老年患者腹腔镜胰十二指肠切除术后教科书结局及影响因素分析

doi:10.3877/cma.j.issn.1674-6899.2025.06.002

目的

探讨老年恶性肿瘤患者行腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy，LPD)后实现教科书式结局(textbook outcome，TO)的影响因素，以及TO与长期预后的关系。

方法

回顾性分析2017年3月至2025年3月在山东第一医科大学附属省立医院胰腺病诊疗中心接受LPD治疗的老年恶性肿瘤患者的临床病理资料。将单因素分析P<0.05的变量纳入多因素logistic回归分析患者术后未达到TO的独立危险因素。

结果

共纳入351例患者，其中215例达到TO，136例未达到TO。TO组患者长期预后显著优于non-TO组(P<0.05)。多因素logistic回归分析结果显示，术前体质量指数(body mass index，BMI，OR 1.095; 95%CI: 1.016~1.180; P＝0.018)、胰腺质地硬(OR 0.568; 95%CI: 0.367~0.934；P＝0.025)、主胰管直径(OR 0.748; 95%CI: 0.616~0.909；P＝0.003)和术后胃排空延迟(OR 5.036; 95%CI: 2.354~10.770；P<0.001)是影响患者术后未达到TO的独立风险因素。

结论

术前BMI高、胰腺质地软、主胰管直径细和术后有胃排空延迟是老年恶性肿瘤患者LPD术后未实现TO的独立危险因素。TO与患者长期生存相关。

关键词: 腹腔镜胰十二指肠切除术, 教科书式结局, 影响因素, 老年人

Objective

To explore the influencing factors for achieving textbook outcome (TO) after laparoscopic pancreaticoduodenectomy (LPD) in elderly patients with malignant tumors, and the relationship between TO and long-term prognosis.

Methods

A retrospective analysis was conducted on the clinicopathological data of elderly patients with malignant tumors who underwent LPD at our center between Mar. 2017 and Mar. 2025. Variables with a significance level of P<0.05 in the univariate analysis were included in a multivariate logistic regression analysis to identify independent risk factors for failure to achieve a TO postoperatively.

Results

This study included a total of 351 patients, among whom 215 achieved a TO, while 136 did not. The long-term prognosis of patients in the TO group was significantly better than that of the non-TO group(P<0.05). The multivariate logistic regression analysis revealed that preoperative BMI (OR 1.095; 95%CI: 1.016-1.180; P=0.018), firm pancreatic texture (OR 0.568; 95%CI: 0.367-0.934; P=0.025), main pancreatic duct diameter (OR 0.748; 95%CI: 0.616-0.909; P=0.003), and postoperative delayed gastric emptying (OR 5.036; 95%CI: 2.354-10.770; P<0.001) were independent risk factors for failure to achieve a TO.

Conclusions

High preoperative body mass index(BMI), soft pancreatic texture, narrow main pancreatic duct diameter, and postoperative delayed gastric emptying are independent risk factors for failure to achieve TO in elderly malignant tumor patients after LPD. TO is associated with long-term survival in these patients.

Key words: Laparoscopic pancreaticoduodenectomy, Textbook outcome, Influencing factors, Elderly patients

图1 行LPD老年患者纳入排除流程图

图2 "教科书式结局"各指标及累计达成情况

表1 TO组和non-TO组患者的基线特征对比

变量	TO组(n＝215)	non-TO组(n＝136)	P值
年龄[岁，M(IQR)]	70.0 (67.0~73.0)	70.0 (67.0~73.0)	0.227
性别，男[例(%)]	131 (60.9)	92 (67.6)	0.203
BMI [kg/m²，M(IQR)]	23.5 (20.7~25.9)	25.0 (22.7~26.1)	0.003
ASA分级[例(%)]
≤Ⅱ	120 (55.8)	89 (65.4)	0.073
≥Ⅲ	95 (44.2)	47 (34.6)
术前胆道引流[例(%)]	37 (17.2)	27 (19.9)	0.532
高血压[例(%)]	74 (34.4)	54 (39.7)	0.316
糖尿病[例(%)]	44 (20.5)	33 (24.3)	0.402
心血管疾病[例(%)]	25 (11.6)	17 (12.5)	0.806
Hb [g/L，M(IQR)]	123.0 (110.0~132.0)	120.0 (105.5~131.0)	0.278
WBC [10⁹/L，M(IQR)]	5.8 (4.9~7.2)	5.8 (4.6~7.8)	0.822
ALB [g/L，M(IQR)]	37.1 (34.4~40.1)	37.3 (34.5~40.0)	0.756
TBIL [μmol/L，M(IQR)]	99.1 (17.9~230.2)	77.1 (17.2~245.1)	0.526
CEA [ng/ml，M(IQR)]	2.8 (1.8~4.4)	2.9 (2.0~5.1)	0.187
CA125 [U/ml，M(IQR)]	13.8 (9.7~21.2)	14.1 (9.7~21.9)	0.735
CA19-9 [U/ml，M(IQR)]	98.0 (30.5~327.0)	73.7 (23.6~236.8)	0.198
肿瘤位置[例(%)]
胰腺	63 (29.3)	29 (21.3)	0.247
胆管	73 (34.0)	53 (39.0)
十二指肠或壶腹	79 (36.7)	54 (39.7)
TNM分期(AJCC 8th)[例(%)]
Ⅰ	70 (32.6)	49 (36.0)	0.799
Ⅱ	130 (60.4)	78 (57.4)
Ⅲ	15 (7.0)	9 (6.6)
肿瘤分化程度[例(%)]
高分化	27 (12.6)	18 (13.2)	0.816
中分化	129 (60.0)	77 (56.7)
低分化	59 (27.4)	41 (30.1)

