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中华腔镜外科杂志(电子版)

中华腔镜外科杂志(电子版) ›› 2025, Vol. 18 ›› Issue (04) : 203 -210. doi: 10.3877/cma.j.issn.1674-6899.2025.04.003

论著

老年患者腹腔镜与开腹胰十二指肠切除术的疗效对比
赵春红1, 杨亚凯2, 徐帅2, 曹昱琨2, 刘军2,†()   
  1. 1250031　济南，中国人民解放军联勤保障部队第九六〇医院
    2250021　济南，山东第一医科大学附属省立医院胰腺病诊疗中心，器官移植肝胆外二科
  • 收稿日期:2025-05-20 出版日期:2025-08-30
  • 通信作者: 刘军

Comparison of the efficacy of laparoscopic and open pancreatoduodenectomy in elderly patients

Chunhong Zhao1, Yakai Yang2, Shuai Xu2, Yukun Cao2, Jun Liu2,†()   

  1. 1960th Hospital, Chinese PLA Joint Logistics Support Force, Jinan 250031, China
    2Department of Pancreatic Disease Diagnosis and Treatment Center, Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan 250021, China
  • Received:2025-05-20 Published:2025-08-30
  • Corresponding author: Jun Liu
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引用本文：

赵春红, 杨亚凯, 徐帅, 曹昱琨, 刘军. 老年患者腹腔镜与开腹胰十二指肠切除术的疗效对比[J/OL]. 中华腔镜外科杂志(电子版), 2025, 18(04): 203-210.

Chunhong Zhao, Yakai Yang, Shuai Xu, Yukun Cao, Jun Liu. Comparison of the efficacy of laparoscopic and open pancreatoduodenectomy in elderly patients[J/OL]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2025, 18(04): 203-210.

目的

旨在比较腹腔镜(laparoscopic pancreaticoduodenectomy，LPD)与开腹胰十二指肠切除术(open pancreatoduodenectomy，OPD)在老年患者中的临床疗效。

方法

回顾性分析2015年1月至2022年12月间接受LPD或OPD治疗的老年(>65岁)胰头及壶腹周围良、恶性肿瘤患者的临床及随访资料。采用1∶1倾向性评分匹配(propensity score-matching，PSM)方法平衡组间差异，通过单因素及多因素logistic回归分析筛选90 d死亡率的独立预后因子。

结果

410例老年患者中，LPD组236例，OPD组174例。匹配后LPD组术失血量更少(100 ml vs. 200 ml，P<0.001)、术中输血率更低(10.4% vs. 19.0%，P ＝ 0.029)、淋巴结清扫数目更多(11.0枚vs. 10.0枚，P＝0.014)、术后住院时间更短(13.0 d vs. 16.0 d，P＝0.013)。两组在严重并发症、再次手术、90 d再入院及死亡率方面无显著差异(P>0.05)。多因素分析显示，术后出血(post-pancreatectomy hemorrhage，PPH)是90 d死亡率的独立预后因子。匹配后胰腺导管腺癌(pancreatic ductal adenocarcinoma，PDAC)患者的总生存期(overall survival，OS)在LPD与OPD组间无差异(22.5个月vs. 20.4个月，P＝0.672)。

结论

LPD对老年患者安全可行，且具有术中失血少、术后恢复快的优势。

关键词: 腹腔镜胰十二指肠切除术, 开腹胰十二指肠切除术, 老年, 胰腺导管腺癌, 倾向性评分匹配
Objective

To compare the clinical outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreatoduodenectomy (OPD) in elderly patients.

Methods

Clinical and follow-up data of elderly patients (> 65 years) who underwent LPD or OPD between Jan. 2015 and Dec. 2022 were retrospectively analyzed. A 1∶1 propensity score-matching (PSM) analysis was performed to minimize differences between groups. Univariate and multivariate logistic regression analysis were used to select independent prognostic factors for 90-day mortality.

