Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
Int J Surg. 2020 Oct;82:108-115. doi: 10.1016/j.ijsu.2020.08.013. Epub 2020 Aug 27.
Converted laparoscopic hepatectomies are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy is expected of usefulness in clinical practice, given its technical peculiarities. The purpose of the study was the identification of risk factors and the development of a risk score for conversion of laparoscopic right hepatectomy.
Laparoscopic right hepatectomy performed at a single hepatobiliary surgical center were analyzed. The cohort was split in half to obtain a derivation and a validation set. Risk factors for conversion were identified by uni- and multivariable analysis. A "conversion risk score" was built assigning each factor 1 point and comparing the score with the conversion status for each patient. The accuracy was assessed by the area-under-the-receiver-operator-characteristic-curve.
Among 130 operations, 22 were converted (16.9%). Reasons were: 45.5% oncologic inadequacy, 31.8% bleeding, 9.1% adhesions, 9.1% biliostasis, 4.5% anaesthesiological problems. Independent risk factors for conversion were: previous laparoscopic liver surgery (Hazard Ratio 4.9, p 0.011), preoperative chemotherapy ( Hazard Ratio 6.2, p 0.031), malignant diagnosis (Hazard Ratio 3.3, p 0.037), closeness to hepatocaval confluence or inferior vena cava (Hazard Ratio 4.1, p 0.029), tumor volume (Hazard Ratio 2.9, p 0.024). Conversion rates correlated positively with the score, raising from 0 to 100% when the score increased from 0 to 5 (Spearman: p 0.032 in the derivation set, p 0.020 in the validation set). The risk of conversion showed a sharp increase passing from class 3 to 4, reaching a probability estimated between 60 and 71.4%. The score showed good accuracy (area-under-the-receiver-operator-characteristic-curve 0.82).
Specific risk factors for conversion are identified for laparoscopic right hepatectomy. This score may help in standardizing the choice of a pure laparoscopic or open approach for such challenging resections.
已证实转化腹腔镜肝切除术失去了微创的一些优势，并且已经确定了一些预测高危患者的因素。鉴于腹腔镜右半肝切除术的技术特点，该术式具有特殊的临床应用价值，我们期望能有具体的证据来支持其在临床实践中的应用。本研究旨在确定腹腔镜右半肝切除术中转开腹的危险因素，并建立风险评分。
对单中心行腹腔镜右半肝切除术的患者进行分析。将队列分为两半，分别获得推导组和验证组。通过单变量和多变量分析确定中转的危险因素。建立“中转风险评分”，每个因素赋值 1 分，比较每个患者的评分与中转状态。通过接受者操作特征曲线下面积评估准确性。
在 130 例手术中，有 22 例（16.9%）中转开腹。中转原因包括：45.5%肿瘤学原因、31.8%出血、9.1%粘连、9.1%胆泥形成、4.5%麻醉问题。独立的中转危险因素包括：既往腹腔镜肝切除术（风险比 4.9，p 0.011）、术前化疗（风险比 6.2，p 0.031）、恶性诊断（风险比 3.3，p 0.037）、靠近肝门或下腔静脉（风险比 4.1，p 0.029）、肿瘤体积（风险比 2.9，p 0.024）。中转率与评分呈正相关，当评分从 0 增加到 5 时，中转率从 0%增加到 100%（推导组：Spearman 检验，p 0.032；验证组：Spearman 检验，p 0.020）。从中转风险 3 级增加到 4 级时，转换风险显著增加，估计概率在 60%至 71.4%之间。评分具有良好的准确性（接受者操作特征曲线下面积 0.82）。
本研究确定了腹腔镜右半肝切除术中转开腹的具体危险因素。该评分可能有助于规范此类具有挑战性的肝切除术选择腹腔镜或开腹手术方式。
