腹腔镜胰十二指肠切除术后临床胰瘘危险因素分析

doi:10.3877/cma.j.issn.1674-6899.2017.06.010

目的

探讨腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy, LPD)术后发生临床胰瘘的术前及术中的相关危险因素。

方法

搜集并回顾性分析四川大学华西医院和成都上锦南府医院自2010年10月至2017年1月157例行LPD的患者相关临床资料。按照是否发生临床胰瘘分为两组，对两组患者的术前及术中相关临床资料进行单因素分析，对于单因素分析有意义(P< 0.05)的指标进一步行多因素分析。

结果

胰瘘总发生率为40.76%，其中临床胰瘘(B、C级胰瘘)发生率为20.38%(32例)。单因素分析发现，饮酒史、十二指肠病变、未保留幽门、手术时间长、软胰可能是LPD术后胰瘘的危险因素，进一步行多因素分析显示软胰(OR＝4.146，P＝0.003)和手术时间长(OR＝1.008，P＝0.002)是LPD术后发生临床胰瘘的独立危险因素。临床胰瘘患者腹部出血和脓毒血症发生率更高及更高的再手术率和死亡率，同时住院时间更长。

结论

软胰和手术时间长是LPD术后发生临床胰瘘的独立危险因素，对于软胰及手术时间长的行LPD患者，术后应采取积极的措施预防LPD术后临床胰瘘的发生。

关键词: 腹腔镜胰十二指肠切除术, 临床胰瘘, 危险因素, 单因素分析, 多因素分析

Objective

This study was to investigate the preoperative and intraoperative risk factors of clinically relevant pancreatic fistula(CRPF)after laparoscopic pancreaticoduodenectomy(LPD).

Methods

After applying the exclusion criteria, a total of 157 consecutive patients who performed LPD were enrolled in the study. The clinical data were collected and analyzed from Oct. 2010 to Jan. 2017. In this study, ISGPF grade B, C is defined as CRPF, no PF or ISGPF grade A is defined as non-clinically relevant pancreatic fistula(NCRPF). All patients were divided into two groups according to whether the CRPF developed. The preoperative and intraoperative factors which may influence the development of CRPF were analyzed by univariate analysis. Those factors (P< 0.05) which have influence on the development of CRPF were analyzed by multivariate analysis again.

Results

Sixty-four cases (40.76%) developed PF. Thirty-two (20.38%) of 157 patients developed CRPF. The univariate analysis revealed that the history of drinking, duodenal lesions, resection of pylorus, long operation time, perioperative transfusion, soft pancreas, the maximum temperature of preoperative day may be the risk factors of CRPF. Multivariable analysis showed that soft pancreas and long operation time were independent risk factors of CRPF after LPD. Further analysis showed that the incidence of postoperative bleeding or chylous leakage was significantly decreased, the postoperative hospitalization time was significantly shortened in the group of lower risk of CRPF while the rate of reoperation or puncture was not increased.

Conclusions

Soft pancreas and long operation time are independent risk factors of CRPF after LPD. For those patients, more attention should be paid and increased positive measures should be taken to prevent the occurrence of CRPF after LPD.

Key words: Laparoscopy pancreaticoduodenectomy, Clinically relevant pancreatic fistula, Risk factor, Univariate analysis, Multivariate analysis

