Risk factors for textbook outcomes of intrahepatic cholangiocarcinoma after hepatectomy
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摘要:目的
探讨影响肝内胆管癌肝切除术后达到教科书式结局(TO)的危险因素分析。
方法采用回顾性队列研究方法。收集2014年9月至2019年8月中山大学附属第一医院收治的155例肝内胆管癌行肝切除术患者的临床病理资料;男90例,女65例;年龄为60(26~82)岁。观察指标:(1)治疗情况。(2)TO情况。(3)影响术后达到TO的危险因素分析。采用门诊和电话方式进行随访,了解患者术后生存情况。随访时间截至2020年10月。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Mann‑Whitney U检验。计数资料以绝对数表示,组间比较采用χ²检验或Yates校正χ²检验或Fisher确切概率法。采用Kaplan‑Meier法计算生存率和绘制生存曲线,Log‑rank检验进行生存分析。单因素分析根据资料类型选择对应的统计学方法。多因素分析采用Logistic回归模型前进法。通过绘制受试者工作特征(ROC)曲线评价指标诊断价值(最佳截断值)。
结果(1)治疗情况。155例患者完成肝切除术,其中46例行小范围肝切除,109例行大范围肝切除;21例联合行胆管切除重建;95例行淋巴结清扫,其中41例淋巴结术后组织病理学检查结果阳性。155例患者手术时间为250.0(95.0~720.0)min,术中出血量为300.0(50.0~15 000.0)mL;ROC曲线计算达到TO的手术时间及术中出血量最佳截断值分别为247.5 min、325.0 mL。155例患者中,44例术中输血,10例术后输血(其中5例为术中、术后均输血);74例发生术后并发症,其中39例为轻症并发症,35例为严重并发症。155例患者总住院时间为19(8~77)d。(2)TO情况。155例患者中,150例达到R0切除,120例无主要术后并发症,106例围手术期无输血,79例住院时间无延长,152例术后30 d内无死亡,150例出院后30 d内无再入院。155例患者中,56例术后达到TO,99例术后未达到TO。(3)影响术后达到TO的危险因素分析。单因素分析结果显示:术前减轻黄疸治疗、术前肝功能Child‑Pugh分级、术前无症状白细胞增多、术前总胆红素、术前碱性磷酸酶、术前CA19‑9、术前CA125、手术时间、术中出血量、肿瘤长径、T分期、N分期是影响患者术后达到TO的相关因素(χ²=4.31、4.31、4.38、4.80,Z=-4.15,χ²=10.74、15.44、16.59、27.53、6.53、6.77、9.26,P<0.05);胆道重建也是影响患者术后达到TO的相关因素(P<0.05)。多因素分析结果显示:术前减轻黄疸治疗、术前无症状白细胞增多、术前CA19‑9>35 U/mL、术前CA125>35 U/mL、术中出血量>325.0 mL是影响肝内胆管癌肝切除术患者达到TO的独立危险因素(优势比=74.77,11.73,2.40,4.86,6.42,95%可信区间为1.80~113.39,1.19~115.54,1.04~5.53,1.78~13.26,2.41~17.11,P<0.05)。
结论术前减轻黄疸治疗、术前无症状白细胞增多、术前CA19‑9>35 U/mL、术前CA125>35 U/mL、术中出血量>325.0 mL是影响肝内胆管癌患者肝切除术后达到TO的独立危险因素。
Abstract:ObjectiveTo investigate the risk factors for textbook outcomes (TO) of intra-hepatic cholangiocarcinoma (ICC) after hepatectomy.
