目的 探讨腹腔镜肝切除术中转开放手术危险因素及构建中转开放手术的风险预测模型.方法 回顾性分析2019年6月至2022年5月南方医科大学南方医院肝胆外科收治的938例行腹腔镜肝切除术病人的临床病例信息,依据是否中转开放手术分为腹腔镜组(836例)和中转组(102例),收集所有纳入病人基本信息和临床病例资料,分析两组组间差异及因素,基于多因素分析结果构建中转开放手术列线图预测模型.结果 单因素分析结果显示,在有无腹部手术史、有无血管性介入治疗史、是否首次行肝切除、有无腹腔积液、肝肿瘤最大直径、是否为困难肝段切除、切除范围等,差异具有统计学意义(P＜0.05).多因素分析结果显示,有腹部手术史(OR=1.716,95％CI 为 1.023-2.878)、非首次行肝切除(OR=3.585,95％CI 为 1.705-7.538)、肝肿瘤最大直径≥5cm(OR=2.680,95％CI 为 1.646-4.363)、困难肝段切除(OR=2.953,95％CI为 1.755-4.967)、肝段切除范围≥3 个肝段(OR=1.901,95％CI为1.099-3.290)为腹腔镜肝切除术中转开放手术的独立危险因素(P均＜0.05).依据多因素分析结果,纳入5个独立危险因素变量,构建腹腔镜肝切除术中转开放手术的列线图模型.模型的C-index为0.746(95％CI为 0.692-0.800),Hosmer-Lemeshow拟合优度检验结果P=0.541＞0.05,绘制 ROC 曲线,曲线下面积(AUC)为0.746(95％CI为0.692-0.800,P＜0.001).绘制的临床决策曲线(DCA)结果示在阈值概率范围0.05～0.70内模型具有临床效用.结论 有腹部手术史,非首次行肝切除,肝肿瘤最大直径≥5 cm,困难肝段切除,肝段切除范围≥3个肝段是腹腔镜肝切除术中转开放手术的独立危险因素.基于此构建的列线图模型的校准曲线拟合程度理想,在预测的中转开放手术率与实际的中转开放手术率有较好的一致性,模型具有良好预测能力,但仍有待行外部验证来进一步证实.

BACKGROUND:The effects of postoperative adjuvant therapy for high-risk recurrent hepatocellular carcinoma (HCC) in immunotherapy are still under investigation. This study evaluated the preventive effects and safety of postoperative adjuvant therapy, including atezolizumab, and bevacizumab, against the early recurrence of HCC with high-risk factors. METHODS:The complete data of HCC patients who underwent radical hepatectomy with or without postoperative adjuvant therapy after two-year follow-up were analyzed retrospectively. The patients were divided into high-risk or low-risk groups based on HCC pathological characteristics. High-risk recurrence patients were divided into postoperative adjuvant treatment and control groups. Due to the difference in approaches in postoperative adjuvant therapies, they were divided into transarterial chemoembolization (TACE), atezolizumab, and bevacizumab (T + A), and combination (TACE+T + A) groups. The two-year recurrence-free survival rate (RFS), overall survival rate (OS), and associated factors were analyzed. RESULTS:The RFS in the high-risk group was significantly lower than that in the low-risk group (P = 0.0029), and the two-year RFS in the postoperative adjuvant treatment group was significantly higher than that in the control group (P = 0.040). No severe complications were observed in those who received atezolizumab and bevacizumab or other therapy. CONCLUSION:Postoperative adjuvant therapy was related to two-year RFS. TACE, T + A, and the combination of these two approaches were comparable in reducing the early recurrence of HCC without severe complications.

