190例胆总管下段癌手术的疗效及预后影响因素分析(多中心研究)

Curative Effects and Logistic Analysis of Prognostic Factors in 190 Cases of Distal Bile Duct Carcinoma(A Multicenter Study)

目的探讨胆总管下段癌的诊断、手术方法和疗效。方法回顾性分析2010年1月至2019年12月湖南省肿瘤医院、海军军医大学附属东方肝胆外科医院、湘潭市中心医院和南华大学附属第二医院的190例胆总管下段癌患者的临床资料,总结其手术方法和疗效。采用Logistic回归分析预后影响因素。结果190例病人中,术前ERCP、MRCP、CT、超声穿刺和MRI阳性检出率分别为93.2%(177/190)、90.5%(172/190)、85.3%(162/190)、64.7%(123/190)和63.2%(120/190)。190例患者均接受手术治疗,其中137例患者行胰十二指肠切除术(pancreaticoduodenectomy,PD),53例患者行胆肠Roux-en-Y吻合术。PD术后并发症发生率为23.4%(32/137),包括B/C级胰瘘8例(5.8%,其中B级6例,C级2例),胆漏5例(3.6%),单纯腹腔感染4例(2.9%),肺部感染3例(2.2%),肠瘘3例(2.2%),胃排空延迟2例(1.5%),术后出血7例(5.1%,其中腹腔术野出血4例,消化道出血3例);发生围手术期死亡5例(3.6%)。53例胆肠Roux-en-Y吻合术的术后并发症发生率为13.2%(7/53),包括胆漏4例(7.5%),单纯腹腔感染1例(1.9%),胰瘘1例(1.9%),肠瘘1例(1.9%)。190例胆总管下段癌患者的1、3、5年总体生存率分别为67.11%、33.94%和15.81%;137例胆总管下段癌PD术患者的1、3、5年总体生存率分别为81.41%、41.26%和19.38%;53例胆肠Roux-en-Y吻合术患者的1、3、5年总体生存率分别为29.28%、14.16%和6.61%。单因素回归分析显示,手术方式、淋巴结转移、转移性淋巴结比率、肿瘤分化程度、TNM分期、门静脉系统侵犯、神经侵犯和术前CA19-9可能是影响远期预后的危险因素(P<0.05);多因素分析显示影响术后生存率的独立危险因素为手术方式、转移性淋巴结比率、肿瘤分化程度和门静脉系统侵犯(P<0.05)。结论胆总管下段癌以腺癌为主,ERCP、MRCP、CT和超声穿刺是其主要的诊断方法。根治性PD术是胆总管下段癌最有效的治疗方法。影响患者预后的独立危险因素为手术方式、转移性淋巴结比率、肿瘤分化程度和门静脉系统侵犯。

Objective To explore the diagnosis,surgical methods,and therapeutic effects of distal bile duct carcinoma.Methods The clinical data of 190 patients with distal bile duct carcinoma admitted in the past 10 years were analyzed retrospectively from January 2010 to December 2019,and the surgical methods and its therapeutic effects were analyzed in Hunan Cancer Hospital,Eastern Hepatobiliary Surgery Hospital of Navy Medical University,Xiangtan Central Hospital and the Second Affiliated Hospital of University of South China.Logistic regression analysis was used for its prognostic factors.Results Of 190 cases,the detectable rate of preoperative ERCP,MRCP,CT,ultrasonically guided fine needle puncture and MRI examination was 93.2%(177/190),90.5%(172/190),85.3%(162/190),64.7%(123/190)and 63.2%(120/190)respectively.There were 137 cases underwent pancreaticoduodenectomy(PD)and 53 cases underwent Roux-en-Y hepaticojejunostomy.The postoperative complication rate of PD was 23.4%(32/137),including pancreatic fistula of 8 cases(5.8%)(grade B,n=6;grade C,n=2),bile leakage of 5 cases(3.6%),intra-abdominal infection of 4 cases(2.9%),pulmonary infection of 3 cases(2.2%),intestinal fistula of 3 cases(2.2%),delayed gastric emptying of 2 cases(1.5%)and postoperative hemorrhage of 7 cases(intraperitoneal hemorrhage of 4 cases,digestive bleeding of 3 cases).And there were 5 deaths(3.6%)in the perioperative period.The postoperative complication rate of Roux-en-Y hepaticojejunostomy was 13.2%(7/53),including bile leakage of 4 cases(7.5%),abdominal infection of 1 case(1.9%),pancreatic fistula of 1 case(1.9%)and intestinal fistula of 1 cases(1.9%).The 1-,3-and 5-year overall survival rate of 190 patients was 67.11%,33.94%and 15.81%respectively.The 1-,3-and 5-year overall survival rate of 137 cases of PD was 81.41%,41.26%and 19.38%respectively.The 1-,3-and 5-year overall survival rate of Roux-en-Y hepaticojejunostomy was 29.28%,14.16%and 6.61%respectively.Univariate analysis showed that the survival rates were related with the surgical procedures,lymph node metastasis,lymph node metastasis rates,tumor differentiation,TNM stage,portal vein system invasion,nerve invasion and preoperative CA19-9(P<0.05).Multivariate analysis demonstrated that the survival rates were related with the surgical procedures,lymph node metastasis rates,tumor differentiation and portal vein system invasion(P<0.05).Conclusions The preoperative ERCP,MRCP,CT and ultrasound puncture are the main diagnostic methods for distal bile duct carcinoma.The radical resection is the most effective treatment,and radical pancreatoduodenectomy is the first choice.The lymph node metastasis rates,tumor differentiation,portal vein system invasion and radical resection are the independent risk factors.Early diagnosis and early treatment of tumor is the key point to improve therapeutic effects of distal bile duct carcinoma.