MethodsThe retrospective cohort study was conducted. The clinicopathological data of 155 ICC patients who underwent hepatectomy in the First Affiliated Hospital of Sun Yat‑sen University from September 2014 to August 2019 were collected. There were 90 males and 65 females, aged 60(range, 26‒82)years. Observation indicators: (1) treatment situations; (2) TO situations; (3) analysis of risk factors for postoperative TO. Follow‑up was conducted using outpatient examination and telephone interview to detect postoperative sur-vival of patients up to October 2020. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent samples t test. Measurement data with skewed distribution were represented as M(range), and comparison between groups was analyzed using the Mann‑Whitney U test. Count data were described as absolute numbers, and comparison between groups was analyzed using the chi‑square test, Yates' calibration chi-square test or Fisher exact probability. The Kaplan‑Meier method was used to calculate survival rates and draw survival curves. The Log‑rank test was used for survival analysis. The univariate analysis was conducted using the corresponding statistical methods based on data type. The Logistic regression model was used for multivariate analysis. The receiver operating characteristic (ROC) curve was used for evaluating the diagnostic value of indicators (the optimal cut‑off value).
Results(1) Treatment situations. Of the 155 patients, 46 cases underwent minor hepatectomy and 109 cases underwent major hepatectomy. Twenty‑one of the 155 patients underwent combined bile duct reconstruction. Ninety‑five of the 155 patients underwent lymph node dissection, including 41 cases with positive lymph node by postoperative histopathological examinations. The operation time and volume of intraoperative blood loss of the 155 patients were 250.0(range, 95.0‒720.0)minutes and 300.0(range, 50.0‒15 000.0)mL, respectively. The optimal cut‑off values of the operation time and volume of intraoperative blood loss for TO calculated by ROC curve were 247.5 minutes and 325.0 mL, respectively. Of the 155 patients, 44 cases received intraoperative blood transfusion and 10 cases received postoperative blood transfusion (5 cases with intraoperative and postoperative blood transfusion). Seventy‑four of the 155 patients had postoperative complications, including 39 cases with mild complications and 35 cases with serious complications. The total duration of hospital stay of the 155 patients was 19 (range, 8‒77)days. (2) TO situations. Of the 155 patients, 150 cases achieved R0 resection, 120 cases had no major postoperative complications, 106 cases had no perioperative blood transfusion, 79 cases had no prolonged duration of hospital stay, 152 cases had no death within postoperative 30 days and 150 cases had no readmission within 30 days after discharge. Of the 155 patients, 56 cases achieved postoperative TO, while 99 patients did not achieve TO. (3) Analysis of risk factors for postoperative TO. Results of univariate analysis showed that preoperative biliary drainage, preoperative Child‑Pugh grading of liver function, preoperative asymp-tomatic leukocytosis, preoperative total bilirubin, preoperative alkaline phosphatase, preoperative CA19‑9, preoperative CA125, operation time, volume of intraoperative blood loss, tumor diameter, pathological T staging and pathological N staging were related factors for preoperative TO of ICC patients undergoing hepatectomy (χ²=4.31, 4.31, 4.38, 4.80, Z=‒4.15, χ²=10.74, 15.44, 16.59, 27.53, 6.53, 6.77, 9.26, P<0.05). Bile duct reconstruction was also a related factor for postoperative TO of ICC patients (P<0.05). Results of multivariate analysis showed that preoperative biliary drainage, preoperative asymptomatic leukocytosis, preoperative CA19‑9 >35 U/mL, preoperative CA125 >35 U/mL and volume of intraoperative blood loss >325.0 mL were independent risk factors for postoperative TO of ICC patients undergoing hepatectomy (odds ratio=74.77, 11.73, 2.40,4.86, 6.42, 95% confidence intervals as 1.80‒113.39, 1.19‒115.54, 1.04‒5.53, 1.78‒13.26, 2.41‒17.11, P<0.05).
ConclusionsPreoperative biliary drainage, preoperative asymptomatic leukocytosis, preoperative CA19‑9 >35 U/mL, preoperative CA125 >35 U/mL and volume of intraoperative blood loss >325.0 mL are independent risk factors for postoperative TO of ICC patients undergoing hepatectomy.
