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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2024, Vol. 17 ›› Issue (04) : 222 -226. doi: 10.3877/cma.j.issn.1674-6899.2024.04.006

论著

腹腔镜肝切除术联合微波消融治疗多发性结直肠癌肝转移
宋华传1, 季鹏1, 姚焕章1, 王永帅1, 张珅瑜1, 宋瑞鹏1, 王继洲1,†()   
  1. 1. 230002　安徽，中国科学技术大学第一附属医院肝胆外科
  • 收稿日期:2024-05-29 出版日期:2024-08-30
  • 通信作者: 王继洲

Laparoscopic hepatectomy combined with intraoperative microwave ablation in the treatment of multiple colorectal liver metastases

Huachuan Song1, Peng Ji1, Huanzhang Yao1, Yongshuai Wang1, Shenyu Zhang1, Ruipeng Song1, Jizhou Wang1,†()   

  1. 1. Department of Hepatobiliary Surgery, the First Affiliated Hospital of University of Science and Technology of China, Anhui 230002, China
  • Received:2024-05-29 Published:2024-08-30
  • Corresponding author: Jizhou Wang
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宋华传, 季鹏, 姚焕章, 王永帅, 张珅瑜, 宋瑞鹏, 王继洲. 腹腔镜肝切除术联合微波消融治疗多发性结直肠癌肝转移[J]. 中华腔镜外科杂志(电子版), 2024, 17(04): 222-226.

Huachuan Song, Peng Ji, Huanzhang Yao, Yongshuai Wang, Shenyu Zhang, Ruipeng Song, Jizhou Wang. Laparoscopic hepatectomy combined with intraoperative microwave ablation in the treatment of multiple colorectal liver metastases[J]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2024, 17(04): 222-226.

目的

比较腹腔镜肝切除术联合微波消融与仅腹腔镜肝切除术治疗多发性结直肠癌肝转移(colorectal liver metastases，CRLM)的术后并发症发生率和复发情况。

方法

回顾性分析了2018年12月至2024年1月中国科学技术大学第一附属医院124例接受腹腔镜肝切除术联合或不联合腹腔镜超声引导微波消融治疗的多发性CRLM患者的临床资料。其中，腹腔镜肝切除术联合微波消融组42(33.9%)例、腹腔镜肝切除术组82(66.1%)例。采用单因素和多因素logistic回归模型分析与术后主要并发症相关的因素。Kaplan-Meier生存分析方法和对数秩检验用于比较不同手术组患者的无复发生存(recurrence-free survival, RFS)情况。

结果

腹腔镜肝切除术联合微波消融组患者的病灶数目更多(P<0.001)，肝两叶受累比例更高(P<0.001)。20(16.1%)例发生Clavien-Dindo分级Ⅱ级及以上的并发症。多因素分析结果提示，体质量指数(body mass index，BMI) ≥24.0 kg/m2 (OR 5.11, 95%CI: 1.54～16.95, P＝0.008)和术中输血(OR＝7.90，95%CI: 1.00～62.15，P＝0.050)是术后主要并发症的独立危险因素。两种手术方式的RFS差异无统计学意义(P＝0.81)，中位RFS分别为8.8个月和10.2个月。

结论

腹腔镜肝切除联合微波消融为肿瘤数目较多和肝两叶受累的CRLM患者提供了一个根治性手术的机会。CRLM个体化治疗时，可以在保留肝功能的情况下，采取更加积极的根治性手术方案以改善预后。

关键词: 结直肠癌肝转移, 腹腔镜肝切除, 微波消融, 术后并发症, 无复发生存率
Objective

To compare the postoperative complications and recurrence of multiple colorectal liver metastases (CRLM) treated by laparoscopic hepatectomy combined with microwave ablation and laparoscopic hepatectomy alone.

Methods

The clinical data of 124 patients with multiple CRLM who underwent laparoscopic hepatectomy combined with or without intraoperative microwave ablation from Dec. 2018 to Jan. 2024 were retrospectively analyzed. 42 cases (33.9%) underwent laparoscopic hepatectomy combined with microwave ablation, and 82 cases (66.1%) underwent laparoscopic hepatectomy. Univariate and multivariate Logistic regression models were used to analyze the factors associated with major postoperative complications. Kaplan-Meier survival analysis and logarithmic rank test were used to compare recurrence-free survival (RFS) in different surgical groups.

