摘要
目的:通过对复发性肝包虫病患者进行回顾性研究,探讨影响肝包虫术后复发率的相关因素,应用截面取样法研究复发性肝包虫的生长规律及影响其生长发育的可能因素,对患者实施再次手术并进行随访研究,评价传统术式和肝包虫外膜内外囊完整切除术对复发性肝包虫病的不同疗效,为临床复发性肝包虫病的防治提供参考。
方法:选取我院1995年11月-2008年11月间收治的277例各类囊型肝包虫病患者,男性148例,女性129例,年龄5-83岁,平均为31.2±12.1岁,其中复发性肝包虫病患者103例,男性57例,女性46例,年龄17-79岁,平均35.4±9.3岁。将年龄、性别、药物治疗、外囊是否切开、是否合并其他脏器包虫、有无前次术后并发症及肝脏基础疾病等七个因素作为危险因素引入Logistic回归模型来分析其对复发率的影响,将单因素分析中有统计学意义的因素引入Logistic多元回归分析,得出影响肝包虫复发率的危险因素。应用截面取样法研究复发性肝包虫的生长规律并作生长曲线拟合。对可能影响复发性肝包虫生长速度的患者年龄、性别、药物治疗、囊肿位置、囊肿数目、合并胆瘘、囊肿数目、合并其他脏器包虫、肝脏基础疾病、外囊壁是否钙化及复发次数等因素进行单因素分析,将单因素分析中有统计学意义的因素引入Logistic多元回归分析,得出影响复发性肝包虫生长速度的主要危险因素。比较传统术式(内囊摘除术)和新术式(肝包虫外膜内外囊完整切除术)在手术耗时、出血量、术后平均住院日、术后残腔并发证(胆漏、感染、积液)、死亡率及原位复发率等方面的差异,评价两种术式在治疗复发性肝包虫病中的优缺点。
结果:①单因素分析表明:年龄、性别、前次术后并发症及肝脏基础疾病四个因素与肝包虫的复发率无关,无统计学意义(依前述顺序其p值依次为:p=0.878,p=0.554,p=0.053,p=0.794);而药物治疗、外囊切开、伴有其他脏器包虫三个因素与肝包虫的复发率相关,均具有统计学意义(依前述顺序其p值依次为: p=0.039,p=0.000,p=0.032),将单因素分析有统计学意义的三个变量进行多因素条件logistic回归模型,用后退法将不显著的因子依次剔除,仅筛选出外囊切开一个因素为肝包虫复发的危险因素,且为强危险因素(OR=6.979,可信区间3.742～15.357);多因素分析未筛选出肝包虫复发的保护因素。②复发性肝包虫早期呈线性生长,持续46.5个月,生长速度0.2cm/月,之后增长速度逐渐减缓,其最大截面平均直径保持在一个较稳定的平台期。③单因素分析表明:年龄、药物治疗、囊肿数目、合并胆瘘、合并其他脏器包虫及复发次数六个因素与复发性肝包虫的生长速度有关,均有统计学意义(依前述顺序其p值依次为:p=0.046, p=0.019,p=0.043,p=0.037,p=0.035,p=0.045,);而性别、囊肿位置、外囊壁是否钙化及合并肝脏基础疾病四个因素与复发性肝包虫的生长速度无关,均无统计学意义(依前述顺序其p值依次为:p=0.794,p=0.053,p=0.816,p=0.842)。多因素分析表明:药物治疗、合并胆瘘、合并其他脏器包虫及复发次数可独立影响复发性肝包虫的生长速度,其OR值依次为药物治疗0. 630、合并胆瘘0. 457、合并其他脏器包虫0. 516、复发次数0. 806。④103例复发性肝包虫患者中再次手术方式为传统术式(内囊摘除术)37(35.9%)例,术后出现残腔并发症9(24.3%)例,最终完成随访35(94.6%)例,6(17.1%)例复发;实施新手术方式(肝包虫外膜内外囊完整切除术)66(64.1%)例,术后未见残腔并发症发生,最终完成随访61(92.4%)例,1(1.6%)例复发。两种手术方式均无手术死亡发生。
结论:药物治疗、外囊切开、伴有其他脏器包虫三个因素与肝包虫的复发率相关,规范的药物治疗可降低肝包虫的术后复发率,外囊切开及伴有其他脏器包虫是造成术后复发率高的危险因素,其中外囊切开可独立影响肝包虫的复发率;复发性肝包虫早期生长速度较快,呈线性生长,持续46.5个月,平均0.2cm/月,其后生长缓慢;高龄、规范的药物治疗、肝包虫囊肿多发、合并胆瘘、合并其他脏器包虫及多次复发等六个因素可减慢复发性肝包虫的生长速度,其中规范的药物治疗、合并胆瘘、合并其他脏器包虫及多次复发可独立减慢复发性肝包虫的生长速度;在处理复发性肝包虫方时,外膜内外囊完整切除术并发症及复发率低于传统术式,应作首选。
Objective Through a retrospective study on recurrent hepatic hydatid disease, investigate the relevant factors that influence the recurrence rate of the hepatic hydatid disease; Through cross-section sampling study,investigate the recurrent cyst’s growth pattern and possible factors; Through re-operation and long-term follow-up study, evaluate two surgical procedures’efficacy on recurrent hepatic hydatid disease and provide reference for clinical prevention and control.
