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腹腔镜肝切除术难度评分系统的临床应用价值

史志龙 徐浩 柴长鹏 杨思捷 周文策

史志龙, 徐浩, 柴长鹏, 等. 腹腔镜肝切除术难度评分系统的临床应用价值[J]. 临床肝胆病杂志, 2021, 37(8): 1888-1893. DOI: 10.3969/j.issn.1001-5256.2021.08.027
引用本文: 史志龙, 徐浩, 柴长鹏, 等. 腹腔镜肝切除术难度评分系统的临床应用价值[J]. 临床肝胆病杂志, 2021, 37(8): 1888-1893. DOI: 10.3969/j.issn.1001-5256.2021.08.027
SHI ZL, XU H, CHAI CP, et al. Clinical application value of difficulty score systems before laparoscopic liver resection[J]. J Clin Hepatol, 2021, 37(8): 1888-1893. DOI: 10.3969/j.issn.1001-5256.2021.08.027
Citation: SHI ZL, XU H, CHAI CP, et al. Clinical application value of difficulty score systems before laparoscopic liver resection[J]. J Clin Hepatol, 2021, 37(8): 1888-1893. DOI: 10.3969/j.issn.1001-5256.2021.08.027

腹腔镜肝切除术难度评分系统的临床应用价值

DOI: 10.3969/j.issn.1001-5256.2021.08.027
基金项目: 

甘肃省卫生行业科研计划项目 GSWSKY2018-51

甘肃省兰州市人才创新创业项目 2017-RC-37

详细信息
    通讯作者:

    周文策,zhouwc129@126.com

  • 中图分类号: R657.3

Clinical application value of difficulty score systems before laparoscopic liver resection

Funds: 

Health Industry Research Plan Project of Gansu Province GSWSKY2018-51

Talent Innovation and Entrepreneurship Project of Lanzhou City 2017-RC-37

  • 摘要:   目的  探讨3种腹腔镜肝切除术难度评分系统(DSS)评估手术难度和预测短期术后结果的准确性。  方法  选取2015年6月—2020年5月于兰州大学第一医院行腹腔镜肝切除术的患者142例,收集患者术前、术中和术后临床资料。根据术前资料,用DSS-B评分、Hasegawa评分和Halls评分3种DSS对每个患者手术的难度进行评分并分为低、中、高难度3组,比较各组间术中资料的差异,以验证3种DSS的准确性;用术后资料评估DSS对短期术后结果的预测能力。正态分布的计量资料多组间比较采用方差分析,进一步两两比较采用LSD-t检验;非正态分布的计量资料多组间比较及进一步两两比较均采用Kruskal-Wallis H检验。计数资料组间比较采用χ2检验或Fisher精确概率法,两两比较的P值用Bonferroni法校正。通过绘制受试者工作特征曲线(ROC曲线)并计算曲线下面积(AUC),评价DSS对术后并发症的预测效能。  结果  142例患者中,DSS-B评分低、中、高难度组分别有37、56、49例;Hasegawa评分低、中、高难度组分别有70、47、25例;Halls评分低、中、高难度组分别有46、62、34例。DSS-B评分、Hasegawa评分和Halls评分在低、中、高难度组之间手术时间、术中出血量、肝门阻断率均随难度评分的升高而增高(P值均<0.001);术中输血率方面,DSS-B评分仅在中难度与高难度组间差异有统计学意义(P<0.017),Halls评分在低难度与高难度组间差异有统计学意义(P<0.017),而Hasegawa评分低难度与中难度、高难度组比较,差异均有统计学意义(P值均<0.017);中转开腹率方面,DSS-B评分中难度与高难度组间差异有统计学意义(P<0.017),Hasegawa评分、Halls评分可区分低难度与高难度组间差异(P值均<0.017)。术后住院时间方面DSS-B评分和Halls评分均只能区分低难度与高难度组间差异(P值均<0.05),Hasegawa评分则可区分低难度与中难度、高难度的组间差异(P值均<0.05);术后并发症发生率方面仅Hasegawa评分可有效区分高难度与低难度、中难度的组间差异(P值均<0.017)。DSS-B评分、Halls评分和Hasegawa评分预测术后并发症的AUC分别为0.636(95%CI:0.515~0.758)、0.557(95%CI:0.442~0.673)、0.760(95%CI:0.654~0.866),其中Hasegawa评分的预测效能最大。  结论  DSS-B评分和Hasegawa评分可较好地评估腹腔镜肝切除术难度,Hasegawa评分在预测短期术后结果方面具有优势。