Results

Of the 410 elderly patients, 236 underwent LPD and 174 OPD. After PSM, the LPD group had a less estimated blood loss (EBL) (100 ml vs. 200 ml, P<0.001), lower rates of intraoperative transfusion (10.4% vs. 19.0%, P=0.029), more lymph node harvest (11.0 vs. 10.0, P=0.014) and shorter postoperative length of stay (LOS) (13.0 days vs. 16.0 days, P=0.013). There were no significant differences in serious complications, reoperation, 90-day readmission and mortality rates (all P>0.05). Multivariate logistic regression analysis showed that post-pancreatectomy hemorrhage (PPH) was an independent risk factor for 90-day mortality. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) who underwent LPD or OPD had similar overall survival (OS) (22.5 months vs. 20.4 months, P=0.672) after PSM.

Conclusions

It is safe and feasible for elderly patients to undergo LPD with less EBL and a shorter postoperative LOS.

Key words: Laparoscopic pancreatoduodenectomy, Open pancreatoduodenectomy, Elderly patients, Pancreatic ductal adenocarcinoma, Propensity score matching
表1 倾向性评分匹配前后的人口统计学和病理学特征
变量 PSM前(n＝410) P值 PSM后(n＝326) P值
LPD组(n＝236) OPD组(n＝174) LPD组(n＝163) OPD组(n＝163)
年龄(岁) 69.5(67.0~72.8) 69.0(67.0~73.0) 0.372 70.0(67.0~73.0) 69.0(67.0~73.0) 0.951
男性(例) 144.0(61.0) 113.0(64.9) 0.417 107.0(65.6) 105.0(64.4) 0.816
BMI(±s, kg/m2) 23.4±3.1 23.5±3.6 0.740 23.4±3.0 23.5±3.7 0.874
ASA分级[例(%)]            
≤Ⅱ 138.0(58.5) 116.0(66.7) 0.091 102.0(62.6) 107.0(65.6) 0.564
Ⅲ 98.0(41.5) 58.0(33.3)   61.0(37.4) 56.0(34.4)  
体能状态评分[例(%)]            
0 88(37.3) 75(43.1) 0.067 68(41.7) 72(44.2) 0.536
1 86(36.4) 70(40.2)   59(36.2) 63(38.7)  
2 62(26.3) 29(16.7)   36(22.1) 28(17.2)  
术前合并症[例(%)]            
无 107(45.3) 94(54.0) 0.082 81(49.7) 90(55.2) 0.318
有 129(54.7) 80(46.0)   82(50.3) 73(44.8)  
CA199(U/ml) 85.3(20.7~253.7) 114.3(38.0~408.8) 0.035 126.0(33.6~297.0) 101.5(34.9~351.5) 0.866
CEA(ng/ml) 2.7(1.8~4.3) 3.4(2.4~5.5) <0.001 3.0(2.2~4.8) 3.2(2.4~5.2) 0.285
CA125(U/ml) 13.8(9.2~20.2) 17.5(12.3~28.1) <0.001 15.0(10.2~24.1) 17.1(11.9~26.1) 0.081
病理学诊断[例(%)]            