Methods The 277 cases(148men,129women), who underwent surgeries from December 1995 to December 2008 in our hospital, for hydatid cyst of the liver, were retrospectively reviewed, the age range was from 5 to 83 years (mean=31.2±12.1years).Among the total, 103 cases(57men,46women) were recurrent hepatic hydatid disease, the age range was from 17 to 79 years (mean=35.4±9.3years). The recurrence rates were assessed as well as the following seven potential factors: age, gender, type (whether the initial recurrence or multiple recurrence), drug treatment, whether the incision outside the capsule, previous postoperative complications eight factors of as risk factors through Logistic regression models to analyze its impact on the relapse rate. Through the application of cross-section sampling study, investigate the recurrent cyst’s growth pattern and drawthe growth curve. Analyze the following factors’impact on the recurrent cyst’s growth rate: age, gender, drug treatment, cyst with biliary fistula, cyst number, with other organ hydatid, liver foundamental disease and outside calcificated capsule.From time-consuming operation, bleeding volume, the average postoperative hospital stay, postoperative complications residual cavity Cert (bile leakage, infection, effusion), mortality and recurrence rate in situ.et al. evaluate two surgical procedures(traditional procedure and Subadventitial Total Exocystectomy) in the treatment of recurrent hepatic hydatid disease.
Results①Single-factor analysis showed that age, previous post-operative complications and liver foundamental disease had nothing to do with liver hydatid relapse rates, no statistic significance(p=0.878, p=0.053,p=0.794); And drug treatment, outside the capsule open, with other organs’echinococcosis et al. impact the relapse rate (p=0.047,p=0.039,p=0.000,p=0.032),Logistic Multivariate analysis show that outside the capsule open was the only risk factor(OR=6.979,95%CI 3.742～15.357).②Recurrent liver hydatid cysts was linear growth in the earlier 46.5months,0.2cm/month, then the growth rate gradually slowed down, its average diameter of the largest cross-section maintained a long-term stable plateau.③Single-factor analysis showed that:age, drug treatment、the number of cysts, with biliary fistula, with other organs’echinococcosis and recurrence frequency impact the recurrent liver hydatid cysts’growth rate(p=0.046,p=0.019,p=0.043,p=0.037,p=0.035,p=0.045,);but gender, cyst location, calcificated outer capsule and liver foundamental diseases had nothing to do with the recurrent liver hydatid cysts’growth rate, no statistical significanc(ep=0.794,p=0.053,p=0.816,p=0.842). Logistic Multivariate analysis show that drug treatment、with biliary fistula and combined echinococcosis can independently impact the recurrent liver hydatid growth rate(OR=0. 630、0. 457、0. 516、0. 806。).④Among 103 recurrent cases, 37(35.9%) cases re-undergo the traditional procedure (cystectomy), residual cavity complications cases 9(24.3%), finally completed follow-up cases35(94.6%),recurrence cases6(17.1%), 66(64.1%) cases re-undergo the new procedure (Subadventitial Total Exocystectomy , external capsule will be completely removed), no residual cavity complications, finally completed follow-up cases61(92.4%),recurrence cases1(1.6%),
Conclusion Drug treatment, outside the capsule open, with other organs’echinococcosis can. impact the relapse rate, outside the capsule open can independently mpact the relapse rate. Recurrent liver hydatid cysts show a linear growth in the earlier stage,and then the growth rate gradually slowed down, its average diameter of the largest cross-section maintained a long-term stable plateau. Age, drug treatment, the number of cysts, with biliary fistula, with other organs’echinococcosis and recurrence frequency impact the recurrent liver hydatid cysts’growth rate, among the total, drug treatment, with biliary fistula and combined echinococcosis can independently impact the recurrent liver hydatid growth rate. Compared with traditional surgical procedure, Subadventitial Total Exocystectomy has a lower complications and recurrence rate and should be preferred.
引文
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