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《中华消化外科杂志》2018年5月第17卷第5期论著

腹腔镜结直肠癌根治术联合肝转移灶射频消融术与开腹结直肠癌肝转移根治术的疗效分析

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郭鹏,张治清,兰远志,等.腹腔镜结直肠癌根治术联合肝转移灶射频消融术与开腹结直肠癌肝转移根治术的疗效分析[J].中华消化外科杂志,2018,17(5):459-465.DOI:10.3760/cma.j.issn.1673-9752.2018.05.009.
【摘要】

目的:比较腹腔镜结直肠癌根治术联合肝转移灶射频消融术(RFA)与开腹结直肠癌肝转移根治术治疗结直肠癌肝转移的临床疗效。
方法:采用回顾性队列研究方法。收集2012年9月至2017年4月福建医科大学孟超肝胆医院收治的80例和重庆医科大学附属第三医院收治的40例结直肠癌肝转移患者的临床病理资料。60例患者行腹腔镜结直肠癌根治术联合肝转移灶RFA,设为腹腔镜联合RFA组;60例患者行开腹结直肠癌肝转移根治术,设为开腹手术组。观察指标:(1)手术及术后恢复情况。(2)随访和生存情况。采用门诊和电话方式进行随访,了解患者术后生存情况。随访时间截至2017年5月。正态分布的计量资料以±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)表示。计数资料比较采用x2检验或Fisher确切概率法。重复测量数据采用重复测量方差分析。采用Kaplan-Meier法计算患者生存率、绘制生存曲线,采用Log-rank检验进行生存分析。
结果:(1)手术及术后恢复情况:①腹腔镜联合RFA组和开腹手术组患者均顺利完成手术,腹腔镜联合RFA组无中转开腹。腹腔镜联合RFA组患者手术时间、术中出血量、术后并发症(总体并发症、死亡、腹痛、恶心呕吐、肝功能异常、胸腔积液、非结石性胆囊炎、消化性溃疡)、术后住院时间分别为(135±34)min、(451±197)mL、31例、0、18例、6例、6例、4例、3例、2例、(13±4)d,开腹手术组患者上述指标分别为(165±49)min、(794±204)mL、42例、1例、15例、9例、10例、11例、5例、5例、(19±4)d,两组患者手术时间、术中出血量、术后总体并发症、术后住院时间比较,差异均有统计学意义(t=3.983,9.394, x2=4.232,t=9.148,P<0.05);而两组患者术后死亡、腹痛、恶心呕吐、肝功能异常、胸腔积液、非结石性胆囊炎、消化性溃疡比较,差异均无统计学意义(x2=0.376,0.686,1.154,3.733,0.134,0.607,P>0.05)。②腹腔镜联合RFA组患者术前、术后1 d、术后3 d丙氨酸氨基转移酶(ALT)分别为(70±9)U/L、(399±36)U/L、(231±19)U/L,总胆红素(TBil)分别为(21±3)μmol/L、(26±3)μmol/L、(23±5)μmol/L,凝血酶原时间(PT)分别为(17.3±2.4)s、(20.2±4.4)s、(18.9±2.8)s;开腹手术组患者上述指标分别为(68±8)U/L、(412±39)U/L、(253±22)U/L,TBil分别为(21±4)μmol/L、(28±4)μmol/L、(27±8)μmol/L,PT分别为(16.6±3.0)s、(22.1±5.2)s、(20.1±4.4)s。两组患者术前、术后1 d、术后3 d ALT、TBil、PT比较,差异均有统计学意义(F=16.727,13.115,4.194,P<0.05)。(2)随访和生存情况:120例患者均获得术后随访,随访时间为7~24个月,中位随访时间为20个月。腹腔镜联合RFA组患者术后1、2年无瘤生存率和1、2年总体生存率分别为23.3%、11.9%、85.0%、40.0%,开腹手术组患者分别为20.0%、12.8%、83.3%、38.3%,两组患者上述指标比较,差异均无统计学意义(x2=0.145,0.069,0.012,0.196,P>0.05)。进一步分析结果显示:腹腔镜联合RFA组肝转移灶数目为1个、2个、3个、>3个患者术后2年总体生存率分别为53.3%、38.2%、40.0%、16.7%,不同肝转移灶数目患者2年总体生存率比较,差异有统计学意义(x2=20.949,P<0.05)。开腹手术组肝转移灶数目为1个、2个、3个、>3个患者术后2年总体生存率分别为50.0%、35.7%、40.0%、15.4%,不同肝转移灶数目患者2年总体生存率比较,差异有统计学意义(x2=21.349,P<0.05)。
结论:腹腔镜结直肠癌根治术联合肝转移灶RFA治疗结直肠癌肝转移创伤小、并发症少、术后恢复快,具有微创优势;肝转移灶数目少,结直肠癌肝转移患者预后较好。

