基于PSM分析腹腔镜肝切除联合Hassab术治疗合并门静脉高压症肝癌疗效

Analysis of clinical efficacy of laparoscopic hepatectomy combined with Hassab's procedure for primary liver cancer complicated with portal hypertension based on propensity score matching

目的基于倾向性评分匹配(PSM)探讨腹腔镜肝切除联合Hassab术治疗合并门静脉高压症原发性肝癌(肝癌)患者的安全性和疗效。方法回顾性分析2013年1月至2019年12月在首都医科大学附属北京地坛医院行肝切除联合Hassab术治疗的82例合并门静脉高压症肝癌患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男62例,女20例;年龄22~70岁,中位年龄52岁。根据手术方式不同分为腹腔镜手术组(腹腔镜组,36例)和开腹手术组(开腹组,46例)。采用PSM将两组患者的基线资料进行1∶1匹配,最终两组各入选25例。比较两组围手术期情况及预后情况。术后住院时间等比较采用Mann-Whitney U检验。并发症发生率比较采用χ^(2)检验。生存分析采用Kaplan-Meier法和Log-rank检验。结果腹腔镜组术后下床活动时间、术后进食时间、术后住院时间中位数分别为3(3)、4(3)、11(6)d,明显低于开腹组的5(1)、5(1)、16(9)d(Z=-4.162,-3.682,-3.785;P<0.05)。腹腔镜组术后总并发症发生率为48%(12/25),明显低于开腹组的76%(19/25)(χ^(2)=4.160,P<0.05)。腹腔镜组以Ⅰ级并发症为主,开腹组以Ⅱ、Ⅲ级并发症为主(P=0.007);腹腔镜组腹腔积液发生率为24%(6/25),明显低于开腹组的52%(13/25)(χ^(2)=4.160,P<0.05)。腹腔镜组术后1、3、5年无瘤生存率分别为88.0%、64.4%和59.0%,开腹组相应为88.0%、75.3%和57.0%;腹腔镜组术后1、3、5年总体生存率分别为95.7%、86.3%、79.1%,开腹组相应为100%、89.8%、80.9%;两组术后无瘤生存率和总体生存率差异无统计学意义(χ^(2)=0.080,0.044;P>0.05)。结论对于合并门静脉高压症肝癌患者,在详细的肝功能评估基础上,采用腹腔镜肝切除联合Hassab术是安全和有效的。与开腹手术相比,腹腔镜肝切除联合Hassab术具有微创、术后恢复快、并发症发生率低的优势。

Objective To evaluate the safety and efficacy of laparoscopic hepatectomy combined with Hassab's procedure in the treatment of primary liver cancer(PLC)complicated with portal hypertension based on propensity score matching(PSM).Methods Clinical data of 82 PLC patients complicated with portal hypertension who underwent hepatectomy combined with Hassab's procedure in Beijing Ditan Hospital affiliated to Capital Medical University from January,2013 to December,2019 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,62 patients were male and 20 female,aged from 22 to 70 years,with a median age of52 years.According to different surgical methods,all patients were divided into the laparoscopic surgery group(n=36)and open surgery group(n=46).Baseline data in two groups were subject to 1∶1 PSM,and 25 patients were enrolled in each group.Perioperative conditions and clinical prognosis were observed between two groups.The length of postoperative hospital stay was compared by Mann-Whitney U test.The incidence of postoperative complications was compared with Chi-square test.Survival analysis was performed by Kaplan-Meier method and Log-rank test.Results In the laparoscopic surgery group,the median off-bed activity time,postoperative feeding time and the length of postoperative hospital stay were 3(3),4(3)and 11(6)d,significantly shorter than 5(1),5(1)and 16(9)d in the open surgery group(Z=-4.162,-3.682,-3.785;P<0.05).The incidence of postoperative complications in the laparoscopic surgery group was 48%(12/25),significantly lower than 76%(19/25)in the open surgery group(χ^(2)=4.160,P<0.05).In the laparoscopic surgery group,postoperative complications were mainly classified as gradeⅠ,whereas gradeⅡandⅢin the open surgery group(P=0.007).In the laparoscopic surgery group,the incidence of ascites was 24%(6/25),significantly lower than 52%(13/25)in the open surgery group(χ^(2)=4.160,P<0.05).In the laparoscopic surgery group,the postoperative 1-,3-and 5-year tumor-free survival rates were 88.0%,64.4%and 59.0%,and 88.0%,75.3%and 57.0%in the open surgery group,respectively.In the laparoscopic surgery group,the postoperative 1-,3-and 5-year overall survival rates were 95.7%,86.3%and 79.1%,and 100%,89.8%and 80.9%in the open surgery group,respectively.No significant differences were noted in the postoperative tumor-free and overall survival rates between two groups(χ^(2)=0.080,0.044;P>0.05).Conclusions Laparoscopic hepatectomy combined with Hassab's procedure is a safe and efficacious treatment for PLC patients complicated with portal hypertension based upon comprehensive liver function evaluation.Compared with open surgery,laparoscopic hepatectomy combined with Hassab's procedure possesses multiple advantages of minimal invasiveness,rapid postoperative recovery and low incidence of postoperative complications.