Clinical Application Of PVE In The Treatment Of Bismuth-Corlett Type Ⅲ And Type Ⅳ Hilar Cholangiocarcinoma

Objective:The treatment plan for hilar cholangiocarcinoma is generally radical surgical treatment,especially for patients classified as type Ⅲ and type Ⅳ by Bismuth-Corlett classification method,which usually requires radical surgical resection.The radical surgical resection range is usually large,and R0 resection requires the removal of tumor tissue and most of the liver,so the possibility of postoperative liver failure increases.The main cause of postoperative liver failure is severe complications after hepatectomy,especially in patients with severe chronic diseases where liver regeneration is difficult to achieve.Major medical centers carry out portal vein embolization(PVE)in recent years,which has many benefits for patients with Preoperative portal bile duct carcinoma of type Ⅲ and type Ⅳ and liver cancer that require resection of large liver volume.Preoperative PVE can not only improve future liver remnant(FLR)capacity,but also reduce tumor volume,thereby reducing the volume of pre-resected liver,further reducing the risk of surgery and the incidence of postoperative complications,improving surgical safety,and achieving the goal of negative tumor margin.And it will not increase the difficulty of operation in the operation.Objective to explore the clinical application of PVE in the treatment of Bismuth-Corlett type Ⅲ and Ⅳ hilar cholangiocarcinoma,including the liver regeneration and prognosis of patients with hilar cholangiocarcinoma after portal vein embolization,blood biochemical changes before and after PVE,and the influencing factors of postoperative survival time of patients,etc.To provide some experience and instructions for clinical treatment of hilar cholangiocarcinoma patients,in order to realize better liver regeneration function and strive for longer survival time.Methods:Clinical data of 72 patients with Bismuth-Corlett type Ⅲ and Type Ⅳhilar cholangiocarcinoma treated by PVE were collected from Hepatobiliary and Pancreatic Center,Tsinghua Changgeng Hospital affiliated to Tsinghua University from June 2016 to December 2021.According to the observation end points:The median FLR regeneration rate at 3 weeks after PVE was divided into high regeneration group(38 patients)and low regeneration group(34 patients).The basic information,liver regeneration,liver function,kidney function,coagulation function and other related blood biochemical indexes of the two groups were retrospectively analyzed.Kaplan-meier was used to draw the survival curve,and log-rank test was used to compare the difference in survival time between the two groups.Logistic regression was used to analyze the influencing factors of postoperative liver regeneration.Cox proportional risk model was used to analyze the factors related to long-term prognosis of patients with hilar cholangiocarcinoma treated by PVE.Results:This study shows that:Bismuth-corlett type before PVE(P=0.027),CA19-9 level(P=0.037),regional lymph node metastasis(P=0.019)and liver fibrosis(P=0.014)were different between the high and low regeneration groups,while other indicators showed no statistical difference between the two groups in basic data.Comparison of blood biochemical indexes before PVE between high regeneration group and low regeneration group showed that:There were significant differences in total bilirubin(P=0.001),direct bilirubin(P=0.001),total protein(P=0.001),albumin(P=0.049),serum creatinine(P=0.001),fibrinogen(P=0.001)and hemoglobin(P=0.001)between the high regeneration group and the low regeneration group,(P<0.05).After PVE,there were differences in intraoperative blood loss(P=0.017),intraoperative plasma input(P=0.006)and resection volume(P=0.001)between the high liver regeneration group and the low liver regeneration group,while there were no significant differences in other indicators between the two groups.There were 72 patients with hilar cholangiocarcinoma,49 patients died and 23 patients were lost.The overall median survival time was 12.17 months,with a 95%confidence interval of 7.934 to 16.406.In the high regeneration group,the median survival time was 18.0 months,95%confidence interval was 9.384 to 26.616,and 13 cases were deleted.In the low regeneration group,the median survival time was 5.8 months,95%confidence interval(CI)was 0.001 to 12.368,and 10 cases were deleted.The overall survival time of the two groups was statistically different(P=0.041).Univariate analysis of liver regeneration showed that there was a statistical correlation between cholangiocarcinoma type(P=0.029),lymph node metastasis(P=0.040),CA19-9(P=0.040)and fibrosis degree(P=0.011).There was no correlation between age,gender,lymph node metastasis,degree of differentiation,hilar blockade time and operation time and liver regeneration after PVE.Among them,the probability of low liver regeneration in patients with liver fibrosis was 3.534 times higher than that in patients without fibrosis before surgery,and liver fibrosis was an independent factor affecting liver regeneration.Univariate analysis of survival time of hilar cholangiocarcinoma patients after PVE showed that lymph node metastasis(P=0.001),serum CA19-9 level(P=0.001),differentiation degree(P=0.002),fibrosis(P=0.011)were statistically correlated with the survival time of hilar cholangiocarcinoma patients after PVE.There was no significant correlation between the other items and the life span.CA19-9(P=0.001)was an independent factor affecting the survival time of patients.Conclusion:PVE can promote liver regeneration in patients with Bismuth-Corlett type Ⅲ type Ⅳ hilar cholangiocarcinoma.Compared with the low regeneration group,the liver function and renal function in the high regeneration group were different from before PVE to 30 days after operation.The liver and kidney in the high regeneration group could make good compensation,and the blood biochemical indexes of liver and kidney fluctuated less and tended to normal level more quickly.The median survival time of high regeneration group was longer than that of low regeneration group.The influencing factors of liver regeneration may be related to cholangiocarcinoma type,lymph node metastasis,CA19-9 and fibrosis degree.The probability of low liver regeneration in patients with liver fibrosis was 3.534 times higher than that in patients without liver fibrosis before surgery.Liver fibrosis is an independent factor affecting liver regeneration.Factors affecting the survival time of HCCA patients after PVE include lymph node metastasis,serum CA19-9 level,differentiation degree and fibrosis.CA19-9 was an independent factor affecting the survival time of patients.