切换至 "中华医学电子期刊资源库"
高级检索
中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2023, Vol. 12 ›› Issue (04) : 395 -400. doi: 10.3877/cma.j.issn.2095-3232.2023.04.007

所属专题： 临床研究；

临床研究

腹腔镜下肝左叶肝内胆管细胞癌根治术优化三步法的应用价值
廖承煜, 江斌华, 黄龙, 王丹凤, 田毅峰, 陈实†()   
  1. 350001　福州市，福建医科大学省立临床医学院
    350001　福州市，福建医科大学省立临床医学院；350001　福州市，福建省立医院肝胆胰外科
    350001　福州市，福建医科大学省立临床医学院；350001　福州市，福建省立医院麻醉科
  • 收稿日期:2023-02-23 出版日期:2023-08-10
  • 通信作者: 陈实
  • 基金资助:
    福建省卫生健康中青年领军人才项目(2021（60）)

Application value of modified three-step technique in laparoscopic radical resection of intrahepatic cholangiocarcinoma of left lobe

Chengyu Liao, Binhua Jiang, Long Huang, Danfeng Wang, Yifeng Tian, Shi Chen†()   

  1. Provincial Clinical Medical College of Fujian Medical University, Fuzhou 350001, China
    Provincial Clinical Medical College of Fujian Medical University, Fuzhou 350001, China; Department of Hepatobiliary and Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou 350001, China
    Provincial Clinical Medical College of Fujian Medical University, Fuzhou 350001, China; Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou 350001, China
  • Received:2023-02-23 Published:2023-08-10
  • Corresponding author: Shi Chen
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

廖承煜, 江斌华, 黄龙, 王丹凤, 田毅峰, 陈实. 腹腔镜下肝左叶肝内胆管细胞癌根治术优化三步法的应用价值[J]. 中华肝脏外科手术学电子杂志, 2023, 12(04): 395-400.

Chengyu Liao, Binhua Jiang, Long Huang, Danfeng Wang, Yifeng Tian, Shi Chen. Application value of modified three-step technique in laparoscopic radical resection of intrahepatic cholangiocarcinoma of left lobe[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2023, 12(04): 395-400.

目的

探讨腹腔镜下肝左叶肝内胆管细胞癌（ICC）根治术优化三步法的临床应用价值。

方法

回顾性分析2013年1月至2020年3月在福建省立医院行腹腔镜根治术的114例进展期肝左叶ICC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51例，女63例；年龄37~79岁，中位年龄63岁。2013年1月至2017年12月患者采用传统流程"清扫淋巴结-左半肝切除"的腹腔镜根治术（传统组，86例）；2018年1月至2020年3月患者采用"预解剖肝门部血管-左半肝切除-淋巴结清扫"的优化三步法流程腹腔镜根治术（优化组，28例）。采用1∶2倾向性评分匹配（PSM）比较两组患者临床资料，围手术期情况比较采用Mann-Whitney U检验，并发症发生率比较采用χ2检验。

结果

按1∶2 PSM后，优化组28例，传统组56例。优化组手术时间中位数为225（140）min、切肝时间为107（124）min、等待时间为30（6）min、淋巴结清扫时间为76（15）min、术中出血量为200（175）ml，明显少于传统组的270（115）min、150（99）min、112（15）min、92（15）min、300（300）ml（Z=-2.616，-2.676，-7.442，-4.876，-2.008；P<0.05）。优化组淋巴结清扫数为10（5）个、切取的阳性淋巴结数为4（3）个，明显多于传统组的7（5）、3（1）个（Z=2.441，3.044；P<0.05）。优化组住院费用为4.2（0.2）万元，明显低于传统组的4.4（0.6）万元（Z=-3.150，P<0.05）。优化组术后并发症3例，传统组10例，两组总并发症发生率差异无统计学意义（χ2=0.284，P>0.05）。

结论

腹腔镜下肝左叶ICC根治术优化三步法能提高切肝质量和淋巴结清扫质量，减少出血，缩短手术时间，加快术后恢复。

关键词: 肝肿瘤, 肝内胆管细胞癌, 腹腔镜, 外科手术, 淋巴结清扫, 优化三步法, 倾向性评分匹配
Objective

To evaluate the clinical application value of modified three-step technique in laparoscopic radical resection of intrahepatic cholangiocarcinoma (ICC) of the left lobe.

Methods

Clinical data of 114 patients with advanced ICC of the left lobe who underwent laparoscopic radical resection in Fujian Provincial Hospital from January, 2013 to March, 2020 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 51 patients were male and 63 female, aged from 37 to 79 years, with a median age of 63 years. Patients undergoing laparoscopic radical surgery with traditional process of "lymph node dissection-left hepatectomy" from January, 2013 to December, 2017 were assigned into the traditional group (n=86), and their counterparts receiving modified three-step technique in laparoscopic radical surgery of "pre-dissection of hilar vessels-left hepatectomy-lymph node dissection" from January, 2018 to March, 2020 were allocated into the modified group (n=28). Clinical data between 2 groups were compared by 1∶2 propensity score matching (PSM). Perioperative conditions were compared by Mann-Whitney U test. The incidence of complications was compared by Chi-square test.