Results

The number of lesions in laparoscopic hepatectomy combined with microwave ablation group was higher (P<0.001), and the proportion of hepatic bilobar involvement was higher (P< 0.001). Complications of Clavien-Dindo grade Ⅱ and higher occurred in 20 (16.1%) patients. Multivariate analysis suggested that BMI ≥ 24.0 kg/m2 (OR 5.11, 95%CI: 1.54-16.95, P=0.008)and intraoperative blood transfusion (OR 7.90, 95%CI: 1.00-62.15, P=0.050) was independent risk factors for postoperative complications. There was no significant difference in RFS between the two groups (P=0.81), and the median RFS was 8.8 and 10.2 months, respectively.

Conclusions

Laparoscopic hepatectomy combined with microwave ablation provides an opportunity for radical surgery in multiple CRLM patients with bilobar involvement. In the individual treatment of CRLM, a more aggressive radical surgical strategy can be adopted to improve the prognosis while preserving liver function.

Key words: Colorectal liver metastases, Laparoscopic hepatectomy, Microwave ablation, Postoperative complications, Recurrence-free survival
表1 患者基线特征描述[例(%)]
项目 腹腔镜肝切除组(n＝82) 联合微波消融组(n＝42) P值
男性 55 (67.07) 25 (59.52) 0.406
年龄≥60岁 32 (39.02) 18 (42.86) 0.681
BMI≥24 kg/m2 36 (43.90) 21 (50.00) 0.519
高血压 31 (37.80) 16 (38.10) 0.975
糖尿病 11 (13.41) 11 (26.19) 0.078
RAS基因突变 28 (50.91) 22 (62.86) 0.266
原发肿瘤位置，结肠 44 (53.66) 23 (56.10) 0.798
原发肿瘤淋巴结阳性 51 (69.86) 28 (75.68) 0.522
同时性肝转移 50 (60.98) 30 (73.17) 0.181
肝转移灶数目 2.00 (2.00～3.00) 3.50 (3.00～5.75) <0.001
最大转移灶直径≥3.0 cm 29 (35.37) 12 (28.57) 0.447
肝两叶受累 30 (36.59) 29 (69.05) <0.001
术前CEA≥10 ng/ml 33 (40.24) 14 (33.33) 0.453
术前化疗 58 (71.60) 34 (80.95) 0.258
原发灶同期手术 25 (30.49) 10 (23.81) 0.434
术中出血量(ml) 100.00 (50.00～100.00) 100.00 (50.00～100.00) 0.579
手术时间(min) 210.00 (151.25～298.25) 237.50 (180.75～317.75) 0.124
术中输血 5 (6.10) 2 (4.76) 0.760
术后住院时间(d) 7.00 (5.00～10.75) 6.50 (5.00～8.75) 0.458
术后主要并发症 15 (18.29) 5 (11.90) 0.360
表2 单因素和多因素logistic回归分析与术中主要并发症相关的因素
暴露因素 例(%) 单因素分析OR(95%CI) P值 多因素分析OR(95%CI) P值
男性 80(64.5) 0.79(0.30, 2.12) 0.645    
年龄≥60岁 50(40.3) 0.76(0.28, 2.07) 0.597    
BMI≥24 kg/m2 57(46.0) 4.43(1.50, 13.11) 0.007 5.11(1.54, 16.95) 0.008
高血压 47(37.9) 1.11(0.42, 2.96) 0.833    
糖尿病 22(17.7) 1.19(0.36, 4.00) 0.773    
RAS基因突变 50(55.6) 0.90(0.30, 2.73) 0.850    
原发肿瘤位置，结肠 67(54.5) 0.81(0.31, 2.11) 0.661    
原发肿瘤淋巴结阳性 79(71.8) 1.12(0.37, 3.43) 0.842    
同时性肝转移 80(65.0) 3.60(0.99, 13.07) 0.052 2.14(0.50, 9.08) 0.303
最大转移灶直径≥3.0 cm 41(33.1) 1.84(0.69, 4.88) 0.220    
肝两叶受累 59(47.6) 1.12(0.43, 2.92) 0.813    
术前CEA≥10 ng/ml 47(37.9) 1.11(0.42, 2.96) 0.833    
原发灶同期手术 35(28.2) 4.07(1.51, 10.99) 0.006 2.55(0.81, 8.03) 0.111
腹腔镜肝切除术联合消融 42(33.9) 0.60(0.20, 1.79) 0.363    
术中输血 7(5.6) 4.41(0.91, 21.48) 0.066 7.90(1.00, 62.15) 0.050
图1 Kaplan-Meier生存曲线：两种手术方式治疗多发性结直肠癌肝转移无复发生存率比较
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