表1 TO组和non-TO组患者的基线特征对比

变量	TO组(n＝215)	non-TO组(n＝136)	P值
年龄[岁，M(IQR)]	70.0 (67.0~73.0)	70.0 (67.0~73.0)	0.227
性别，男[例(%)]	131 (60.9)	92 (67.6)	0.203
BMI [kg/m²，M(IQR)]	23.5 (20.7~25.9)	25.0 (22.7~26.1)	0.003
ASA分级[例(%)]
≤Ⅱ	120 (55.8)	89 (65.4)	0.073
≥Ⅲ	95 (44.2)	47 (34.6)
术前胆道引流[例(%)]	37 (17.2)	27 (19.9)	0.532
高血压[例(%)]	74 (34.4)	54 (39.7)	0.316
糖尿病[例(%)]	44 (20.5)	33 (24.3)	0.402
心血管疾病[例(%)]	25 (11.6)	17 (12.5)	0.806
Hb [g/L，M(IQR)]	123.0 (110.0~132.0)	120.0 (105.5~131.0)	0.278
WBC [10⁹/L，M(IQR)]	5.8 (4.9~7.2)	5.8 (4.6~7.8)	0.822
ALB [g/L，M(IQR)]	37.1 (34.4~40.1)	37.3 (34.5~40.0)	0.756
TBIL [μmol/L，M(IQR)]	99.1 (17.9~230.2)	77.1 (17.2~245.1)	0.526
CEA [ng/ml，M(IQR)]	2.8 (1.8~4.4)	2.9 (2.0~5.1)	0.187
CA125 [U/ml，M(IQR)]	13.8 (9.7~21.2)	14.1 (9.7~21.9)	0.735
CA19-9 [U/ml，M(IQR)]	98.0 (30.5~327.0)	73.7 (23.6~236.8)	0.198
肿瘤位置[例(%)]
胰腺	63 (29.3)	29 (21.3)	0.247
胆管	73 (34.0)	53 (39.0)
十二指肠或壶腹	79 (36.7)	54 (39.7)
TNM分期(AJCC 8th)[例(%)]
Ⅰ	70 (32.6)	49 (36.0)	0.799
Ⅱ	130 (60.4)	78 (57.4)
Ⅲ	15 (7.0)	9 (6.6)
肿瘤分化程度[例(%)]
高分化	27 (12.6)	18 (13.2)	0.816
中分化	129 (60.0)	77 (56.7)
低分化	59 (27.4)	41 (30.1)

表2 TO组和non-TO组患者的手术结局对比

变量	TO组(n＝215)	non-TO组(n＝136)	P值
肿瘤最大直径[cm，M(IQR)]	2.5 (1.5~3.0)	2.5 (1.5~3.5)	0.656
手术时间[min，M(IQR)]	300.0 (240.0~367.0)	309.0 (250.0~373.0)	0.394
术中出血量[ml，M(IQR)]	100.0 (50.0~200.0)	70.0 (50.0~200.0)	0.743
淋巴结清扫数量[个，M(IQR)]	13.0 (10.0~16.0)	13.0 (10.0~16.0)	0.855
胰腺质地[例(%)]			0.004
软	86 (40.0)	76 (55.9)
硬	129 (60.0)	60 (44.1)
主胰管直径[mm，M(IQR)]	3.0 (2.0~4.0)	2.0 (1.0~3.8)	<0.001
术中输血[例(%)]	44 (20.5)	26 (19.1)	0.758
R0切除[例(%)]	193 (89.8)	123 (90.4)	0.837
术后胃排空延迟[例(%)]	11 (5.1)	29 (21.3)	<0.001
神经侵犯[例(%)]	83 (38.6)	51 (37.5)	0.836
血管侵犯[例(%)]	13 (6.0)	7 (5.1)	0.723
术后住院时间[d，M(IQR)]	15.0 (14.0~17.0)	16.0 (14.3~17.0)	0.076