【Abstract】

Objective:To compare the clinical effects between laparoscopic radical resection combined with radiofrequency ablation (RFA) and open radical resection for colorectal liver metastases.
Methods: The retrospective cohort study was conducted. The clinicopathological data of 120 colorectal liver metastases patients who were admitted to the Mengchao Hepatobiliary Hospital of Fujian Medical University (80 patients) and the Third Affiliated Hospital of Chongqing Medical University (40 patients) between September 2012 and April 2017 were collected. Sixty patients undergoing laparoscopic radical resection of colorectal cancer combined with RFA of liver metastases were allocated into the laparoscopy with RFA group, and 60 undergoing open radical resection of colorectal liver metastases were allocated into the open group. Observation indicators: (1) surgical and postoperative situations; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to May 2017. Measurement data with normal distribution were represented as ±s, and comparisons between groups were analyzed using independent-sample t test. Measurement data with skewed distribution were described as M (range). Comparisons of count data were analyzed using chi-square test or Fisher exact probability. The repeated measures data were analyzed using the repeated measures ANOVA. The survival curve and rate were respectively drawn and calculated by the Kaplan-Meier method, and the Log-rank test was used for survival analysis.
Results:(1) Surgical and postoperative situations: ① All the patients underwent successful surgery, without conversion to open surgery in the laparoscopy with RFA group. Operation time, volume of intraoperative blood loss, cases with overall complications, death, abdominal pain, nausea and vomiting, liver dysfunction, pleural effusion, non-calculus cholecystitis and peptic ulcer and duration of postoperative hospital stay were respectively (135±34)minutes, (451±197)mL, 31, 0, 18, 6, 6, 4, 3, 2, (13±4)days in the laparoscopy with RFA group and (165±49)minutes, (794±204)mL, 42, 1, 15, 9, 10, 11, 5, 5, (19±4)days in the open group, with statistically significant differences in operation time, volume of intraoperative blood loss, cases with overall complications and duration of postoperative hospital stay between groups (t=3.983, 9.394, x2=4.232, t=9.148, P<0.05), and no statistically significant differences in cases with death, abdominal pain, nausea and vomiting, liver dysfunction, pleural effusion, non-calculus cholecystitis and peptic ulcer between groups (x2=0.376, 0.686, 1.154, 3.733, 0.134, 0.607, P>0.05). ② Levels of alanine aminotransferase (ALT), total bilirubin (TBil) and prothrombin time (PT) before operation, at day 1 and 3 postoperatively were respectively (70±9)U/L, (399±36)U/L, (231±19)U/L, (21±3)μmol/L, (26±3)μmol/L, (23±5)μmol/L, (17.3±2.4)seconds, (20.2±4.4)seconds, (18.9±2.8)seconds in the laparoscopy with RFA group and (68±8)U/L, (412±39)U/L, (253±22)U/L, (21±4)μmol/L, (28±4)μmol/L, (27±8)μmol/L, (16.6±3.0)seconds, (22.1±5.2)seconds, (20.1±4.4)seconds in the open group, with statistically significant differences in the levels of ALT, TBil and PT before operation, at day 1 and 3 postoperatively between groups (F=16.727, 13.115, 4.194, P<0.05). (2) Follow-up and survival situations: 120 patients were followed up for 7-24 months, with a median time of 20 months. The postoperative 1- and 2-year tumor-free survival rates, 1- and 2-year overall survival rates were respectively 23.3%, 11.9%, 85.0%, 40.0% in the laparoscopy with RFA group and 20.0%, 12.8%, 83.3%, 38.3% in the open group, with no statistically significant difference in above indicators between groups (x2=0.145, 0.069, 0.012, 0.196, P>0.05). Further analysis showed that postoperative 2-year overall survival rate of patients with 1, 2, 3 and >3 liver metastasis lesions were respectively 53.3%, 38.2%, 40.0%, 16.7% in the laparoscopy with RFA group and 50.0%, 35.7%, 40.0%, 15.4% in the open group, with a statistically significant difference in 2-year survival rate of patients with different liver metastasis lesions in the laparoscopy with RFA group (x2=20.949, P<0.05) and in the open group (x2=21.349, P<0.05).
Conclusions:There are some advantages of fewer traumas, less complications, faster postoperative recovery and minimally invasive in laparoscopic radical resection combined with RFA for colorectal liver metastases, meanwhile, less liver metastasis lesions and better prognosis are found.

DOI:10.3760/cma.j.issn.1673-9752.2018.05.009
基金项目:国家自然科学基金面上项目(81672376)
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