目的:通過傾向得分匹配（PSM）的方法,證實在肝癌破裂出血的病人中,肝切除相比較于非手術(shù)治療是否可以獲得更好的預(yù)后。方法:我中心共有216患肝癌破裂病人被納入研究。其中,130例病人接受了手術(shù)治療（急診或者延期手術(shù)）,86例病人接受了非手術(shù)治療。傾向得分匹配被用于校正兩組病人的基線特征差異。并進(jìn)行影響長期生存的單因素和多因素的危險因素模型分析。結(jié)果:PSM分析前,手術(shù)組和非手術(shù)組的病人的中位生存期（MST）分別為13.7（IQR 7.2–35.4）月、2.5（0.5–7.4）月。單因素（HR 3.756,95%CI 2.766-5.101;P<0.001）和多因素（HR 3.141,95%CI 2.198-4.488;P<0.001）生存分析都證實,非手術(shù)治療方式預(yù)示著較差的總體生存。PSM后,每組分別有35例病人,兩組基線特征均衡性好。手術(shù)組病例（15.0月）的中位總體生存期優(yōu)于非手術(shù)組病例（3.2月）（HR 3.029,95%CI 1.745-5.258;P<0.001）。多因素生存分析顯示,非手術(shù)治療是致使不良預(yù)后的危險因素（HR 2.792,95%CI 1.5... 

【文章來源】：華中科技大學(xué)湖北省 211工程院校 985工程院校 教育部直屬院校

【文章頁數(shù)】：94 頁

【學(xué)位級別】：博士

【部分圖文】：

肝部分切除組與非手術(shù)組(TAE+保守治療)傾向評分匹配前(A)和后(B)的總體生存率曲線。

這228例病人的流行病特征、臨床指標(biāo)、實驗室檢查見表1。本研究共納入了206例男性,22名女性。201例病人合并乙肝,僅有17例病人合并丙肝。肝切除組、手術(shù)止血組、TAE組和保守治療組四組病人的平均年齡分別為:46.3±11.5歲,53.1±10.7歲,47.8±12.9歲,50.8±14.0歲。肝切除組、手術(shù)止血組、TAE組和保守治療組四組病人的中位生存時間分別為:13.1月,4.9月,3.1月,0.6月。1.5.2 PSM前后病人基線特征比較

共有142例肝癌破裂病人接受了手術(shù)治療,其中有12例僅進(jìn)行了出血腫瘤的手術(shù)止血而無法行根治性切除,如微波固化治療、肝動脈結(jié)扎、縫扎治療。共有130例病人行肝部分切除術(shù),其中接受急診肝切除(EmPH)治療病人共計30例,接受延期肝切除(SPH)治療共100例。而SPH又包含SEPH治療67例,SDPH治療33例(圖1)。病人的流行病和臨床病理學(xué)體征見表1。有兩例病人行TAE治療后出血未止,隨即行EmPH。有8例入院前曾于外院獲得首次手術(shù)治療,其中3例外院治療后止血無效,遂于我院行EmPH,另有5例經(jīng)外院止血有效后再來我院行SPH。在130例手術(shù)病人中,有126病人(96.9%)獲得了R0根治切除。接受肝切除術(shù)病人的術(shù)中平均肝血流阻斷時間為13.5±7.4min。術(shù)后并發(fā)癥發(fā)生率為59.2%(n=77),其中大部分都處于Clavien-Dindo并發(fā)癥分級的I-II級(n=61)。

【參考文獻(xiàn)】：
期刊論文
[1]Liver cancer incidence and mortality in China: Temporal trends and projections to 2030[J]. Rongshou Zheng,Chunfeng Qu,Siwei Zhang,Hongmei Zeng,Kexin Sun,Xiuying Gu,Changfa Xia,Zhixun Yang,He Li,Wenqiang Wei,Wanqing Chen,Jie He.  Chinese Journal of Cancer Research. 2018(06)
[2]《原發(fā)性肝癌診療規(guī)范》（2017版）解讀[J]. 張志偉,陳孝平.  臨床外科雜志. 2018(01)
[3]肝癌切除技術(shù)創(chuàng)新與發(fā)展[J]. 陳孝平,張萬廣.  中華普外科手術(shù)學(xué)雜志(電子版). 2017(05)
[4]Hydrochloric acid-enhanced radiofrequency ablation for treating a large hepatocellular carcinoma with spontaneous rapture:a case report[J]. Ru-Hai Zou,Yang-Kui Gu,Fei Gao,Tian-Qi Zhang,Wang Yao,Xiong-Ying Jiang,Yan-Yang Zhang.  Chinese Journal of Cancer. 2017(01)
[5]以手術(shù)治療為主的肝癌個體化綜合治療[J]. 陳孝平,朱鵬.  中國實用外科雜志. 2016(06)
[6]Hepatic resection beyond barcelona clinic liver cancer indication:When and how[J]. Mattia Garancini,Enrico Pinotti,Stefano Nespoli,Fabrizio Romano,Luca Gianotti,Vittorio Giardini.  World Journal of Hepatology. 2016(11)
[7]Risk factors and surgical outcomes for spontaneous rupture of BCLC stages A and B hepatocellular carcinoma: A case-control study[J]. Jing Li,Liang Huang,Cai-Feng Liu,Jie Cao,Jian-Jun Yan,Feng Xu,Meng-Chao Wu,Yi-Qun Yan.  World Journal of Gastroenterology. 2014(27)
[8]Emergency caudate lobectomy for ruptured hepatocellular carcinoma with multiple primary cancers[J]. Long-Hao Sun,Hong-Qiu Han,Peng-Zhi Wang,Wei-Jun Tian.  World Journal of Gastroenterology. 2013(03)
[9]Predictors and clinical outcomes for spontaneous rupture of hepatocellular carcinoma[J]. Qian Zhu,Jing Li,Jian-Jun Yan,Liang Huang,Meng-Chao Wu,Yi-Qun Yan.  World Journal of Gastroenterology. 2012(48)
[10]Grading and staging of hepatic fibrosis,and its relationship with noninvasive diagnostic parameters[J]. Lun-Gen Lu Min-De Zeng Yi-Min Mao Ji-Qiang Li De-Kai Qiu Ai-Ping Cao, Shanghai Institute of Digestive Disease, Renji Hospital, Shanghai Second Medical University, Shanghai 200001, China Mo-Bin Wan Cheng-Zhong Li, Department of Infectious Diseases, Changhai Hospital, Shanghai 200433, China Jun Ye, Department of Infectious Diseases, Putou District Central Hospital, Shanghai 200062, China Xiong Cai, Department of Infectious Diseases, Changzheng Hospital, Shanghai 200003, China Cheng-Wei Chen, Shanghai Liver Diseases Research Center, Nanjing Military Command, Shanghai 200233, China Ji-Yao Wang, Department of Gastroenterology, Zhongshan Hospital, Shanghai 200032, China Shan-Ming Wu, Shanghai Infectious Hospital, Shanghai 200085, China Jin-Shui Zhu, Department of Gastroenterology, Shanghai NO.6 Hospital, Shanghai 200233, China Xia-Qiu Zhou, Department of Infectious Diseases, Ruijin Hospital, Shanghai 200025, China.  World Journal of Gastroenterology. 2003(11)



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