| Laparoscopic liver resection(LLR)is increasingly used in hepatocellular carcinoma,requiring laparoscopic efficacy,surgical techniques,and surgical instruments to be studied.In the first part of this study,a series of clinical researches was conducted on 382 cases of LLR due to hepatocellular carcinoma in Guangdong Hospital of TCM from January 2010 to January 2022.The factors related to post-hepatectomy liver failure(PHLF)through univariate and multivariate analysis were found and constructed predictive models of regression equation and nomogram;The univariate analysis found that the parenchyma-first approach is a protective factor for PHLF after LLR.To further investigate the impact of surgical approach on postoperative liver function,the second part of this study brought clinical datas from Nanfang Hospital of Southern Medical University and PLA Southern Theater General Hospital,then conducted a retrospective analysis of the cohort after propensity score matching(PSM)of liver cancer patients who underwent LLR in three centers from January 2019 to January 2022,and compared the impact of different surgical approaches on postoperative liver function and other curative effects.Chapter Ⅰ:Analysis of risk factors and predictive model construction for postoperative liver failure after laparoscopic resection for hepatocellular carcinomaObjective:Liver failure is the main complication and cause of death after liver resection.The first part of this study is to retrospectively analyze the case data of laparoscopic liver cancer resection,aiming to find out the risk factors causing PHLF and build a risk prediction model,so as to provide evidences for clinical prevention.Methods:The clinical data of 382 patients with HCC who underwent laparoscopic hepatectomy in Guangdong Hospital of TCM were collected and retrospectively analyzed.39 perioperative factors that may be related to PHLF were selected for univariate and multivariate analysis.Then,the regression equation and nomogram were constructed based on the independent risk factors selected from the multivariate analysis,and the area under the curve(Area under the curve,AUC)of the subject’s operating characteristic curve(Receiver operating characteristic,ROC)was calculated.Results:Among 382 cases,71 cases(18.6%)experienced PHLF:45 cases(11.78%)were classified as grade A,21 cases(5.50%)as grade B,and 5 cases(1.03%)as grade C,among which 5 cases died(0.52%),2 of which were grade B(9.52%)and 3 were grade C(60.0%).The remaining cases were cured after conservative treatment.Relevant factors included chronic viral hepatitis(OR:2.113,95%CI:1.001-4.458,P=0.046),liver cirrhosis(OR:2.055,95%CI:1.214-3.479,P=0.008),HBV-DNA quantification(OR:2.139,95%CI:1.025-4.464,P=0.050),ICG-R15(OR:NA,95%CI:NA,P=0.017),extended hepatectomy(OR:2.256,95%CI:1.333-3.819,P=0.003),remaining liver volume(OR:6.304,95%CI:2.262-17.567,P=0.001),operation time(OR:7.739,95%CI:3.720-16.097,P=0.000),portal occlusion time(OR:6.849,95%CI:3.691-12.711,P=0.000),bleeding volume(OR:NA,95%CI:NA,P=0.002),and parenchyma-first approach(OR:0.551,95%CI:0.328-0.927,P=0.033),and these 10 factors were related to the development of PHLF after laparoscopic liver resection.The OR value of liver parenchyma-first approach was less than 1,which might be a protective factor for PHLF after laparoscopic liver resection,while the OR values of the other 9 variables were greater than 1 and indicated risk factors for PHLF after laparoscopic liver resection.Logistic stepwise regression analysis of the 10 factors ultimately screened 5 risk factors that were significantly related to PHLF:bleeding volume(OR:1.002,95%CI:1.001-1.003,P=0.001),ICG-R15(OR:1.082,95%CI:1.002-1.169,P=0.044),grade Ⅲ-Ⅳ liver cirrhosis(OR:1.925,95%CI:1.074-3.450,P=0.028),portal occlusion time≥60 min(OR:5.129,95%CI:2.633-9.992,P=0.000),and remaining liver volume≤40%(OR:5.479,95%CI:1.669-17.991,P=0.005).Based on the independent risk factors,the regression equation logit(PHLF)=-3.401+0.002 × blood loss+0.079 × ICGR15+0.655× cirrhosis+1.635 × portal occlusion time+1.701 × residual liver volume was constructed.The goodness of fit of the model P=0.256,and the AUC is 0.736,C-index is 0.756.Conclusion:Mutiple factors can lead to PHLF after laparoscopic resection of hepatocellular carcinoma,and preventive measures should be taken against the risk factors.The parenchyma-first approach may be a protective factor for PHLF,and further research is needed.Chapter Ⅱ:The effect of laparoscopic liver cancer resection approachs on postoperative liver function and other outcomes:a multicenter propensity score matching studyObjective:In the chapter I of our research,we found that the