肝硬度值预测肝癌肝切除术后并发症的应用价值

Application value of the liver stiffness measurement on complications after hepatectomy

目的探讨肝硬度值预测肝癌患者肝切除术后并发症的应用价值。方法采用回顾性病例对照研究方法。收集2011年1月至2017年4月绵阳市中心医院收治的121例行肝切除术肝癌患者的临床资料。121例患者行肝纤维扫描检查，检测肝硬度值，其中81例行腹腔镜肝切除术，设为腹腔镜组；40例行开腹肝切除术，设为开腹组。观察指标：（1）两组患者术中及术后情况比较。（2）影响肝癌患者术后并发症的危险因素分析。（3）肝硬度值与术后并发症的曲线下面积（AUC）。（4）肝硬度值≤17．5kPa时两组患者术中和术后情况比较。（5）肝硬度值〉17．5kPa时两组患者术中和术后情况比较。（6）肝硬度值≤17．5kPa与肝硬度值〉17．5kPa腹腔镜组患者术中和术后情况比较。计量资料用牙±s表示，两样本均数比较采用t检验，计数资料和单因素比较采用疋。检验或Fisher确切概率法，单因素分析P〈0．1作为纳入多因素分析的条件，多因素分析采用logistic回归模型。肝硬度值术后并发症临界值通过受试者工作特征（ROC）曲线计算。结果（1）两组患者术中及术后情况比较：121例患者均顺利完成手术。腹腔镜组4例患者中转开腹。腹腔镜组患者Pringle阻断为51例，开腹组为17例，两组比较，差异有统计学意义（驴=4．555．P〈0．05）。腹腔镜组和开腹组患者手术时间、术中出血量、术中输血、肝纤维化评分（Ishak评分）、术后并发症、住院时间分别为（248±78）min和（221±78）min、（292±229）mL和（281±194）mL、14例和9例、1～3分为14例和9例、4～6分为67例和31例、29例和10例、（12±7）d和（13±6）d，两组患者上述指标比较，差异均无统计学意义（t=1．843，0．282，x2=0．473，0．473，1．431，t=0．075，P〉0．05）。（2）影响肝癌患者术后并发症的危险因素分析：121例患者中39例出现术后并发症。单因素分析结果显示：吲哚菁绿15min滞留率（ICG R15）、肝硬度值、术中出血量、Ishak评分是影响肝癌患者术后发生并发症的危险因素（x2=7．161，32．490，7．725，2．863，P〈0．1）。多因素分析结果显示：肝硬度值〉15．0kPa是影响肝癌患者术后发生并发症的独立危险因素[比值比（OR）=6．906，95％可信区间为2．307～20．672，P〈0．05]。（3）肝硬度值与术后并发症的AUC：肝切除术后发生并发症的肝硬度值临界值为〉17．5kPa，灵敏度为64．1％，特异度为85．4％，AUC为0．749（95％可信区间：0．662—0．824，P〈0．05）。（4）肝硬度值≤17．5kPa时两组患者术中和术后情况比较：腹腔镜组与开腹组患者住院时间分别为（10±5）d和（13±7）d，两组比较，差异均有统计学意义（t=2．389，P〈0．05）。（5）肝硬度值〉17．5kPa时两组患者术中和术后情况比较：腹腔镜组与开腹组患者手术时间、术中出血量、术后并发症、肝功能不全分别为（277±76）min和（212±109）min、（505±232）mL和（328±250）mL、2l例和4例、17例和2例，两组患者上述指标比较，差异均有统计学意义（t=2．060，2．057．P〈0．05）。（6）肝硬度值≤17．5kPa与肝硬度值〉17．5kPa腹腔镜组患者术中和术后情况比较：肝硬度值≤17．5kPa与肝硬度值〉17．5kPa腹腔镜组患者手术时间、术中出血量、术后并发症、肝功能不全、住院时间分别为（236±76）min和（277±76）min、（197±153）mL和（505±232）mL、8例和21例、3例和17例、（10±5）d和（16±9）d，两组患者上述指标比较，差异有统计学意义（t=0．657，3．398，X2=36．547，36．475，t=17．414，P〈0．05）。结论肝硬度值是肝癌患者肝切除术后发生并发症的独立危险因素，当肝硬度值〉17．5kPa时，腹腔镜肝切除术较开腹肝切除术具有更高的并发症发生危险。

