Hobeika Christian, Nault Jean Charles, Barbier Louise, Schwarz Lilian, Lim Chetana, Laurent Alexis, Gay Suzanne, Salamé Ephrem, Scatton Olivier, Soubrane Olivier, Cauchy François
Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France.
Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France.
JHEP Rep. 2020 Jul 30;2(6):100153. doi: 10.1016/j.jhepr.2020.100153. eCollection 2020 Dec.
BACKGROUND & AIMS: The quality of surgical care of patients with HCC is associated with improved long-term prognosis and may also be influenced by the type of surgical approach. The present study aimed at evaluating the role of the laparoscopic approach on quality of surgical care and long-term prognosis in optimal HCC surgical candidates.
All consecutive patients undergoing open (OLR) or laparoscopic liver resection (LLR) for early-stage HCC in cirrhosis (METAVIR F4) at 5 French expert hepato-pancreatico-biliary centres between 2010 and 2018 were enrolled. Quality of surgical care was defined by textbook outcome (TO), a combination of 6 criteria representing ideal hospitalisation. Factors associated with TO were determined on multivariate analysis. Comparison between LLR and OLR was performed after propensity score matching (PSM). The primary endpoint was disease-free survival (DFS). Statistical cure was modelled using a non-mixture model.
Overall, 425 patients were included. Median follow-up was 42.0 months. LLR was performed in 267 (62.8%) patients. TO was achieved in 140 (32.9%) patients. LLR was independently associated with TO (odds ratio [OR] 2.81; 95% CI 1.29-6.12; = 0.009). After PSM, LLR patients cumulated higher number of TO criteria than OLR patients (5 4; = 0.012). The 1-, 3-, and 5-year DFS of LLR patients with and without TO were 82.3%, 64.4%, and 62.5%, and 76.9%, 51.4%, and 30.2%, respectively ( = 0.003). On multivariable Cox regression, TO was independently associated with improved DFS (hazard ratio 0.34; = 0.001). The cure fraction of the whole population was 24.4%. Patients achieving TO had increased cure fraction than patients not achieving TO (32.6% 18.1%).
Quality of surgical care improves the prognosis of patients with early-stage HCC and is promoted by the laparoscopic approach.
The overall quality of surgical care, as measured by TO, plays a pivotal role in the prognosis and, in particular, on the probability of statistical cure of patients with resectable early-stage HCC occurring in cirrhosis. By influencing TO, laparoscopy has an indirect impact on the probability of cure and long-term management of these patients. This study strongly supports the promising curative role of mini-invasive treatments for early-stage HCC, such as low-difficulty LLR.
肝癌患者的外科治疗质量与长期预后改善相关，且可能受手术方式类型的影响。本研究旨在评估腹腔镜手术方式在最佳肝癌手术候选患者的外科治疗质量及长期预后中的作用。
纳入2010年至2018年期间在5家法国专家级肝胰胆中心因早期肝癌在肝硬化（METAVIR F4）患者中接受开腹肝切除术（OLR）或腹腔镜肝切除术（LLR）的所有连续患者。外科治疗质量由教科书式结局（TO）定义，TO是代表理想住院情况的6项标准的组合。通过多变量分析确定与TO相关的因素。在倾向评分匹配（PSM）后对LLR和OLR进行比较。主要终点为无病生存期（DFS）。使用非混合模型对统计学治愈进行建模。
总体而言，共纳入425例患者。中位随访时间为42.0个月。267例（62.8%）患者接受了LLR。140例（32.9%）患者达到TO。LLR与TO独立相关（比值比[OR] 2.81；95%置信区间1.29 - 6.12；P = 0.009）。PSM后，LLR患者累积达到的TO标准数量高于OLR患者（5比4；P = 0.012）。有和没有达到TO的LLR患者的1年、3年和5年DFS分别为82.3%、64.4%和62.5%，以及76.9%、51.4%和30.2%（P = 0.003）。在多变量Cox回归分析中，TO与DFS改善独立相关（风险比0.34；P = 0.001）。总体人群的治愈比例为24.4%。达到TO的患者比未达到TO的患者有更高的治愈比例（32.6%比18.1%）。
外科治疗质量改善了早期肝癌患者的预后，且腹腔镜手术方式可促进这一改善。
以TO衡量的外科治疗总体质量在预后中起关键作用，尤其对肝硬化中可切除早期肝癌患者的统计学治愈概率而言。通过影响TO，腹腔镜手术对这些患者的治愈概率及长期管理有间接影响。本研究有力支持了微创治疗对早期肝癌（如低难度LLR）的有前景的治愈作用。