     

  • 图  1  3种DSS预测术后并发症的ROC曲线

    表  1  3种腹腔镜肝切除难度评分表

    评分类型 评分标准 难度等级
    DSS-B评分 ①肿瘤位置(Ⅲ:1分;Ⅱ、Ⅵ:2分;Ⅳ、Ⅴ:3分;Ⅶ、Ⅷ:5分) 低:1~3分
    ②肿瘤大小(<3 cm:0分;≥3 cm:1分) 中:4~6分
    ③肝切除范围(部分楔形切除:0分;左外叶切除:2分;肝段切除:3分;肝叶切除:4分) 高:7~10分
    ④肿瘤接近主要脉管(无:0分;有:1分)
    ⑤肝功能Child-Pugh分级(A级:0分;B级:1分)
    Hasegawa评分 ①肿瘤位置(Ⅱ~Ⅳ:0分;Ⅴ、Ⅵ:1分;Ⅶ、Ⅷ:2分) 低:0~1分
    ②肝切除范围(非解剖肝切除或腹腔镜下肝左外叶切除:0分;解剖性肝段切除:2分;肝大部切除:3分) 中:2~3分
    ③PLT(>100×109/L:0分;≤100×109/L:1分) 高:≥4分
    ④BMI(<30 kg/m2:0分;≥30 kg/m2:1分)
    Halls评分 ①病灶大小(<3 cm:0分;3~5 cm:2分;>5 cm:3分) 低:0~2分
    ②肿物性质(良性:0分;恶性:2分) 中:3~5分
    ③肝切除类型(小范围切除:0分;技术性大切除:2分;解剖性大部切除:4分) 高:6~9分
    ④既往开腹肝脏手术史(无:0分;有:5分) 极高:≥10分
    ⑤术前化疗(无:0分;有:1分)
    注:Ⅰ~Ⅷ,肝Couinaud分段。
    下载: 导出CSV

    表  2  患者临床基线资料

    项目 数值
    男/女(例) 86/56
    年龄(岁) 51.56±11.54
    BMI(kg/m2) 23.25±3.34
    麻醉ASA分级(Ⅰ/Ⅱ/Ⅲ,例) 2/111/29
    肝硬化[例(%)] 76(53.5)
    肝功能Child-Pugh分级(A/B/C,例) 132/10/0
    诊断(例)
      肝细胞癌 86
      肝内胆管癌 8
      肝血管瘤 22
      肝包虫 16
      肝脏局灶性结节增生 7
      其他 3
    既往开腹肝脏手术史[例(%)] 6(4.2)
    术前化疗史[例(%)] 7(4.9)
    中转开腹[例(%)] 10(7.0)
    肝门阻断[例(%)] 74(52.1)
    术中输血[例(%)] 13(9.2)
    术后并发症(例)
      Ⅰ级 16
      Ⅱ级 5
      Ⅲa级 1
      Ⅲb级 2
    Ⅳa级 1
    术后主要并发症[例(%)] 4(2.8)
    难度分级
      DSS-B评分(低/中/高,例) 37/56/49
      Hasegawa评分(低/中/高,例) 70/47/25
      Halls评分(低/中/高/极高,例) 46/62/34/0
    下载: 导出CSV

