Abstract:
Objective To evaluate the effects of concept and techniques of precision hepatic surgery on the perioperative safety of patients who received major hepatectomy.
Methods The clinical data of 1250 patients with hepatic diseases who received major hepatectomy at the Chinese PLA General Hospital from January 1986 to January 2012 were retrospectively analyzed. All the patients were divided into 2 groups, 459 patients who were admitted from January 1986 to December 2006 were in the traditional surgery group, and 791 patients who were admitted from January 2007 to January 2012 were in the precision surgery group. The perioperative conditions of the patients in the 2 groups were compared, and the risk factors of morbidity and mortality were analyzed. The patients were followed up via outpatient examination , mail or telephone till December 2012. The measurement data, nonnormal data and count data were analyzed using independent sample t test, nonparametric MannWhitney U test and chisquare test, respectively. The univariate and multivariate analysis were done using the chisquare test and bivariate Logistic regression analysis, respectively. The survival rates were calculated by using the KaplanMeier method, and the survival was analyzed using the Logrank test.
Results The ratios of anatomical hepatectomy and unanatomical hepatectomy were 62.31%(286/459) and 37.69%(173/459) in the traditional surgery group, and 85.59%(677/791) and 14.41%(114/791) in the precision surgery group, with significant difference between the 2 groups (X2=88.98, 88.98, P<0.05). The ratios of right hemihepatectomy, left hemihepatectomy and extended left hemihepatectomy were 18.52%(85/459), 29.85%(137/459) and 3.05%(14/459) in the traditional surgery group, which were significantly lower than 28.45%(225/791), 37.67%(298/791) and 6.32%(50/791) in the precision surgery group (X2=15.35, 7.84, 6.40, P<0.05). The ratios of hepatic inflow occlusion with Pringle maneuver and selective inflow occlusion were 66.01%(303/459) and 12.42%(57/459) in the traditional surgery group, 27.18%(215/791) and 31.73%(251/791) in the precision surgery group, with significant difference between the 2 groups (X2=180.49, 58.35, P<0.05). The operation time, median volume of intraoperative blood loss, ratio of intraoperative blood transfusion, duration of postoperative hospital stay, morbidity and mortality were (291±124)minutes, 750 ml, 62.75%(288/459), (18±14)days, 26.36%(121/459) and 3.49%(16/459) in the traditional surgery group, and (337±142)minutes, 550 ml, 35.40%(280/791),(14±9)days, 20.73%(164/791) and 1.52%(12/791) in the precision surgery group, with significant difference between the 2 groups (t=-5.74, Z=-2.01, X2=87.62, t=5.90, X2=5.23, 5.14, P<0.05). The results of univariate analysis showed that age>60 years, hepatic cirrhosis, hepatic inflow occlusion, operation time>360 minutes, volume of intraoperative blood loss>800 ml, intraoperative blood transfusion, vessel reconstruction, preoperative total bilirubin>17.1mol/L, preoperative albumin<35 g/L were correlated with the morbidity (X2=5.16, 6.64, 6.33, 4.82, 32.01, 44.91, 4.75, 8.42, 9.36, P<0.05); hepatic cirrhosis, volume of intraoperative blood loss>800 ml, intraoperative blood transfusion and preoperative platelet<100×109/L were correlated with the mortality (X2=4.21,22.31,12.68,32.25, P<0.05). The results of multivariate analysis showed that volume of intraoperative blood loss>800 ml, intraoperative blood transfusion, hepatic inflow occlusion and preoperative albumin<35 g/L were the independent risk factors of morbidity odds ratio=2.642,2.515,1.637,1.796,P<0.05); volume of intraoperative blood loss>800 ml, intraoperative blood transfusion and preoperative platelet<100×109/L were the independent risk factors of mortality (odds ratio=1.325, 1.682, 3.742, P<0.05). A total of 345 patients in the traditional surgery group and 651 patients in the precision surgery group were followed up for 11-96 months. The 1,3, 5year survival rates of patients with primary liver cancer in the traditional surgery group were 83.5%,51.6%,42.0%, and the 1,3 year survival rates of patients with primary liver cancer of the precision surgery group were 85.4% and 63.8%. There was a significant difference in the 3 year survival rate between the 2 groups (X2=3.96, P<0.05). The 1, 3,5 year survival rates of patients with hilar cholangiocarcinoma of the traditional surgery group were 63.1%, 31.4% and 26.7%, and the 1, 3 year survival rates of patients with hilar cholangiocarcinoma of the precision surgery group were 71.3% and 48.1%. There was a significant difference in the 3year survival rate between the 2 groups (X2=3.95,P<0.05).
Conclusion Application of the concept and techniques of precision hepatic surgery significantly decreases the perioperative morbidity and mortality, increase the safety and improves the long term efficacy of treatment.
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