ALPPS一期术后未能行二期手术原因的临床分析

Failure to perform second-stage operation after first one of associating liver partition and portal vein ligation for staged hepatectomy:analysis of 62 cases

目的总结联合肝脏分隔和门静脉结扎二步肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)一期术后未能行二期手术的常见临床原因,进一步探讨影响二期手术进行的危险因素。方法采用横断面研究方法,收集2013年10月至2021年12月期间连续行ALPPS治疗的肝脏肿瘤患者的临床资料。其中男性54例,女性8例,年龄(49.1±10.4)岁。按是否成功行二期手术分为二期手术组和未行二期手术组。收集统计患者未行二期手术的临床原因,分析比较患者肿瘤直径、临床分期、Child-Pugh评分和肝脏分隔方式等基线特征、一期术前术后肝功能(转氨酶、胆红素和白蛋白水平)、术后并发症等临床资料。结果62例患者,有45例患者成功行二期手术,17例患者未行二期手术,其占比为27.4%。未行二期手术患者中开腹ALPPS组2例,射频辅助ALPPS(RALPPS)组11例,腹腔镜ALPPS组4例。在二期手术组和未行二期手术组患者中,肿瘤最大直径、门静脉癌栓形成差异具有统计学意义(P<0.05)。肝功能方面,一期术前白蛋白、总胆红素和一期术后谷草转氨酶、总胆红素两组差异具有统计学意义(P<0.05)。肺部炎症、胸水、腹水为常见一期术后并发症,其中一期术后腹水两组患者差异具有统计学意义(P<0.05),两组患者Ⅲ级及以上并发症发生率差异具有统计学意义(P<0.001)。未行二期手术的患者的临床原因为肝脏未明显增生,未来残肝体积(future liver remnant volume,FLRV)不足,肝脏功能和储备功能差,并发症发生和肿瘤进展。多因素分析显示影响二期手术进行的危险因素为肿瘤最大直径、癌栓形成和一期术后并发症等级。结论对于肿瘤较大、门静脉癌栓形成肝癌患者选择ALPPS手术需慎重。

ObjectiveTo summarize the clinical reasons for failing to perform the second stage of operation after the first stage of operation of associating liver partition and portal vein ligation for staged hepatectomy(ALPPS),and to explore the risk factors affecting the second stage of operation.MethodsA sectional-cross study was conducted on 62 patients(54 males and 8 females,age:49.1±10.4)with liver tumors who were continuously treated with ALPPS from October 2013 to December 2021.The patients were divided into the second stage of operation group and the non-second-stage operation group according to whether they accepted the second stage of operation or not.The clinical reasons why patients were failing to have the second stage of operation were collected.The data of patients,including the tumor diameter,clinical stages,Child-Pugh score,liver separation mode,liver function(levels of transaminase,bilirubin and albumin)in the preoperative and postoperative of first stage operation period,and complications were analyzed.ResultsAmong the 62 patients,45 patients successfully underwent the second stage of operation,and 17 patients failed to accept the second stage of operation,accounting for 27.4%.Among the patients who failed to accept the second stage of operation,there were 2 cases in the open ALPPS group,11 cases in the radiofrequency assisted ALPPS(RALPS)group,and 4 cases in the laparoscopic ALPPS group.The difference of maximum tumor diameter and the formation of portal vein tumor thrombus was statistically significant(P<0.05).In terms of liver function,the differences in the level of albumin and total bilirubin tested before the first stage of operation and the level of aspartate aminotransferase and total bilirubin tested after the first stage of operation were statistically significant(P<0.05).Pulmonary inflammation,pleural effusion and ascites were common complications of the first stage operation.There was significant difference between the 2 groups in complications of ascites of the first stage of operation(P<0.05).There was significant difference in the incidence of complications(≥gradeⅢ)between the 2 groups(P<0.001).The clinical causes that patients failed to accepted the second stage of operation were no obvious liver hyperplasia,insufficient future liver remnant volume(FLRV),poor liver function and hepatic reserve function,complications and progression of tumor.Multivariate analysis showed that the risk factors affecting the second stage of operation were the maximum tumor diameter,the formation of tumor thrombus and the grade of complications of the first stage operation.ConclusionALPPS should be selected carefully for patients with large tumor and portal vein thrombosis.