目的:HCC患者的手术护理质量与改善的长期预后相关,也可能受手术方式的影响。本研究旨在评估腹腔镜方法对最佳HCC手术候选人的手术护理质量和长期预后的作用。
方法:2010年至2018年期间,在5个法国专家肝胰胆道中心接受开放(OLR)或腹腔镜肝切除术(LLR)治疗肝硬化早期HCC(METAVIRF4)的所有连续患者入选。手术护理质量由教科书结果(TO)定义,6项标准的组合代表理想的住院。通过多变量分析确定与TO相关的因素。在倾向评分匹配(PSM)后进行LLR和OLR之间的比较。主要终点是无病生存期(DFS)。使用非混合物模型对统计固化进行建模。
结果:总体而言,包括425名患者。中位随访时间为42.0个月。267例(62.8%)患者进行了LLR。140例(32.9%)患者达到了TO。LLR与TO独立相关(比值比[OR]2.81;95%CI1.29-6.12;p=0.009)。PSM之后,LLR患者累积的TO标准数量高于OLR患者(5vs.4;p=0.012)。1-,3-,有和没有TO的LLR患者的5年DFS为82.3%,64.4%,62.5%,76.9%,51.4%,和30.2%,分别(p=0.003)。在多变量Cox回归中,TO与改善的DFS独立相关(风险比0.34;p=0.001)。整个人群的治愈率为24.4%。与未达到TO的患者相比,达到TO的患者的治愈分数增加(32.6%vs.18.1%)。
结论:手术护理质量改善了早期HCC患者的预后,并通过腹腔镜方法得到了促进。
背景:外科护理的整体质量,以TO衡量,在预后中起着关键作用,特别是,关于发生在肝硬化中的可切除早期HCC患者的统计治愈概率。通过影响TO,腹腔镜检查对这些患者的治愈概率和长期管理有间接影响.这项研究强烈支持早期肝癌的微创治疗的有希望的疗效。如低难度LLR。
OBJECTIVE: The quality of surgical care of patients with HCC is associated with improved long-term prognosis and may also be influenced by the type of surgical approach. The present study aimed at evaluating the role of the laparoscopic approach on quality of surgical care and long-term prognosis in optimal HCC surgical candidates.
METHODS: All consecutive patients undergoing open (OLR) or laparoscopic liver resection (LLR) for early-stage HCC in cirrhosis (METAVIR F4) at 5 French expert hepato-pancreatico-biliary centres between 2010 and 2018 were enrolled. Quality of surgical care was defined by textbook outcome (TO), a combination of 6 criteria representing ideal hospitalisation. Factors associated with TO were determined on multivariate analysis. Comparison between LLR and OLR was performed after propensity score matching (PSM). The primary endpoint was disease-free survival (DFS). Statistical cure was modelled using a non-mixture model.
RESULTS: Overall, 425 patients were included. Median follow-up was 42.0 months. LLR was performed in 267 (62.8%) patients. TO was achieved in 140 (32.9%) patients. LLR was independently associated with TO (odds ratio [OR] 2.81; 95% CI 1.29-6.12; p = 0.009). After PSM, LLR patients cumulated higher number of TO criteria than OLR patients (5 vs. 4; p = 0.012). The 1-, 3-, and 5-year DFS of LLR patients with and without TO were 82.3%, 64.4%, and 62.5%, and 76.9%, 51.4%, and 30.2%, respectively (p = 0.003). On multivariable Cox regression, TO was independently associated with improved DFS (hazard ratio 0.34; p = 0.001). The cure fraction of the whole population was 24.4%. Patients achieving TO had increased cure fraction than patients not achieving TO (32.6% vs. 18.1%).
CONCLUSIONS: Quality of surgical care improves the prognosis of patients with early-stage HCC and is promoted by the laparoscopic approach.
BACKGROUND: The overall quality of surgical care, as measured by TO, plays a pivotal role in the prognosis and, in particular, on the probability of statistical cure of patients with resectable early-stage HCC occurring in cirrhosis. By influencing TO, laparoscopy has an indirect impact on the probability of cure and long-term management of these patients. This study strongly supports the promising curative role of mini-invasive treatments for early-stage HCC, such as low-difficulty LLR.