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Keywords:
- Bile duct neoplasms /
- Hepatectomy /
- Textbook outcomes /
- Prognosis /
- Risk factors
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肝内胆管癌是起源于二级胆管及其分支以上的胆管上皮细胞恶性肿瘤,发病率在全世界范围内呈上升趋势[1‑4]。根治性切除术是达到有效治愈的唯一手段,但患者远期疗效较差,5年总生存率为10%~40%[4‑6]。目前的研究多为单独分析临床、病理学、手术情况等各因素对预后的影响,然而,个体结局或单一指标并不能很好地反映和评价疾病的诊断与治疗水平[7‑8]。因此,近年来教科书式结局(text⁃book outcomes,TO)被用于术后结局、护理及医院诊断与治疗质量的评估,其优于个体结局或单一指标[9‑12]。本研究回顾性分析2014年9月至2019年8月中山大学附属第一医院收治的155例肝内胆管癌行肝切除术患者的临床病理资料,探讨影响术后达到TO的危险因素。
资料与方法
一、一般资料
采用回顾性队列研究方法。收集155例肝内胆管癌行肝切除术患者的临床病理资料;男90例,女65例;年龄为60(26~82)岁。本研究通过中山大学附属第一医院医学伦理委员会审批,批号为[2021]677。患者及家属均签署知情同意书。
二、纳入标准和排除标准
纳入标准:(1)行肝切除术且术后组织病理学检查确诊为肝内胆管癌。(2)未合并其他恶性肿瘤。(3)临床病理资料完整。
排除标准:(1)术后组织病理学检查为混合型肝胆管细胞癌或其他转移性肿瘤。(2)行姑息性手术或(和)肿瘤肉眼观未完全切除(R2切除)。(3)行肝移植。(4)临床病理资料缺失。
三、观察指标和评价标准
观察指标:(1)治疗情况包括肝切除类型、联合胆道重建、淋巴结清扫、手术时间、术中出血量、围手术期输血、术后并发症、总住院时间。(2)TO情况:R0切除、术后主要并发症、围手术期输血、住院时间延长情况、术后30 d死亡情况、出院后30 d内再入院情况。(3)影响术后达到TO的危险因素分析:性别、年龄、HBsAg、肝硬化、胆管结石、术前减轻黄疸治疗、术前肝功能Child‑Pugh分级、术前无症状WBC增多、术前Hb、术前PT、术前TBil、术前AST、术前ALT、术前ALP、术前CEA、术前CA19‑9、术前CA125、术前AFP、肝切除类型、胆道重建、手术时间、术中出血量、肿瘤长径、肿瘤数目、肿瘤组织分化程度、T分期、N分期、周围神经侵犯、血管侵犯。
评价标准:术前无症状WBC增多为除外术前脓毒血症、全身炎症反应综合征、伤口感染、肾功能衰竭、近期使用类固醇或术前48 h内肺炎等炎症因素引起的术前WBC>11×109/L[13]。R0切除:肿瘤距切缘距离>1 cm,显微镜下肝切缘未见肿瘤细胞。大范围肝切除:根据Couinaud分段,切除≥3个肝段[14]。肿瘤长径:切除标本中肿瘤的最大径,对于多发肿瘤患者,以最大病灶测量病变。围手术期输血:术中或术后有输血治疗。术后主要并发症:住院期间发生的内科或外科并发症,根据Clavien⁃Dindo分类系统分级为Ⅲ、Ⅳ分级[15]。病理学TNM分期:参照美国癌症联合委员会(AJCC)颁布的第8版肝内胆管癌分期系统[16]。TO结局:R0切除、无主要术后并发症、围手术期无输血、住院时间无延长(总住院时间≤中位总住院时间)、术后30 d内无死亡、出院后30 d内无再入院[9]。
四、随访
采用门诊和电话方式进行随访,了解患者术后生存情况。随访时间截至2020年10月。
五、统计学分析
应用SPSS 26.0统计软件进行分析。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Mann‑Whitney U检验。计数资料以绝对数表示,组间比较采用χ²检验或Yates校正χ2检验或Fisher确切概率法。采用Kaplan‑Meier法计算生存率和绘制生存曲线,Log‑rank检验进行生存分析。单因素分析根据资料类型选择对应的统计学方法。多因素分析采用Logistic回归模型前进法。通过绘制受试者工作特征(receiver operating charac⁃teristic,ROC)曲线评价指标诊断价值(最佳截断值)。P<0.05为差异有统计学意义。
