背景:几种治疗方法可诱导肝脏恶性肿瘤患者的肝脏肥大,但未来肝脏残存量不足(FLR)。在这里,本研究的目的是使用网络荟萃分析(NMA)比较现有外科技术的疗效和安全性.
方法:我们搜索了PubMed,WebofScience,和Cochrane图书馆来自数据库,用于从数据库开始到2022年2月发布的摘要和全文文章。主要结果是不同手术的疗效,包括标准化的FLR(sFLR)增加,肝切除术的时间,切除率,和R0切缘。次要结果是不同治疗的安全性,包括Clavien-Dindo≥3a和90天死亡率。
结果:27项研究,包括三项随机对照试验(RCT),三项前瞻性试验(PT),和21项回顾性试验(RTs),本研究共招募了2075例患者.NMA表明,与门静脉栓塞(PVE)相比,联合肝分区和门静脉结扎用于分期肝切除术(ALPPS)的sFLR增加要高得多(55.25%,95%CI45.27-65.24%),或肝静脉剥夺(LVD)(43.26%,95%CI22.05-64.47%),或两期肝切除术(TSH)(30.53%,95%CI16.84-44.21%),或门静脉结扎(PVL)(58.42%,95%CI37.62-79.23%)。与PVE相比,ALPPS显示肝切除术的时间明显更短(-32.79d,95%CI-42.92-22.66),或LVD(-34.02d,95%CI-47.85-20.20),或TSH(-22.85d,95%CI-30.97-14.72),或PVL(-43.37d,95%CI-64.11-22.62);与TSH相比,ALPPS被认为是最高的切除率(OR=6.09;95%CI2.76-13.41),或PVL(OR=3.52;95%CI1.16-10.72),或PVE(OR=4.12;95%CI2.19-7.77)。ALPPS的切除率与LVD相当(OR=2.20;95%CI0.83-5.86)。当考虑R0重率时,它们之间没有显着差异。与其他治疗相比,ALPPS的Clavien-Dindo≥3a并发症发生率和90天死亡率更高,尽管不同程序之间没有显着差异。
结论:ALPPS表现出更高的再生率,更短的时间进行肝切除术,切除率高于PVL,PVE,或TSH。当考虑R0重率时,它们之间没有显着差异。然而,与其他治疗相比,ALPPS出现Clavien-Dindo≥3a并发症发生率和90天死亡率较高的趋势。
BACKGROUND: Several treatments induce liver hypertrophy for patients with liver malignancies but insufficient future liver remnant (FLR). Herein, the aim of this study is to compare the efficacy and safety of existing surgical techniques using network meta-analysis (NMA).
METHODS: We searched PubMed, Web of Science, and Cochrane Library from databases for abstracts and full-text articles published from database inception through Feb 2022. The primary outcome was the efficacy of different procedures, including standardized FLR (sFLR) increase, time to hepatectomy, resection rate, and R0 resection margin. The secondary outcome was the safety of different treatments, including the rate of Clavien-Dindo≥3a and 90-day mortality.
RESULTS: Twenty-seven studies, including three randomized controlled trials (RCTs), three prospective trials (PTs), and twenty-one retrospective trials (RTs), and a total number of 2075 patients were recruited in this study. NMA demonstrated that the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) had much higher sFLR increase when compared to portal vein embolization (PVE) (55.25%, 95% CI 45.27-65.24%), or liver venous deprivation(LVD) (43.26%, 95% CI 22.05-64.47%), or two-stage hepatectomy (TSH) (30.53%, 95% CI 16.84-44.21%), or portal vein ligation (PVL) (58.42%, 95% CI 37.62-79.23%). ALPPS showed significantly shorter time to hepatectomy when compared to PVE (-32.79d, 95% CI -42.92-22.66), or LVD (-34.02d, 95% CI -47.85-20.20), or TSH (-22.85d, 95% CI -30.97-14.72), or PVL (-43.37d, 95% CI -64.11-22.62); ALPPS was considered as the highest resection rate when compared to TSH (OR=6.09; 95% CI 2.76-13.41), or PVL (OR =3.52; 95% CI 1.16-10.72), or PVE (OR =4.12; 95% CI 2.19-7.77). ALPPS had comparable resection rate with LVD (OR =2.20; 95% CI 0.83-5.86). There was no significant difference between them when considering the R0 marge rate. ALPPS had a higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments, although there were no significant differences between different procedures.
CONCLUSIONS: ALPPS demonstrated a higher regeneration rate, shorter time to hepatectomy, and higher resection rate than PVL, PVE, or TSH. There was no significant difference between them when considering the R0 marge rate. However, ALPPS developed the trend of higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments.