腹腔镜结直肠癌根治性切除联合同期腹腔镜或开腹肝大部切除术治疗同时性结直肠癌肝转移的疗效分析

Efficacy of laparoscopic colorectal radical resection combined with simultaneous laparoscopic or open major hepatectomy for synchronous colorectal liver metastases

目的 探讨腹腔镜结直肠癌根治性切除联合同期腹腔镜或开腹肝大部切除术治疗同时性结直肠癌肝转移的临床疗效.方法 采用回顾性队列研究方法.收集2010年7月至2015年9月北京大学第三医院收治的14例同时性结直肠癌肝转移患者的临床资料.其中7例行腹腔镜结直肠癌根治性切除联合腹腔镜肝大部切除术（TLCRMH）设为TLCRMH组,7例行腹腔镜结直肠癌根治性切除联合开腹肝大部切除术（LCROMH）设为LCROMH组.经内镜和影像学检查明确结直肠癌以及肝转移灶情况,通过多学科团队联合会诊,制订诊断与治疗方案.肝切除手术中,全肝行术中超声检查,肝脏切除范围≥3个肝段.收集两组患者（1）手术资料：肝切除方式、RFA、手术时间、术中失血情况（出血量、输血量）、原发灶病理学检查结果（T分期、N分期、神经浸润、脉管侵犯）.（2）术后情况：ICU入住时间、开始进食流质食物时间、术后ALT、术后TBil、术后并发症、术后住院时间.（3）随访结果：患者生存情况和肿瘤复发情况.患者均采用门诊复查的方式随访,术后2年内每3个月复查1次,2年后每6个月复查1次.复查项目包括血清肿瘤标志物、胸部CT、腹部CT、肝脏MRI等;术后1年复查结肠镜.随访时间截至2015年12月.计数资料采用x2检验,正态分布的计量资料用x±s表示,采用t检验;偏态分布的计量资料用M（Qn）和M（范围）表示,采用Mann-Whitney U检验.Kaplan-Meier法绘制生存曲线,并计算总体生存率和无瘤生存率,Log-rank检验进行生存分析.结果 （1）手术情况：TLCRMH组患者中1例行左半肝切除,6例行右半肝切除;LCROMH组患者中7例均行右半肝切除.TLCRMH组4例和LCROMH组6例患者行肝转移灶局部切除或RFA,涉及的肝段为Ⅱ、Ⅲ或Ⅳ段.TLCRMH组和LCROMH组患者的手术时间、术中出血量、术中输血量分别为（651±218） min、（1 387±871）mL、（914 ±641） mL和（535±83） min、（1 357±991）mL、（857±360） mL,两组比较,差异均无统计学意义（t=1.320,0.060,0.206,P＞0.05）.两组患者原发结直肠癌T分期（T2期、T3期、T4期）、N分期（N0期、N1期、N2期）、发生神经浸润、发生脉管侵犯例数分别为1例、5例、1例、3例、4例、0例、3例、2例和0例、4例、3例、1例、4例、2例、2例、3例,两组比较,差异均无统计学意义（x2=2.111,3.000,0.311,0.311,P＞0.05）.（2）术后情况：TLCRMH组和LCROMH组患者开始进流质食物时间、术后ALT、术后TBil、术后并发症、术后住院时间分别为（4.3±1.0）d、（105±47） U/L、（34±25） μmol/L、3例（Dindo-Clavien分级分别为Ⅲa、Ⅲb、Ⅳa级）、（27±21）d和（4.3±1.1）d、（113±57） U/L、（26±11）μmol/L、4例（Dindo-Clavien分级分别为Ⅰ、Ⅰ、Ⅱ、Ⅳa级）、（19±9）d,两组比较,差异均无统计学意义（t=0.079,-0.286,0.806,x2=0.286,t=0.856,P＞0.05）;而TLCRMH组患者ICU入住时间为（2.1±1.6）d,长于LCROMH组的（1.0±0.6）d,两组比较,差异有统计学意义（t=1.804,P＜0.05）.（3）随访结果：14例患者均获得随访,随访时间为3～ 54个月.TLCRMH组和LCROMH组患者平均随访时间分别为15个月（3～39个月）和30个月（11 ～54个月）.随访期间,TLCRMH组和LCROMH组患者术后1、3年总体生存率分别为100.0％、100.0％和85.7％、64.3％,两组比较,差异无统计学意义（x2=0.676,P＞0.05）.TLCRMH组和LCROMH组术后1、2年累积无瘤生存率分别为64.3％、64.3％和42.9％、14.3％,平均累积无瘤生存时间分别为20.5个月和10.9个月,两组患者累积无瘤生存率比较,差异无统计学意义（x2=3.160,P＞0.05）.结论 腹腔镜结直肠癌根治性切除联合腹腔镜肝大部切除术安全可行,在术后并发症发生率和远期预后方面与腹腔镜结直肠癌根治性切除联合开腹肝大部切除术相当.

