食管静脉曲张对原发性肝癌合并肝硬化根治性切除术预后的影响

目的探讨食管静脉曲张（EV）对原发性肝癌合并肝硬化患者根治性切除术预后的影响。方法回顾性分析2001年1月至2010年12月青岛大学医学院附属医院收治的455例原发性肝癌合并肝硬化患者的临床资料和随访结果。61例患者术前影像学检查出现EV为EV组，394例无EV表现的为无EV组，比较两组患者的手术情况及预后。所有患者术后3个月内每月复查1次，以后每3个月复查1次，随访时间截至2012年12月或患者死亡。计量资料或率的比较采用，检验；Kaplan—Meier法绘制生存曲线，生存率的比较采用Log—rank检验，多因素分析采用COX回归风险模型。结果患者均行根治性肝切除术，其中行肝切除＋贲门周围血管离断术4例，脾切除术18例（包括联合贲门周围血管离断术3例）。EV组患者手术切缘距肿瘤距离〈0．5cm、脾切除、术中出血量≥1000ml和术中输血患者比例显著多于无EV组，两组比较，差异有统计学意义（X2=7．113，18．209，5．527，14．298，P〈0．05）；而两组肝切除范围〉1段、解剖性肝切除、术中进行人肝血流阻断的患者比例比较，差异无统计学意义（X2=0．591，0．124，1．412，P〉0．05）。455例患者中8例发生上消化道出血，患者均无门静脉癌栓存在。EV组和无EV组患者上消化道出血发生率分别为9．84％（6／61）和0．51％（2／394），两组比较，差异有统计学意义（X2=26．611，P〈0．05）。患者均获得随访，中位随访时间为39．0个月（3．0～136．3个月）。455例患者中共有218例死亡，其中Ev组死亡37例，无EV组死亡181例。EV组患者因肝癌、肝病和其他原因死亡者所占比例分别为67．57％（25／37）、29．73％（11／37）和2．70％（1／37），而无EV组患者所占比例分别为86．19％（156／181）、6．63％（12／181）和7．18％（13／181），两组比较，差异有统计学意义（X2=17．780，P〈0．05）。EV组患者根治性切除术后1、2、5、10年生存率分别为85．2％、65．6％、36．7％和15．7％，均低于无EV组患者的91．6％、79．9％、55．4％和35．7％，两组比较，差异有统计学意Y．（X2=12．517，P〈0．05）。EV组患者1、2、5、10年无瘤生存率分别为63．2％、45．9％、22．9％和15．3％，均低于无EV组患者的80．0％、59．5％、39．1％和31．3％，两组比较，差异有统计学意义（X2=8．900，P〈0．05）。单因素分析结果显示：伴有Ev、术前AFP≥20μ/L、肝切除范围〉1段、脾切除、术中输血、肿瘤直径〉5cm、非孤立型肝癌是影响原发性肝癌合并肝硬化患者根治性切除术后预后的危险因素（X2=12．517，5．370，12．711，4．430，7．148，29．616，47．111，P〈0．05）。多因素分析结果显示：肿瘤直径〉5cm和非孤立型肝癌是影响原发性肝癌合并肝硬化患者根治性切除术后的独立危险因素（RR=1．639，2．041，P〈0．05）。结论伴有EV的原发性肝癌合并肝硬化患者根治性切除术的生存时间显著低于无EV的患者，但伴有EV不是影响原发性肝癌合并肝硬化患者根治性切除术后长期生存的独立危险因素。

Effects of esophageal varices on the prognosis of patients with hepatocellular carcinoma and hepatic cirrhosis after radical resection

Objective To investigate the effects of esophageal varices （EV） on the incidence of compli- cations and prognosis of patients with hepatocellular carcinoma （HCC） and hepatic cirrhosis after radical resec- tion. Methods The clinical data of 455 patients with HCC and hepatic cirrhosis who were admitted to the Affiliated Hospital of Qingdao University from January 2001 to December 2010 were retrospectively analyzed. All the patients were divided into the EV group （61 patients） and non-EV group （394 patients） according to the results of pre-operative imaging examination. The intraoperative condition and the prognosis of the patients in the 2 groups were compared. All the patients were re-examined every month within the first 3 months after operation, and then they were re-examined every 3 months thereafter. The follow-up was ended till December, 2012 or the day of patients＇ death. Comparison of the measurement data and rates was done by chi-square test; the survival curve was drawn by Kaplan-Meier method, and the survival was analyzed using the Log-rank test; multivariate analysis was done by Cox proportional hazard regression model. Results All the patients received radical hepatectomy. Four patients received hepatectomy ＋ pericardial devascularization, 18 received hepatectomy ＋ splenectomy （3 of them received pericardial devascularization）. The ratios of patients with the distance between the resection margin and the tumor 〈 0.5 cm, splenectomy, volume of intraoperative blood loss≥1000 ml and intraoperative blood transfusion in the EV group were significantly greater than those in the non-EV group 0（2=7. 113, 18.209, 5. 527, 14. 298, P 〈0.05）. There was no significant difference in the ratio of patients who received multi-segmentectomy, anatomical hepatec- tomy, intraoperative inflow occlusion between the 2 groups （XZ= 0. 591,0. 124, 1. 412, P 〉 0.05）. Eight patients were complicated with upper gastrointestinal bleeding, while no portal vein tumor thrombus was detected in all the patients. The incidences of upper gastrointestinal bleeding of the EV group and the non-EV group were 9.84% （6/61） and 0.51% （2/394）, with significant difference between the 2 groups （X2= 26. 611, P 〈 0.05 ）. The median time of follow-up was 39.0 months （range, 3.0-136.3 months）. There were 218 patients died, including 37 patients in the EV group and 181 in the non-EV group. The ratios of patients died of HCC, hepatic diseases or other reasons were 67.57% （25/37）, 29.73% （11/37） and 2.70% （1/37） in the EV group, and 86.19% （ 156/181 ）, 6.63% （ 12/181 ） and 7.18% （ 13/181 ） in the non-EV group, with significant difference between the 2 groups （X2= 17. 780, P 〈0.05）. The 1-, 2-, 5-, 10-year survival rates after radical resection in the EV group were 85.2% , 65.6% , 36.7% and 15.7%, which were significantly lower than 91.6% , 79.9% , 55.4% and 35.7% of the non-EV group （X2= 12. 517, P 〈 0.05）. The 1-, 2-, 5-, 10-year tumor-free survival rates of the EV group were 63.2% , 45.9% , 22.9% and 15.3% , which were significantly lower than 80.0% , 59.5% , 39.1% and 31.3% （X2= 8. 900, P 〈0.05）. The results of univariate analysis showed that EV, pre-operative alpha-fetoprotein≥20 μg/L, multi-segmentectomy, splenectomy, intraoperative blood transfusion, tumor diameter 〉 5 em, non-solitary tumor were risk faetors influencing the prognosis of patients with HCC and hepatic cirrhosis after radical reseetion （X2 = 12.517, 5. 370, 12. 711,4. 430, 7. 148, 29. 616, 47. 111, P 〈 0.05 ）. The results of multivariate analysis showed that tumor diameter 〉 5 cm and non-solitary tumor were independent risk factors influencing the prognosis of patients with HCC and hepatic cirrhosis after radical resection （ RR = 1. 639, 2. 041, P 〈 0.05）. Conclusion The survival time of cirrhotic HCC patients with EV is significantly shorter than those without EV after radical resection, while EV was not the independent risk factor influencing the survival of cirrhotic HCC patients after radical resection.