联合脾切除对肝癌合并门静脉高压症患者根治性切除术后的生存获益分析

Survival benefit of combined splenectomy in patients with liver cancer complicated with portal hypertension after radical resection

目的探讨联合脾切除对肝癌合并门静脉高压症患者根治性切除术后的生存获益。方法回顾性分析2011年3月至2019年5月在首都医科大学附属北京佑安医院行肝癌根治性治疗的138例肝癌合并门静脉高压症患者临床资料。患者均签署知情同意书,符合医学伦理学规定。其中男84例,女54例;年龄26~76岁,中位年龄55岁。根据手术方式和肝癌分期不同分为根治性治疗联合脾切除术组(HS组,96例),其中T1期肝癌(HS1组)48例,T2期肝癌(HS2组)39例,T3期肝癌(HS3组)9例;同期T1期接受单独肝癌根治性治疗的42例作为对照(HA1组)。生存分析采用Kaplan-Meier法和Log-rank检验。两组围手术期情况比较采用t检验、Mann-Whitney U检验或χ^(2)检验。结果HS组中位RFS、OS分别为22.3、46.0个月。其中HS1组术后1、2、5年RFS分别为90.2%、76.5%、51.0%,HS2组相应为48.6%、24.3%、10.8%,HS3组相应为42.9%、28.6%、28.6%,3组术后1、2、5年RFS比较差异有统计学意义(χ^(2)=22.276,26.206,17.124;P<0.05)。HS1组术后1、2、5年OS分别为95.8%、79.2%、47.9%,HS2组相应为84.6%、69.2%、25.6%,HS3组相应为77.7%、55.6%、33.3%,3组术后5年OS比较差异有统计学意义(χ^(2)=11.416,P<0.05)。HS1组和HA1组术后1、2年RFS分别为95.0%、81.0%和81.3%、66.7%,差异有统计学意义(χ^(2)=6.378,4.944;P<0.05)。HS1组和HA1组术前有曲张静脉破裂出血史20、2例,差异均有统计学意义(χ^(2)=14.581,P<0.05);两组术前Hb中位数分别为115(49)、126(20)g/L,PTA分别为73%(12%)、78%(7%),肝弹性硬度分别为19(12)、15(10)kPa,术中出血量分别为300(275)、150(100)ml,手术时间分别为4.1(2.3)、3.5(1.6)h,差异均有统计学意义(Z=-2.115,-2.768,2.374,3.171,2.804;P<0.05)。两组均无术后早期死亡。结论联合脾切除可提高T1期肝癌合并门静脉高压症患者根治性切除术后早期RFS。此类获益患者术前消化道出血史比例较高、凝血功能较差,肝硬化程度较高,联合脾切除虽然增加手术时间和术中出血量,但总体安全。

Objective To evaluate the survival benefit of combined splenectomy in patients with liver cancer complicated with portal hypertension after radical resection.Methods Clinical data of 138 patients with liver cancer complicated with portal hypertension who underwent radical resection in Beijing You'an Hospital Affiliated to Capital Medical University from March 2011 to May 2019 were retrospectively analyzed.The informed consents of all patients were obtained and the local ethical committee approval was received.Among them,84 patients were male and 54 female,aged from 26 to 76 years,with a median age of 55 years.According to different surgical methods and liver cancer stages,all patients were divided into radical resection combined with splenectomy group(HS group,n=96),including 48 cases of T1 stage liver cancer(HS1 group),39 cases of T2 stage(HS2 group)and 9 cases of T3 stage(HS3 group).42 patients withT1 stage liver cancer who received radical resection alone were used as controls(HA1 group).Survival analysis was performed by Kaplan-Meier method and Log-rank test.Perioperative status between two groups was compared by t test,Mann-Whitney U test or Chi-square test.Results The median RFS and OS in the HS groupwere 22.3 and 46.0 months.The postoperative 1-,2-,5-year RFS were 90.2%,76.5%,51.0%in the HS1 group,48.6%,24.3%,10.8%in the HS2 group,and 42.9%,28.6%,28.6%in the HS3 group,respectively.The differences were statistically significant in the postoperative 1-,2-,5-year RFS among three groups(χ^(2)=22.276,26.206,17.124;P<0.05).The postoperative 1-,2-,5-year OS were 95.8%,79.2%,47.9%in the HS1 group,84.6%,69.2%,25.6%in the HS2 group,and 77.7%,55.6%,33.3%in the HS3 group,respectively.The differences in the postoperative 5-year OS were statistically significant among three groups(χ^(2)=11.416,P<0.05).In the HS1 and HA1 groups,the postoperative 1-and 2-year RFS were 95.0%,81.0%and 81.3%,66.7%respectively,and the differences were statistically significant(χ^(2)=6.378,4.944;P<0.05).In the HS1 and HA1 groups,20 and 2 patients had a history of varicose vein rupture and bleeding,and the difference was statistically significant(χ^(2)=14.581,P<0.05).The median Hb before operation was 115(49)and 126(20)g/L,PTA was 73%(12%)and 78%(7%),liver stiffness was 19(12)and 15(10)kPa,intraoperative blood loss was 300(275)and 150(100)ml,operation time was 4.1(2.3)and 3.5(1.6)h,respectively.The differences were statistically significant(Z=-2.115,-2.768,2.374,3.171,2.804;P<0.05).No patient died early after surgery in two groups.Conclusions Combined splenectomy can improve early RFS of patients with T1 stage liver cancer complicated with portal hypertension after radical resection.A high proportion of preoperative gastrointestinal bleeding history,poor coagulation and high grade of liver cirrhosis are observed in these patients.Although combined splenectomy increases operation time and intraoperative bleeding,it is generally safe.