术中切缘阳性的近端胆管补充切除对肝门部胆管癌患者生存的影响

Impact of additional resection of an intraoperative margin-positive proximal bile duct on the survival rate of patients with hilar cholangiocarcinoma

目的分析切缘阳性的近端胆管补充切除对肝门部胆管癌患者生存的影响。方法回顾分析2000年1月至2017年1月郑州大学第一附属医院行肝门部胆管癌切除患者临床资料。最终入组214例患者,其中男性126例,女性88例,年龄(62.3±17.1)岁。根据近端胆管是否补充切除以及胆管切缘病理情况,将214例患者分为三组,A组(n=161):近端胆管初始切缘阴性即R0切缘;B组(n=21):近端胆管初始为R1切缘补充切除后阴性;C组(n=32):近端胆管初始切缘或补充切除后为R1切缘。生存分析采用Kaplan-Meier法,生存率比较采用log-rank检验。单因素以及多因素Cox回归分析预后影响因素。结果A组、B组、C组患者术后3年累积生存率分别为37.1%、28.6%、0,5年累积生存率为18.5%、10.7%、0。A组与B组患者累积生存率均明显高于C组,差异有统计学意义(均P<0.05)。多因素Cox回归分析,近端胆管R1切缘(HR=3.728,95%CI:2.531~4.936)、切缘宽度>5 mm(HR=0.534,95%CI:0.224~0.857)、T3-4分期(HR=5.655,95%CI:3.174~8.203)是肝门部胆管癌患者根治性手术切除术后总体生存的独立影响因素。结论近端胆管切缘阳性的肝门部胆管癌患者补充切除胆管获得阴性切缘可明显改善生存率。近端胆管R1切缘是肝门部胆管癌患者根治性手术切除术后生存的独立危险因素。

ObjectiveTo study the impact of additional resection of an intraoperative proximal bile duct positive margin on the survival rate of patients with hilar cholangiocarcinoma(HCCA).MethodsThe clinical data of 214 patients with HCCA treated at the First Affiliated Hospital of Zhengzhou University from January 2000 to January 2017 were analyzed.There were 126 males and 88 females,aged(62.3±17.1)years.These patients were divided into three groups according to the pathological status of bile duct margins and whether the proximal bile duct was further resected.Group A consisted of patients with negative margins without additional resection(161 cases).Group B consisted of patients with negative margins after additional resection(21 cases).Group C consisted of patients with R1 resections(32 cases).The Kaplan-Meier method was used for survival analysis and log-rank test was used for inter-group comparison.Univariate and multivariate Cox regression analysis were used to analyze prognostic factors.ResultsThe 3-year and 5-year survival rates of patients in groups A,B,and C were 37.1%,28.6%,0 and 18.5%,10.7%,0,respectively.The cumulative survival rates of patients in group A and group B were significantly higher than that in group C(all P<0.05).Multivariate Cox regression analysis showed that R1 proximal bile duct margin(HR=3.728,95%CI:2.531-4.936),margin width>5 mm(HR=0.534,95%CI:0.224-0.857),and T3-4 staging(HR=5.655,95%CI:3.174-8.203)were independent influencing factors for overall survival of patients with HCCA after attempted radical surgery.ConclusionThe survival rate of patients with HCCA with a positive proximal bile duct margin was significantly improved by further resecting the bile duct to obtain a negative margin.The R1 proximal bile duct margin was an independent risk factor for prognosis in patients with HCCA after attempted radical resection.