【作者】 黄海；

【导师】 刘胜利；

【作者基本信息】 东南大学 ， 外科学， 2005， 硕士

【摘要】 目的:探讨影响胆管癌围手术期风险及预后的危险因素。方法:对62例胆管癌手术患者的临床资料进行回顾性研究。本研究男33例和女29例,年龄44~82岁(62.3±8.4),其中上段胆管癌35例、中段6例、下段21例。手术方式根治性切除18例、姑息性切除19例、单纯胆肠内引流18例、单纯外引流5例、剖腹探查2例。用Logistic回归分析影响围手术期死亡和术后并发症的危险因素,用Cox回归比例风险模型分析影响预后的危险因素。有随访资料的患者方纳入影响预后危险因素的研究。对每一指标行单因素分析,筛选出P<0.1的自变量方可进入多因素分析。用Kaplan -Meier法计算随访病例的累积生存率,并用Log-rank法比较生存率曲线。为分析影响围手术期死亡和术后并发症的危险因素,选用了14个指标包括性别、年龄、术前总胆红素、丙氨酸氨基转移酶(ALT)、门冬氨酸氨基转移酶(AST)、碱性磷酸酶(ALP)、r谷氨酰转肽酶(r-GGT)、白蛋白、术前合并症、手术时间、手术方式、肝功能分级、肿瘤分期、肿瘤分型。分析影响预后的危险因素时选用了15个指标,即肿瘤分期、肿瘤分型、肿瘤分化程度、切缘癌细胞浸润情况、术前合并症、术后并发症及性别、年龄、术前总胆红素、ALT、AST、ALP、r-GGT、白蛋白、肝功能分级。肝功能用Child-pugh分级法判定,用Longmire分型法对肿瘤分型,据UICC标准对肿瘤分期。结果:本研究围手术期死亡7例(11%),其中因多器官功能衰竭死亡4例,呼吸功能衰竭、急性肾功能不全、糖尿病高渗性昏迷死亡各1例。发生术后并发症者20例(32%),其中多器官功能衰竭、胆漏、胆道感染各4例,上消化道出血、肺部感染各3例,糖尿病高渗性昏迷、急性肾功能不全各1例。共随访到44例,总体生存时间为3.1~ 41.8月(12.7±8.1)。目前仍存活4例,已生存时间分别为14.7,17.8,20.8,41.8月。单因素分析显示影响围手术期死亡的可能因素有7个,即年龄(P=0.006)、术前总胆红素(P=0.03)、r-GGT (P=0.027)、白蛋白(P=0.036)、肝功能分级(P=0.063)、肿瘤分期(P=0.062)、术前合并症(P=0.039);仅年龄影响术后并发症的发生(P=0.025)。多因素分析显示显著影响围手术期死亡的危险因素有3个,按影响大小依次是年龄(P=0.01)、肿瘤分期(P=0.049)、r-GGT (P=0.046)。围手术期死亡风险与年龄、r-GGT水平、肿瘤分期成正比。仅年龄(P=0.025)显著影响术后并发症的发生,且年龄与术后并发症的发生成正比。单因素分析显示影响预后的可能因素有5个,即ALP (P=0.064)、r-GGT (P=0.09)、肿瘤分期(P=0.0001)、肿瘤分化程度(P=0.028)、切缘癌细胞浸润情况(P=0.002)。多因素分析显示显著影响预后的危险因素有3个,按影响大小依次是肿瘤分期(P=0.0001)、肿瘤分化程度(P=0.006)、切缘癌细胞浸润情况(P=0.036)。肿瘤分期早、分化程度高、获得切缘无癌细胞浸润的患者预后好。结论:(1)高龄增加胆管癌围手术期死亡和术后发生并发症的风险,而高r-GGT和肿瘤分期晚增加围手术期死亡风险。(2)肿瘤分期早、分化程度高、获得切缘无癌细胞浸润的胆管癌患者预后好。加强早期诊断和获得根治性切除是改善胆管癌预后的关键。更多还原

