淋巴结清扫对肝内胆管癌达到教科书式结局的影响和预后分析

The impact of lymph node dissection on textbook outcomes of intrahepatic cholangiocarcinoma and prognostic analysis

目的探讨淋巴结清扫对肝内胆管癌达到教科书式结局的影响和预后分析。方法采用回顾性队列研究方法。收集2011年12月至2017年12月福建医科大学孟超肝胆医院等4家医学中心收治的376例行肝切除术肝内胆管癌患者的临床病理资料;男242例,女134例;年龄为57(48~63)岁。根据教科书式结局的评价标准,将患者分为达到教科书式结局和未达到教科书式结局。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验;偏态分布的计量资料以M(范围)或M(Q1,Q3)表示,组间比较采用Mann‑Whitney U检验。计数资料以绝对数表示,组间比较采用χ^(2)检验或Yates校正χ^(2)检验或Fisher确切概率法。等级资料比较采用非参数秩和检验。单因素和多因素分析采用Logistic回归模型。采用Kaplan‑Meier法绘制生存曲线,生存分析采用Log‑rank检验。结果(1)教科书式结局情况。376例肝内胆管癌患者均行肝切除术,199例术后达到教科书式结局(40例行淋巴结清扫、159例未行淋巴结清扫),177例术后未达到教科书式结局(76例行淋巴结清扫、101例未行淋巴结清扫)。(2)影响肝内胆管癌患者行肝切除术后达到教科书式结局的因素。多因素分析结果显示:淋巴结清扫、微血管侵犯、神经侵犯及术中出血量>800 mL是影响肝内胆管癌患者行肝切除术后达到教科书式结局的独立危险因素(优势比=2.22,2.95,3.58,4.09,95%可信区间为1.34~3.69,1.43~6.07,1.40~9.17,1.35~12.43,P<0.05)。116例淋巴结清扫患者中,达到教科书式结局、R0切除、术后发生并发症、住院时间延长分别为40、103、38、67例;260例未行淋巴结清扫患者上述指标分别为159、255、41、65例;两者上述指标比较,差异均有统计学意义(χ^(2)=22.90,15.16,13.95,37.78,P<0.05)。(3)随访情况。376例患者术后均获得随访,随访时间为19(1~74)个月。199例达到教科书式结局患者中,40例行淋巴结清扫患者1、2、3年总生存率分别为54.0%、36.6%、26.1%,159例未行淋巴结清扫患者上述指标分别为67.7%、42.7%、34.4%,两者生存情况比较,差异无统计学意义(χ^(2)=1.89,P>0.05)。177例未达到教科书式结局患者中,76例行淋巴结清扫患者1、2、3年总生存率分别为58.9%、25.7%、10.3%,101例未行淋巴结清扫患者上述指标分别为53.0%、28.5%、17.2%,两者生存情况比较,差异无统计学意义(χ^(2)=0.25,P>0.05)。结论淋巴结清扫、微血管侵犯、神经侵犯及术中出血量>800 mL是影响肝内胆管癌患者行肝切除术后达到教科书式结局的独立危险因素;淋巴结清扫增加术后并发症发生比例、延长住院时间,降低达到教科书式结局比例,但不影响患者预后。

Objective To analyze the impact of lymph node dissection on textbook outcomes(TO)and the prognosis of intrahepatic cholangiocarcinoma(ICC).Methods The retrospective cohort study was conducted.The clinicopathological data of 376 ICC patients who underwent hepatectomy in 4 medical centers,including Mengchao Hepatobiliary Hospital of Fujian Medical University et al,from December 2011 to December 2017 were collected.There were 242 males and 134 females,aged 57(range,48−63)years.According to the criteria of TO,patients were classified as two categories,including patients achieving TO and not achieving TO.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was conducted using the independent sample t test.Measurement data with skewed distribution were represented as M(range)or M(Q1,Q3),and comparison between groups was conducted using the Mann-Whitney U test.Count data were represented as absolute numbers,and comparison between groups was conducted using the chi-square test,Yates adjusted chi-square test or Fisher exact probability.Comparison of ordinal data was conducted using the non-parameter rank sum test.Univariate and multivariate analyses were conducted using the Logistic regression model.The Kaplan-Meier method was used to draw survival curve.Survival analysis was conducted using the Log-rank test.Results(1)TO situations.Of the 376 ICC patients who underwent hepatectomy,199 cases achieved TO,including 40 cases with lymph node dissection and 159 cases without lymph node dissection,177 cases did not achieve TO,including 76 cases with lymph node dissection and 101 cases without lymph node dissection.(2)Influencing factors for TO after hepatectomy of ICC patients.Results of multivariate analysis showed that lymph node dissection,microvascular invasion,nerve invasion and the volume of intraoperative blood loss>800 mL were independent risk factors for achieving TO after hepatectomy of ICC patients(odds ratio=2.22,2.95,3.58,4.09,95%confidence interval as 1.34−3.69,1.43−6.07,1.40−9.17,1.35−12.43,P<0.05).Of the 116 patients with lymph node dissection,40 cases achieved TO,103 cases achieved R0 resection,38 cases had postoperative complications,67 cases had delayed hospital stay.The above indicators were 159,255,41,65 of 260 patients without lymph node dissection.There were significant differences in the above indicators between patients with and without lymph node dissection(χ^(2)=22.90,15.16,13.95,37.78,P<0.05).(3)Follow-up.All the 376 patients were followed up for 19(range,1−74)months.Of 199 patients achieving TO,the 1-,2-and 3-year survival rates of 40 patients with lymph node dissection were 54.0%,36.6%and 26.1%,respectively,versus 67.7%,42.7%and 34.4%of 159 patients without lymph node dissection,showing no significant difference between them(χ^(2)=1.89,P>0.05).Of 177 patients not achieving TO,the 1-,2-and 3-year survival rates of 76 cases with lymph node dissection were 58.9%,25.7%and 10.3%,respectively,versus 53.0%,28.5%and 17.2%of 101 cases without lymph node dissection,showing no significant difference between them(χ^(2)=0.25,P>0.05).Conclusions Lymph node dissection,microvascular invasion,nerve invasion and the volume of intraoperative blood loss>800 mL are independent risk factors for achieving TO after hepatectomy of ICC patients.Lymph node dissection may increase the postoperative complication rate,prolong the hospital stay and decrease the rate of achieving TO.However,it does not affect the prognosis of patients.