    表  3  3种DSS各难度组间比较

    组别 例数 术中指标 术后指标
    手术时间(min) 术中出血量(ml) 肝门阻断率[例(%)] 术中输血率[例(%)] 中转开腹率[例(%)] 术后住院时间(d) 术后并发症发生率[例(%)]
    DSS-B评分
      低难度组 37 150.5±73.9 90(20~190) 6(16.2) 2(5.4) 1(2.7) 6(4~8) 4(10.8)
      中难度组 56 242.6±80.51) 200(100~300)1) 23(41.1)1) 1(1.8) 1(1.8) 7(6~9) 7(12.5)
      高难度组 49 364.7±112.61)2) 300(200~550)1)2) 45(91.8)1)2) 10(20.4)2) 8(16.3)2) 8(7~10)1) 14(28.6)
      统计值 F=59.651 H=38.847 χ2=52.825 χ2=10.628 χ2=8.337 H=14.723 χ2=6.246
      P <0.001 <0.001 <0.001 0.004 0.013 0.001 0.045
    Hasegawa评分
      低难度组 70 191.4±83.2 100(50~200) 20(28.6) 1(1.4) 2(2.9) 6(5~8) 4(5.7)
      中难度组 47 289.8±100.61) 200(100~400)1) 29(61.7)1) 6(12.8)1) 3(6.4) 8(7~10)1) 9(19.1)
      高难度组 25 400.4±121.21)2) 500(250~600)1)2) 25(100.0)1)2) 6(24.0)1) 5(20.0)1) 8(7~12)1) 12(48.0)1)2)
      统计值 F=46.383 H=41.574 χ2=40.250 χ2=12.507 χ2=6.947 H=21.164 χ2=20.665
      P <0.001 <0.001 <0.001 0.001 0.022 <0.001 <0.001
    Halls评分
      低难度组 46 173.9±86.4 100(45~200) 8(17.4) 0 1(2.2) 7(4~9) 5(10.9)
      中难度组 62 273.9±97.51) 200(100~325)1) 36(58.1)1) 7(11.3) 2(3.2) 7(6~9) 14(22.6)
      高难度组 34 354.1±133.51)2) 300(200~600)1) 30(88.2)1)2) 6(17.6)1) 7(20.6)1) 8(7~10)1) 6(17.6)
      统计值 F=30.201 H=33.263 χ2=40.880 χ2=9.136 χ2=9.766 H=11.978 χ2=2.497
      P <0.001 <0.001 <0.001 0.008 0.004 0.003 0.278
    注:与低难度组比较,1)P<0.05;与中难度组比较,2)P<0.05。
    下载: 导出CSV
  • [1] KOKUDO N, TAKEMURA N, ITO K, et al. The history of liver surgery: Achievements over the past 50 years[J]. Ann Gastroenterol Surg, 2020, 4(2): 109-117. DOI: 10.1002/ags3.12322.
    [2] BUELL JF, CHERQUI D, GELLER DA, et al. The international position on laparoscopic liver surgery: The Louisville Statement, 2008[J]. Ann Surg, 2009, 250(5): 825-830. DOI: 10.1097/sla.0b013e3181b3b2d8.
    [3] WAKABAYASHI G, CHERQUI D, GELLER DA, et al. Recommendations for laparoscopic liver resection: A report from the second international consensus conference held in Morioka[J]. Ann Surg, 2015, 261(4): 619-629. DOI: 10.1097/SLA.0000000000001184.
    [4] KOMATSU S, SCATTON O, GOUMARD C, et al. Development process and technical aspects of laparoscopic hepatectomy: Learning curve based on 15 years of experience[J]. J Am Coll Surg, 2017, 224(5): 841-850. DOI: 10.1016/j.jamcollsurg.2016.12.037.
    [5] BROWN KM, GELLER DA. What is the learning curve for laparoscopic major hepatectomy?[J]. J Gastrointest Surg, 2016, 20(5): 1065-1071. DOI: 10.1007/s11605-016-3100-8.
    [6] ABU HILAL M, ALDRIGHETTI L, DAGHER I, et al. The Southampton Consensus Guidelines for laparoscopic liver surgery: From indication to implementation[J]. Ann Surg, 2018, 268(1): 11-18. DOI: 10.1097/SLA.0000000000002524.
    [7] BAN D, TANABE M, ITO H, et al. A novel difficulty scoring system for laparoscopic liver resection[J]. J Hepatobiliary Pancreat Sci, 2014, 21(10): 745-753. DOI: 10.1002/jhbp.166.
    [8] GUO Y, LIAO R, LUO F. Establishment of surgical difficulty scoring system for laparoscopic liver resection and its application[J]. Chin J Gen Surg, 2018, 27(1): 22-28. DOI: 10.3978/j.issn.1005-6947.2018.01.004.