表1 157例腹腔镜胰十二指肠切除术患者的术后并发症及相关指标比较

结果		临床胰瘘组	非临床胰瘘组	P值
例数		32	125	?
术后住院时间(d, ±s)		25.2 ± 18.4	15.1 ± 8.6	0.005
胰腺术后出血[例(%)]		7(21.9)	8(6.4)	0.020
?	A级	1(3.1)	3(2.4)	1.000
?	B级	1(3.1)	1(0.8)	0.870
?	C级	5(15.6)	4(3.2)	0.023
胃排空延迟[例(%)]		11(34.4)	13(10.4)	0.002
胆瘘[例(%)]		6(18.8)	1(0.8)	< 0.001
乳糜漏[例(%)]		6(18.8)	7(4.6)	0.040
腹腔感染[例(%)]		4(12.5)	3(2.4)	0.047
肠瘘[例(%)]		2(6.2)	1(0.8)	0.199
切口感染[例(%)]		6(18.8)	5(4.0)	0.011
多器官功能衰竭[例(%)]		2(6.2)	2(1.6)	0.389
ICU监护[例(%)]		3(9.4)	6(4.8)	0.571
术后拔除胃管(d)		2.0(1.0～3.0)	2.0(1.0～3.8)	0.272
术后首次肛门排气(d)		4.5(3.0～5.0)	3.0(2.0～4.0)	< 0.001
术后首次进食(d)		6.0(5.0～8.8)	5.0(3.0～6.0)	0.004
术后拔除引流管(d)		18.0(12.3～24.8)	8.0(7.0～12.0)	< 0.001
术后30 d再手术[例(%)]		6(18.8)	7(5.6)	0.040
术后60 d死亡[例(%)]		2(6.2)	3(2.4)	0.587

表1 157例腹腔镜胰十二指肠切除术患者的术后并发症及相关指标比较

结果		临床胰瘘组	非临床胰瘘组	P值
例数		32	125	?
术后住院时间(d, ±s)		25.2 ± 18.4	15.1 ± 8.6	0.005
胰腺术后出血[例(%)]		7(21.9)	8(6.4)	0.020
?	A级	1(3.1)	3(2.4)	1.000
?	B级	1(3.1)	1(0.8)	0.870
?	C级	5(15.6)	4(3.2)	0.023
胃排空延迟[例(%)]		11(34.4)	13(10.4)	0.002
胆瘘[例(%)]		6(18.8)	1(0.8)	< 0.001
乳糜漏[例(%)]		6(18.8)	7(4.6)	0.040
腹腔感染[例(%)]		4(12.5)	3(2.4)	0.047
肠瘘[例(%)]		2(6.2)	1(0.8)	0.199
切口感染[例(%)]		6(18.8)	5(4.0)	0.011
多器官功能衰竭[例(%)]		2(6.2)	2(1.6)	0.389
ICU监护[例(%)]		3(9.4)	6(4.8)	0.571
术后拔除胃管(d)		2.0(1.0～3.0)	2.0(1.0～3.8)	0.272
术后首次肛门排气(d)		4.5(3.0～5.0)	3.0(2.0～4.0)	< 0.001
术后首次进食(d)		6.0(5.0～8.8)	5.0(3.0～6.0)	0.004
术后拔除引流管(d)		18.0(12.3～24.8)	8.0(7.0～12.0)	< 0.001
术后30 d再手术[例(%)]		6(18.8)	7(5.6)	0.040
术后60 d死亡[例(%)]		2(6.2)	3(2.4)	0.587

表2 157例腹腔镜胰十二指肠切除术患者的临床资料分析

变量		临床胰瘘组(32例)	非临床胰瘘组(125例)	P值
性别(例)		?	?	0.052?
?	男	23	66	?
?	女	9	59	?
年龄(岁，例)		?	?	0.673?
?	≥65	9?	40?	?
?	<65	23	85	?
体质量指数(kg/m²，±s)		22.69 ± 3.14	22.40 ± 2.41	0.579
术前胆道引流(例)		8	28	0.755
吸烟史(例)		13	35	0.167
饮酒史(例)		5	13	0.001
糖尿病史(例)		1	16	0.210
高血压史(例)		8	19	0.190
术前总胆红素(μmol/L)		33.25(11.05～70.93)	39.20(12.30～144.45)	0.559
术前直接胆红素(μmol/L)		21.00(4.75～68.03)	32.8(4.40～133.55)	0.701
术前总蛋白(g/L, ±s)		65.55 ± 7.43	64.64 ± 6.88	0.509
术前白蛋白(g/L, ±s)		37.85 ± 4.15	38.60 ± 5.36	0.467
ALT(U/L)		56.50(27.72～178.75)	43.00(17.50～96.50)	0.134
AST(U/L)		59.00(34.00～104.00)	46.00(22.00～95.00)	0.198
ALT/AST		1.04(0.66～1.31)	1.12(0.85～1.50)	0.225
碱性磷酸酶(U/L)		209.00(80.00～528.75)	225.00(85.00～440.50)	0.863
术前血红蛋白(g/L, ±s)		121.84 ± 26.14	120.94 ± 18.84	0.823
术前血小板计数(10⁹/L, ±s)		223.08 ± 102.75	223.44 ± 88.37	0.984
术前白细胞计数(10⁹/L, ±s)		5.83 ± 1.94	6.18 ± 2.32	0.424
中性分叶核粒细胞(%, ±s)		63.73 ± 11.47	64.21 ± 10.21	0.817
中性粒细胞绝对值(10⁹/L, ±s)		3.82 ± 1.79	4.09 ± 1.96	0.472
淋巴细胞(%, ±s)		24.28 ± 9.40	24.60 ± 8.72	0.853
淋巴细胞绝对值(10⁹/L, ±s)		1.35 ± 0.57	1.43 ± 0.54	0.467
术前PT(s, ±s)		11.93 ± 0.84	11.89 ± 1.12	0.862
术前APTT(s, ±s)		28.36 ± 3.08	27.52 ± 3.80	0.246
术前血清淀粉酶(U/L)		100(55～128)	69(50～110)	0.587
术前CRP(mg/L)		8.19(6.19～39.80)	5.56(2.82～11.55)	0.132
术前PCT(ng/ml)		0.15(0.07～0.40)	0.11(0.04～0.27)	0.397

