Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma.
Preoperative Cholangitis and Future Liver Remnant Volume Determine the Risk of Liver Failure in Patients Undergoing Resection for Hilar Cholangiocarcinoma.
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DOI：
10.1016/j.jamcollsurg.2016.01.060
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发表时间：
2016-07
影响因子：
5.2
通讯作者：
Vauthey JN
中科院分区：
文献类型：
--
作者：
Ribero D;Zimmitti G;Aloia TA;Shindoh J;Fabio F;Amisano M;Passot G;Ferrero A;Vauthey JN
据报道，接受肝门部胆管癌（HCCA）切除术的患者肝脏手术后死亡率最高。在这些患者中，术后死亡通常伴随着肝功能不全的发展。我们试图确定因 HCCA 接受肝切除术的患者术后肝功能不全和肝功能衰竭导致的死亡的相关因素。这项研究包括 1996 年至 2013 年在两个中心连续接受肝切除术以治疗 HCCA 的患者。分析术前临床和手术数据，以确定 i) 肝功能不全和 ii) 肝衰竭相关死亡的独立决定因素。该研究包括 133 名接受右或左大肝切除术 (n=67) 或扩大肝切除术 (n=66) 的患者。术前行胆道引流98例，并发胆管炎40例。所有这些患者的胆管炎在手术前均得到控制。 73 名患者（55%）发生主要（Dindo III-IV）术后并发症，其中 29 名患有肝功能不全。 15 名患者（11%）在术后 90 天内死亡，其中 10 人死于肝功能衰竭。多变量分析显示，术后肝功能不全的预测因素（全部 p<0.05）为术前胆管炎（比值比 [OR]=3.2）、未来肝残余 (FLR) 体积 <30% (OR=3.5)、术前总胆红素水平 >3 mg/dl (OR=4) 和白蛋白水平 <3.5 mg/dl (OR=3.3)。只有术前胆管炎（OR=7.5，p=.016）和FLR体积<30%（OR=7.2，p=.019）才能预测术后肝衰竭相关死亡。术前胆管炎和 FLR 容量不足是肝功能不全和术后肝功能衰竭相关死亡的主要决定因素。鉴于胆汁引流与胆管炎之间的关联，应优化 HCCA 患者的术前处理方法，以尽量减少胆管炎的风险。
The highest mortality rates after liver surgery are reported in patients who undergo resection for hilar cholangiocarcinoma (HCCA). In these patients, postoperative death usually follows the development of hepatic insufficiency. We sought to determine the factors associated with postoperative hepatic insufficiency and death due to liver failure in patients undergoing hepatectomy for HCCA. This study included all consecutive patients who underwent hepatectomy with curative intent for HCCA at two centers from 1996 through 2013. Preoperative clinical and operative data were analyzed to identify independent determinants of i) hepatic insufficiency and ii) liver failure–related death. The study included 133 patients with right or left major (n=67) or extended (n=66) hepatectomy. Preoperative biliary drainage was performed in 98 patients and was complicated by cholangitis in 40 cases. In all these patients, cholangitis was controlled before surgery. Major (Dindo III-IV) postoperative complications occurred in 73 patients (55%), with 29 suffering from hepatic insufficiency. Fifteen patients (11%) died within 90 days after surgery, 10 of them of liver failure. On multivariate analysis, predictors of postoperative hepatic insufficiency (all p<0.05) were preoperative cholangitis (odds ratio [OR]=3.2), future liver remnant (FLR) volume <30% (OR=3.5), preoperative total bilirubin level >3 mg/dl (OR=4), and albumin level <3.5 mg/dl (OR=3.3). Only preoperative cholangitis (OR=7.5, p=.016) and FLR volume <30% (OR=7.2, p=.019) predicted postoperative liver failure–related death. Preoperative cholangitis and insufficient FLR volume are major determinants of hepatic insufficiency and postoperative liver failure–related death. Given the association between biliary drainage and cholangitis, the preoperative approach to patients with HCCA should be optimized to minimize the risk of cholangitis.