结果
一、治疗情况
155例患者完成肝切除术,其中46例行小范围肝切除,109例行大范围肝切除;21例联合行胆管切除重建;95例行淋巴结清扫,其中41例淋巴结术后组织病理学检查结果阳性。155例患者手术时间为250.0(95.0~720.0)min,术中出血量为300.0(50.0~15 000.0)mL;ROC曲线计算达到TO的手术时间及术中出血量最佳截断值分别为247.5 min、325.0 mL(图1,2)。155例患者中,44例术中输血,10例术后输血(其中5例术中、术后均输血);74例发生术后并发症,其中39例为轻症并发症(Clavien⁃DindoⅠ级12例、Ⅱ级27例),35例为严重并发症(Clavien‑Dindo Ⅲa级26例、Ⅲb级1例、Ⅳa级3例、Ⅳb级2例、Ⅴ级3例)。155例患者总住院时间为19(8~77)d。
二、TO情况
155例患者中,150例达到R0切除,120例无主要术后并发症,106例围手术期无输血,79例住院时间无延长,152例术后30 d内无死亡,150例出院后30 d内无再入院。155例患者中,56例术后达到TO,99例术后未达到TO。
三、影响术后达到TO的危险因素分析
单因素分析结果显示:术前减轻黄疸治疗、术前肝功能Child‑Pugh分级、术前无症状WBC增多、术前TBil、术前ALP、术前CA19‑9、术前CA125、胆道重建、手术时间、术中出血量、肿瘤长径、T分期、N分期是影响患者术后达到TO的相关因素(P<0.05);而性别、年龄、HBsAg、肝硬化、胆管结石、术前Hb、术前PT、术前AST、术前ALT、术前CEA、术前AFP、肝切除类型、肿瘤数目、肿瘤组织分化程度、周围神经侵犯、血管侵犯不是影响患者术后达到TO的相关因素(P>0.05)。见表1。
表 1 影响155例肝内胆管癌患者肝切除术后Table 1. Univariate analysis of textbook outcomes in 155 intrahepatic cholangiocarcinoma patients after hepatectomy临床病理因素 赋值 例数 达到TO(例) 统计值 P值 性别 女 0 65 23 χ²=0.03 0.864 男 1 90 33 年龄a Z=-0.17 0.864 乙肝表面抗原 阳性 1 45 16 χ²=0.01 0.924 阴性 0 110 40 肝硬化 有 1 38 11 χ²=1.13 0.289 无 0 117 45 胆道结石 有 1 29 7 χ²=2.22 0.136 无 0 126 49 术前减轻黄疸治疗 有 1 56 1 χ²=4.31 0.038b 无 0 99 55 术前肝功能Child‑Pugh分级 A级 0 141 55 χ²=4.31 0.038 B级 1 14 1 术前无症状白细胞增多c 有 1 140 55 χ²=4.38 0.036 无 0 14 1 术前血红蛋白a Z=-0.69 0.488 术前凝血酶原时间(s) >14 1 6 1 χ²=0.34 0.563 ≤14 0 149 55 术前总胆红素(μmol/L) >22 1 26 4 χ²=4.80 0.029 ≤22 0 129 52 术前谷草转氨酶a Z=-1.53 0.126 术前丙氨酸转氨酶a Z=-1.32 0.188 术前碱性磷酸酶a Z=-4.15 <0.001 术前癌胚抗原(μg/L) >5 1 42 14 χ²=0.20 0.659 ≤5 0 113 42 术前CA19‑9(U/mL) >35 1 93 24 χ²=10.74 0.001 ≤35 0 62 32 术前CA125(U/mL) >35 1 53 8 χ²=15.44 <0.001 ≤35 0 102 48 术前甲胎蛋白(U/mL) >20 1 18 7 χ²=0.07 0.795 ≤20 0 137 49 多因素分析结果显示:术前减轻黄疸治疗、术前无症状WBC增多、术前CA19‑9>35 U/mL、术前CA125>35 U/mL、术中出血量>325.0 mL是影响肝内胆管癌肝切除术患者术后达到TO的独立危险因素(P<0.05)。见表2。
