腹腔镜胰十二指肠切除术后胰漏的相关因素分析
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摘要
目的探讨腹腔镜胰十二指肠切除术后B、C级胰漏发生的预后因素。方法回顾性分析2016年12月～2018年6月83例腹腔镜胰十二指肠切除术的临床资料,对可能与B、C级胰漏有关的围手术期因素进行分析。单因素分析采用χ~2检验,有统计学意义的因素采用非条件logistic回归分析进行多因素分析。结果 83例中11例(13.3%)发生术后B、C级胰漏,其中B级9例(10.8%),C级2例(2.4%)。logistic回归多因素分析显示,术前总胆红素≥171μmol/L (OR=4.636,95%CI:1.080～19.894,P=0.039)、胰腺质地柔软(OR=0.202,95%CI:0.047～0.866,P=0.031)与B、C级胰漏的发生密切相关。BMI≥25(OR=22.347,95%CI:1.462～341.501,P=0.026)、术后未应用生长抑素(OR=0.071,95%CI:0.006～0.799,P=0.032)是胰腺质地柔软患者术后B、C级胰漏发生的相关因素。BMI≥25 (OR=13.474,95%CI:1.258～144.322,P=0.032)、术前采取减黄措施(OR=0.057,95%CI:0.005～0.638,P=0.020)是术前总胆红素≥171μmol/L患者术后B、C级胰漏发生的影响因素。结论胰腺质地柔软及术前总胆红素≥171μmol/L与腹腔镜胰十二指肠切除术后B、C级胰漏发生密切相关。BMI≥25时,此类患者B、C级胰漏发生风险明显增加。当术前总胆红素≥171μmol/L时,宜术前采取减黄措施。对于胰腺质软者,预防性应用生长抑素可在一定程度上降低腹腔镜胰十二指肠切除术后B、C级胰漏发生风险。
Objective To investigate the prognostic factors of grade B and C pancreatic leakage after laparoscopic pancreaticoduodenectomy.Methods Clinical data of 83 cases of laparoscopic pancreaticoduodenectomy performed from December2016 to June 2018 in our hospital were retrospectively analyzed.The risk factors associated with peri-operative grade B and C pancreatic leakage were analyzed.The univariate analysis were conducted by using the chi-square test.Logistic regression model was used for multivariate analysis.Results The grade B and C pancreatic leakage developed in 11(13.3%) patients after surgery,with grade B in 9(10.8%) patients and grade C in 2(2.4%) patients.The multivariate analysis by using logistic regression identified two variables as independent factors associated with grade B and C pancreatic leakage,namely,preoperative total bilirubin level ≥171 μmol/L(OR=4.636,95% CI:1.080-19.894,P=0.039) and soft pancreatic texture(OR=0.202,95% CI:0.047-0.866,P=0.031).The BMI ≥ 25(OR=22.347,95% CI:1.462-341.501,P=0.026) and the non-use of somatostatin after surgery(OR=0.071,95% CI:0.006-0.799,P=0.032) were the related factors for patients with soft pancreatic texture.The BMI ≥ 25(OR=13.474,95% CI:1.258-144.322,P=0.032) and preoperative biliary drainage(OR=0.057,95% CI:0.005-0.638,P=0.020) were predictors of grade B and C pancreatic leakage for patients with high preoperative total bilirubin level(≥171 μmol/L).Conclusions Soft pancreatic texture and preoperative high total bilirubin level(≥171 μmol/L)are closely related to the occurrence of grade B and C pancreatic leakage after laparoscopic pancreaticoduodenectomy.In case of IBM ≥ 25,the risk of grade B and C pancreatic leakage increases significantly.When the preoperative total bilirubin level is higher than 171 μmol/L,it is advisable to give preoperative biliary drainage.For patients with soft pancreas,prophylactic use of somatostatin can reduce the risk of grade B and C pancreatic leakage after laparoscopic pancreaticoduodenectomy.
