本文關(guān)鍵詞：117例肝門部膽管癌病人外科治療及其預(yù)后分析，由筆耕文化傳播整理發(fā)布。

        目的：對經(jīng)外科治療的117例肝門部膽管癌病人的預(yù)后進(jìn)行分析，討論影響其預(yù)后的因素。方法：選取1999年至2012年間山西醫(yī)科大學(xué)第二附屬醫(yī)院和山西省腫瘤醫(yī)院經(jīng)外科治療的117例肝門部膽管癌的病人的資料進(jìn)行病例回顧分析。將性別、年齡、術(shù)前血總膽紅素值、術(shù)前血白蛋白值、術(shù)前腫瘤標(biāo)記物CA199、CA242及CEA的檢測結(jié)果、手術(shù)方式、淋巴結(jié)轉(zhuǎn)移、門靜脈浸潤、畢氏分型（Bismuth-Corletter分型）、組織學(xué)分型總計10個因素作為可能影響預(yù)后的變量，選用統(tǒng)計學(xué)中生存分析對各項變量進(jìn)行分析。對生存率選用Maplan-Meier乘積極限法進(jìn)行統(tǒng)計，單因素生存時間的比較選用log-rank檢驗。對于單因素分析有顯著意義的變量，再用多因素分析。多因素分析采用Cox比例風(fēng)險回歸模型進(jìn)行分析評價。結(jié)果：單因素分析結(jié)果：（1）按性別分組后比較，結(jié)果為男性與女性相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。（2）年齡分組后比較，結(jié)果為≥60歲組與＜60歲組相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。（3）術(shù)前血清總膽紅素分組后比較，結(jié)果為≥170umol/L組與＜170umol/L組相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。（4）術(shù)前血清白蛋白分組后比較，結(jié)果為≥35g/L組與＜35g/L組相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。（5）腫瘤標(biāo)記物分組后比較，CA199值＞35u/L組與≤35u/L組相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）；CA242值＞35u/L組與≤u/L35組相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）；CEA值＞5u/L組與≤5u/L組相比中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。（6）手術(shù)方式分組比較，結(jié)果為根治組、姑息組、內(nèi)引流組及外引流組的中位生存時間總體差異有統(tǒng)計學(xué)意義（P＜0.05）。組間比較結(jié)果示：根治組與其余3組分別比較，中位生存時間延長，差異均有統(tǒng)計學(xué)意義（P＜0.05）；姑息組分別與內(nèi)、外引流組比較，中位生存時間延長，差異有統(tǒng)計學(xué)意義（P＜0.05）；內(nèi)外引流組間比較，中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。（7）畢氏分型分組比較，結(jié)果為Ⅰ型組、Ⅱ型組、Ⅲ型組、Ⅳ型組生存時間總體差異無統(tǒng)計學(xué)意義（P＞0.05）。（8）有無淋巴結(jié)轉(zhuǎn)移比較，有淋巴結(jié)轉(zhuǎn)移組較無淋巴結(jié)轉(zhuǎn)移組中位生存時間縮短，差異有統(tǒng)計學(xué)意義（P＜0.05）。（9）肝門靜脈有無浸潤比較，，有門靜脈浸潤組較無門靜脈浸潤組中位生存時間縮短，差異有統(tǒng)計學(xué)意義（P＜0.05）。（10）組織學(xué)分型比較，結(jié)果為高分化腺癌組、中分化腺癌組、低分化腺癌組及粘液癌組的中位生存時間總體差異有統(tǒng)計學(xué)意義（P＜0.05）。組間比較結(jié)果示：高分化腺癌組較其余3組中位生存時間長，差異有統(tǒng)計學(xué)意義（P＜0.05）；中分化組與低分化組、粘液腺癌組比較，中位生存時間差異有統(tǒng)計學(xué)意義（P＜0.05）；低分化腺癌組、粘液腺癌組比較，中位生存時間的差異無統(tǒng)計學(xué)意義（P＞0.05）。多因素分析結(jié)果：進(jìn)入Cox比例風(fēng)險模型的有手術(shù)方式、有無淋巴結(jié)轉(zhuǎn)移、組織學(xué)分型，即上述三個因素是影響HC預(yù)后的獨立因素。在有無淋巴結(jié)轉(zhuǎn)移與組織學(xué)類型不變的情形下，手術(shù)方式的相對危險度為0.125，相對危險度95%可信區(qū)間為（0.050,0.311），即手術(shù)方式為保護(hù)性因素；根治性手術(shù)治療效果好于姑息性切除、內(nèi)引流及外引流治療者，非根治性切除手術(shù)治療者的死亡風(fēng)險是根治性手術(shù)治療者8倍。在手術(shù)方式和組織學(xué)分型不變的情形下，有淋巴結(jié)轉(zhuǎn)移的相對危險度為2.985，相對危險度95%可信區(qū)間為（1.508,5.910），淋巴結(jié)轉(zhuǎn)移者死亡風(fēng)險是無淋巴結(jié)轉(zhuǎn)移者的2.98倍。在手術(shù)方式和淋巴結(jié)轉(zhuǎn)移不變的情形下，組織學(xué)分型的相對危險度為2.992，相對危險度95%可信區(qū)間為（1.540，5.815），低分化程度者死亡風(fēng)險是較其分化程度高者（中分化者和高分化者）的2.99倍。結(jié)論：1.手術(shù)方式、組織學(xué)類型（腫瘤分化程度）、是否淋巴結(jié)轉(zhuǎn)移、是否門靜脈浸潤是影響肝門部膽管癌病人預(yù)后的關(guān)鍵性因素。2.根治性切除術(shù)較姑息性切除術(shù)及內(nèi)外引流術(shù)預(yù)后好，更適合綜合條件符合要求的肝門部膽管癌病人。組織分化程度越低預(yù)后越差。有淋巴結(jié)轉(zhuǎn)移者預(yù)后較無淋巴結(jié)轉(zhuǎn)移者差。

