岁,平均年龄38岁。准根治性切除组术后并发症发生率为55.7%(34/61),其中低蛋白血症伴胸腔积液18例、肺部感染9例、切口感染3例、胆漏4例;术后复发率14.8%(9/61),随访期间死亡3例。姑息性切除组术后并发症发生率41.4%(12/29),其中胆漏合并残腔感染5例、肺部感染伴胸腔积液3例、 2例梗阻性黄疸、 1例切口感染、 1例胆管鄄支气管漏;术后复发率17.2%(9/29),随访期间死亡3例。准根治性切除与姑息性切除组术后并发症和复发率相比较无统计学意义(P﹥0.05),但在手术时间及出血量方面的差异具有统计学意义(P <0.05)。肝移植组8例患者中,有4例死亡,包括1例急性排斥反应后多器官功能衰竭、 2例凝血功能障碍致消化道出血、 1例肝肾综合症,余4例患者均获得长期生存。结论复杂性肝多房棘球蚴病应针对患者病情制定个体化治疗方案,结合多学科诊疗模式,遵循损伤控制外科原则,以使患者最大化获益。

Objective To explore the clinical treatment strategies for complicated hepatic alveolar echinococcosis and summarize treatment experiences. Methods A retrospective analysis was made on patients with complicated hepatic alveolar echinococcosis admitted to the Affiliated Hospital of Qinghai University from October 2015 to October 2017. According to the distribution of lesions, patients with advanced or mid-stage echinococcosis.were included in the study. Patients with hepatic cystic echinococcosis, early hepatic alveolar echinococcosis, and those treated with albendazole alone were excluded. According to the treatment design, they were divided into the quasi-radical surgical resection group (61 cases), the palliative surgical resection group(29 cases), and the liver transplantation group(8 cases). The operation duration, intraoperative blood loss, postoperative complications, and recurrence during follow-up were analyzed. Data were analyzed with SPSS 20.0. Results Ninety-eight patients were included in the study, including 40 males and 58 females (male to female ratio of 1 ∶ 1.45). The patients aged 5 to 72 years, with an average age of 38 years. The incidence of postoperative complications in the quasi-radical resection group was 55.7% (34/61), including 18 cases of hypoproteinemia accompanied by pleural effusion, 9 with lung infection, 3 with incision infection, and 4 with bile leakage; the recurrence rate was 14.8% (9/61), and 3 died during follow-up. The incidence of postoperative complications in the palliative surgical resection group was 41.4%(12/29), including 5 with bile leakage complicated by residual cavity infection, 3 with pulmonary infection with pleural effusion, 2 with obstructive jaundice, 1 with incision infection, and 1 with bile duct-bronchial leak; the postoperative recurrence rate was 17.2% (9/29), and 3 died during follow-up. There was no significant difference in the postoperative complication incidence or recurrence rate between the quasi-radical resection group and the palliative resection group (P > 0.05), but a significant difference was found in the operation duration and blood loss (P < 0.05). Among the 8 patients who received liver transplantation, 4 died with 1 due to multiple organ failure after acute rejection, 2 gastrointestinal bleeding due to coagulopathy, and 1 hepatorenal syndrome, and the remaining 4 patients had long-term survival. Conclusion The treatment protocol for complicated hepatic alveolar echinococcosis needs to be individualized, in combination with multidisciplinary and highlighting damage control during surgery, in order to maximize patients' benefits.