胰腺导管腺癌 55(23.3) 70(40.2) <0.001 54(33.1) 62(38.0) 0.501
胆管癌 68(28.8) 56(32.2)   54(33.1) 53(32.5)  
壶腹及十二指肠癌 67(28.4) 40(23.0)   38(23.3) 40(24.5)  
神经内分泌瘤 1(0.4) 1(0.6)   0(0.0) 1(0.6)  
胰腺导管内乳头状黏液腺瘤 7(3.0) 2(1.1)   4(2.5) 2(1.2)  
胰腺实性假乳头状瘤 3(1.3) 1(0.6)   1(0.6) 1(0.6)  
囊性肿瘤 6(2.5) 1(0.6)   4(2.5) 1(0.6)  
其他 29(12.3) 3(1.7)   8(4.9) 3(1.8)  
表2 倾向性评分匹配前后两组患者的围手术期治疗结局
变量 PSM前(n＝410) P值 PSM后(n＝326) P值
LPD组(n＝236) OPD组(n＝174) LPD组(n＝163) OPD组(n＝163)
手术时间(min) 305.0(288.0~367.5) 295.0(280.0~400.0) 0.303 305.0(289.0~360.0) 295.0(280.0~390.0) 0.074
术中出血量(ml) 100.0(50.0~200.0) 200.0(100.0~300.0) <0.001 100.0(50.0~200.0) 200.0(100.0~300.0) <0.001
淋巴结清扫个数(枚) 11.0(8.0~17.0) 10.0(8.0~16.0) 0.123 11.0(8.0~17.0) 10.0(8.0~16.0) 0.014
术中输血[例(%)] 29(12.3) 33(19.0) 0.062 17(10.4) 31(19.0) 0.029
血管重建[例(%)] 10(4.2) 16(9.2) 0.042 9(5.5) 13(8.0) 0.377
中转开腹[例(%)] 12(5.1) － － 10(6.1) － －
R0切除[例(%)] 224(94.9) 166(95.4) 0.821 152(93.3) 155(95.1) 0.478
胰腺导管腺癌 50(90.9) 65(92.9)   49(90.7) 57(91.9)  
胆管癌 64(94.1) 54(96.4)   51(94.4) 52(98.1)  
壶腹及十二指肠癌 66(98.5) 39(97.5)   36(94.8) 38(95.0)  
其他 44(95.7) 8(100.0)   16(94.1) 8(100.0)  
胰瘘[例(%)]            
B级 18(7.6) 13(7.5) 0.802 14(8.6) 12(7.4) 0.889
C级 9(3.8) 9(5.2)   6(3.7) 7(4.3)  
胃排空延迟[例(%)]            
B级 19(8.1) 17(9.8) 0.831 14(8.6) 16(9.8) 0.792
C级 7(3.0) 5(2.9)   7(4.3) 5(3.1)  
胆瘘[例(%)] 22(9.3) 16(9.2) 0.965 18(11.0) 15(9.2) 0.582
术后出血[例(%)] 15(6.4) 14(8.0) 0.509 13(8.0) 11(6.7) 0.671
Clavien-Dindo分级≥Ⅲ[例(%)] 34(14.4) 30(17.2) 0.434 29(17.8) 27(16.6) 0.769
术后住院时间(d) 13.0(10.0-18.9) 16.0(12.0-20.5) 0.001 13.0(11.0-20.0) 16.0(12.0-20.6) 0.013
二次手术[例(%)] 10(4.2) 7(4.0) 0.914 9(5.5) 7(4.3) 0.608
90 d再入院率[例(%)] 7(3.0) 7(4.0) 0.560 6(3.7) 7(4.3) 0.777
90 d死亡率[例(%)] 9(3.8) 7(4.0) 0.914 6(3.7) 6(3.7) 1.000
表3 70岁以上患者亚组倾向性评分匹配前后的围手术期治疗结局对比
变量 PSM前(n＝170) P值 PSM后(n＝118) P值
LPD组(n＝97) OPD组(n＝73) LPD组(n＝59) OPD组(n＝59)
手术时间(min) 305.0(288.0~380.0) 295.0(279.0~405.0) 0.378 295.0(286.0~340.0) 295.0(278.0~400.0) 0.074
术中出血量(ml) 100.0(50.0~200.0) 200.0(100.0~300.0) <0.001 100.0(50.0~200.0) 200.0(100.0~300.0) <0.001