    Objective: To analyze the prognosis of117Hilar Cholangiocarcinama patients whounderwent the treatment of surgery, then discuss the factors that effect its prognosis.Method: This retrospective analysis is comprised by informations of117HC patientswho underwent the diagnosis and treatment of surgery from1999to2012in theaffiliated second hospital of shanxi medical university and the tumor hospital ofshanxi province. We choose the survival analysis in medical statistics to analyze allvariables, these variables cover gender, age, preoperative total bilirubin, preoperativealbumin, test results of preoperative tumor markers CA199CA242CEA, surgicalprocedures pattern, lymph node metastasis, portal vein invasion, Bismuth-corlettetype, and histological classification, which may influence the prognosis. TheKaplan-Meier product-limited method estimates the survival rate and the Log-ranktest method is used to contrast the survival times of all the single fact. The markedand significant variables in the Log-rank test is analyzed by the multiple-factoranalysis. The multiple-factor analysis employ the Cox proportional hazardregression model to analyze and assess.Result:Single factor analysis:1. The compare by grouping sex shows that the differences of the median survivaltime between male and female are not statistic significance(P＞0.05).2. The compare by grouping age shows that the differences of the median survivaltime between≥60years and＜60years are not statistic significance(P＞0.05).3. The compare by grouping total bilirubin shows that the differences of the median survival time between≥170umol/L and＜170umol/L are not statistic significance(P＞0.05).4. The compare by grouping preoperative albumin value shows that the differences ofthe median survival time between≥35g/L and＜35g/are not statistic significance(P＞0.05).5. The compare by grouping test results of preoperative tumor markers shows that thedifferences of the median survival time between CA199＞35u/L and≤35u/L are notstatistic significance(P＞0.05),CA242＞35u/L and≤35u/L are not statisticsignificance(P＞0.05),CEA＞5u/Land≤5u/L are not statistic significance(P＞0.05).6. The compare by grouping A(radical resection group), B(palliative resection group),C(internal drainage group), D(external drainage group) shows that the totaldifferences of the median survival time between them are statistic significance (P＜0.05); The radical resection group(A) is longer the median survival time than otherthree groups’and its difference is statistic significance (P＜0.05);The median survivaltime of palliative resection group is longer than the internal drainage group andexternal drainage group respectively and the difference is statistic significance (P＜0.05); In the compare between the internal drainage group and the external drainagegroup, the differences of the median survival time is not statistic significance (P＞0.05).7. The compare by grouping Bismuth-corlette type (BⅠ,BⅡ,BⅢ,BⅣ)shows that thedifferences of the median survival time between them are not statistic significance(P＞0.05).The compare by grouping lymph node metastasis and not one shows that thedifferences of the median survival time between lymph node metastasis group and notlymph node metastasis group are statistic significance(P＜0.05).8. The compare by grouping lymph node metastasis and not one shows that the differences of the median survival time between lymph node metastasis group and notlymph node metastasis group are statistic