Objective To investigate the prognostic factors of grade B and C pancreatic leakage after laparoscopic pancreaticoduodenectomy.Methods Clinical data of 83 cases of laparoscopic pancreaticoduodenectomy performed from December2016 to June 2018 in our hospital were retrospectively analyzed.The risk factors associated with peri-operative grade B and C pancreatic leakage were analyzed.The univariate analysis were conducted by using the chi-square test.Logistic regression model was used for multivariate analysis.Results The grade B and C pancreatic leakage developed in 11(13.3%) patients after surgery,with grade B in 9(10.8%) patients and grade C in 2(2.4%) patients.The multivariate analysis by using logistic regression identified two variables as independent factors associated with grade B and C pancreatic leakage,namely,preoperative total bilirubin level ≥171 μmol/L(OR=4.636,95% CI:1.080-19.894,P=0.039) and soft pancreatic texture(OR=0.202,95% CI:0.047-0.866,P=0.031).The BMI ≥ 25(OR=22.347,95% CI:1.462-341.501,P=0.026) and the non-use of somatostatin after surgery(OR=0.071,95% CI:0.006-0.799,P=0.032) were the related factors for patients with soft pancreatic texture.The BMI ≥ 25(OR=13.474,95% CI:1.258-144.322,P=0.032) and preoperative biliary drainage(OR=0.057,95% CI:0.005-0.638,P=0.020) were predictors of grade B and C pancreatic leakage for patients with high preoperative total bilirubin level(≥171 μmol/L).Conclusions Soft pancreatic texture and preoperative high total bilirubin level(≥171 μmol/L)are closely related to the occurrence of grade B and C pancreatic leakage after laparoscopic pancreaticoduodenectomy.In case of IBM ≥ 25,the risk of grade B and C pancreatic leakage increases significantly.When the preoperative total bilirubin level is higher than 171 μmol/L,it is advisable to give preoperative biliary drainage.For patients with soft pancreas,prophylactic use of somatostatin can reduce the risk of grade B and C pancreatic leakage after laparoscopic pancreaticoduodenectomy.
引文
1 Kantor O,Talamonti MS,Sharpe S,et al.Laparoscopic pancreaticoduodenectomy for adenocarcinoma provides short-term oncologic outcomes and long-term overall survival rates similar to those for open pancreaticoduodenectomy.Am J Surg,2017,213(3):512-515.
2 Adam MA,Choudhury K,Dinan MA,et al.Minimally invasive versus open pancreaticoduodenectomy for cancer:practice patterns and short-term outcomes among 7061 patients.Ann Surg,2015,262(2):372-377.
3 Pessaux P,Varma D,Arnaud J,et al.Pancreatoduodenectomy:superior mesenteric artery first approach.J Gastrointest Surg,2006,10(8):607-6112.
4洪德飞,刘建华,刘亚辉,等.一针法胰肠吻合用于腹腔镜胰十二指肠切除术多中心研究.中国实用外科杂志,2018,38(7):792-795.
5马晨阳,胡明华,王小明,等.腹腔镜胰十二指肠切除术中解剖技巧与手术体会(附30例报告).中国微创外科杂志,2016,16(8):720-723.
6 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.Surgery,2017,161(3):584-591.
7 Park SY,Park CH,Cho SB,et al.What is appropriate procedure for preoperative biliary drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy?Surg Laparosc Endosc Percutan Tech,2011,21(5):344-348.
8 De Carlis L,Ferla F,Di Sandro S,et al.Pancreatico-duodenectomy and postoperative pancreatic fistula:risk factors and technical considerations in a specialized HPB center.Updates Surg,2014,66(2):145-150.
9 Zhang T,Xu J,Wang T,et al.Enucleation of pancreatic lesions:indications,outcomes,and risk factors for clinical pancreatic fistula.JGastrointest Surg,2013,17(12):2099-2104.
10 Pratt WB,Callery MP,Vollmer CM.Risk prediction for development of pancreatic fistula using the ISGPF classification scheme.World JSurg,2008,32(3):419-428.
11 Pratt WB,Maithel SK,Vanounou T,et al.Clinical and economic validation of the International Study Group of Pancreatic Fistula(ISGPF)classification scheme.Ann Surg,2007,245(3):443-451.
12 Kim WS,Choi DW,Choi SH,et al.Clinical validation of the ISGPFclassification and the risk factors of pancreatic fistula formation following duct-to-mucosa pancreaticojejunostomy by one surgeon at a single center.J Gastrointest Surg,2011,15(12):2187-2192.
13 Deng Y,Zhao B,Yang M,et al.Association between the incidence of pancreatic fistula after pancreaticoduodenectomy and the degree of pancreatic fibrosis.J Gastrointest Surg,2018,22(3):438-443.
14胡丙洋,冷建军,万涛,等.511例胰十二指肠切除术患者胰瘘危险因素分析.中华肝胆外科杂志,2015,21(6):377-381.
