肝癌合并肝硬化患者行腹腔镜肝切除术后并发症的Clavien-Dindo分级及危险因素

Risk factors and Clavien-Dindo classification of surgical complications after laparoscopic hepatectomy for hepatocarcinoma with cirrhosis

目的:探讨腹腔镜肝切除(laparoscopic hepatectomy,LH)治疗肝癌合并肝硬化术后并发症的Clavien-Dindo分级情况及危险因素。方法:回顾性分析2013年1月至2016年12月于郑州大学附属洛阳中心医院行LH的134例肝癌合并肝硬化患者,根据Clavien-Dindo分级系统分析LH术后并发症的发生情况,并分析其相关危险因素。结果:术后30例患者出现并发症,发生率为22.39%,其中3例患者死亡,病死率为2.24%。按照Clavien-Dindo分级系统,Ⅰ级6例,Ⅱ级6例,Ⅲ级11例,Ⅳ级4例,Ⅴ级3例。单因素分析结果显示术后并发症与美国麻醉医师协会分级(American Society of Anesthesiologist,ASA)、Child-Pugh分级、15 min吲哚氰绿滞留率(indocyanine green retention at15 minutes,ICGR15)、肝硬化程度、剩余肝体积/全肝体积比(future liver volume/total liver volume,FLV/TLV)和术者经验有关(P<0.05),与年龄、性别、巴塞罗那分期、Edmonson分级、白蛋白、总胆红素、凝血酶原时间、甲胎蛋白、病毒性肝炎、病灶大小、病灶个数、卫星灶、微血管侵犯、包膜、腹水、手术出血量、手术时间、肝切除方式、肝门阻断、术中输血和联合胆囊切除无关(P>0.05)。多因素分析结果显示,ASA Ⅲ级、ICGR15≥20%和重度肝硬化是术后并发症发生的独立危险因素(P<0.05),而FLV/TLV≥50%和术者经验≥40例是术后并发症发生的独立保护因素(P<0.05)。结论:肝癌合并肝硬化患者行LH术后并发症发生率较高,尤其是合并ASA分级高、肝功能储备差、重度肝硬化和术者经验缺乏者。

Objective： To investigate risk factors and Clavien-Dindo classification of surgical complications after laparoscopic hepatectomy（LH） for hepatocarcinoma with cirrhosis. Methods： Clinical data of 134 patients who underwentLH for hepatocarcinoma with cirrhosis in our hospital from Jan. 2013 to Dec. 2016 were reviewed. The surgical complications were analyzed according to Clavien-Dindo classification and its risk factors were evaluated. Results： Of 134 patients, 30 cases（22.39%） had postoperative surgical complications and3 cases（2.24%） died. According to the Clavien-Dindo classification, 6 cases were detected in grade Ⅰ,6 cases in grade Ⅱ, 11 cases in grade Ⅳ and 3 cases in grade Ⅴ. Univariate analysis identified the following risk factors as American Society of Anesthesiologist（ASA） classification, Child-Pugh grade, indocyanine green retention at 15 minutes（ICGR15）, degree of cirrhosis, future liver volume/total liver volume（FLV/TLV） and surgical experience（P〈0.05）. But age, gender, staging of Barcelona Clinic Liver Cancer, Edmonson classification, albumin, total bilirubin, prothrombin time, α-fetoprotein, viral hepatitis, lesion size, number of lesions, satellite opacities, micro vascular invasion, tumor capsule, ascites, blood loss, operation time, type of hepatectomy, hepatic portal occlusion, intraoperative blood transfusion and cholecystectomy did not have a significant effect on occurrence of postoperative surgical complications（P〈0.05）. Logistic regression analysis revealed that ASA grade Ⅲ, ICGR15 ≥20% and severe cirrhosis were independent risk factors（P〈0.05）.However, FLV/TLV ≥50% and surgical experience ≥40 cases were independent protective factors（P〈0.05）.Conclusion： The hepatocarcinoma patients with cirrhosis underwent LH have a high incidence of postoperative surgical complications, especially with high degree of ASA, poor liver function reserve, severe cirrhosis, large extent of hepatectomy, and lack of surgical experience.