腹腔镜下肝左叶肝内胆管细胞癌根治术优化三步法的应用价值

Application value of modified three-step technique in laparoscopic radical resection of intrahepatic cholangiocarcinoma of left lobe

目的探讨腹腔镜下肝左叶肝内胆管细胞癌(ICC)根治术优化三步法的临床应用价值。方法回顾性分析2013年1月至2020年3月在福建省立医院行腹腔镜根治术的114例进展期肝左叶ICC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51例,女63例;年龄37~79岁,中位年龄63岁。2013年1月至2017年12月患者采用传统流程"清扫淋巴结-左半肝切除"的腹腔镜根治术(传统组,86例);2018年1月至2020年3月患者采用"预解剖肝门部血管-左半肝切除-淋巴结清扫"的优化三步法流程腹腔镜根治术(优化组,28例)。采用1∶2倾向性评分匹配(PSM)比较两组患者临床资料,围手术期情况比较采用Mann-Whitney U检验,并发症发生率比较采用χ^(2)检验。结果按1∶2 PSM后,优化组28例,传统组56例。优化组手术时间中位数为225(140)min、切肝时间为107(124)min、等待时间为30(6)min、淋巴结清扫时间为76(15)min、术中出血量为200(175)ml,明显少于传统组的270(115)min、150(99)min、112(15)min、92(15)min、300(300)ml(Z=-2.616,-2.676,-7.442,-4.876,-2.008;P<0.05)。优化组淋巴结清扫数为10(5)个、切取的阳性淋巴结数为4(3)个,明显多于传统组的7(5)、3(1)个(Z=2.441,3.044;P<0.05)。优化组住院费用为4.2(0.2)万元,明显低于传统组的4.4(0.6)万元(Z=-3.150,P<0.05)。优化组术后并发症3例,传统组10例,两组总并发症发生率差异无统计学意义(χ^(2)=0.284,P>0.05)。结论腹腔镜下肝左叶ICC根治术优化三步法能提高切肝质量和淋巴结清扫质量,减少出血,缩短手术时间,加快术后恢复。

Objective To evaluate the clinical application value of modified three-step technique in laparoscopic radical resection of intrahepatic cholangiocarcinoma(ICC)of the left lobe.Methods Clinical data of 114 patients with advanced ICC of the left lobe who underwent laparoscopic radical resection in Fujian Provincial Hospital from January,2013 to March,2020 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,51 patients were male and 63 female,aged from 37 to 79 years,with a median age of 63 years.Patients undergoing laparoscopic radical surgery with traditional process of"lymph node dissection-left hepatectomy"from January,2013 to December,2017 were assigned into the traditional group(n=86),and their counterparts receiving modified three-step technique in laparoscopic radical surgery of"pre-dissection of hilar vessels-left hepatectomy-lymph node dissection"from January,2018 to March,2020 were allocated into the modified group(n=28).Clinical data between 2 groups were compared by 1∶2 propensity score matching(PSM).Perioperative conditions were compared by Mann-Whitney U test.The incidence of complications was compared by Chi-square test.Results After 1∶2 PSM,28 cases were allocated in the modified group and56 cases in the traditional group.In the modified group,the median operation time,liver resection time,waiting time,lymph node dissection time and intraoperative blood loss were 225(140)min,107(124)min,30(6)min,76(15)min and 200(175)ml,significantly less than 270(115)min,150(99)min,112(15)min,92(15)min and 300(300)ml in the traditional group(Z=-2.616,-2.676,-7.442,-4.876,-2.008;P<0.05),respectively.In the modified group,the number of lymph node dissection was 10(5),and the number of positive dissected lymph node was 4(3),significantly higher than 7(5)and 3(1)in the traditional group(Z=2.441,3.044;P<0.05).The hospitalization expense in the modified group was 4.2(0.2)×10^(4)Yuan,significantly less compared with 4.4(0.6)×10^(4)Yuan in the traditional group(Z=-3.150,P<0.05).3 cases developed postoperative complications in the modified group and 10 in the traditional group.No significant difference was observed in the total incidence of complications between two groups(χ^(2)=0.284,P>0.05).Conclusions Modified three-step technique in laparoscopic radical resection of ICC of the left lobe can improve the quality of liver resection and lymph node dissection,reduce the intraoperative bleeding,shorten the operation time and accelerate postoperative recovery.