significance(P＜0.05).9. The compare by grouping portal vein invasion and not one shows that thedifferences of the median survival time between portal vein invasion group and notportal vein invasion group are statistic significance(P＜0.05).10. The compare by grouping the histological classification including A(high or welldifferentiated adenocarcinoma group), B(moderately differentiated adenocarcinomagroup), C(poorly differentiated adenocarcinoma group), D(mucinous adenocarcinomagroup) shows that the total differences of the median survival time between them arestatistic significance(P＜0.05); The well differentiated adenocarcinoma group(A) islongest the median survival time than other three groups’ and its difference is statisticsignificance(P＜0.05);The median survival time of moderately differentiatedadenocarcinoma group(B) is longer than the other two groups respectively and thedifference is statistic significance (P＜0.05); In the compare between the poorlydifferentiated adenocarcinoma group and the mucinous adenocarcinoma group, thedifferences of the median survival time is not statistic significance (P＞0.05).Multiple-factor analysis:There are some independent factors to enter into the Cox proportional hazardregression model that includes the surgical approach, the lymph node metastasis andthe histological classification. They are the independent factors which could effect theprognosis of HC. If two facts about the lymph node metastasis and the histologicalclassification were constant, RR(the relative risk) of the surgical approach would be0.125,95%CI(confidence interval) for RR would be (1.540,5.815). It means that thesurgical approach is a protective factor. The efficacy of the radical resection group isbetter than the others including the alliative resection group, the internal drainagegroup and the external drainage group. The mortality risk of patient who accepts the no radical resection treatment are8times greater than one of patient who accepts theradical resection treatment. If two facts about the surgical approach and thehistological classification were constant, RR of the lymph node metastasis would be2.985,95%CI for RR would be （1.508,5.910）. It means that the mortality risk ofpatient who has the lymph node metastasis are2.5times greater than the one who hasnot the lymph node metastasis. If two facts about the surgical approach and the lymphnode metastasis were constant, RR of the histological classification would be2.992,95%CI for RR would be （1.540,5.815）. It means that the mortality risk of patientwho has the poorly differentiated adenocarcinoma are2.99times greater than the onewho has not the poorly differentiated adenocarcinoma including the mucinousadenocarcinoma and the high or well differentiated adenocarcinoma.Conclusion:1. The surgical procedures pattern, histological classification, lymphnode metastasis, and portal vein invasion in HC patient are the important factors ofinfluencing hilar cholangiocarcinoma patient’s prognosis;2. The prognosis of radicalresection is better than the others about palliative resection, internal drainage, andexternal drainage group, so it is preference to the adequate synthetical evaluationhilar cholangiocarcinoma patient

117例肝門部膽管癌病人外科治療及其預(yù)后分析

摘要5-8Abstract8-11前言12-14資料與方法14-17結(jié)果17-19討論19-26結(jié)論26-27參考文獻(xiàn)27-30附錄30-33綜述33-42    參考文獻(xiàn)39-42攻讀學(xué)位期間發(fā)表文獻(xiàn)況42-43致謝43-45個人簡歷45

  本文關(guān)鍵詞：117例肝門部膽管癌病人外科治療及其預(yù)后分析，由筆耕文化傳播整理發(fā)布。