| BackgroundPrimary liver cancer is one of the malignant tumors with high morbidity and mortality in the world,and most of its pathological type is hepatocellular carcinoma(HCC),accounting for more than 90%.China is the high morbidity area,according to the latest Cancer Statistics in China: HCC ranks No.4 in male's morbidity of malignant tumors,and its mortality ranks No.3 in the overall number of investigations,It is a serious threat to the the Chinese people's life and health.For the treatment of HCC,it is generally accepted that radical resection is the best choice,and there are two types of radical resection: anatomical and non-anatomical hepatectomy.Anatomical hepatectomy is resection which base on the Couinaud's segment,including single segmentectomy and multiple segmentectomy.Non-anatomical hepatectomy is also called the irregular hepatectomy,in which the tumor is complete removed but the hepatic anatomy is not considered in,general requirements for the resection margin(RM)is at least 1.0cm.At present,there is no conclusion about the influence of anatomical versus non-anatomical hepatectomy on the prognosis of HCC.Since HCC micrometastases is main occured through portal vein thrombosis,the early satellite lesions and the major tumor is located in the same liver segment,theoretically anatomical hepatectomy can remove more intrahepatic metastatic lesions,thereby reducing recurrence.In recent years,with the gradual maturity of laparoscopic surgical techniques and constantly update in equipment.The application of laparoscopic hepatectomy in the liver surgery will continue to expand.It has been already confirmed that laparoscopic hepatectomy surgery in the treatment of HCC is safe and feasible,in selected cases,can achieve the same long-term outcome to open hepatectomy,and has the advantages of less trauma,faster recovery,less complications,which is minimally invasive surgery inherent,the recent effect is better than that of open hepatectomy.Recent literature reports indicate that the number ofcases of laparoscopic hepatectomy treating HCC showed a growth trend in worldwide,an increasing number of patients with HCC will be the indication of minimally invasive hepatectomy.The purpose of HCC resection is to ensure clean and tumor-free margins,and to ensure that sufficient reserve liver function in volume.Anatomical hepatectomy is performed on the basis of without destroying the remaining liver blood vessels and bile ducts,this approach can maximize the retention of residual liver function,but operation is more precise and complex,the technical requirements is higher than normal hepatectomy.In china,more than80% HCC patients with cirrhosis,non-anatomical hepatectomy can reduce the resection of the tumor-free area and retain more liver parenchyma,reduce the possibility of postoperative liver dysfunction;in addition,non-anatomical hepatectomy technical requirements are relatively low and it is easy to be popularized.The prognosis influence of anatomical and non anatomical hepatectomy for HCC under open conditions is uncertain,in the published literatures the level of clinical evidence in home and abroad are Class B or C base on the standard definition of evidence-based medicine,has not retrieved the clinical A level evidence.Laparoscopic hepatectomy has the characteristics of magnifying visual field,clear field of operation,fine dissection.It also has the same anatomical and non-anatomical hepatectomy.Currently laparoscopic hepatectomy treating HCC reported mostly is descriptive and retrospective study,evidence-based medical evidence level is low,has yet to see prognosis prospective controlled study on laparoscopic anatomical hepatectomy and non-anatomical hepatectomy for HCC.Due to the technical difficulty of laparoscopic segment resection and the requirements for the operational precision,the treatment of laparoscopic hepatectomy for HCC in the literature reported main is still extensive hepatectomy and non-anatomical hepatectomy,the laparoscopic anatomical liver segment resection,especially I,VII,VIII segment resection operation reports rarely,is still in the stage of technologic exploration.Through clinical prospective randomized controlled trial.Comparative analysis perioperative and follow-up results of laparoscopic anatomical hepatectomy and non-anatomical hepatectomy in the treatment of HCC patients.Regard Paitient's survival time as the main indicators of the research to investigate the two kinds of operations' impact on short-term efficacy of oncologic results for HCC.Provide high evidence-based medicalevidence for the selection of invasive hepatectomy on HCC,and through this study establish and improve laparoscopic anatomical hepatectomy technique.MethodsThe research is strictly designed accordance with the prospective randomized controlled trial,according to the preoperative inclusion and exclusion criteria,using a random number table method patients were respectively divided into the following group : laparoscopic anatomical hepatectomy group(LAH)and laparoscopic non-anatomical hepatectomy group(LNAH),in accordance with optimal efficiency test to estimate sample size of 110 cases.According to the random number patients received corresponding laparoscopic hepatectomy,prophylactic anti-infection,acid