肝切除联合血管切除重建治疗肝内胆管癌并血管侵犯疗效与安全性的多中心回顾性研究

Analysis of the efficacy of hepatectomy combined with vascular resection and reconstruction in treatment of intrahepatic cholangiocarcinoma with vascular invasion:a multi-center retrospective analysis

背景与目的:在过去,大血管(门静脉、下腔静脉等)侵犯被认为是肝内胆管癌(ICC)根治性切除的禁忌证,随着手术技术的进步,目前肝切除联合血管切除重建的安全性逐渐被认可,但其疗效如何尚无定论。因此,本研究通过国内多中心数据探讨ICC并血管侵犯患者肝切除联合血管切除重建的安全性和疗效,以及术后辅助治疗的价值。方法:回顾性收集2010年1月—2021年6月国内12家三甲医院收治的1040例行根治性切除术的ICC患者临床病理资料,包括未发生血管侵犯872例,血管侵犯168例(其中行联合血管切除重建35例,行常规ICC根治术未行血管切除133例)。分析全组及不同类型患者的总生存(OS)时间;在血管侵犯的患者中,分析血管切除重建对患者的主要临床指标与OS时间的影响,以及术后辅助治疗对患者OS时间的影响。结果:全组患者中位OS时间为18(9.4~30.6)个月,无血管侵犯患者中位OS时间为18.51(10~32)个月,血管侵犯患者中,未血管切除患者中位OS时间为16.3(9.4~28)个月,血管切除患者中位OS时间为10(5.5~21.6)个月。生存分析结果显示,血管侵犯患者无论是否行血管切除,OS时间均低于无血管侵犯患者(均P<0.05),血管切除重建对血管侵犯患者的OS无明显改善作用(P=0.662);两两1∶1倾向评分匹配后分析显示,血管侵犯患者无论是否行血管切除,中位OS时间均低于无血管侵犯患者,但差异无统计学意义(无血管侵犯vs.血管切除:26个月vs.21.8个月,P=0.087;无血管侵犯vs.未血管切除:27个月vs.16个月,P=0.068),血管切除重建对血管侵犯患者的OS无明显改善作用(P=0.293)。在血管侵犯的患者中,血管切除重建患者手术时间及术后住院时间均长于未血管切除患者(均P<0.05),而术后并发症等其他临床指标均无明显差异(均P>0.05);同种类型血管侵犯患者的亚组分析结果显示,血管切除重建对不同类型的血管侵犯患者的OS均无改善作用(均P>0.05);无论是否行血管切除重建,术后辅助治疗对患者的OS均有一定的改善作用,但差异均无统计学意义(均P>0.05)。结论:血管侵犯是ICC患者预后的危险因素,血管切除重建不能明显改善患者预后,且可能增加患者手术时间及术后住院时间。对血管侵犯是ICC患者术后进行辅助治疗可能有助于改善预后。

Background and Aims:In the past,the invasion of major vessels(such as the portal vein and inferior vena cava)was considered a contraindication for radical resection of intrahepatic cholangiocarcinoma(ICC).With advancements in surgical techniques,the safety of liver resection combined with vascular resection and reconstruction is gradually being recognized,but its efficacy remains inconclusive.Therefore,this study was conducted to investigate the safety and efficacy of liver resection with vascular resection and reconstruction for ICC patients with vascular invasion and the value of postoperative adjuvant therapy using multi-center data from domestic institutions.Methods:The clinicopathologic data of 1040 ICC patients who underwent radical resection between January 2010 and June 2021 in 12 grade A tertiary hospitals in China were retrospectively collected.This cohort included 872 patients without vascular invasion and 168 patients with vascular invasion(among whom 35 underwent combined vascular resection and reconstruction,and 133 underwent conventional radical ICC resection without vascular resection).Overall survival(OS)was analyzed for the entire cohort and patient subgroups.The impact of vascular resection and reconstruction on major clinical variables and OS of patients with vascular invasion and the influence of postoperative adjuvant therapy on OS were analyzed.Results:The median OS for the entire cohort was 18(9.4-30.6)months.The median OS for patients without vascular invasion was 18.51(10-32)months,while for patients with vascular invasion,the median OS was 16.3(9.4-28)months for those without vascular resection and 10(5.5-21.6)months for those with vascular resection and reconstruction.Survival analysis indicated that patients with vascular invasion had lower OS than those without vascular invasion,regardless of whether vascular resection was performed(all P<0.05).Vascular resection and reconstruction did not significantly improve OS for patients with vascular invasion(P=0.662).After 1∶1 propensity score matching,the median OS for patients with vascular invasion remained lower than those without vascular invasion,but the differences were not statistically significant(non-vascular invasion vs.vascular resection:26 months vs.21.8 months,P=0.087;non-vascular invasion vs.non-vascular resection:27 months vs.16 months,P=0.068),and vascular resection and reconstruction did not significantly improve OS(P=0.293).Among patients with vascular invasion,vascular reconstruction led to longer operative time and length of postoperative hospitalization than those without vascular resection(all P<0.05).In contrast,other clinical variables,such as postoperative complications,showed no significant differences(all P>0.05).Subgroup analysis of patients with similar types of vascular invasion indicated that vascular resection and reconstruction did not improve OS for patients with different kinds of vascular invasion(all P>0.05).Regardless of whether vascular resection and reconstruction were performed,postoperative adjuvant therapy positively impacted OS,but the differences were not statistically significant(both P>0.05).Conclusion:Vascular invasion is a prognostic risk factor for ICC patients,and vascular resection plus reconstruction does not significantly improve patients'prognosis,possibly leading to longer operative time and length of postoperative hospitalization.Postoperative adjuvant therapy for ICC patients with vascular invasion may help improve prognosis.