肝硬化肝细胞癌和非肝硬化肝细胞癌患者肝癌切除术预后因素分析

Prognostic factors of hepatectomy in hepatocellular carcinoma patients with and without liver cirrhosis

目的探讨影响肝硬化肝细胞癌(hepatocellular carcinoma,HCC)和非肝硬化HCC患者预后的相关因素。方法回顾性分析2008年6月至2013年6月于清流县医院和福建医科大学附属孟超肝胆医院行肝癌切除术的224例HCC患者的临床资料。根据术后病理结果分为肝硬化HCC组(HCC-C组,131例)和非肝硬化HCC组(HCC-NC组,93例)。比较两组患者术中情况(包括手术时间、术中出血量、输血率、第一肝门阻断率、肝切除范围和手术方式)和术后情况(包括围术期并发症发生率、围术期病死率),分析影响HCC患者预后的因素。结果 (1)HCC-C组患者术中出血量显著高于HCC-NC组,差异有统计学意义(z=-2.193,P=0.03)。两组患者的手术时间、输血率和肝门阻断率的差异无统计学意义(z=-15.212,P=0.835;χ~2=0.969,P=0.537;χ~2=2.236,P=0.692)。(2)HCC-C组和HCC-NC组患者围术期并发症发生率分别为30.53%(40/131)和21.50%(20/93),差异有统计学意义(χ~2=12.013,P=0.02)。其中HCC-C组和HCC-NC组患者肺部感染、腹腔感染、肝功能衰竭发生率分别为6.11%(8/131)、3.05%(4/131)、5.34%(7/131)和3.23%(3/93)、2.16%(2/93)、1.08%(1/93),差异有统计学意义(χ~2值分别为11.857、4.465、7.326,P值分别为0.04、0.02、0.03)。HCC-C组患者和HCCNC组患者围术期病死率分别为6.11%(8/131)和2.15%(2/93),差异有统计学意义(χ~2=8.352,P=0.04)。(3)多因素分析结果显示:年龄≥60岁、Child-Pugh B级、手术时间> 360分钟、输血、肝切除范围≥3段和肝硬化是影响HCC患者预后的独立危险因素(P均<0.05);ALB <38 g/L、Child-Pugh B级、输血和肝切除范围≥3段是HCC-C组患者围术期发生肝功能衰竭的独立危险因素(P均<0.05);术中出血量> 1200 ml是HCC-NC组患者围术期发生肝功能衰竭的独立危险因素(OR=15.077,95%CI:2.695～84.353,P=0.02)。结论肝硬化是影响HCC患者肝癌切除术预后的独立危险因素。HCC-C组患者出现围术期肝功能衰竭和病死的风险显著高于HCC-NC组患者。

Objective To investigate the prognostic factors of hepatectomy in hepatocellular carcinoma （HCC） patients with and without liver cirrhosis. Methods The clinical data of 224 patients with HCC underwent hepatectomy in Qingliu County Hospital and Mengchao Hepatobiliary Hospital Affiliated to Fujian Medical University from June 2008 to June 2013 were retrospectively analyzed. According to the postoperative pathological results, 131 HCC patients with liver cirrhosis were taken as HCC-C group, 93 HCC patients without liver cirrhosis were taken as HCC-NC group. The intraoperative conditions （including operative time, intraoperative bleeding volume, blood transfusion rate, first hilar occlusion rate, hepatectomy range and operation mode） and postoperative conditions （including perioperative complications, perioperative mortality） were observed and compared between the two groups. Prognostic factors in patients with HCC were analyzed. Results ①The intraoperative bleeding volume of patients in HCC-C group was significantly higher than that in HCC-NC group, the difference was statistically significant （z = -2.193, P = 0.03）. There were no significant differences in operation time, blood transfusion rate and first hilar occlusion rate between the two groups （z = -15.212, P = 0.835; χ 2 = 0.969, P = 0.537; χ 2 = 2.236, P = 0.692）. ②The incidence of perioperative complications in HCC-C group and HCC-NC group were 30.53% （40/131） and 21.50% （20/93）, respectively. The difference was statistically significant （χ 2 = 12.013, P = 0.02）. The incidence rate of pulmonary infection, abdominal infection and liver failure was 6.11% （8/131）, 3.05% （4/131）, 5.34% （7/131） in HCC-C group and 3.23% （3/93）, 2.16% （2/93）, 1.08% （1/93） in HCC-NC group, respectively, and the differences were statistically significant between the two groups （χ 2 = 11.857, 4.465, 7.326; P = 0.04, 0.02, 0.03）. The mortality rate of perioperative period was 6.11% （8/131） in HCC-C group and 2.15% （2/93） in HCC-NC group, respectively, the difference was statistically significant between the two groups （χ 2 = 8.352, P = 0.04）. ③Multivariate analysis results showed that ≥ 60 years old, Child- Pugh B grade, operative time ≥ 360 minutes, transfusion, extent of liver resection≥ 3 segments and liver cirrhosis were the independent risk factors of prognosis for patients with HCC （P 〈 0.05）; ALB 〈 38 g/L, Child-Pugh B grade, trasnfusion and extent of liver resection ≥ 3 segments were the independent risk factors of liver failure in perioperative period for patients in HCC-C group （P 〈 0.05）; blood loss 〉 1200 ml was the independent risk factor of liver failure for patients in HCC-NC group in perioperative period （OR = 15.077, 95%CI： 2.695～84.353, P = 0.02）. Conclusions Liver cirrhosis is an independent risk factor for the prognosis of hepatectomy in patients with HCC. The risk of liver failure and death of patients in HCC-C group is significantly higher than that of patients in HCC-NC group.