Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Ecole Doctorale Interdisciplinaire Sciences Santé 205 - Equipe Mixte de Recherche 3738, Université Lyon 1, Lyon, France.
Department of Hepatopancreatobiliary Surgery and Liver Transplantation, Hôpital Beaujon, Clichy, France.
Br J Surg. 2018 Jan;105(1):128-139. doi: 10.1002/bjs.10647. Epub 2017 Nov 13.
Biliary leakage remains a major cause of morbidity after liver resection. Previous prognostic studies of posthepatectomy biliary leakage (PHBL) lacked power, population homogeneity, and model validation. The present study aimed to develop a risk score for predicting severe PHBL.
In this multicentre observational study, patients who underwent liver resection without hepaticojejunostomy in one of nine tertiary centres between 2012 and 2015 were randomly assigned to a development or validation cohort in a 2 : 1 ratio. A model predicting severe PHBL (International Study Group of Liver Surgery grade B/C) was developed and further validated.
A total of 2218 procedures were included. PHBL of any severity and severe PHBL occurred in 141 (6·4 per cent) and 92 (4·1 per cent) patients respectively. In the development cohort (1475 patients), multivariable analysis identified blood loss of at least 500 ml, liver remnant ischaemia time 45 min or more, anatomical resection including segment VIII, transection along the right aspect of the left intersectional plane, and associating liver partition and portal vein ligation for staged hepatectomy as predictors of severe PHBL. A risk score (ranging from 0 to 5) was built using the development cohort (area under the receiver operating characteristic curve (AUROC) 0·79, 95 per cent c.i. 0·74 to 0·85) and tested successfully in the validation cohort (AUROC 0·70, 0·60 to 0·80). A score of at least 3 predicted an increase in severe PHBL (19·4 versus 2·6 per cent in the development cohort, P < 0·001; 15 versus 3·1 per cent in the validation cohort, P < 0·001).
The present risk score reliably predicts severe PHBL. It represents a multi-institutionally validated prognostic tool that can be used to identify a subset of patients at high risk of severe PHBL after elective hepatectomy.
胆漏仍然是肝切除术后发病率的主要原因。以前关于肝切除术后胆漏（PHBL）的预后研究缺乏效力、人群同质性和模型验证。本研究旨在建立预测严重 PHBL 的风险评分。
在这项多中心观察性研究中，2012 年至 2015 年间在 9 个三级中心中的 1 个中心接受无胆肠吻合肝切除术的患者以 2:1 的比例随机分配到发展或验证队列。建立并进一步验证了预测严重 PHBL（国际肝外科学研究组分级 B/C）的模型。
共纳入 2218 例手术。严重程度不同的 PHBL 和严重 PHBL 分别发生在 141 例（6.4%）和 92 例（4.1%）患者中。在发展队列（1475 例患者）中，多变量分析确定出血量至少 500ml、肝残余缺血时间 45 分钟或以上、解剖性切除包括第 8 段、沿左交点右侧横断和联合肝分割及门静脉结扎分阶段肝切除术以及 associating 肝分割及门静脉结扎分阶段肝切除术与严重 PHBL 相关。使用发展队列建立风险评分（范围为 0 至 5 分）（接受者操作特征曲线下面积（AUROC）为 0.79，95%置信区间为 0.74 至 0.85），并在验证队列中成功进行了测试（AUROC 为 0.70，0.60 至 0.80）。评分至少为 3 预测严重 PHBL 增加（发展队列中为 19.4%比 2.6%，P<0.001；验证队列中为 15%比 3.1%，P<0.001）。
本风险评分可可靠预测严重 PHBL。它代表了一种经过多机构验证的预后工具，可以用于识别择期肝切除术后严重 PHBL 风险较高的患者亚组。
