肝门部胆管癌根治手术中联合血管切除及重建的临床疗效Meta分析

背景与目的:对于肝门部胆管癌(HCCA)而言,血管侵犯是主要的手术治疗障碍之一。联合血管切除及重建后的各个临床研究指标不一,结论也存在一定的争议,本研究通过Meta分析方法系统评价HCCA根治术中联合血管切除及重建的安全性、切除有效性及近远期疗效。方法:检索多个国内外数据库,收集HCCA根治术中联合血管切除及重建与无血管切除比较的研究,前者包括肝动脉切除及重建和门静脉切除及重建,检索起止时间均为2009年1月1日—2019年1月1日。采用Meta分析方法比较两种术式的安全性、根治效果及近远期疗效指标。结果:最终纳入18篇文献(均为回顾性研究),共3 260例患者,其中行联合血管切除及重建904例(血管切除组),未行血管切除2 356例(对照组);分亚组的研究中含肝动脉切除及重建237例(肝动脉切除亚组)与门静脉切除及重建560(门静脉切除亚组)。Meta分析结果显示,与对照组比较,血管切除组的术后总并发症(OR=1.09,95% CI=0.78～1.54,P=0.61)、肝衰竭(OR=0.84,95% CI=0.56～1.24,P=0.36)的发生率均无明显差异,但血管并发症(OR=6.79,95% CI=2.16～21.38,P=0.01)与肝脓肿(OR=7.47,95% CI=2.63～21.18,P=0.01)的发生率升高;术后病死率无统计学差异(OR=1.27,95% CI=0.84～1.93,P=0.25);术后1、3、5年的总体生存率差异均有统计学差异(OR=0.69,95% CI=0.56～0.85;OR=0.62,95% CI=0.52～0.75;OR=0.61,95% CI=0.49～0.76,均P0.05);R_0切除率无统计学差异(OR=0.96,95% CI=0.66～1.40,P=0.84)。亚组分析显示,肝动脉切除亚组和门静脉切除亚组与对照组总并发症发生率均无统计学差异(均P0.05);肝动脉切除亚组的5年总生存率低于对照组(OR=0.44,95% CI=0.30～0.67,P=0.01),但门静脉切除亚组的5年总生存率与对照组无明显差异(OR=0.89,95% CI=0.68～1.17,P=0.42)。此外,R_0切除组患者5年生存率高于R_1切除组,无淋巴结转移患者5年生存率高于有淋巴结转移患者(均P0.05)。结论:HCCA根治术中联合血管切除及重建是总体可接受的,可以一定程度上提高R_0切除率,改善患者预后。当合并门静脉侵犯时,可以行联合血管的R_0切除不增加术后并发症和死亡,也不会恶化预后。当合并肝动脉侵犯是手术R_0切除的唯一障碍时,不能简单地将其作为根治性手术的禁忌证,仍可以手术治疗,但需慎重处理,从而使患者获益。

Meta-analysis of clinical efficacy of combined vascular resection plus reconstruction in radical resection of hilar cholangiocarcinoma

Background and Aims: The diagnosis and treatment of intrahepatic bile duct stones, especially the stones located in multiple hepatic segments or the complicated hepatolithiasis with a history of multiple biliary tract surgeries, is one of the difficult problems in hepatobiliary surgery. How to remove the stones in one step is one of the current research interests. Considering that the computer-based three-dimensional reconstruction visualization technology has been increasingly used in hepatectomy in recent years, this study was designed to investigate the clinical application value of computer-based three-dimensional reconstruction technology in the diagnosis and treatment of complicated intra- and extrahepatic bile duct stones. Methods: The clinical data of patients with hepatolithiasis treated in the Department of Biliary and Pancreatic Surgery of the First Affiliated Hospital of University of Science and Technology of China, who underwent computer-based three-dimensional reconstruction before operation from January 1, 2018 to July 31, 2019 were retrospectively analyzed. Results: A total of 19 patients with complicated hepatolithiasis admitted during above period were enrolled. Of the patients, the classification of hepatolithiasis was type I in 9 cases, type II a in 6 cases, type IIb in 3 cases and type IIc in 1 case, 12 cases had concomitant extrahepatic bile duct stones, 1 case was complicated with hepatic space-occupying lesions and 1 case was combined with right hepatic schistosomiasis. The surgical procedures including left hepatectomy performed in 3 cases, right hepatectomy performed in 7 cases, and common bile duct exploration plus drainage performed in 9 cases. The coincidence of preoperative three-dimensional reconstruction with the real intra-operative findings were that the coincidence rate of the running patterns of the portal vein and hepatic artery were 78.95%, the coincidence rates of both stone distribution in bile duct and liver volume were 84.21%, and the total accuracy rate was 73.68%. No residual stones were detected by immediate postoperative cholangiography, and no postoperative cholangitisor bile duct injuries occurred.Conclusion: The preoperative computer-based three-dimensional reconstruction technology can accurately describe the distribution of intrahepatic bile duct stones and accurately measure the liver volume. It has important clinical application value in the diagnosis of complex hepatolithiasis and individual planning of surgical procedures, and can help achieve the greatest degree of stone removal in one step.