15 Gouillat C,Chipponi J,Baulieux J,et al.Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy.Br J Surg,2001,88(11):1456-1462.
16伍炜,黄生福,王群伟,等.胰十二指肠切除术后胰瘘的多因素分析.中国普通外科杂志,2011,20(3):241-244.
17 El Nakeeb A,Salah T,Sultan A,et al.Pancreatic anastomotic leakage after pancreaticoduodenectomy.Risk factors,clinical predictors,and management(single center experience).World JSurg,2013,37(6):1405-1418.
18 Di Mola FF,Tavano F,Rago RR,et al.Influence of preoperative biliary drainage on surgical outcome after pancreaticoduodenectomy:single centre experience.Langenbecks Arch Surg,2014,399(5):649-657.
19 Gaujoux S,Cortes A,Couvelard A,et al.Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy.Surgery,2010,148(1):15-23.
2 Adam MA,Choudhury K,Dinan MA,et al.Minimally invasive versus open pancreaticoduodenectomy for cancer:practice patterns and short-term outcomes among 7061 patients.Ann Surg,2015,262(2):372-377.
3 Pessaux P,Varma D,Arnaud J,et al.Pancreatoduodenectomy:superior mesenteric artery first approach.J Gastrointest Surg,2006,10(8):607-6112.
4洪德飞,刘建华,刘亚辉,等.一针法胰肠吻合用于腹腔镜胰十二指肠切除术多中心研究.中国实用外科杂志,2018,38(7):792-795.
5马晨阳,胡明华,王小明,等.腹腔镜胰十二指肠切除术中解剖技巧与手术体会(附30例报告).中国微创外科杂志,2016,16(8):720-723.
6 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.Surgery,2017,161(3):584-591.
7 Park SY,Park CH,Cho SB,et al.What is appropriate procedure for preoperative biliary drainage in patients with obstructive jaundice awaiting pancreaticoduodenectomy?Surg Laparosc Endosc Percutan Tech,2011,21(5):344-348.
8 De Carlis L,Ferla F,Di Sandro S,et al.Pancreatico-duodenectomy and postoperative pancreatic fistula:risk factors and technical considerations in a specialized HPB center.Updates Surg,2014,66(2):145-150.
9 Zhang T,Xu J,Wang T,et al.Enucleation of pancreatic lesions:indications,outcomes,and risk factors for clinical pancreatic fistula.JGastrointest Surg,2013,17(12):2099-2104.
10 Pratt WB,Callery MP,Vollmer CM.Risk prediction for development of pancreatic fistula using the ISGPF classification scheme.World JSurg,2008,32(3):419-428.
11 Pratt WB,Maithel SK,Vanounou T,et al.Clinical and economic validation of the International Study Group of Pancreatic Fistula(ISGPF)classification scheme.Ann Surg,2007,245(3):443-451.
12 Kim WS,Choi DW,Choi SH,et al.Clinical validation of the ISGPFclassification and the risk factors of pancreatic fistula formation following duct-to-mucosa pancreaticojejunostomy by one surgeon at a single center.J Gastrointest Surg,2011,15(12):2187-2192.
13 Deng Y,Zhao B,Yang M,et al.Association between the incidence of pancreatic fistula after pancreaticoduodenectomy and the degree of pancreatic fibrosis.J Gastrointest Surg,2018,22(3):438-443.
14胡丙洋,冷建军,万涛,等.511例胰十二指肠切除术患者胰瘘危险因素分析.中华肝胆外科杂志,2015,21(6):377-381.
15 Gouillat C,Chipponi J,Baulieux J,et al.Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy.Br J Surg,2001,88(11):1456-1462.
16伍炜,黄生福,王群伟,等.胰十二指肠切除术后胰瘘的多因素分析.中国普通外科杂志,2011,20(3):241-244.
17 El Nakeeb A,Salah T,Sultan A,et al.Pancreatic anastomotic leakage after pancreaticoduodenectomy.Risk factors,clinical predictors,and management(single center experience).World JSurg,2013,37(6):1405-1418.
18 Di Mola FF,Tavano F,Rago RR,et al.Influence of preoperative biliary drainage on surgical outcome after pancreaticoduodenectomy:single centre experience.Langenbecks Arch Surg,2014,399(5):649-657.
19 Gaujoux S,Cortes A,Couvelard A,et al.Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy.Surgery,2010,148(1):15-23.