Objective To explore the clinical effect of laparoscopic colorectal radical resection combined with simultaneous laparoscopic or open major hepatectomy for synchronous colorectal liver metastases （SCRLM）.Methods The retrospective cohort study was adopted.The clinical data of 14 patients with SCRLM who were admitted to the Peking University Third Hospital from July 2010 to September 2015 were collected.Seven patients undergoing total laparoscopic colorectal radical resection combined with major hepatectomy （TLCRMH） were allocated into the TLCRMH group and 7 patients undergoing laparoscopic colorectal radical resection combined with open major hepatectomy （LCROMH） were allocated into the LCROMH group.The statuses of colorectal cancer and metastatic lesions were detected by endoscopy and imaging examination,and diagnostic and therapeutic plans were confirmed through the consultation of muhidisciplinary team.During the hepatectomy,total liver ultrasonography was performed and the extent of liver resection was above 3 hepatic segments.The follow-up of outpatient reexamination was applied to all the patients once every 3 months within postoperative year 2 and once every 6 months after 2 years till December 2015.（1） During operation,method of liver resection,radiofrequency ablation （RFA）,operation time,volumes of intraoperative blood loss and blood transfusion,pathological results of primary lesions （T stage,N stage,nerve invasion and canalis haemalis invasion） were collected.（2） After operation,duration of intensive care unit （ICU） care,time for fluid diet intake,postoperative alanine transaminase （ALT）,total bilirubin （TBil）,complications and duration of hospital stay were collected.（3） Survival of patients and recurrence of tumor were followed up.Count data were analyzed by the chi-sqaure test.Measurement data with normal distribution were presented as x ± s and analyzed using the t test.Measurement data with skewed distribution were described as M（Qn） and M（range） and analyzed using the Mann-Whitney U test.The survival curve was drawn by the Kaplan-Meier method,and overall survival rate and tumor-free survival rate were calculated.The survival analysis was done using the Log-rank test.Results （1） The status of operation：1 and 6 patients in the TLCRMH group underwent respectively left and right hemihepatectomies and 7 patients in the LCROMH group underwent right hemihepatectomy.Four and 6 patients in the TLCRMH and LCROMH groups received local resection of liver metastatic lesions or RFA at segment Ⅱ,Ⅲ or Ⅳ of liver,respectively.The operation time,volumes of intraoperative blood loss and blood transfusion were （651 ± 218）minutes,（1 387 ± 871）mL,（914 ±641）mL in the TLCRMH group and （535 ± 83） minutes,（1 357 ±991）mL,（857 ± 360） mL in the LCROMH group,respectively,with no significant difference between the 2 groups （t =1.320,0.060,0.206,P ＞ 0.05）.The numbers of patients in T2,T3,T4,N0,N1,N2 stages,with nerve invasion and canalis haemalis invasion were 1,5,1,3,4,0,3,2 in the TLCRMH group and 0,4,3,1,4,2,2,3 in the LCROMH group,respectively,showing no significant difference between the 2 groups （x2=2.111,3.000,0.311,0.311,P ＞ 0.05）.（2） After operation,time for fluid diet intake,ALT,TBil,number of patients with complications and duration of hospital stay were （4.3 ± 1.0） days,（105 ± 47） U/L,（34 ± 25） μmol/L,3 （Ⅲ a,Ⅲ b and Ⅳ a grades of Dindo-Clavien grade）,（27 ± 21）days in the TLCRMH group and （4.3 ± 1.1）days,（113 ± 57）U/L,（26 ± 11） μmol/L,4 （Ⅰ,Ⅰ,Ⅱ and Ⅳ a grades of Dindo-Clavien grade）,（19 ± 9）days,respectively,showing no significant difference between the 2 groups （t =0.079,-0.286,0.806,X2 =0.286,t =0.856,P ＞ 0.05）.The duration of ICU care in the TLCRMH and LCROMH groups were （2.1 ± 1.6） days and （1.0 ± 0.6） days,with a significant difference between the 2 groups （t =1.804,P ＜ 0.05）.（3） The status of follow-up：all the patients were followed up for 3-54 months,and the median follow-up time was 15 months （range,3-39 months） in the TLCRMH group and 30 months （range,11-54 months） in the LCROMH group.The 1-,3-year overall survival rates were 100.0％ and 100.0％ in the TLCRMH group and 85.7％ and 64.3％ in the LCROMH group,respectively,showing no significant difference between the 2 groups （x2 =0.676,P ＞ 0.05）.The postoperative 1-,2-year cumulative tumor-free survival rates and overage cumulative tumor-free survival time were 64.3％,64.3％ and 20.5 months in the TLCRMH group and 42.9％,14.3％ and 10.9 months in the LCROMH group,respectively,showing no significant difference between the 2 groups （x2=3.160,P ＞ 0.05）.Conclusion TLCRMH is safe and feasible for patients with SCLM,and it is comparable with LCROMH in the incidence of postoperative complication and long-term outcomes.