Wiggers Jimme K, Groot Koerkamp Bas, Cieslak Kasia P, Doussot Alexandre, van Klaveren David, Allen Peter J, Besselink Marc G, Busch Olivier R, D'Angelica Michael I, DeMatteo Ronald P, Gouma Dirk J, Kingham T Peter, van Gulik Thomas M, Jarnagin William R
Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands.
J Am Coll Surg. 2016 Aug;223(2):321-331.e1. doi: 10.1016/j.jamcollsurg.2016.03.035. Epub 2016 Apr 5.
Liver surgery for perihilar cholangiocarcinoma (PHC) is associated with postoperative mortality ranging from 5% to 18%. The aim of this study was to develop a preoperative risk score for postoperative mortality after liver resection for PHC, and to assess the effect of biliary drainage of the future liver remnant (FLR).
A consecutive series of 287 patients submitted to major liver resection for presumed PHC between 1997 and 2014 at 2 Western centers was analyzed; 228 patients (79%) underwent preoperative drainage for jaundice. Future liver remnant volumes were calculated with CT volumetry and completeness of FLR drainage was assessed on imaging. Logistic regression was used to develop a mortality risk score.
Postoperative mortality at 90 days was 14% and was independently predicted by age (odds ratio [OR] per 10 years = 2.1), preoperative cholangitis (OR = 4.1), FLR volume <30% (OR = 2.9), portal vein reconstruction (OR = 2.3), and incomplete FLR drainage in patients with FLR volume <50% (OR = 2.8). The risk score showed good discrimination (area under the curve = 0.75 after bootstrap validation) and ranking patients in tertiles identified 3 (ie low, intermediate, and high) risk subgroups with predicted mortalities of 2%, 11%, and 37%. No postoperative mortality was observed in 33 undrained patients with FLR volumes >50%, including 10 jaundiced patients (median bilirubin level 11 mg/dL).
The mortality risk score for patients with resectable PHC can be used for patient counseling and identification of modifiable risk factors, which include FLR volume, FLR drainage status, and preoperative cholangitis. We found no evidence to support preoperative biliary drainage in patients with an FLR volume >50%.
肝门部胆管癌（PHC）肝切除术的术后死亡率为5%至18%。本研究的目的是制定PHC肝切除术后的术前死亡风险评分，并评估未来肝残余（FLR）胆道引流的效果。
分析了1997年至2014年期间在2个西方中心接受疑似PHC大肝切除术的287例连续患者；228例患者（79%）因黄疸接受了术前引流。采用CT容积测量法计算未来肝残余体积，并通过影像学评估FLR引流的完整性。使用逻辑回归分析制定死亡风险评分。
90天术后死亡率为14%，年龄（每10岁比值比[OR]=2.1）、术前胆管炎（OR=4.1）、FLR体积<30%（OR=2.9）、门静脉重建（OR=2.3）以及FLR体积<50%的患者中FLR引流不完全（OR=2.8）可独立预测术后死亡。风险评分显示出良好的区分度（自抽样验证后曲线下面积=0.75），将患者按三分位数排序可确定3个（即低、中、高）风险亚组，预测死亡率分别为2%、11%和37%。33例FLR体积>50%的未引流患者中未观察到术后死亡，其中包括10例黄疸患者（中位胆红素水平11mg/dL）。
可切除PHC患者的死亡风险评分可用于患者咨询和确定可改变的风险因素，这些因素包括FLR体积、FLR引流状态和术前胆管炎。我们没有发现证据支持FLR体积>50%的患者进行术前胆道引流。