suppression,nutritional support and symptomatic treatment were routinely given in postoperative time.Statistics two groups of patients with general information: gender,age,ratio of CHB/CHC and cirrhosis,preoperative liver function,Child-Pugh classification,AFP,position of tumor center.Operation results:surgical approach,operative time,blood loss,blood transfusion rate,conversion to laparotomy rate,endoscopic Pringle maneuver occlusion time and blocking rate,complications and incidence,postoperative hospitalization time,time to diet,the change of liver function after operation in one week.Pathological results: the differentiation of tumor cells,the tumor size,the resection margin.After the operation,the patients were followed up through telephone and outpatient review by the Department of hepatobiliary surgery,Southwest Hospital,Third Military Medical University.All patients at review time should do the abdominal color Doppler ultrasound,test liver function and AFP,patients with viral hepatitis test corresponding hepatitis markers and virus DNA or RNA copy.Patients with suspected recurrence,enhanced CT,contrast-enhanced ultrasound or specific MRI-specific diagnosis.Definite case receive laparoscopic or open hepatectomy,RF,TACE or liver transplantation and other treatment according to the size,location,number of lesions and the patient's general condition after the comprehensive assessment.The review will be did once every 3 months in the 1st year after operation,once every 4 months in the 2nd years,then once every six months,the following-up will be did once every three months,follow-up deadline is April 1st,2016.ConsequenceFrom April 2014 to January 2016,110 patiens met the inclusion criteria were included in the Department of hepatobiliary surgery,Southwest Hospital,Third Military Medical University,and there were 55 patients in LAH group and LNAH group,respactivelly.Two groups' patient in: age,sex ratio,Hepatitis B and Hepatitis C infection,preoperative liver function,Child-Pugh,grading,ICGR-15,AFP,proportion of liver cirrhosis,tumor number,diameter of tumor,tumor involving the liver segments had no statistically significant difference,indicating that the two groups were comparable.Perioperative outcomesTwo groups had no perioperative death.In the LAH group,four patients converted to laparotomy,in the LNAH group 5 cases converted to laparotomy.Two groups' rate of conversion(9.1% vs 7.3%,P = 0.728),inflow occlusion rate(43.6% vs 58.2%,P = 0.127),perioperative blood transfusion rate(10.9 vs 20.0 %,P = 0.187),time to diet(1.54± 0.58 vs 1.59 ± 0.61 d,P = 0.306),postoperative hospital stay(10.54 ± 3.80 vs 10.94± 3.25 d,P = 0.267)had no significant difference.The operation time(238.02 ± 92.51 vs198.73 ± 85.705 min,P = 0.023),intraoperative blood loss(312.00 ± 215.41 vs 451.45± 353.27 ml,P = 0.014),duration of inflow occlusion(10.31 ± 13.89 vs 18.27 ± 19.53 min,P = 0.029),morbidity(7.3% vs 21.8%,P = 0.031),tumor margins(2.11 ± 0.66 vs 1.76± 0.71 cm,P=0.031)were significantly different,LAH group was better in intraoperative blood loss,duration of inflow occlusion,morbidity,tumor margins,but LAH group's operation time was longer.All of the patients were confirmed with hepatocellular carcinoma in Pathological result.Classificating the pathology results by Edmondson grading,LAH group:grade ? in 16 cases,grade ? in 30 cases,? grade in 6 cases,? in 3 cases;LNAH group: ? grade in 19 cases,? grade in 25 cases,grade ? in 8 cases,grade ? in 3 cases,no significant differenceafter test(P=0.621).The AST,ALT and TBIL values in 1st,3rd,5th days after operation was significantly lower in LAH group.Follow-up ResultsThe deadline of follow-up was April 1,2016,the median of follow-up period was 14.6months(range from 3 to 24 months).To the end of follow-up,LAH group had 6 cases of recurrence.In the recurrent cases,4 cases died after several times' therapies.LNAH group had13 cases of recurrence,.In the recurrent cases,7 cases died after several times' therapies.In LAH group and LNAH group the 1,2-year overall survival rates were 95.6% vs 90.1%,86.3%vs 79.5%(P = 0.248),respectively,the difference was not statistically significant.the 1,2-year tumor-free survival rates were to 91.8% vs 79.7%,81.9% vs 71.3%(P = 0.042),respectively,the difference was statistically significant.Conclusion1.Compared with laparoscopic non-anatomical hepatectomy,laparoscopic anatomical hepatectomy can reduce intraoperative bleeding,Pringle time,postoperative liver damage,and surgical complications rate.2.laparoscopic anatomical hepatectomy can improve the early disease-free survival,but the two type of hepatectomy for HCC had no difference in the early overall survival rate.3.The study provided a high-level evidence-based medical evidence for the selection of laparoscopic hepatectomy in the treatment of HCC,and established a series of technical methods for laparoscopic anatomical segmentectomy.Since this study was a single-center prospective randomized controlled trial,the number of cases is a little less,and it's a intermediate stage summary,the follow-up time is not long enough,here still need multicenter,large sample prospective randomized controlled trial and long time follow-up to provide more sufficient evidence for the conclusion of this study. |
PDF Full Text Request