表2 TO组和non-TO组患者的手术结局对比

变量	TO组(n＝215)	non-TO组(n＝136)	P值
肿瘤最大直径[cm，M(IQR)]	2.5 (1.5~3.0)	2.5 (1.5~3.5)	0.656
手术时间[min，M(IQR)]	300.0 (240.0~367.0)	309.0 (250.0~373.0)	0.394
术中出血量[ml，M(IQR)]	100.0 (50.0~200.0)	70.0 (50.0~200.0)	0.743
淋巴结清扫数量[个，M(IQR)]	13.0 (10.0~16.0)	13.0 (10.0~16.0)	0.855
胰腺质地[例(%)]			0.004
软	86 (40.0)	76 (55.9)
硬	129 (60.0)	60 (44.1)
主胰管直径[mm，M(IQR)]	3.0 (2.0~4.0)	2.0 (1.0~3.8)	<0.001
术中输血[例(%)]	44 (20.5)	26 (19.1)	0.758
R0切除[例(%)]	193 (89.8)	123 (90.4)	0.837
术后胃排空延迟[例(%)]	11 (5.1)	29 (21.3)	<0.001
神经侵犯[例(%)]	83 (38.6)	51 (37.5)	0.836
血管侵犯[例(%)]	13 (6.0)	7 (5.1)	0.723
术后住院时间[d，M(IQR)]	15.0 (14.0~17.0)	16.0 (14.3~17.0)	0.076

图3 TO组和non-TO组患者长期生存结局对比注：A.无病生存期对比；B.总生存期对比

表3 单因素和多因素logistic回归分析老年恶性肿瘤患者行LPD术后未达到教科书式结局的影响因素

变量	单因素分析			多因素分析
变量	B	OR (95% CI)	P值	B	OR (95% CI)	P值
年龄，岁	0.036	1.037 (0.996~1.090)	0.161
性别，男vs.女	－0.293	0.746 (0.475~1.172)	0.203
BMI(kg/m²)	0.114	1.120 (1.044~1.202)	0.002	0.091	1.095 (1.016~1.180)	0.018
ASA分级，Ⅲvs. ≤Ⅱ	－0.405	0.667 (0.428~1.040)	0.074
高血压，有vs.无	0.227	1.255 (0.805~1.956)	0.316
糖尿病，有vs.无	0.219	1.245 (0.745~2.080)	0.402
心血管疾病，有vs.无	0.082	1.086 (0.563~2.095)	0.806
Hb(g/L)	－0.006	0.994 (0.982~1.006)	0.326
ALB(g/L)	－0.008	0.992 (0.950~1.035)	0.701
TBIL(μmol/L)	－0.001	0.999 (0.998~1.001)	0.452
术前胆道引流，有vs.无	0.175	1.192 (0.687~2.066)	0.532
最大肿瘤直径(cm)	0.065	1.067 (0.912~1.249)	0.419
手术时间(min)	0.000	1.000 (0.998~1.002)	0.756
术中失血量(ml)	－0.001	0.999 (0.998~1.001)	0.433
术中输血，是vs.否	－0.085	0.919 (0.535~1.578)	0.758
胰腺质地，硬vs.软	－0.642	0.526 (0.341~0.813)	0.004	－0.535	0.586 (0.367~0.934)	0.025
主胰管直径(mm)	－0.371	0.690 (0.575~0.829)	<0.001	－0.291	0.748 (0.616~0.909)	0.003
DGE，是vs.否	1.615	5.026 (2.416~10.455)	<0.001	1.617	5.036 (2.354~10.770)	<0.001

表3 单因素和多因素logistic回归分析老年恶性肿瘤患者行LPD术后未达到教科书式结局的影响因素

变量	单因素分析			多因素分析
变量	B	OR (95% CI)	P值	B	OR (95% CI)	P值
年龄，岁	0.036	1.037 (0.996~1.090)	0.161
性别，男vs.女	－0.293	0.746 (0.475~1.172)	0.203
BMI(kg/m²)	0.114	1.120 (1.044~1.202)	0.002	0.091	1.095 (1.016~1.180)	0.018
ASA分级，Ⅲvs. ≤Ⅱ	－0.405	0.667 (0.428~1.040)	0.074
高血压，有vs.无	0.227	1.255 (0.805~1.956)	0.316
糖尿病，有vs.无	0.219	1.245 (0.745~2.080)	0.402
心血管疾病，有vs.无	0.082	1.086 (0.563~2.095)	0.806
Hb(g/L)	－0.006	0.994 (0.982~1.006)	0.326
ALB(g/L)	－0.008	0.992 (0.950~1.035)	0.701
TBIL(μmol/L)	－0.001	0.999 (0.998~1.001)	0.452
术前胆道引流，有vs.无	0.175	1.192 (0.687~2.066)	0.532
最大肿瘤直径(cm)	0.065	1.067 (0.912~1.249)	0.419
手术时间(min)	0.000	1.000 (0.998~1.002)	0.756
术中失血量(ml)	－0.001	0.999 (0.998~1.001)	0.433
术中输血，是vs.否	－0.085	0.919 (0.535~1.578)	0.758
胰腺质地，硬vs.软	－0.642	0.526 (0.341~0.813)	0.004	－0.535	0.586 (0.367~0.934)	0.025
主胰管直径(mm)	－0.371	0.690 (0.575~0.829)	<0.001	－0.291	0.748 (0.616~0.909)	0.003
DGE，是vs.否	1.615	5.026 (2.416~10.455)	<0.001	1.617	5.036 (2.354~10.770)	<0.001

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Analysis of textbook outcomes and influencing factors in elderly patients after laparoscopic pancreaticoduodenectomy

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Analysis of textbook outcomes and influencing factors in elderly patients after laparoscopic pancreaticoduodenectomy