【作者】 汪涛；

【导师】 万赤丹；

【作者基本信息】 华中科技大学 ， 肝胆外科， 2020， 硕士

【摘要】 目的:通过荟萃分析来探讨联合肝脏分隔和门静脉结扎的分阶段肝切除术(associating liver partition and portal vein ligation for staged hepatectomy,ALPPS)和传统两阶段肝切除术(conventional two-stage hepatectomy,c TSH)治疗剩余肝体积(future liver remnant,FLR)不足的肝脏恶性肿瘤的可行性、安全性和有效性。资料与方法:通过检索Pub Med/Medline、Cochrane Library、Embase、Web of Science、CNKI、WANFANG DATA、CBM、VIP等中英文数据库,根据纳入和排除标准及文献质量评估,选取ALPPS与c TSH治疗肝脏恶性肿瘤的的临床对照研究,提取两组的临床对比资料,包括两步手术完成率、FLR增长率、两步手术间隔时间、R0切除率、90天死亡率、术后并发症发生率、术后肝衰竭发生率、总住院时间、术后1年无瘤生存率等。采用Revman5.3进行meta分析。结果:共纳入14篇临床对照研究(13篇队列研究,1篇随机对照研究),共1015例患者,其中ALPPS组310例,c TSH组705例。两组间年龄、性别、伴肝硬化比例、术前化疗比例、肿瘤类型等基线资料具有可比性。meta分析结果如下:与c TSH相比,ALPPS具有更高的FLR增长率(MD=27.74,95%CI=18.17-37.31,P<0.00001)、更短的两步手术间隔时间(MD=-31.60,95%CI=-39.16～-24.03,P<0.00001)、更高的两步手术完成率(OR=8.60,95%CI=4.84-15.28,P<0.00001)、更高的R0切除率(OR=3.48,95%CI=2.19-5.55,P<0.00001),围手术期90天死亡率、术后肝衰竭发生率、总住院时间以及长期肿瘤预后在两组间无显著差异,但其术后并发症发生率要高于c TSH(总并发症:OR=1.82,95%CI=1.06-3.15,P=0.03;主要并发症:OR=1.83,95%CI=1.28-2.62,P=0.0009);在Year>2015亚组中ALPPS的术后并发症发生率并不高于c TSH(总并发症:OR=1.29,95%CI=0.63-2.66,P=0.48;主要并发症:OR=1.30,95%CI=0.79-2.14,P=0.30);在HCC亚组中ALPPS的FLR增长率并不高于c TSH(MD=10.12,95%CI=-2.63～22.87,P=0.12)。结论:1.与cTSH相比,ALPPS具有更高的FLR增长率、更短的两步手术间隔时间、更高的两步手术完成率、更高的R0切除率,围手术期90天死亡率、术后肝衰竭发生率、总住院时间以及长期肿瘤预后在两组间无差别,其术后并发症发生率在早期要高于c TSH。2.近几年通过严格的患者选择、手术经验的积累和手术技术的改进,ALPPS的安全性得到了较大的提升,术后并发症发生率与c TSH相当。ALPPS是治疗FLR不足的肝脏恶性肿瘤可行的、安全的、有效的手术方式。3.对于合并肝硬化的HCC患者,FLR的增生受到限制,ALPPS的运用应当慎重,其在不合并肝脏基础疾病的转移性肝脏恶性肿瘤中的运用应该是主要的适应证,但在严格筛选的轻度肝硬化的HCC患者中,ALPPS也有其应用的价值。更多还原

【Abstract】 Objective:A meta-analysis to explore the feasibility,safety,and effectiveness of associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)compared with conventional two-stage hepatectomy(c TSH)for the treatment of liver malignancies with insufficient future liver remnant(FLR).Materials and methods:By searching Pub Med/Medline,Cochrane Library,Embase,Web of Science,CNKI,WANFANG DATA,CBM,VIP Chinese and English databases,according to the inclusion and exclusion criteria and literature quality assessment,select the clinical controlled studies of ALPPS vensus c TSH for the treatment of liver malignancies.Clinical comparison data of the two groups were extracted,including two-step operation completion rate,FLR growth rate,two-step operation interval time,R0 resection rate,90-day mortality,mobidity,postoperative liver failure rate,total hospital stay,1-year tumor-free survival rate etc.The meta-analysis was performed using the software of Revman5.3.Results:There were 14 clinical controlled studies included in total(13 cohort studies and 1 randomized controlled study),a total of 1015 patients,including 310 in ALPPS group and 705 in c TSH group.Baseline data such as age,sex,proportion of patients with cirrhosis,proportion of preoperative chemotherapy,and tumor type were comparable between the two groups.The meta-analysis results were as follows: Compared with c TSH,ALPPS had higher FLR growth rate(MD = 27.74,95% CI = 18.17-37.31,P <0.00001),shorter two-step surgical interval(MD =-31.60,95% CI =-39.16 ～-24.03,P <0.00001),higher completion rate of two-step surgery(OR = 8.60,95% CI = 4.84-15.28,P <0.00001),higher R0 resection rate(OR = 3.48,95% CI = 2.19-5.55,P <0.00001).The perioperative 90-day mortality,liver failure rate,total hospital stay,and long-term tumor prognosis were not significantly different between the two groups,but the postoperative morbidity was higher in ALPPS group(overall morbidity: OR = 1.82,95% CI = 1.06-3.15,P = 0.03 <0.05;major morbidity: OR = 1.83,95% CI = 1.28-2.62,P = 0.0009).In Year>2015 subgroup,the postoperative morbidity of ALPPS was not higher than that of c TSH(overall morbidity: OR = 1.29,95% CI = 0.63-2.66,P = 0.48;major morbidity: OR = 1.30,95% CI = 0.79-2.14,P = 0.30).In HCC subgroup,the FLR growth rate of ALPPS was not higher than that of c TSH(MD = 10.12,95% CI =-2.63 to 22.87,P = 0.12).Conclusion:1.Compared with c TSH,ALPPS has higher FLR growth rate,shorter two-step operation interval,higher two-step operation completion rate,higher R0 resection rate.The perioperative 90-day mortality,liver failure rate,total hospital stay,and long-term tumor prognosis were not significantly different between the two groups,but the postoperative morbidity of ALPPS was higher than that of c TSH in the early stage.2.In recent years,through strict patient selection,accumulation of surgical experience and improvement of surgical technique,the safety of ALPPS has been greatly improved,and the postoperative morbidity of ALPPS has been comparable to c TSH.ALPPS is a feasible,safe and effective surgical choice for patients of liver malignancies with insufficient FLR.3.For HCC patients with liver cirrhosis,the proliferation of FLR is limited,and the use of ALPPS should be cautious.Its application in metastatic liver malignancies without liver disease should be the main indication.However,ALPPS also has its application value in strict selected HCC patients with mild cirrhosis.更多还原