淋巴结清扫个数(枚) 11.0(8.0~16.0) 11.0(8.0~16.0) 0.423 11.0(8.0~17.0) 11.0(8.0~16.0) 0.412
术中输血[例(%)] 16(16.5) 13(17.8) 0.822 7(11.9) 10(16.9) 0.432
血管重建[例(%)] 4(4.1) 6(8.2) 0.261 2(3.4) 4(6.8) 0.675
R0切除[例(%)] 96(99.0) 71(97.3) 0.577 58(98.3) 57(96.6) 1.000
胰瘘[例(%)]            
B级 7(7.2) 4(5.5) 0.209 3(5.1) 4(6.8) 0.245
C级 3(3.1) 7(9.6)   1(1.7) 5(8.5)  
胃排空延迟[例(%)]            
B级 7(7.2) 7(9.6) 0.336 4(6.8) 7(11.9) 0.365
C级 3(3.1) 0(0.0)   2(3.4) 0(0.0)  
胆瘘[例(%)] 12(12.4) 8(11.0) 0.777 10(16.9) 6(10.2) 0.282
术后出血[例(%)] 6(6.2) 10(13.7) 0.097 3(5.1) 8(13.6) 0.113
Clavien-Dindo分级≥Ⅲ[例(%)] 14(14.4) 17(23.3) 0.139 8(13.6) 14(23.7) 0.156
术后住院时间(d) 14.5(12.0~21.0) 16.7(12.0~20.0) 0.006 14.0(11.0~19.0) 16.0(12.0~20.0) 0.021
二次手术[例(%)] 3(3.1) 3(4.1) 0.722 2(3.4) 2(3.4) 1.000
90 d再入院率[例(%)] 3(3.1) 5(6.8) 0.436 2(3.4) 3(5.1) 0.648
90 d死亡率[例(%)] 2(2.1) 5(6.8) 0.244 1(1.7) 3(5.1) 0.611
图1 接受LPD或OPD的PDAC患者PSM前后总生存期的Kaplan-Meier曲线注：A.PSM前PDAC患者的总生存期；B.PSM后PDAC患者的总生存期
表4 老年患者胰十二指肠切除术后90 d死亡率的单因素和多因素logistic回归分析
变量 单因素分析 多因素分析
B OR(95%CI) P值 B OR(95%CI) P值
年龄(每年) －0.014 0.986(0.871~1.116) 0.825      
性别(女vs.男) －0.601 0.548(0.174~1.731) 0.305      
BMI(kg/m2) 0.081 1.084(0.933~1.259) 0.293      
ASA分级(Ⅲ vs. ≤Ⅱ) －0.634 0.531(0.168~1.675) 0.280      
手术类型(OPD vs. LPD) 0.056 1.057(0.386~2.896) 0.914      
手术时间(min) 0.002 1.002(0.996~1.007) 0.568      
术中出血量(ml) 0.001 1.001(0.999~1.003) 0.216      
术中输血(是vs.否) 0.658 1.931(0.602~6.193) 0.268      
中转开腹(是vs.否) －18.030 0.000(0.000~NA) 0.999      
胰瘘            
B级vs.无或生化瘘 1.249 3.488(0.693~17.561) 0.130 0.146 1.157(0.149~8.985) 0.889
C级vs.无或生化瘘 3.471 32.182(9.622~107.633) <0.001 1.656 5.237(0.689~39.794) 0.110
胃排空延迟            
B级vs.无或A级 1.845 6.326(1.997~20.044) 0.002 1.087 2.966(0.622~14.130) 0.172
C级vs.无或A级 2.060 7.844(1.497~41.095) 0.015 0.458 1.581(0.166~15.045) 0.690
胆瘘(是vs.否) 0.862 2.367(0.643~8.707) 0.195      
术后出血(是vs.否) 3.180 24.043(8.121~71.177) <0.001 1.975 7.206(1.032~50.331) 0.046
二次手术(是vs.否) 2.672 14.470(4.344~48.195) <0.001 －0.464 0.629(0.095~4.179) 0.631
再入院(是vs.否) 1.515 4.548(0.928~22.281) 0.062      
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