【Abstract】 Objective: To investigate the risk factors which influenced the perioperative mortality and morbidity , the prognosis after operation in cholangiocarcinoma.Methods: Sixty two patients with cholangiocarcinoma after operation were reviewed retrospectively, of which 33 men and 29 women with the age of 44 to 82 years (62.3±8.4) were included. Of the patients, 35 were upper-side cholangiocarcinoma , 6 were middle-side and 21 were lower-side. 18 were underwent radical resection, 19 palliative resection, 18 internal drainage, 5 external drainage and 2 laparotomy exploration.Logistic regression test was used in the perioperative mortality and morbidity study for multivariate analysis. In analysis of the risk factors influencing the prognosis, Cox regression proportional hazard model was used for multivariate analysis. Only patients with communication were entered Cox regression proportional hazard model. Before multivariate analysis, each parameter was evaluated with univariate analysis to define whether it was statistical significance (P<0.1) or not. Then the parameters with statistical significance entered for further multivariate analysis. Cumulative survival rate of patients with communication was calculated with Kaplan-Meier test. Survival curves were compared with Log-rank test.Fourteen parameters including sex, age, preoperative total bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), r-glutamyltransferase (r-GGT), albumin, accompanied diseases, operative time and method, liver function classification, tumour stage and type were chosen to analysis the risk factors which were correlated to the perioperative mortality and morbidity. In study of the risk facters influencing the prognosis, however, 15 parameters were chosen, of which there were tumour stage and type and differentiation grade, residual resection margin, accompanied diseases, complication, and sex, age, preoperative total bilirubin, ALT, AST, ALP, r-GGT, albumin, liver function classification. The liver function was classified according to Child-pugh method and the tumor type was definded by Longmire classification, and the tumor stage was classified by UICC tumor stage standard.Results: In the study, 7 patients (11%) died perioperatively, of which there were 4 with multi-organ function failure, 1 with lung function failure, 1 with acute renal dysfunction and 1 with diabetes hyperosmolar coma. Complications occurred in 20 patients (32%), of whichthere were 4 with multi-organ function failure, 4 with bile leakage, 4 with bile duct infection , 3 with upper gastrointestinal bleeding, 3 with lung infection , 1 with diabetes hyperosmolar coma and 1 with acute renal dysfunction. 44 patients were followed up with the overall survival time of 3.1 to 41.8 months (12.7±8.1). Of the patients , 4 are still alive with the survival time from 14.7 to 41.8 months.Univariate analysis showed that the 7 factors might influence the perioperative mortality including age (P=0.006), preoperative total bilirubin (P=0.03), r-GGT (P=0.027), albumin (P=0.036), accompanied diseases (P=0.039), tumour stage (P=0.062), liver function classification (P=0.063)。In contrast, only age was related to the morbidity (P=0.025). In multivariate analysis, however, results showed that 3 factors significantly influenced the perioperative mortality, which in rank were age (P=0.01), tumour stage (P=0.049), r-GGT (P=0.046). The perioperative mortality was positively related to the patient age, tumour stage, r-GGT. Only patient age (P=0.025) was significantly related to the morbidity.Five factors might influenced the prognosis in univariate analysis including ALP (P=0.064), r-GGT (P=0.09), tumour stage (P=0.0001) and differentiation grade (P=0.028), residual resection margin (P=0.002). Multivariate analysis presented that 3 factors influenced significantly prognosis, which in rank were tumour stage (P=0.0001), tumour differentiation grade (P=0.006), residual resection margin (P=0.036). The prognosis was well in the patients with early tumour stage and higher tumour differentiation grade and margin- negative residual resection.Conclusion: (1) Age increase the perioperative mortality and morbidity risk, while high r-GGT and late tumour stage increase the morbidity risk. (2)The prognosis is well in the patients with cholangiocarcinoma at early tumour stage, higher tumour differentiation grade and margin-negative residual resection. Acquired early diagnosis and radical resection are the key to improve the prognosis in patients with cholangiocarcinoma.更多还原