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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2021, Vol. 15 ›› Issue (05) : 321 -325. doi: 10.3877/cma.j.issn.1674-0793.2021.05.001

论著

输血和输血量对肝细胞癌根治切除术后复发的影响
戚超英1,†(), 宋泽兵2, 潘鹏飞1, 黄柳芳1, 龚凤球1   
  1. 1. 510080　广州，中山大学附属第一医院手术室
    2. 510080　广州，中山大学附属第一医院肝外科
  • 收稿日期:2021-07-28 出版日期:2021-09-28
  • 通信作者: 戚超英

Impact of blood transfusion and transfusion volume on postsurgical recurrence of hepatocellular carcinoma

Chaoying Qi1,†(), Zebing Song2, Pengfei Pan1, Liufang Huang1, Fengqiu Gong1   

  1. 1. Operating Room, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
    2. Department of Hepatic Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
  • Received:2021-07-28 Published:2021-09-28
  • Corresponding author: Chaoying Qi
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戚超英, 宋泽兵, 潘鹏飞, 黄柳芳, 龚凤球. 输血和输血量对肝细胞癌根治切除术后复发的影响[J/OL]. 中华普通外科学文献(电子版), 2021, 15(05): 321-325.

Chaoying Qi, Zebing Song, Pengfei Pan, Liufang Huang, Fengqiu Gong. Impact of blood transfusion and transfusion volume on postsurgical recurrence of hepatocellular carcinoma[J/OL]. Chinese Archives of General Surgery(Electronic Edition), 2021, 15(05): 321-325.

目的

探讨输血和输血量是否可促进肝细胞癌（HCC）术后复发。

方法

回顾性分析中山大学附属第一医院2010年1月至2015年12月行根治性肝切除术的HCC患者1 051例，根据术中输血的情况分为4组：无输血组（G1，691例）、输血量≤ 400 ml组（G2，92例）、输血量>400~1 000 ml组（G3，114例）和输血量>1 000 ml组（G4，154例）。比较各组术后无复发生存率（RFS）和总体生存率（OS），Cox风险回归模型分析研究HCC术后复发的危险因素。

结果

G1、G2、G3和G4组术后中位RFS分别为17.0、8.0、7.0、6.0个月，术后中位生存时间分别为96.0、31.0、28.0、25.0个月；G1组的术后生存显著优于其他三组（P<0.05）；而G2、G3、G4组间术后中位RFS、OS比较，差异无统计学意义。Cox多因素回归分析显示，术中输血是影响HCC术后复发的危险因素（HR=1.392，P<0.001），而输血量对术后复发无显著影响。

结论

输血是HCC术后复发的危险因素，而输血量对HCC术后复发无影响。术前精准评估、术中精细操作和严格把握输血指征可改善HCC的预后。

关键词: 癌,肝细胞, 肝切除术, 输血量, 复发
Objective

To evaluate whether blood transfusion and transfusion volume can promote recurrence of hepatocellular carcinoma (HCC) after surgery.

Methods

1 051 HCC patients undergoing curative liver resection from January 2010 to December 2015 in the First Affiliated Hospital of Sun Yat-sen University were retrospectively reviewed. The patients were allocated into group G1 (no blood transfusion, 691 cases), group G2 (blood transfusion ≤ 400 ml, 92 cases), group G3 (transfusion >400-1 000 ml, 114 cases) and group G4 (transfusion >1 000 ml, 154 cases) according to the volume of blood transfusion. Postoperative relapse-free survival (RFS) and overall survival (OS) among the groups were compared. Furthermore, Cox multivariate analysis was applied to identify the risk factors associated with postoperative recurrence.

Results

The median RFS of group G1, G2, G3 and G4 was 17.0, 8.0, 7.0 and 6.0 months, respectively. The median OS was 96.0, 31.0, 28.0 and 25.0 months, respectively. The median RFS and OS of group G1 were markedly longer than those of group G2, G3 and G4 (P<0.05). However, the median RFS and OS were comparable among group G2, G3 and G4. Cox multivariate analysis revealed that blood transfusion was a risk factor associated with postoperative recurrence of HCC (HR=1.392, P<0.001), but not the volume of blood transfusion.

Conclusions

Blood transfusion is the risk factor associated with HCC recurrence, but the volume of blood transfusion does not influence postsurgical recurrence of HCC. Precise preoperative evaluation, refined intraoperative manipulation and strict blood transfusion criteria may improve prognosis of HCC.