临床病理因素 赋值 例数 达到TO(例) 统计值 P值 肝切除类型 大范围 1 109 36 χ²=1.53 0.216 小范围 0 46 20 胆道重建 有 1 21 0 - <0.001d 无 0 134 56 手术时间(min) >247.5 1 78 16 χ²=16.59 <0.001 ≤247.5 0 77 40 术中出血量(mL) >325.0 1 65 8 χ²=27.53 <0.001 ≤325.0 0 90 48 肿瘤长径(cm) >5 1 82 22 χ²=6.53 0.011 ≤5 0 73 34 肿瘤数目(个) ≥2 1 45 13 χ²=1.44 0.230 1 0 110 43 肿瘤分化程度e 高‑中分化 0 45 33 χ²=3.66 0.056 低‑未分化 1 85 10 T分期 T1a期 0 37 20 χ²=6.77 0.009 T1b~T4期 1 118 36 N分期 N0期 1 54 25 χ²=9.26 0.010 Nx期 2 60 24 N1期 3 41 7 周围神经侵犯 有 1 39 11 χ²=1.42 0.234 无 0 116 45 血管侵犯 有 1 57 15 χ²=3.76 0.052 无 0 98 41 注: T分期和N分期依据美国癌症联合委员会第8版TNM分期系统;a为连续变量,采用M(范围)表示,155例肝内胆管癌肝切除术患者的年龄、术前血红蛋白、术前谷草转氨酶、术前丙氨酸转氨酶、术前碱性磷酸酶分别为60(26~82)岁、134(75~165)g/L、27(11~334)U/L、21(6~275)U/L、103(43~846)U/L,56例术后达到教科书式结局的患者上述指标分别为60.5(35~79)岁、135.5(92~165)g/L、25.5(14~334)U/L、20(7~257)U/L、86(51~242)U/L,99例术后未达到教科书式结局的患者上述指标分别为60(26~82)岁、133(75~164)g/L、27(11~253)U/L、22(6~275)U/L、117(43~846)U/L;b采用Yates校正χ2检验;c术前无症状白细胞增多1例患者数据缺失;d采用Fisher确切概率法;e肿瘤分化程度有25例患者无分化程度描述;TO为教科书式结局;“-”为此项无 达到教科书式结局的多因素分析讨论
一、TO对评估肝内胆管癌患者肝切除术预后的意义
本研究结果显示:术后达到TO患者总生存率明显优于未达到TO患者,与雷正清等[9]的研究结果相似。这表明术后达到TO这一理想外科术后结局对提高肝内胆管癌患者预后有重要临床意义。
临床病理因素 b值 标准误 Wald值 优势比 95%可信区间 P值 术前减轻黄疸治疗 4.31 1.90 5.14 74.77 1.80~113.39 0.023 术前无症状白细胞增多 2.46 1.17 4.45 11.73 1.19~115.54 0.035 术前CA19‑9>35 U/mL 0.88 0.43 4.25 2.40 1.04~5.53 0.039 术前CA125>35 U/mL 1.58 0.51 9.51 4.86 1.78~13.26 0.002 术中出血量>325.0 mL 1.86 0.50 13.85 6.42 2.41~17.11 <0.001 二、影响术后达到TO的主要评估指标
本研究结果显示:155例患者中仅56例术后达到TO。在构成TO的各项评估指标中,围手术期输血、术后出现主要并发症可延长患者住院时间,围手术期输血将增加患者肝切除术后主要并发症发生率。因此,限制患者肝切除术后达到TO的主要评估指标为围手术期输血、术后出现主要并发症和住院时间延长。
三、肝内胆管癌患者肝切除术后达到TO的影响因素分析
本研究多因素分析结果显示:影响术后达到TO的独立危险因素为术前减轻黄疸治疗、术前无症状WBC增多、术前CA19‑9>35 U/mL、术前CA125>35 U/mL、术中出血量>325.0 mL。