Objective To explore the application value of the liver stiffness measurement （LSM） on complications after hepatectomy. Methods The retrospective case-control study was conducted. The clinical data of 121 hepatocellular carcinoma （HCC） patients who underwent hepatectomy in the Mianyang Central Hospital from January 2011 to April 2017 were collected. All 121 patients received LSM using Fibro Scan, and 81 undergoing laparoscopic liver resection （LR） and 40 undergoing open liver resection （OR） were respectively allocated into the LR and OR groups. Observation indicators： （ 1 ） comparisons of intra- and post-operative situations; （2） risk factors analysis affecting postoperative complication of HCC patients; （3） area under the curve （AUC） of LSM and postoperative complications; （4） comparisons of intra- and post-operative situations, when LSM≤17. 5 kPa; （5） comparisons of intra- and post-operative situations, when LSM 〉 17. 5 kPa; （6） comparisons of intra- and post-operative situations between patients with LSM ~〈 17. 5 kPa and LSM 〉 17. 5 kPa in the LR group. Measurement data were represented as x±s, and mean comparisons between groups were done using the t test. Comparisons of count data and univariate analysis were analyzed using the chi-square test and Fisher exact probability. The multivariate analysis was done using the logistic regression model, using P〈0.01 as a inclusion criteria in the univariate analysis. The critical value of postoperative complication was calculated using the receiver operating characteristic curve （ROC）. Results （ 1 ） Comparisons of intra- and post-operative situations ： all the 121 patients underwent successful surgery, including 4 with conversion to open surgery in the LR group. Cases with Pringle manner were 51 in the LR group and 17 in the OR group, with a statistically significant difference （X2 =4. 555, P〈0.05 ）. Operation time, volume of intraoperative blood loss, ease with intraoperative blood transfusion, Ishak score of 1- 3 and 4-6 scores, postoperative complications and duration of hospital stay were respectively （248±78）minutes, （292±229）mL, 14, 14, 67, 29, （12±7）days in the LR group and （221± 78）minntes, （281±194）mL, 9, 9, 31, 10, （13±6）days in the OR group, with no statistically significant difference between groups （ t = 1. 843, 0. 282, X2 = 0. 473, 0. 473, 1.431, t = 0. 075, P〉0. 05）. （2） Risk factors analysis affecting postoperative complication of HCC patients： 39 of 121 patients had postoperative complications. Results of univariate analysis showed that retention 15-minute rate of indocyanine green （ICG R15） , LSM, volume of intraoperative blood loss and Ishak score were risk factors affecting postoperative complication of HCC patients （X2 = 7. 161, 32. 490, 7. 725, 2. 863, P〈0. 1 ）. Results of multivariate analysis showed that LSM 〉 15.0 kPa was an independent risk factor affecting postoperative complication of HCC patients [ odds ratio （OR）= 6. 906, 95% confidence interval （CI） ： 2. 307 - 20. 672, P〈 0. 05 ]. （ 3 ） AUC of LSM and postoperative complication ： when LSM of postoperative complication 〉 17. 5 kPa, sensitivity, specificity and AUC were respectively 64. 1%, 85.4% and 0. 749 （95%CI： 0. 662-0. 824, P〈0. 05）. （4） Comparisons of intra- and post-operative situations, when LSM ≤ 17.5 kPa ： duration of hospital stay was respectively （10±5） days in the LR group and （13±7） days in the OR group, with a statistically significant difference between groups （t = 2. 389, P〈0.05）. （5） Comparisons of intra- and post-operative situations, when LSM 〉 17.5 kPa： operation time, volume of intraoperative blood loss, cases with postoperative complications and hepatic dysfunction were respectively （277±76） minutes, （505±232） mL, 21, 17 in the LR group and （212± 109）minutes, （328±250）mL, 4, 2 in the OR group, with statistically significant differences between groups （ t = 2. 060, 2. 057, P〈0. 05）. （6） Comparisons of intra- and post-operative situations between patients with LSM ≤ 17.5 kPa and LSM 〉 17.5 kPa in the LR group： operation time, volume of intraoperative blood loss, cases with postoperative complications and hepatic dysfunction and duration of hospital stay were respectively （ 236± 76） minutes, （ 197± 153 ） mL, 8, 3, （ 10± 5 ） days in the LR group and （ 277± 76）minutes, （505±232） mL, 21, 17, （16±9）days in the OR group, with statistically significant differences between groups （t=0.657, 3.398, x2=36.547, 36.475, t=17.414, P〈0.05）. Conclusion LSM is an independent risk factor affecting postoperative complications after hepatectomy, when LSM 〉 17. 5 kPa, LR is associated with higher incidence of postoperative complications compared with OR.