表2 157例腹腔镜胰十二指肠切除术患者的临床资料分析

变量		临床胰瘘组(32例)	非临床胰瘘组(125例)	P值
性别(例)		?	?	0.052?
?	男	23	66	?
?	女	9	59	?
年龄(岁，例)		?	?	0.673?
?	≥65	9?	40?	?
?	<65	23	85	?
体质量指数(kg/m²，±s)		22.69 ± 3.14	22.40 ± 2.41	0.579
术前胆道引流(例)		8	28	0.755
吸烟史(例)		13	35	0.167
饮酒史(例)		5	13	0.001
糖尿病史(例)		1	16	0.210
高血压史(例)		8	19	0.190
术前总胆红素(μmol/L)		33.25(11.05～70.93)	39.20(12.30～144.45)	0.559
术前直接胆红素(μmol/L)		21.00(4.75～68.03)	32.8(4.40～133.55)	0.701
术前总蛋白(g/L, ±s)		65.55 ± 7.43	64.64 ± 6.88	0.509
术前白蛋白(g/L, ±s)		37.85 ± 4.15	38.60 ± 5.36	0.467
ALT(U/L)		56.50(27.72～178.75)	43.00(17.50～96.50)	0.134
AST(U/L)		59.00(34.00～104.00)	46.00(22.00～95.00)	0.198
ALT/AST		1.04(0.66～1.31)	1.12(0.85～1.50)	0.225
碱性磷酸酶(U/L)		209.00(80.00～528.75)	225.00(85.00～440.50)	0.863
术前血红蛋白(g/L, ±s)		121.84 ± 26.14	120.94 ± 18.84	0.823
术前血小板计数(10⁹/L, ±s)		223.08 ± 102.75	223.44 ± 88.37	0.984
术前白细胞计数(10⁹/L, ±s)		5.83 ± 1.94	6.18 ± 2.32	0.424
中性分叶核粒细胞(%, ±s)		63.73 ± 11.47	64.21 ± 10.21	0.817
中性粒细胞绝对值(10⁹/L, ±s)		3.82 ± 1.79	4.09 ± 1.96	0.472
淋巴细胞(%, ±s)		24.28 ± 9.40	24.60 ± 8.72	0.853
淋巴细胞绝对值(10⁹/L, ±s)		1.35 ± 0.57	1.43 ± 0.54	0.467
术前PT(s, ±s)		11.93 ± 0.84	11.89 ± 1.12	0.862
术前APTT(s, ±s)		28.36 ± 3.08	27.52 ± 3.80	0.246
术前血清淀粉酶(U/L)		100(55～128)	69(50～110)	0.587
术前CRP(mg/L)		8.19(6.19～39.80)	5.56(2.82～11.55)	0.132
术前PCT(ng/ml)		0.15(0.07～0.40)	0.11(0.04～0.27)	0.397

