Department of Hepatobiliary and Pancreatic Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China.
Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital, Zhejiang Shuren University, Shulan International Medical College, Hangzhou, China
BMJ Open. 2023 May 8;13(5):e067222. doi: 10.1136/bmjopen-2022-067222.
Hepatectomy is the best treatment for patients with intrahepatic cholangiocarcinoma (ICC) at present, but there has been controversy about the width of surgical margins. In this study, we systematically investigated the effects of different surgical margin widths on the prognosis of patients with ICC undergoing hepatectomy.
Systematic review and meta-analysis.
PubMed, Embase and Web of Science databases were systematically searched from inception to June 2022.
Cohort studies reported in English with patients who underwent negative marginal (R0) resection were included. The effects of surgical margin width on overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS) in patients with ICC were assessed.
Two investigators independently conducted literature screening and data extraction. Risk of bias was assessed using funnel plots and quality was assessed by the Newcastle-Ottawa Scale. Forest plots of HRs and their 95% CIs for outcome indicators were plotted. Heterogeneity was assessed and determined quantitatively using I, and the stability of the study results was evaluated using sensitivity analysis. Analyses were performed using Stata software.
Nine studies were included. With the wide margin group (≥10 mm) as the control, pooled HR of OS in the narrow margin group (<10 mm) was 1.54 (95% CI 1.34 to 1.77). HRs of OS in three subgroups where the margin was less than 5 mm ranged from 5 mm to 9 mm, or was less than 10 mm in length were 1.88 (1.45 to 2.42), 1.33 (1.03 to 1.72) and 1.49 (1.20 to 1.84), respectively. Pooled HR of DFS in the narrow margin group (<10 mm) was 1.51 (1.14 to 2.00). Pooled HR of RFS in the narrow margin group (<10 mm) was 1.35 (1.19 to 1.54). HRs of RFS in three subgroups where the margin was less than 5 mm ranged from 5 mm to 9 mm, or was less than 10 mm in length were 1.38 (1.07 to 1.78), 1.39 (1.11 to 1.74) and 1.30 (1.06 to 1.60), respectively. Neither lymph node lesions (HR 1.44, 95% CI 1.22 to 1.70) nor lymph node invasion (2.14, 1.39 to 3.28) was favourable for postoperative OS in patients with ICC. Lymph node metastasis (1.31, 1.09 to 1.57) was unfavourable for RFS in patients with ICC.
Patients with ICC who underwent curative hepatectomy with a negative margin ≥10 mm may have a long-term survival advantage, but lymph node dissection also needs to be considered. In addition, tumour-related pathological features need to be explored to see if they affect the surgical outcome of R0 margins.
肝切除术是目前治疗肝内胆管细胞癌（ICC）的最佳方法，但手术切缘宽度仍存在争议。本研究系统探讨了不同切缘宽度对接受肝切除术的 ICC 患者预后的影响。
系统评价和荟萃分析。
从建库至 2022 年 6 月，系统检索了 PubMed、Embase 和 Web of Science 数据库。
纳入了报道接受阴性切缘（R0）切除术的 ICC 患者的英文队列研究。评估了手术切缘宽度对 ICC 患者总生存（OS）、无病生存（DFS）和无复发生存（RFS）的影响。
两名研究者独立进行文献筛选和数据提取。使用漏斗图评估偏倚风险，使用 Newcastle-Ottawa 量表评估质量。绘制森林图以显示结局指标的 HR 及其 95%CI。使用 I 评估异质性并进行定量测定，使用敏感性分析评估研究结果的稳定性。使用 Stata 软件进行分析。
纳入了 9 项研究。以宽切缘组（≥10mm）为对照组，窄切缘组（<10mm）的 OS 汇总 HR 为 1.54（95%CI 1.34 至 1.77）。切缘<5mm、5mm 至 9mm 或<10mm 长度的三组中 OS 的 HR 分别为 5mm 至 9mm（5mm 至 9mm）为 1.88（1.45 至 2.42），1.33（1.03 至 1.72）和 1.49（1.20 至 1.84）。窄切缘组（<10mm）的 DFS 汇总 HR 为 1.51（1.14 至 2.00）。窄切缘组（<10mm）的 RFS 汇总 HR 为 1.35（1.19 至 1.54）。切缘<5mm、5mm 至 9mm 或<10mm 长度的三组中 RFS 的 HR 分别为 1.38（1.07 至 1.78）、1.39（1.11 至 1.74）和 1.30（1.06 至 1.60）。淋巴结病变（HR 1.44，95%CI 1.22 至 1.70）和淋巴结侵犯（2.14，1.39 至 3.28）均不利于 ICC 患者术后 OS。淋巴结转移（1.31，1.09 至 1.57）不利于 ICC 患者的 RFS。
接受阴性切缘≥10mm 的 ICC 患者行根治性肝切除术可能具有长期生存优势，但也需要考虑淋巴结清扫。此外，还需要探讨肿瘤相关的病理特征，以确定其是否影响 R0 切缘的手术结果。