    郭杨, 廖锐, 罗放. 腹腔镜下肝切除术手术难度评分系统的建立与应用[J]. 中国普通外科杂志, 2018, 27(1): 22-28. DOI: 10.3978/j.issn.1005-6947.2018.01.004.
    [9] KAWAGUCHI Y, FUKS D, KOKUDO N, et al. Difficulty of laparoscopic liver resection: Proposal for a new classification[J]. Ann Surg, 2018, 267(1): 13-17. DOI: 10.1097/SLA.0000000000002176.
    [10] HASEGAWA Y, WAKABAYASHI G, NITTA H, et al. A novel model for prediction of pure laparoscopic liver resection surgical difficulty[J]. Surg Endosc, 2017, 31(12): 5356-5363. DOI: 10.1007/s00464-017-5616-8.
    [11] HALLS MC, BERARDI G, CIPRIANI F, et al. Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection[J]. Br J Surg, 2018, 105(9): 1182-1191. DOI: 10.1002/bjs.10821.
    [12] The Hepatic Surgery Group of Chinese Medical Association. Expert consensus on laparoscopic hepatectomy and guideline for operative procedure (2013 edition)[J]. Chin J Dig Surg, 2013, 12(3): 161-165. DOI: 10.3760/cma.j.issn.1673-9752.2013.03.001.

    中华医学会外科学分会肝脏外科学组. 腹腔镜肝切除专家共识与手术操作指南(2013版)[J]. 中华消化外科杂志, 2013, 12(3): 161-165. DOI: 10.3760/cma.j.issn.1673-9752.2013.03.001.
    [13] BELGHITI J, CLAVIEN P, GADZIJEV E, et al. The Brisbane 2000 terminology of liver anatomy and resections[J]. HPB, 2000, 2(3): 333-339. DOI: 10.1016/S1365-182X(17)30755-4.
    [14] CLAVIEN PA, BARKUN J, de OLIVEIRA ML, et al. The Clavien-Dindo classification of surgical complications: Five-year experience[J]. Ann Surg, 2009, 250(2): 187-196. DOI: 10.1097/SLA.0b013e3181b13ca2.
    [15] CHEN L, LI Y. The risk factors and prediction systems for posthepatectomy complications[J]. J Clin Hepatol, 2019, 35(1): 217-221. DOI: 10.3969/j.issn.1001-5256.2019.01.048.