Key words: Carcinoma, hepatocellular, Hepatectomy, Volume of blood transfusion, Recurrence
表1 各组肝细胞癌患者的临床资料比较
项目 G1组 G2组 G3组 G4组 统计值 P值
例数 691 92 114 154    
年龄(岁) 50.2±11.9 50.0±12.1 52.9±12.3 50.9±12.4 1.751a 0.155
性别[例(%)]         8.110b 0.044
  男 631 (91.3) 73 (79.3) 101 (88.6) 134 (87.0)    
  女 60 (8.7) 19 (20.7) 13 (11.4) 20 (13.0)    
合并肝硬化[例(%)] 479 (69.3) 61 (66.3) 85 (74.6) 118 (76.6) 4.922b 0.178
HBsAg阳性[例(%)] 593 (85.8) 81 (88.0) 93 (81.6) 125 (81.2) 3.810b 0.283
术前血红蛋白(g/L) 142.2±18.5 134.6±19.1 129.7±22.0 126.8±24.1 34.262a <0.001
术前血小板(×109/L) 192.6±68.7 195.9±83.0 210.5±114.0 214.4±106.0 3.953a 0.008
Child-Pugh分级[例(%)]         63.505b <0.001
  A 668(96.7) 81 (88.0) 103 (90.4) 122 (79.2)    
  B 23 (3.3) 11 (12.0) 11 (9.6) 32 (20.8)    
肿瘤直径(cm) 7.6±3.4 8.7±3.8 9.4±4.1 10.8±6.3 29.899a <0.001
肿瘤数量[例(%)]         10.594b 0.014
  单个 506 (73.2) 67 (72.8) 71 (62.3) 97 (63.0)    
  多个 185 (26.8) 25 (27.2) 43 (37.7) 57 (37.0)    
术前甲胎蛋白[μg/L,例(%)]         2.763b 0.430
  <400 400 (57.9) 45 (48.9) 63 (55.3) 87 (56.5)    
  ≥400 291 (42.1) 47 (51.1) 51 (44.7) 67 (43.5)    
肿瘤分化[例(%)]         6.089b 0.413
  Ⅰ~Ⅱ 479 (69.3) 60 (65.2) 78 (68.4) 99 (64.3)    
  Ⅲ~Ⅳ 212 (30.7) 32 (34.8) 36 (31.6) 55 (35.7)    
肿瘤包膜[例(%)]         18.221b <0.001
  完整 564 (81.6) 67 (72.8) 83 (72.8) 104 (67.5)    
  不完整 127 (18.4) 25 (27.2) 31 (27.2) 50 (32.5)    
合并门静脉癌栓[例(%)] 112 (16.2) 24 (26.1) 31 (27.2) 47 (30.5) 22.290b <0.001
肝切除范围[例(%)]         13.764b 0.003
  大块 321 (46.5) 45 (48.9) 62 (54.4) 96 (62.3)    
  小块 370 (53.5) 47 (51.1) 52 (45.6) 58 (37.7)    
肝切除方式[例(%)]         8.110b 0.044
  解剖性 247 (35.7) 38 (41.3) 40 (35.1) 73 (47.4)    
  非解剖性 444 (64.3) 54 (58.7) 74 (64.9) 81 (52.6)    
术中出血量(ml) 300 (100~3 000) 600 (150~2 500) 800 (150~5 000) 1 800 (200~12 000) 332.967c <0.001
输血量(ml) 0 400 (150~400) 800 (483.5~950) 1 600 (1 000~7 850) 1 051.000c <0.001
图1 输血量对四组肝细胞癌患者术后复发的总生存率的影响　A为输血对术后无复发生存率（RFS）的影响；B为输血对术后总体生存率（OS）的影响；无输血组（G1），输血量≤ 400 ml组（G2），输血量>400~1 000 ml组（G3），输血量>1 000 ml组（G4）
表2 影响HCC术后复发的危险因素分析
变量 单因素分析 多因素分析
HR (95%可信区间) P值 HR (95%可信区间) P值
年龄(≤50岁 vs >50岁) 0.673 (0.575~0.788) <0.001 0.986 (0.979~0.993) <0.001
性别(男 vs女) 0.744 (0.567~0.975) 0.032 0.701 (0.530~0.928) 0.013
肝硬化(有 vs无) 1.309 (1.094~1.566) 0.003 1.278 (1.062~1.538) 0.009
HBsAg (阳性 vs阴性) 1.081 (0.868~1.343) 0.492    
Child-Pugh分级(B vs A) 1.435 (1.093~1.883) 0.009    
肿瘤直径( >5 cm vs ≤5 cm) 1.055 (1.043~1.067) <0.001 1.391 (1.116~1.735) 0.003
肿瘤数量(多个vs单个) 1.836 (1.559~2.163) <0.001 1.398 (1.174~1.663) <0.001
术前甲胎蛋白(≥400 μg/L vs <400 μg/L) 1.632 (1.395~1.910) <0.001 1.334 (1.131~1.574) 0.001
肿瘤分化(Ⅲ~ⅣvsⅠ~Ⅱ) 0.883 (0.750~1.041) 0.139    
肿瘤包膜(不完整vs完整) 0.655 (0.547~0.786) <0.001    
合并门静脉癌栓(是vs否) 2.155 (1.796~2.586) <0.001 1.514 (1.247~1.837) <0.001
肝切除范围(大块vs小块) 1.677 (1.432~1.965) <0.001 1.258 (1.059~1.493) 0.009
肝切除方式(解剖性vs非解剖性) 1.377 (1.140~1.568) <0.001    
出血量( >1 000 ml vs ≤1 000ml) 1.479 (1.207~1.811) <0.001    
是否输血 (是 vs否) 1.567 (1.334~1.840) <0.001 1.392 (1.180~1.642) <0.001
输血量(ml)        
  ≤400 vs>400~1 000 1.152 (0.918~1.447) 0.222    
  ≤400 vs >1 000 0.936 (0.751~1.167) 0.557    
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