Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA.
J Gastrointest Surg. 2019 Jun;23(6):1157-1165. doi: 10.1007/s11605-019-04139-7. Epub 2019 Feb 28.
The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear.
Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model.
A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522).
While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.
对于患有晚期肝硬化的患者，与开腹肝切除术（OLR）相比，腹腔镜肝切除术（LLR）的安全性和肿瘤学结果，用于治疗肝细胞癌（HCC），目前仍不清楚。
从国家癌症数据库中确定了 2010 年至 2014 年间接受 HCC 切除术的患者。纳入严重纤维化、单病灶、M0、已知分级、切缘状态、肿瘤大小、住院时间、30 天和 90 天死亡率、30 天再入院、手术方式和完整随访的患者。对 LLR：OLR 进行了 1:1 的倾向评分匹配分析。使用多变量 Cox 比例风险模型评估 LLR 的预后效果。
共纳入 1799 例肝切除术患者（小切除（n=491，27.3%）；大切除（n=1308，72.7%））。193 例（10.7%）LLR 患者中，190 例符合匹配条件。LLR 与 OLR 之间的患者特征、切缘状态和 30 天（p=0.141）、90 天死亡率（p=0.121）或 30 天再入院率（p=0.784）均无差异。LLR 的中位住院时间较短（6 天 vs 8 天，p=0.001）。LLR 与 OLR 的中位总生存期（OS）相似（分别为 44.2 个月和 39.5 个月，p=0.064）。OS 较差的预测因素包括年龄较大（风险比（HR）1.04，p=0.034）、存在 2 种以上合并症（HR 1.29，p=0.012）、分级 3-4 级疾病（HR 1.81，p=0.025）、N1 疾病（HR 1.04，p=0.048）和 R1 切缘（HR 1.34，p=0.002）。调整混杂因素后，与 OLR 相比，LLR 不是 OS 的显著危险因素（HR 1.14，95%CI 0.76-1.71，p=0.522）。
虽然 LLR 在晚期肝硬化合并 HCC 患者中是安全的，但基于术前可获得的因素（合并症、年龄、基础肝病程度和高质量的肿瘤外科手术）进行最佳的患者选择，将决定长期生存。