    陈龙, 李钺. 肝切除术后并发症的危险因素及预测评分系统[J]. 临床肝胆病杂志, 2019, 35(1): 217-221. DOI: 10.3969/j.issn.1001-5256.2019.01.048.
    [16] HAN HS, SHEHTA A, AHN S, et al. Laparoscopic versus open liver resection for hepatocellular carcinoma: Case-matched study with propensity score matching[J]. J Hepatol, 2015, 63(3): 643-650. DOI: 10.1016/j.jhep.2015.04.005.
    [17] CIRIA R, CHERQUI D, GELLER DA, et al. Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing[J]. Ann Surg, 2016, 263(4): 761-777. DOI: 10.1097/SLA.0000000000001413.
    [18] XIANG L, LI J, CHEN J, et al. Prospective cohort study of laparoscopic and open hepatectomy for hepatocellular carcinoma[J]. Br J Surg, 2016, 103(13): 1895-1901. DOI: 10.1002/bjs.10294.
    [19] YOON YI, KIM KH, CHO HD, et al. Long-term perioperative outcomes of pure laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: A retrospective study[J]. Surg Endosc, 2020, 34(2): 796-805. DOI: 10.1007/s00464-019-06831-w.
    [20] ZHANG NP, ZHANG XJ. Evaluation of different hepatic blood flow blocking methods in laparoscopic hepatectomy of patients with liver cancer[J/CD]. Chin J Liver Dis (Electronic Version), 2019, 11(3): 58-63. DOI: 10.3969/j.issn.1674-7380.2019.03.011.

    张能平, 张雄杰. 不同肝血流阻断方式在肝癌患者腹腔镜肝切除术中的应用[J/CD]. 中国肝脏病杂志(电子版), 2019, 11(3): 58-63. DOI: 10.3969/j.issn.1674-7380.2019.03.011.
    [21] CIRIA R, AYLLON MD, BRICEÑO J. Difficulty scores in laparoscopic liver surgery-getting closer to a powerful and necessary tool[J]. Hepatobiliary Surg Nutr, 2019, 8(4): 428-430. DOI: 10.21037/hbsn.2019.02.11.
    [22] IM C, CHO JY, HAN HS, et al. Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy[J]. Surg Endosc, 2017, 31(1): 430-436. DOI: 10.1007/s00464-016-4994-7.
    [23] LEE SY, GOH B, SEPIDEH G, et al. Laparoscopic liver resection difficulty score-a validation study[J]. J Gastrointest Surg, 2019, 23(3): 545-555. DOI: 10.1007/s11605-018-4036-y.
    [24] XIA AD, WANG W, BAI G, et al. Practicability of surgical difficulty scoring model for laparoscopic liver resection[J/CD]. Chin J Laparoscopic Surgery (Electronic Edition), 2020, 13(3): 166-172. DOI: 10.3877/cma.j.issn.1674-6899.2020.03.009.

    夏阿东, 王巍, 白光, 等. 腹腔镜肝切除评分模型可行性分析[J/CD]. 中华腔镜外科杂志(电子版), 2020, 13(3): 166-172. DOI: 10.3877/cma.j.issn.1674-6899.2020.03.009.
    [25] YANG J, YANG Z, JIA G, et al. Clinical practicality study of the difficulty scoring systems DSS-B and DSS-ER in laparoscopic liver resection[J]. J Laparoendosc Adv Surg Tech A, 2019, 29(1): 12-18. DOI: 10.1089/lap.2018.0150.
    [26] RUSSOLILLO N, MAINA C, FLERES F, et al. Comparison and validation of three difficulty scoring systems in laparoscopic liver surgery: A retrospective analysis on 300 cases[J]. Surg Endosc, 2020, 34(12): 5484-5494. DOI: 10.1007/s00464-019-07345-1.
    [27] RATTI F, D'ALESSANDRO V, CIPRIANI F, et al. Influence of body habitus on feasibility and outcome of laparoscopic liver resections: A prospective study[J]. J Hepatobiliary Pancreat Sci, 2016, 23(6): 373-381. DOI: 10.1002/jhbp.350.
    [28] TRIPKE V, HUBER T, MITTLER J, et al. Prediction of complexity and complications of laparoscopic liver surgery: The comparison of the Halls-score to the IWATE-score in 100 consecutive laparoscopic liver resections[J]. J Hepatobiliary Pancreat Sci, 2020, 27(7): 380-387. DOI: 10.1002/jhbp.731.
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  • 收稿日期:  2021-01-07
  • 修回日期:  2021-01-22
  • 刊出日期:  2021-08-16
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