Results

After 1∶2 PSM, 28 cases were allocated in the modified group and56 cases in the traditional group. In the modified group, the median operation time, liver resection time, waiting time, lymph node dissection time and intraoperative blood loss were 225(140) min, 107(124) min, 30(6) min, 76(15) min and 200(175) ml, significantly less than 270(115) min,150(99) min, 112(15) min,92(15) min and 300(300) ml in the traditional group (Z=-2.616, -2.676, -7.442, -4.876, -2.008; P<0.05), respectively. In the modified group, the number of lymph node dissection was 10(5), and the number of positive dissected lymph node was 4(3), significantly higher than 7(5) and 3(1) in the traditional group (Z=2.441, 3.044; P<0.05). The hospitalization expense in the modified group was 4.2(0.2)×104 Yuan, significantly less compared with 4.4(0.6)×104 Yuan in the traditional group (Z=-3.150, P<0.05). 3 cases developed postoperative complications in the modified group and 10 in the traditional group. No significant difference was observed in the total incidence of complications between two groups (χ2=0.284, P>0.05).

Conclusions

Modified three-step technique in laparoscopic radical resection of ICC of the left lobe can improve the quality of liver resection and lymph node dissection, reduce the intraoperative bleeding, shorten the operation time and accelerate postoperative recovery.