Objective:To investigate the application value of cystic plate approach (CPA) for extrahepatic right hepatic pedicle dissection in minimally invasive anatomical hepatectomy (MIALR).Methods:The retrospective cohort study was conducted. The clinicopathological data of 42 patients with primary liver cancer who underwent laparoscopic right hemi-hepatectomy in Nanfang Hospital of Southern Medical University from August 2020 to August 2022 were collected. There were 36 males and 6 females, aged (55±13)years. Of the 42 patients, 25 cases undergoing CPA for extrahepatic right hepatic pedicle dissection were divided into the CPA group, and 17 cases undergoing traditional approach for extrahepatic right hepatic pedicle dissection were divided into the traditional approach group. Observation indicators: (1) surgical situations; (2) postoperative situations. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M( IQR), and comparison between groups was conducted using the Mann?Whitney U test. Count data were described as absolute numbers, and comparison between groups was conducted using the chi?square test or Fisher exact probability. Comparison of ordinal data was conducted using the non‐parameter rank sum test. Results:(1) Surgical situations. All patients in the two groups underwent laparoscopic right hemi-hepatectomy successfully, with the surgical margin as negative. The operative time, volume of intraoperative blood loss, time of dissection of the targeted hepatic pedicle, cases undergoing dissection of the trunk of right anterior hepatic pedicle and its operation time, cases undergoing dissection of the trunk of right posterior hepatic pedicle and its operation time, cases with hepatic pedicle injury, cases with hepatic tissue injury, cases with dissection space as large and small were 150.00(130.00)minutes, 100.00(100.00)mL, 472.00(201.00)seconds, 10 and 366.00(94.75)seconds, 9 and 564.00(138.50)seconds, 2, 2, 25, 0 in patients of the CPA group, versus 140.00(113.00)minutes, 100.00(125.00)mL, 670.00(107.00)seconds, 8 and 663.00(136.00)seconds, 7 and 783.00(189.00)seconds, 8, 5, 2, 19 in patients of the traditional approach group. There were significant differences in the time of dissection of the targeted hepatic pedicle, time of dissection of the trunk of right anterior hepatic pedicle, time of dissection of the trunk of right posterior hepatic pedicle, hepatic tissue injury, dissection space between the two groups ( Z=-4.809, -3.254, -3.188, χ2=6.493, 34.314, P<0.05) and there was no significant difference in the operation time, volume of intraoperative blood loss, dissection of the trunk of right anterior hepatic pedicle, dissection of the trunk of right posterior hepatic pedicle, hepatic tissue injury between the two groups ( Z=-0.282, -0.412, χ2=0.095, 0.002, 1.976, P>0.05). (2) Postoperative situations. There was no patient undergoing postoperative hemorrhage in both of the two groups. The alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin (TBil) and prothrombin time (PT) at postoperative day 3, cases with postoperative biliary fistula, pathological type of tumor (hepatocellular carcinoma, intrahepatic cholangiocarcinoma) were 68.00(48.50)U/L, 52.00(35.50)U/L, 28.30(12.35)mmol/L, 12.40(2.40)seconds, 2, 21, 4 in patients of the CPA group. The above indicators were 58.00(25.00)U/L, 41.00(19.50)U/L, 26.80(14.25)mmol/L, 12.50(2.95)seconds, 5, 15, 2 in patients of the traditional approach group. There was no significant difference in the ALT, AST, TBil, PT at postoperative day 3, cases with postoperative biliary fistula between the two groups ( Z=-1.218, -1.488, -0.205, -0.320, χ2=1.976, P>0.05), and there was no significant difference in the pathological type of tumor between the two groups ( P>0.05). Conclusion:Application of CPA for extrahepatic right hepatic pedicle dissection in MIALR is safe and feasible.

目的 评估初始不可切除肝癌经转化治疗后行序贯手术切除的临床疗效和分析其临床特征.方法 回顾性收集并分析南方医科大学南方医院2020年1月至2021年12月期间收治的13例初始不可切除肝癌患者的临床数据.结果 13例患者中,12例为男性患者,1例为女性患者,年龄50.0±12.7岁(23～72岁);Child-Pugh分级标准均为A级;CNLC Stage分级Ib期5例,Ⅱa期2例,Ⅱb期2例,Ⅲa期3例,Ⅲb期1例;ECOG ps评分均≤1分;肝硬化者有6例,无肝硬化者7例;有门脉癌栓者2例,无门脉癌栓者11例;治疗前最大肿瘤直径9.8±2.7 cm,治疗前中位AFP为848.1 ng/mL(IQR:20.0～4638.1 ng/mL);有乙肝者12例,无乙肝者1例.转化治疗方案:TACE+免疫方案治疗的有2例、TACE+靶向+免疫方案治疗的有6例、HAIC+靶向+免疫方案3例及TACE+HAIC+靶向+免疫方案治疗的2例.中位转化时间为3.4月(IQR:2.7～5.5月),转化治疗后术前的肿瘤最大直径为7.1±2.2 cm,转化治疗后术前的中位AFP水平17.2 ng/mL(IQR:4.0～121.6 ng/mL),术前影像学评估(mRECIST)CR 2例,PR 5例,PD 1例,SD 5例,肿瘤学转化7例,外科学转化6例,术前PS评分均≤1分.转化后行手术切除:10例行肝部分切除,3例行半肝切除,经腹腔镜手术6例,开腹手术7例.中位手术时间295.0 min(IQR:230.5～418.0 min),中位术中出血量300 mL(IQR:100～375 mL),术后中位住院天数为10 d(IQR:7～13 d),术后中位拔除引流管的时间为7 d(IQR:5.5～13 d).术后病理结果pCR 6例,pPR有7例,MVI分级M010例,M1有3例,均为<5处脉管内癌栓,其中2例为1处脉管内癌栓,无一例切缘阳性病例.术后出现心衰1例,术后出现肺动脉栓塞1例,术后出现胆漏1例.术后中位随访时间11.9月(IQR:6.3～15.1月),3位患者出现复发,随访期间无一例患者死亡.结论 转化后行序贯手术切除的临床疗效效果肯定,安全性尚可.