目前对于存在梗阻性黄疸患者术前是否行减轻黄疸治疗仍存在争议。有研究者认为术前减轻黄疸治疗可以通过降低患者胆红素水平,改善肝脏等脏器功能,进而提高手术耐受性,减少术后并发症或死亡的发生[17‑20]。但也有研究者认为:术前减轻黄疸治疗会延误手术时机,增加感染、胆漏等并发症发生风险[21‑22]。虽然本研究中术前减轻黄疸治疗没有影响术后并发症发生率以及远期预后,但其延长了患者总住院时间,从而影响患者肝切除术后达到TO。
炎症反应是促进肿瘤发生发展的重要影响因素[23‑26]。近年来的研究结果显示:术前无症状WBC增多是多种肿瘤的不良预后因素,与疾病术后并发症发生率、病死率有关[27‑30]。本研究中术前无症状WBC增多的患者术后主要并发症发生率较高,进而影响患者术后达到TO,其原因可能与肿瘤组织中集落刺激因子及其受体表达上调等炎症微环境相关,但具体机制仍有待进一步研究[31‑33]。
术前CA19‑9、术前CA125均为评估肝内胆管癌诊断及预后的血清学检测指标[34‑36]。已有研究结果显示:术前CA19‑9升高的肝内胆管癌患者具有更高的淋巴结转移风险,术前CA19‑9、术前CA125在胆管癌可切除性方面也具有预测价值[37‑38]。本研究结果显示:术前CA19‑9>35 U/mL、术前CA125>35 U/mL均是影响患者术后达到TO的独立危险因素。因此,上述指标在评估肿瘤恶性程度、手术难度及术后短期结局具有预测价值。
已有研究结果显示:输血可以引发机体免疫抑制反应[39‑41]。这是影响恶性肿瘤患者术后短期及远期疗效的相关因素[42‑45]。但有研究者认为:输血原因(术中失血)比输血对患者预后的影响更具临床意义[46]。其可能原因是除术中出血量多导致的输血外,患者一般情况、对缺血耐受程度等均可影响输血率[47]。本研究结果显示:术中出血量通过影响患者肝切除术达到TO,从而影响预后。这进一步表明提高手术质量,控制术中出血量对改善患者预后具有重要意义。
综上,术前减轻黄疸治疗、术前无症状WBC增多、术前CA19‑9>35 U/mL、术前CA125>35 U/mL、术中出血量>325.0 mL是影响肝内胆管癌患者肝切除术后达到TO的独立危险因素。
赵莹:数据整理,论文撰写,统计学分析;庹情松、梁倚华、陈燕柔:临床数据整理,病例随访;廖冰:病例搜集,病理数据整理;殷晓煜、赖佳明、梁力建:研究指导,论文修改;陈东:研究指导,论文修改,经费支持所有作者均声明不存在利益冲突赵莹, 庹情松, 廖冰, 等. 影响肝内胆管癌肝切除术后教科书式结局的危险因素分析[J]. 中华消化外科杂志, 2022, 21(7): 923-930. DOI: 10.3760/cma.j.cn115610-20220514-00273.http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20220514-22273
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表 1 影响155例肝内胆管癌患者肝切除术后
Table 1 Univariate analysis of textbook outcomes in 155 intrahepatic cholangiocarcinoma patients after hepatectomy
临床病理因素 赋值 例数 达到TO(例) 统计值 P值 性别 女 0 65 23 χ²=0.03 0.864 男 1 90 33 年龄a Z=-0.17 0.864 乙肝表面抗原 阳性 1 45 16 χ²=0.01 0.924 阴性 0 110 40 肝硬化 有 1 38 11 χ²=1.13 0.289 无 0 117 45 胆道结石 有 1 29 7 χ²=2.22 0.136 无 0 126 49 术前减轻黄疸治疗 有 1 56 1 χ²=4.31 0.038b 无 0 99 55 术前肝功能Child‑Pugh分级 A级 0 141 55 χ²=4.31 0.038 B级 1 14 1 术前无症状白细胞增多c 有 1 