Key words: Liver neoplasms, Intrahepatic cholangiocarcinoma, Laparoscopes, Surgical procedures, operative, Dissected lymph node, Optimized three-step process, Propensity score matching (PSM)
表1 优化组和传统组腹腔镜肝左叶ICC根治术患者PSM前后基线资料比较
指标 PSM前 PSM后
优化组 传统组 统计值 P值 优化组 传统组 统计值 P值
年龄[岁，M（QR）] 61（12） 63（12） Z=-0.943 0.346 61（12） 60（12） Z=1.212 0.226
性别（例）     χ2=0.043 0.836     χ2=0.618 0.432
男 13 38     13 21    
女 15 48     15 35    
BMI[kg/m2，M（QR）] 22.1（5.2） 23.7（4.7） Z=-1.304 0.192 22.1（5.2） 22.5（3.0） Z=-0.185 0.853
ASA分级（例）     χ2=1.630 0.428     χ2=0.345 0.842
Ⅰ级 4 14     4 6    
Ⅱ级 14 52     14 27    
Ⅲ级 10 20     10 23    
糖尿病（例） 5 11 χ2=0.449 0.503 5 8 χ2=0.182 0.670
高血压病（例） 11 32 χ2=0.039 0.844 11 15 χ2=1.365 0.243
腹部手术史（例） 2 10 - 0.502 2 3 - 1.000
Child-Pugh分级（例）     - 1.000     - 1.000
A级 27 81     27 53    
B级 1 5     1 3    
CEA[g/L，M（QR）] 4.6（10.9） 4.4（8.8） Z=0.303 0.762 4.6（10.9） 4.3（10.3） Z=0.878 0.380
CA19-9[kU/L，M（QR）] 107（510） 96（443） Z=0.484 0.628 107（510） 276（1 869） Z=-0.745 0.456
肿瘤个数（例）     - 0.094     - 0.681
单发 25 84     25 52    
多发 3 2     3 4    
术前T分期（例）     χ2=0.413 0.521     χ2=0.965 0.326
T1/T2 21 59     21 47    
T3/T4 7 27     7 9    
血管侵犯（例） 6 15 χ2=0.223 0.636 6 12 χ2=0.000 1.000
图1 腹腔镜左肝ICC根治术患者术中出血量、等待时间、乳酸水平的关系注：方格中数字代表相关性系数rs，蓝色代表正相关，红色代表负相关，颜色越深则相关性系数越大；ICC为肝内胆管细胞癌；*为P<0.05，**为P<0.01，***为P<0.001
表2 优化组和传统组腹腔镜肝左叶ICC根治术患者术中情况比较
指标 优化组 传统组 统计值 P值
手术时间[min，M(QR)] 225(140) 270(115) Z=-2.616 0.009
切肝时间[min，M(QR)] 107(124) 150(99) Z=-2.676 0.007
等待时间[min，M(QR)] 30(6) 112(15) Z=-7.442 <0.001
淋巴结清扫时间[min，M(QR)] 76(15) 92(15) Z=-4.876 <0.001
术中出血量[ml，M(QR)] 200(175) 300(300) Z=-2.008 0.045
术中输血(例) 4 15 χ2=1.666 0.197
术中中转(例) 0 2 - 0.550
血管重建(例) 4 6 χ2=0.014 0.905
乳酸水平[g/L，M(QR)]        
术前 0.8(0.4) 0.8(0.4) Z=-1.119 0.905
切肝前 1.1(0.5) 1.5(0.3) Z=-5.266 <0.001
切肝后 1.7(0.3) 2.1(0.8) Z=-3.609 <0.001
手术后 1.4(0.4) 1.8(0.8) Z=-4.305 <0.001
切缘(例)     - 1.000
R0 27 54    
R1 1 2    
淋巴结转移(例) 25 52 - 0.681
淋巴结清扫数[个，M(QR)] 10(5) 7(5) Z=2.411 0.016
阳性淋巴结数[个，M(QR)] 4(3) 3(1) Z=3.044 0.002
完全清扫(例) 24 42 χ2=0.716 0.398
表3 优化组和传统组腹腔镜肝左叶ICC根治术患者术后情况比较
指标 优化组 传统组 统计值 P值
术后下床时间[d，M(QR)] 2.0(1.0) 2.5(1.0) Z=-1.674 0.094
术后进食时间[d，M(QR)] 2.0(0.5) 2.0(0.5) Z=-4.123 <0.001
术后排便时间[d，M(QR)] 2.0(1.0) 3.0(2.0) Z=-2.673 0.008
术后住院时间[d，M(QR)] 11.0(3.0) 12.0(3.0) Z=-1.764 0.078
住院费用[万元，M(QR)] 4.2(0.2) 4.4(0.6) Z=-3.150 0.002
术后并发症（例） 3 10 χ2=0.284 0.594
并发症分级（例）     χ2=4.816 0.427
Ⅰ 1 5    
Ⅱ 1 8    
Ⅲ 2 6    
Ⅳ 1 2    
Ⅴ 0 2    
死亡（例） 0 2 - 0.550
[1]
Bagante F, Spolverato G, Weiss M, et al. Assessment of the lymph node status in patients undergoing liver resection for intrahepatic cholangiocarcinoma: the New Eighth Edition AJCC Staging System[J]. J Gastrointest Surg, 2018, 22(1):52-59.
[2]
Hobeika C, Cauchy F, Fuks D, et al. Laparoscopic versus open resection of intrahepatic cholangiocarcinoma: nationwide analysis[J]. Br J Surg, 2021, 108(4):419-426.
[3]
Zhang XF, Xue F, Dong DH, et al. Number and station of lymph node metastasis after curative-intent resection of intrahepatic cholangiocarcinoma impact prognosis[J]. Ann Surg, 2021, 274(6): e1187-1195.
[4]
Ratti F, Fiorentini G, Cipriani F, et al. Perioperative and long-term outcomes of laparoscopic versus open lymphadenectomy for biliary tumors: a propensity-score-based, case-matched analysis[J]. Ann Surg Oncol, 2019, 26:564-575.
[5]
Wei F, Lu C, Cai L, et al. Can laparoscopic liver resection provide a favorable option for patients with large or multiple intrahepatic cholangiocarcinomas?[J]. Surg Endosc, 2017, 31(9):3646-3655.
[6]
Fagenson AM, Pitt HA, Lau KN. Perioperative blood transfusions or operative time: which drives post-hepatectomy outcomes?[J]. Am Surg, 2022, 88(7):1644-1652.
[7]
Yu L, Sun H, Jin H, et al. The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: a prospective randomized controlled trial[J]. BMC Surg, 2020, 20(1):25.
[8]
Davies SJ, Vistisen ST, Jian Z, et al. Ability of an arterial waveform analysis-derived hypotension prediction index to predict future hypotensive events in surgical patients[J]. Anesth Analg, 2020, 130(2):352-359.
[9]
Whelehan DF, Connelly TM, Burke JR, et al. Self-reported surgeon health behaviours: a multicentre, cross-sectional exploration into the modifiable factors that impact surgical performance with the association of surgeons in training[J]. Ann Med Surg, 2021(65): 102299.