表3 157例腹腔镜胰十二指肠切除术患者的术中变量与胰瘘相关性分析

变量		临床胰瘘组(32例)	非临床胰瘘组(125例)	P值
胰管支撑管(例)		22	100	0.172
术中发现腹水(例)		7	31	0.730
侵犯血管(例)		6	12	0.147
LPRPD/LPPPD(例)		16/16	35/90	0.018
手术时间(min, ±s)		530.03 ± 103.28	475.47 ± 77.23	0.008
ASA分级≥3级(例)		16	59	0.748
术中出血量(ml, ±s)		232.50 ± 129.42	199.44 ± 168.43	0.303
术中输血(例)		8	23	0.403
软胰(例)		25	60	0.002
胰管直径≥3 mm(例)		14	70	0.215
病变部位(例)		?	?	?
?	十二指肠	18	46	0.046
?	胆总管	5	25	0.574
?	胰腺	9	54	0.121
病变大小(cm, ±s)		2.30± 0.92	2.53± 1.36	0.380

表3 157例腹腔镜胰十二指肠切除术患者的术中变量与胰瘘相关性分析

变量		临床胰瘘组(32例)	非临床胰瘘组(125例)	P值
胰管支撑管(例)		22	100	0.172
术中发现腹水(例)		7	31	0.730
侵犯血管(例)		6	12	0.147
LPRPD/LPPPD(例)		16/16	35/90	0.018
手术时间(min, ±s)		530.03 ± 103.28	475.47 ± 77.23	0.008
ASA分级≥3级(例)		16	59	0.748
术中出血量(ml, ±s)		232.50 ± 129.42	199.44 ± 168.43	0.303
术中输血(例)		8	23	0.403
软胰(例)		25	60	0.002
胰管直径≥3 mm(例)		14	70	0.215
病变部位(例)		?	?	?
?	十二指肠	18	46	0.046
?	胆总管	5	25	0.574
?	胰腺	9	54	0.121
病变大小(cm, ±s)		2.30± 0.92	2.53± 1.36	0.380

表4 157例腹腔镜胰十二指肠切除术患者的胰瘘的多因素分析

变量	回归系数(B)	标准误(SE)	统计量(Wald)	P值	OR值	95%CI
软胰	1.422	0.477	8.882	0.003	4.146	1.627～10.561
手术时间长	0.008	0.002	9.548	0.002	1.008	1.003～1.012
常量	－6.041	1.332	20.569	<0.000	0.002	－

表4 157例腹腔镜胰十二指肠切除术患者的胰瘘的多因素分析

变量	回归系数(B)	标准误(SE)	统计量(Wald)	P值	OR值	95%CI
软胰	1.422	0.477	8.882	0.003	4.146	1.627～10.561
手术时间长	0.008	0.002	9.548	0.002	1.008	1.003～1.012
常量	－6.041	1.332	20.569	<0.000	0.002	－

