腹腔镜与开腹肝切除术治疗肝细胞癌术后复发模式的倾向性评分研究

Recurrence pattern after laparoscopic versus open hepatectomy for hepatocellular carcinoma:a propensity score matching analysis

目的对比腹腔镜肝切除术(laparoscopic hepatectomy,LH)和开腹肝切除术(open hepatectomy,OH)治疗肝细胞癌的远期疗效并对肝细胞癌术后的复发模式进行探讨。方法按照纳入和排除标准回顾性纳入2015年1月至2018年12月期间四川大学华西医院肝脏外科与肝移植中心行肝切除术的肝细胞癌患者,根据手术方式的不同分为LH组和OH组,按1∶1倾向性评分匹配后比较2组患者术后肝细胞癌的复发情况,同时通过Cox比例风险回归模型进行潜在的复发危险因素分析并构建列线图预测模型。结果本研究共纳入符合标准的977例行肝切除术的肝细胞癌患者,其中LH组385例、OH组592例,按1∶1倾向性评分匹配后每组纳入323例患者进行分析。LH组和OH组分别有124例(38.4%)和118例(36.5%)患者发现肿瘤复发,中位无瘤生存时间分别为10个月和9个月,LH组和OH组的无复发生存曲线比较差异无统计学意义(P=0.763)。最常见的复发模式是肝内复发,最常采用经动脉化学治疗栓塞术治疗,2组复发模式和复发后的治疗方式选择比较差异均无统计学意义(P>0.05)。在整个队列中无一例患者出现标本取出切口或Trocar孔的复发或转移。通过Cox比例风险回归模型分析发现,年龄≤60岁、白蛋白-胆红素分级2级、术后甲胎蛋白>8μg/L、肿瘤直径≥5 cm、多个肿瘤数目、分化程度低分化增加肝细胞癌LH后复发几率(P<0.05),结合临床将这些因素纳入构建的列线图预测肝细胞癌LH后复发的一致性指数为0.704[95%CI(0.659,0.753)]。结论肝内复发仍是肝细胞癌术后复发的最常见模式且LH并不会增加Trocar孔复发或种植的风险。

Objective To compare the long-term outcomes of laparoscopic hepatectomy(LH)and open hepatectomy(OH)in the treatment of hepatocellular carcinoma(HCC),and to discuss the recurrence patterns of HCC after surgery.Methods Patients with HCC who underwent hepatectomy and met inclusion and exclusion criteria from January 2015 to December 2018 were retrospectively enrolled,then were divided into LH and OH groups according to surgical methods.The results of HCC recurrence after LH and OH were compared after 1∶1 propensity score matching between the two groups.The potential risk factors for recurrence were assessed by Cox proportional hazards regression and a nomogram was constructed.Results A total of 977 patients with HCC who underwent hepatectomy were enrolled.Of these,385 underwent LH and 592 underwent OH.After 1∶1 propensity score matching,323 patients were enrolled in each group for analysis.The tumor recurrences were found in 124 patients(38.4%)and 118 patients(36.5%)and the median tumor free survival time was 10 months and 9 months in the LH group and OH group,respectively.The most common recurrence pattern was the intrahepatic recurrence,and the most common treatment was the transarterial chemoembolization.There was no significant difference of the relapse free survival curve between the LH and OH groups(P=0.763).In the entire cohort,no patient had recurrence or metastasis of specimen removal incisions or Trocar pores.No significant differences in the recurrence pattern and treatment between the LH and OH groups(P>0.05).Cox proportional hazards regression analysis showed that the age≤60 years old,grade 2 of albumin-bilirubin grade,postoperative alpha fetoprotein>8μg/L,tumor diameter≥5 cm,multiple tumors,and low differentiation increased the recurrence of HCC after LH(P<0.05).The nomogram including these factors and combining with clinical practice was constructed,its consistent index for predicting the recurrence of HCC after LH was 0.704[95%CI(0.659,0.753)].Conclusion Intrahepatic recurrence is still the most common pattern of postoperative HCC recurrence,and LH doesn’t increase risk of incision recurrence or implantation.