[10]
Weber SM, Ribero D, O'Reilly EM, et al. Intrahepatic cholangiocarcinoma: expert consensus statement[J]. HPB, 2015, 17(8):669-680.
[11]
Spolverato G, Bagante F, Weiss M, et al. Comparative performances of the 7th and the 8th editions of the American Joint Committee on Cancer staging systems for intrahepatic cholangiocarcinoma[J]. J Surg Oncol, 2017, 115(6):696-703.
[12]
Yamamoto M, Kobayashi T, Oshita A, et al. Laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the Hiroshima Surgical study group of Clinical Oncology (HiSCO)[J]. Surg Endosc, 2020, 34(11):5055-5061.
[13]
Brustia R, Laurent A, Goumard C, et al. Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: report of an international multicenter cohort study with propensity score matching[J]. Surgery, 2022, 171(5):1290-1302.
[14]
Zhu Y, Song J, Xu X, et al. Safety and feasibility of laparoscopic liver resection for patients with large or multiple intrahepatic cholangiocarcinomas: a propensity score based case-matched analysis from a single institute[J]. Medicine, 2019, 98(49):e18307.
[15]
Zhang XF, Chakedis J, Bagante F, et al. Trends in use of lymphadenectomy in surgery with curative intent for intrahepatic cholangiocarcinoma[J]. Br J Surg, 2018, 105(7):857-866.
[16]
Lauterio A, De Carlis R, Centonze L, et al. Current surgical management of peri-hilar and intra-hepatic cholangiocarcinoma[J]. Cancers, 2021, 13(15):3657.
[17]
Chen S, Huang L, Qiu FN, et al. Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: a propensity, long-term follow-up analysis at a single center[J]. Surgery, 2018, 163(4):714-720.
[18]
Grantcharov PD, Boillat T, Elkabany S, et al. Acute mental stress and surgical performance[J]. BJS Open, 2019, 3(1):119-125.
[19]
Chrouser KL, Xu J, Hallbeck S, et al. The influence of stress responses on surgical performance and outcomes: literature review and the development of the surgical stress effects (SSE) framework[J]. Am J Surg, 2018, 216(3):573-584.
[20]
Croome KP, Farnell MB, Que FG, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches?[J]. Ann Surg, 2014, 260(4):633-638.
[21]
Lemke M, Karanicolas PJ, Habashi R, et al. Elevated lactate is independently associated with adverse outcomes following hepatectomy[J]. World J Surg, 2017, 41(12):3180-3188.
[22]
Chacon E, Eman P, Dugan A, et al. Effect of operative duration on infectious complications and mortality following hepatectomy[J]. HPB, 2019, 21(12):1727-1733.
[1] 韩丹, 王婷, 肖欢, 朱丽容, 陈镜宇, 唐毅. 超声造影与增强CT对儿童肝脏良恶性病变诊断价值的对比分析[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 939-944.
[2] 杜晓辉, 崔建新. 腹腔镜右半结肠癌D3根治术淋巴结清扫范围与策略[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 5-8.
[3] 周岩冰, 刘晓东. 腹腔镜右半结肠癌D3根治术消化道吻合重建方式的选择[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 9-13.
[4] 张焱辉, 张蛟, 朱志贤. 留置肛管在中低位直肠癌新辅助放化疗后腹腔镜TME术中的临床研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 25-28.
[5] 王春荣, 陈姜, 喻晨. 循Glisson蒂鞘外解剖、Laennec膜入路腹腔镜解剖性左半肝切除术临床应用[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 37-40.
[6] 李建美, 邓静娟, 杨倩. 两种术式联合治疗肝癌合并肝硬化门静脉高压的安全性及随访评价[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 41-44.
[7] 李晓玉, 江庆, 汤海琴, 罗静枝. 围手术期综合管理对胆总管结石并急性胆管炎患者ERCP +LC术后心肌损伤的影响研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 57-60.
[8] 甄子铂, 刘金虎. 基于列线图模型探究静脉全身麻醉腹腔镜胆囊切除术患者术后肠道功能紊乱的影响因素[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 61-65.
[9] 逄世江, 黄艳艳, 朱冠烈. 改良π形吻合在腹腔镜全胃切除消化道重建中的安全性和有效性研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 66-69.
[10] 曹迪, 张玉茹. 经腹腔镜生物补片修补直肠癌根治术后盆底疝1例[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 115-116.
[11] 燕速, 霍博文, 徐惠宁. 4K荧光腹腔镜扩大右半结肠CME+D3根治术及No.206、No.204组淋巴结清扫术[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 14-14.
[12] 李凯, 陈淋, 向涵, 苏怀东, 张伟. 一种U型记忆合金线在经脐单孔腹腔镜阑尾切除术中的临床应用[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 15-15.
[13] 易明超, 汪鑫, 向涵, 苏怀东, 张伟. 一种T型记忆金属线在经脐单孔腹腔镜胆囊切除术中的临床应用[J]. 中华普外科手术学杂志(电子版), 2023, 17(06): 599-599.
[14] 孙秀艳, 徐庆蕾, 马鹏涛, 胡志元, 郭传真, 祝成红. 腹腔镜胃癌根治术中患者体温变化与压力性损伤及受压部位微环境的相关性分析[J]. 中华消化病与影像杂志(电子版), 2023, 13(06): 480-484.
[15] 程相阵. 腹茧症9例诊治分析并文献复习[J]. 中华临床医师杂志(电子版), 2023, 17(9): 968-971.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号