liver parenchyma-first approach maybe a protective factor for PHLF in laparoscopic liver resection.The surgical method of liver parenchyma-first approach can simplify the surgical procedure and to a certain extent overcome the problem of the previous laparoscopic anatomical liver resection operation being complicated and easily causing damage to important ducts.In the second part of this study,clinical data and surgical results of laparoscopic liver resection continuously performed from January 2019 to January 2022 at Guangdong Hospital of TCM,Nanfang Hospital of Southern Medical University and PLA Southern Theater General Hospital will be analyzed,respectively.The recent and long-term efficacy of anatomical liver resection with liver parenchyma-first approach and liver Glissonean pedicle-first approach will be compared.Methods:Inclusion and exclusion criteria was established,The cases using liver parenchyma-first approach were designated as the PA group,and those using liver Glissonean pedicle-first approach were designated as the GA group.A matched cohort was obtained by propensity score matching method,and the general information,surgical information,postoperative liver function,postoperative complications,recovery status and survival period of the two groups were compared in the cohort.Results:Before matching,there were 202 cases in the cohort,with 82 cases in the GA group and 120 cases in PA group.Before matching,the GA group and the PA group differed in age and surgical difficulty score,with P values of 0.003 and 0.020,respectively.After matching through the set conditions using PSM method,there were 122 cases in the cohort,with 61 cases in each group.There was no statistical difference in gender,weight,tumor location,giant liver cancer,surgical difficulty score,and preoperative liver function index between the two groups(P>0.05).After matching,the surgical method of the matched cases in the GA group and PA group was consistent,including left external lobectomy in 15 cases,accounting for 24.6%,left hepatectomy in 11 cases,accounting for 18.0%;right hepatectomy in 9 cases,accounting for 14.8%;central hepatectomy in 16 cases,accounting for 26.2%;right anterior lobe resection in 6 cases,accounting for 9.8%;sectionectomy of segment Ⅳin 2 cases,accounting for 3.3%;sectionectomy of segment Ⅷ in 2 cases,accounting for 3.3%.There was no statistical difference in preoperative liver function indexes such as PLT,TBIL,AST,ALT,ALB,PTa(P>0.05).In terms of surgical information,the surgical time for GA group was 308.94±95.29 min and for PA group was 260.26±70.59 min,and there was a statistical difference between the two groups(P=0.017);the hepatic inflow occlusion time for GA group was 61.11±15.58 min and for PA group was 52.11±7.70 min,and there was a statistical difference between the two groups(P=0.037);the hepatic inflow occlusion times for GA group was 4.28±1.07 times and for PA group was 3.58 ± 0.61 times,and there was a statistical difference between the two groups(P=0.019);in terms of bleeding volume and transfusion volume,there was no statistical difference between the two groups(P>0.05).In terms of postoperative liver function indexes,TBIL,AST and ALT in the PA group on the fifth day after surgery were significantly lower than those in the GA group,and the difference between the two groups was statistically significant(P=0.047,P=0.014 and P=0.010),and there was no difference in other indexes(P>0.05);the difference of PHLF between the two groups is statistically significant(P=0.040),however,there was no statistically significant difference in the occurrence of level B and C between the two groups(P=0.569).In terms of complications,there was a statistical difference between the GA group and the PA group in bile leakage(P=0030),and there was no statistical difference in abdominal infection,upper gastrointestinal bleeding,abdominal bleeding,reoperation rate,and recovery status and mortality between the two groups.The postoperative pathological data and adjuvant treatment in the matched cohort were basically consistent,and there was no statistical difference in the three-year OS and DFS between the two groups(P>0.05).Conclusion:Compared with the liver Glissonean pedicle-first approach,the liver parenchyma-first approach has less impact on postoperative liver function.At the same time,it can reduce the operative time and hepatic inflow occlusion time,reduce the incidence of postoperative complications such as bile leakage.However,both approaches have no difference in serious complications and long-term prognosis,indicating that both approaches are safe. |
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