140 55 χ²=4.38 0.036 无 0 14 1 术前血红蛋白a Z=-0.69 0.488 术前凝血酶原时间(s) >14 1 6 1 χ²=0.34 0.563 ≤14 0 149 55 术前总胆红素(μmol/L) >22 1 26 4 χ²=4.80 0.029 ≤22 0 129 52 术前谷草转氨酶a Z=-1.53 0.126 术前丙氨酸转氨酶a Z=-1.32 0.188 术前碱性磷酸酶a Z=-4.15 <0.001 术前癌胚抗原(μg/L) >5 1 42 14 χ²=0.20 0.659 ≤5 0 113 42 术前CA19‑9(U/mL) >35 1 93 24 χ²=10.74 0.001 ≤35 0 62 32 术前CA125(U/mL) >35 1 53 8 χ²=15.44 <0.001 ≤35 0 102 48 术前甲胎蛋白(U/mL) >20 1 18 7 χ²=0.07 0.795 ≤20 0 137 49 临床病理因素 赋值 例数 达到TO(例) 统计值 P值 肝切除类型 大范围 1 109 36 χ²=1.53 0.216 小范围 0 46 20 胆道重建 有 1 21 0 - <0.001d 无 0 134 56 手术时间(min) >247.5 1 78 16 χ²=16.59 <0.001 ≤247.5 0 77 40 术中出血量(mL) >325.0 1 65 8 χ²=27.53 <0.001 ≤325.0 0 90 48 肿瘤长径(cm) >5 1 82 22 χ²=6.53 0.011 ≤5 0 73 34 肿瘤数目(个) ≥2 1 45 13 χ²=1.44 0.230 1 0 110 43 肿瘤分化程度e 高‑中分化 0 45 33 χ²=3.66 0.056 低‑未分化 1 85 10 T分期 T1a期 0 37 20 χ²=6.77 0.009 T1b~T4期 1 118 36 N分期 N0期 1 54 25 χ²=9.26 0.010 Nx期 2 60 24 N1期 3 41 7 周围神经侵犯 有 1 39 11 χ²=1.42 0.234 无 0 116 45 血管侵犯 有 1 57 15 χ²=3.76 0.052 无 0 98 41 注: T分期和N分期依据美国癌症联合委员会第8版TNM分期系统;a为连续变量,采用M(范围)表示,155例肝内胆管癌肝切除术患者的年龄、术前血红蛋白、术前谷草转氨酶、术前丙氨酸转氨酶、术前碱性磷酸酶分别为60(26~82)岁、134(75~165)g/L、27(11~334)U/L、21(6~275)U/L、103(43~846)U/L,56例术后达到教科书式结局的患者上述指标分别为60.5(35~79)岁、135.5(92~165)g/L、25.5(14~334)U/L、20(7~257)U/L、86(51~242)U/L,99例术后未达到教科书式结局的患者上述指标分别为60(26~82)岁、133(75~164)g/L、27(11~253)U/L、22(6~275)U/L、117(43~846)U/L;b采用Yates校正χ2检验;c术前无症状白细胞增多1例患者数据缺失;d采用Fisher确切概率法;e肿瘤分化程度有25例患者无分化程度描述;TO为教科书式结局;“-”为此项无 达到教科书式结局的多因素分析临床病理因素 b值 标准误 Wald值 优势比 95%可信区间 P值 术前减轻黄疸治疗 4.31 1.90 5.14 74.77 1.80~113.39 0.023 术前无症状白细胞增多 2.46 1.17 4.45 11.73 1.19~115.54 0.035 术前CA19‑9>35 U/mL 0.88 0.43 4.25 2.40 1.04~5.53 0.039 术前CA125>35 U/mL 1.58 0.51 9.51 4.86 1.78~13.26 0.002 术中出血量>325.0 mL 1.86 0.50 13.85 6.42 2.41~17.11 <0.001 -
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