1	Pedrazzoli S, Beger HG, Obertop H, et al. A surgical and pathological based classification of resective treatment of pancreatic cancer. summary of an international workshop on surgical procedures in pancreatic cancer [J]. Dig Surg，1999, 16(4): 337-345.
2	Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single－institution experience [J]. J Gastro－intest Surg，2006, 10(9): 1199-1210.
3	Braga M, Capretti G, Prcorelli N, et al. A prognostic score to predict major complications after pancreaticoduodenectomy [J]. Ann Surg，2011, 254(5): 702-707.
4	Balcom JH, Rattner DW, Warshaw AL, et al. Ten－year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization [J]. Arch Surg，2001, 136(4): 391-398.
5	Fuks D, Piessen G, Huet E, et al. Life－threatening postoperative pancreatic fistula (grade c) after pancreaticoduodenectomy: incidence, prognosis, and risk factors [J]. Am J Surg，2009, 197(6): 702-709.
6	Tani M, Kawai M, Yamaue H. Intraabdominal hemorrhage after a pancreatectomy [J]. J Hepatobiliary Pancreat Surg，2008, 15(3): 257-261.
7	吴祥虎，朱峰，王敏，等．腹腔镜胰十二指肠切除术的安全性和有效性研究[J/CD]．中华腔镜外科杂志(电子版)，2015，8(1): 8-11.
8	Ugo Boggi, Gabriella Amorese, Fabio Vistoli, et al. Laparoscopic pancreaticoduodenectomy: a systematic literature review [J]. Surg Endosc，2015, 29(1): 9-23.
9	Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition [J]. Surgery，2005, 138(1): 8-13.
10	Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the international study group (isgps) definition and grading of postoperative pancreatic fistula: 11 years after [J]. Surgery，2017, 161(3): 584-591.
11	Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the international study group of pancreatic surgery (ISGPS) [J]. Surgery，2007, 142(5): 761-768.
12	Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an international study group of pancreatic surgery (ISGPS) definition [J]. Surgery，2007, 142(1): 20-25.
13	Duconseil P, Turrini O, Ewald J, et al. Biliary complications after pancreaticoduodenectomy: skinny bile ducts are surgeons′ enemies [J]. World J Surg，2014, 38(11): 2946-2951.
14	Kaas R, Rustman LD, Zoetmulder FA. Chylous ascites after oncological abdominal surgery: incidence and treatment [J]. Eur J Surg Oncol，2001, 27(2): 187-189.
15	张华，王明俊，王昕，等．腹腔镜胰十二指肠切除术45例体会[J]．中国普外基础与临床杂志，2014，21(8): 940-945.
16	Bassi C, Butturini G, Molinari E, et al. Pancreatic fistula rate after pancreatic resection. the importance of definitions [J]. Dig Surg.，2004, 21(1): 54-59.
17	Miller BC, Christein JD, Behrman SW, et al. Assessing the impact of a fistula after a pancreaticoduodenectomy using the postoperative morbidity index [J]. HPB (Oxford)，2013, 15(10): 781-788.
18	Vallance AE, Young AL, Macutkiewicz C, et al. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review [J]. HPB (Oxford)，2015, 17(11): 1040-1048.
19	Schmidt CM, Choi J, Powell ES, et al. Pancreatic fistula following pancreaticoduodenectomy：clinical predictors and patient outcomes[J]. Hpb Surgery, 2009, 2009(1): 404520-404520.
20	Aranha GV, Aaron JM, Shoup M, et al. Current management of pancreatic fistula after pancreaticoduodenectomy [J]. Surgery，2006, 140(4): 561-568.
21	Lin JW, Cameron JL, Yeo SJ, et al. Risk factors and outcomes in postpancreatico－duodenectomy pancreaticocutaneous fistula [J]. J Gastrointst Surg，2004, 8(8): 951-959.
22	Chebli JM, Gaburri PD, Souza AF, et al. Internal pancreatic fistulas: proposal of a management algorithm based on a case series analysis [J]. J Clin Gastroenterol，2004, 38(9): 795-800.
23	Wang M, Meng L, Cai Y, et al. Learning curve for laparoscopic pancreaticoduodenectomy: a cusum analysis [J]. J Gastrointest Surg，2016, 20(5): 924-935.
24	Oliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy [J]. Ann Surg，2006, 244(6): 931-937.
25	Wada K, Traverso LW. Pancreatic anastomotic leak after the whipple procedure is reduced using the surgical microscope [J]. Surgery，2006, 139(6): 735-742.
26	Tajima Y, Kuroki T, Tsutsumi R, et al. Risk factors for pancreatic anastomotic leakage: the significance of preoperative dynamic magnetic resonance imaging of the pancreas as a predictor of leakage [J]. J Am Coll Surg，2006, 202(5): 723-731.
27	Castro SM, Busch OR, Gulik TM, et al. Incidence and management of pancreatic leakage after pancreatoduodenectomy [J]. Br J Surg，2005, 92(9): 1117-1123.
28	Gouma DJ, Geenen RC, Gulik TM, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume [J]. Ann Surg，2000, 232(6): 786-795.

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Analysis of risk factors of clinically relevant pancreatic fistula after laparoscopic pancreaticoduodenectomy

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Analysis of risk factors of clinically relevant pancreatic fistula after laparoscopic pancreaticoduodenectomy