Ribero Dario, Zimmitti Giuseppe, Aloia Thomas A, Shindoh Junichi, Fabio Forchino, Amisano Marco, Passot Guillaume, Ferrero Alessandro, Vauthey Jean-Nicolas
Department of General Surgery and Surgical Oncology, Ospedale Mauriziano Umberto I, Torino, Italy (Ribero, Zimmitti, Forchino, Amisano, Ferrero), Department of Hepatobiliary and Pancreatic Surgery, European Institute of Oncology, Milano, Italy (Ribero), Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (Zimmitti), and Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA (Aloia, Shindoh, Passot, Vauthey).
J Am Coll Surg. 2016 Jul;223(1):87-97. doi: 10.1016/j.jamcollsurg.2016.01.060. Epub 2016 Feb 13.
The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA.
This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at 2 centers, from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of hepatic insufficiency and liver failure-related death.
The study included 133 patients with right or left major (n = 67) or extended (n = 66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III to IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them from liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p < 0.05) were preoperative cholangitis (odds ratio [OR] 3.2), future liver remnant (FLR) volume < 30% (OR 3.5), preoperative total bilirubin level >3 mg/dL (OR 4), and albumin level < 3.5 mg/dL (OR 3.3). Only preoperative cholangitis (OR 7.5, p = 0.016) and FLR volume < 30% (OR 7.2, p = 0.019) predicted postoperative liver failure-related death.
Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure-related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.
据报道，肝门部胆管癌（HCCA）患者行肝切除术后死亡率最高。在这些患者中，术后死亡通常继发于肝功能不全。我们试图确定HCCA肝切除患者术后肝功能不全及肝衰竭死亡的相关因素。
本研究纳入了1996年至2013年期间在2个中心接受根治性肝切除术治疗HCCA的所有连续患者。分析术前临床和手术数据，以确定肝功能不全和肝衰竭相关死亡的独立决定因素。
该研究包括133例行右半肝或左半肝（n = 67）或扩大肝切除术（n = 66）的患者。98例患者术前行胆管引流，其中40例并发胆管炎。在所有这些患者中，胆管炎在手术前得到控制。73例患者（55%）发生严重（Dindo III至IV级）术后并发症，其中29例出现肝功能不全。15例患者（11%）在术后90天内死亡，其中10例死于肝衰竭。多因素分析显示，术后肝功能不全的预测因素（均p < 0.05）为术前胆管炎（比值比[OR] 3.2）、未来肝残余（FLR）体积< 30%（OR 3.5）、术前总胆红素水平> 3 mg/dL（OR 4）和白蛋白水平< 3.5 mg/dL（OR 3.3）。只有术前胆管炎（OR 7.5，p = 0.016）和FLR体积< 30%（OR 7.2，p = 0.019）可预测术后肝衰竭相关死亡。
术前胆管炎和FLR体积不足是肝功能不全和术后肝衰竭相关死亡的主要决定因素。鉴于胆管引流与胆管炎之间的关联，应优化HCCA患者的术前处理，以尽量降低胆管炎风险。
