Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
Division of Surgical Oncology, Department of Surgery, Duke University, Durham, NC.
J Am Coll Surg. 2014 Apr;218(4):827-34. doi: 10.1016/j.jamcollsurg.2013.12.036. Epub 2014 Jan 10.
Despite the rising incidence of hepatocellular carcinoma (HCC), challenges and controversy persist in optimizing treatment. As recent randomized trials suggest that ablation can have oncologic equivalence compared with resection for early HCC, the relative morbidity of the 2 approaches is a central issue in treatment decisions. Although excellent contemporary perioperative outcomes have been reported by a few hepatobiliary units, it is not clear that they can be replicated in broader practice. Our objective was to help inform this treatment dilemma by defining perioperative outcomes in a broader set of patients as represented in NSQIP-participating institutions.
Mortality and morbidity data were extracted from the 2005-2010 NSQIP Participant Use Data Files based on Current Procedural Terminology (hepatectomy and ablation) and ICD-9 (HCC). Perioperative outcomes were reviewed, and factors associated with morbidity and mortality were identified with multivariable logistic regression.
Eight hundred and thirty-seven (52%) underwent minor hepatectomy, 444 (28%) underwent major hepatectomy, and 323 (20%) underwent surgical ablation. Mortality rates were 3.4% for minor hepatectomy, 3.7% for ablation, and 8.3% for major hepatectomy (p < 0.01). Major complication rates were 21.3% for minor hepatectomy, 9.3% for ablation, and 35.1% for major hepatectomy (p < 0.01). When controlling for confounders, ablation was associated with decreased mortality (adjusted odds ratio = 0.20; 95% CI, 0.04-0.97; p = 0.046) and major complications (adjusted odds ratio = 0.34; 95% CI, 0.22-0.52; p < 0.001).
Exceedingly high complication rates after major hepatectomy for HCC exist in the broader NSQIP treatment environment. These data strongly support the use of parenchymal-sparing minor resections or ablation over major hepatectomy for early HCC when feasible.
尽管肝细胞癌（HCC）的发病率不断上升，但在优化治疗方面仍存在挑战和争议。由于最近的随机试验表明，消融治疗在早期 HCC 方面与切除术具有相同的肿瘤学效果，因此两种方法的相对发病率是治疗决策中的一个核心问题。尽管一些肝胆单位报告了出色的当代围手术期结果，但尚不清楚它们是否可以在更广泛的实践中复制。我们的目的是通过在参与 NSQIP 的机构中定义更广泛的患者人群中的围手术期结果来帮助解决这一治疗难题。
根据当前程序术语（肝切除术和消融术）和 ICD-9（HCC），从 2005 年至 2010 年的 NSQIP 参与者使用数据文件中提取死亡率和发病率数据。审查了围手术期结果，并使用多变量逻辑回归确定了与发病率和死亡率相关的因素。
837 例（52%）接受了小肝切除术，444 例（28%）接受了大肝切除术，323 例（20%）接受了手术消融术。小肝切除术的死亡率为 3.4%，消融术为 3.7%，大肝切除术为 8.3%（p<0.01）。小肝切除术的主要并发症发生率为 21.3%，消融术为 9.3%，大肝切除术为 35.1%（p<0.01）。在控制混杂因素后，消融术与死亡率降低相关（调整后的优势比=0.20；95%置信区间，0.04-0.97；p=0.046）和主要并发症（调整后的优势比=0.34；95%置信区间，0.22-0.52；p<0.001）。
在更广泛的 NSQIP 治疗环境中，大肝切除术治疗 HCC 的并发症发生率极高。这些数据强烈支持在可行的情况下，使用保留实质的小切除术或消融术代替大肝切除术治疗早期 HCC。
