联合肝脏离断和门静脉结扎二步肝切除术对晚期结直肠癌伴肝转移患者的临床研究

Clinical Study of Combined Liver Dissection and Portal Vein Ligation in Two-step Hepatectomy for Patients with Advanced Colorectal Cancer with Liver Metastases

目的该研究为前瞻性对照研究,旨在从剩余肝脏体积增生速率、肿瘤手术切除率、围术期并发症发生率和死亡率进行联合肝脏离断和门静脉结扎二步肝切除术(associating liver partition and portal vein ligation for staged hepatectomy, ALPPS)和门静脉栓塞后肝切除术(two-stage hepatectomy,TSH)对比研究,探讨ALPPS对晚期结直肠癌伴肝转移治疗的安全性和有效性。方法选取2014年9月-2018年10月在天津医科大学总医院住院的20例患者,其中男性11例,女性9例。行联合肝脏离断和门静脉结扎二步肝切除术(ALPPS)的10例患者为ALPPS组,行门静脉栓塞后肝切除术(TSH)的10例患者为TSH组。通过CT容量分析软件评估剩余肝脏体积(future remnant liver, FLR)大小,s FLR<30%的CRLM患者纳入研究。主要指标为肝肿瘤手术切除率,次要指标包括:①一阶段术中及术后相关指标:术中:两种手术方法一阶段术中出血量;术后:术后7、14、28 d 3个时间点的FLR(mL)和s FLR(%),0~7 d KGR,二阶段手术开始前的血常规、肝功能和凝血功能MELD评分;②二阶段术中、术后相关指标:术中:两种手术方法二阶段术中出血量;术后:治疗失败率,Clavien-Dindo并发症分级,肝切除边缘阴性率,术后30 d死亡率和90 d死亡率。结果 ALPPS组的切除率为90.00%(9/10),TSH组的切除率为50.00%(5/10),OR值为9.0[95%(CI)0.8~100.1],差异无统计学意义(P>0.05);ALPPS组与TSH组比较如下:两组术后Clavien-Dindo≥3a并发症[33.33%(3/9) vs 40.00%(2/5)];30 d的死亡率11.11%(1/9) vs 0.00%(0/10)(χ~2=0.600,P>0.05);90 d的死亡率11.11%vs 20.00%(P>0.05);7 d内FLR增生肥大体积(567±142.0)mL vs (434±139)mL(t=2.12,P<0.05);FLR生长速率为(33.5±8.2)m L/d vs (12.7±4.7)mL/d(t=6.96,P<0.001);sFLR在7 d内达到30%比率[80.00%(8/10)vs30.00%(3/10)(χ~2=5.05,P<0.05)];s FLR在14 d内达到30%比率[90.00%(9/10)vs 40.00%(4/10)(χ~2=5.49,P<0.05)];s FLR在28 d内达到30%比率[90.00%(9/10)vs 50.00%(5/10)(χ~2=3.81,P>0.05)];一阶段所需时间(11±11.0)d vs(43±15)d(t=5.44,P<0.001);肝脏切缘阴性率[88.89%(8/9) vs 60.00%(3/5)(χ~2=1.590,P>0.05)]。结论 ALPPS与TSH具有相同的切缘阴性率,能满足肝肿瘤转移灶最大限度的切除,增加实现R0切除的机会。

Objective This study is a prospective,controlled study of combined liver dissection and portal vein ligation in two-step hepatectomy from residual liver volume hyperplasia,tumor resection rate,perioperative complication rate,and mortality associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)and portal vein embolization(TSH),to investigate the safety and efficacy of ALPPS in the treatment of advanced colorectal cancer with liver metastasis.Methods Twenty patients admitted to the General Hospital of Tianjin Medical University from September 2014 to October 2018 were enrolled,including 11 males and 9 females.Ten patients who underwent two-step liver resection and portal vein ligation(ALPPS)were in the ALPPS group,and 10 patients who underwent portal resection(TSH)were TSH group.The residual remnant liver(FLR)size was assessed by CT volume analysis software,and CRLM patients with sFLR<30%were included in the study.The main indicators were surgical resection rate of liver tumors.Secondary indicators included:1.One-stage intraoperative and postoperative related indicators:intraoperative:two surgical methods in one stage of intraoperative blood loss;postoperative:postoperative 7,14,28 FLR(mL)and sFLR(%)at 3 time points,KGR of 0-7 days,MELD scores of blood routine,liver function and coagulation function before the start of the second-stage operation;2.Intraoperative and postoperative related indicators:intraoperative:two surgical methods of two-stage intraoperative blood loss;postoperative:treatment failure rate,Clavien-Dindo complications grade,liver resection margin negative rate,postoperative 30-day mortality and 90-day mortality.Results The resection rate of ALPPS group was 90.00%(9/10),the resection rate of TSH group was 50.00%(5/10),and the OR value was 9.0[95%(CI)0.8-100.1],The difference was statistically significant(P>0.05);ALPPS group and TSH group were compared as follows:postoperative Clavien-Dindo≥3 a complications in the two groups[33.33%(3/9)vs 40.00%(2/5)];30-day mortality 11.11%(1/9)vs 0.00%(0/10)(χ^2=0.600,P>0.05);90-day mortality11.11%vs 20.00(P>0.05);FLR hypertrophy volume within 7 days(567±142)mL vs(434±89.0)mL(t=2.12,P<0.05);FLR growth rate was(33.5±8.2)mL/d vs(12.7±4.7)mL/d(t=6.96,P<0.001);sFLR reached 30%ratio within 7 days[80.00%(8/10)vs 30.00%(3/10)(χ^2=5.05,P<0.05)];sFLR reached a 30%ratio within 14 days[90.00%(9/10)vs 40.00%(4/10)(χ^2=5.49,P<0.05)];sFLR reached a 30%ratio in 28 days[90.00%(9/10)vs 50.00%(5/10)(χ^2=3.81,P>0.05)];time required for one phase(11±11.0)d vs(43±15.0)d(t=5.44,P<0.001);negative rate of liver margin[88.89%(8/9)vs 60.00%(3/5)(χ^2=1.590,P>0.05)].Conclusion ALPPS and TSH have the same negative margin of margin,which can meet the maximum resection of liver tumor metastases and increase the chance of R0 resection.