术前胆道引流持续时间与胰十二指肠切除术后并发症的相关性研究

Correlation of the duration of preoperative biliary drainage and postoperative complications after pancreaticoduodenectomy

目的探讨术前胆道引流持续时间对胰十二指肠切除术后手术相关并发症发生的影响。方法回顾性分析2016年1月至2020年7月于首都医科大学附属北京友谊医院行胰十二指肠切除术并术前接受胆道引流的102例肝胰管壶腹周围良性和恶性肿瘤患者临床资料。根据术前胆道引流中位持续时间,将患者分成短时引流组(≤胆道引流中位持续时间)和长时引流组(>胆道引流中位持续时间)。比较两组患者一般资料、胆道引流效果、炎症相关指标、术后并发症发生情况,采用多因素logistic回归分析筛选术后严重并发症发生的危险因素。结果102例患者中位年龄63岁(43~80岁),男性68例(66.7%),女性34例(33.3%)。术前胆道引流中位持续时间14 d。短时引流组68例,长时引流组34例。短时引流组和长时引流组在年龄、性别、体质量指数(BMI)、高血压、糖尿病、上腹部手术史、美国麻醉医师协会(ASA)分级、癌胚抗原、糖类抗原125、甲胎蛋白、凝血酶原时间、胰肠吻合方式、手术时间、肿瘤良恶性方面,差异均无统计学意义(均P>0.05);与短时引流组相比,长时引流组中转开腹率高、失血量多、住院时间长(均P<0.05)。胆道引流前,短时引流组丙氨酸氨基转移酶(ALT)水平高于长时引流组(Z=-2.59,P=0.009),两组间天冬氨酸氨基转移酶(AST)、清蛋白、总胆红素、直接胆红素水平差异均无统计学意义(均P>0.05);胆道引流后,短时引流组直接胆红素水平高于长时引流组(Z=-3.34,P=0.001),两组间ALT、AST、清蛋白、总胆红素水平差异均无统计学意义(均P>0.05)。术后第1、3天,两组间白细胞计数、中性粒细胞计数、淋巴细胞计数及中性粒细胞与淋巴细胞比值差异均无统计学意义(均P>0.05)。短时引流组和长时引流组手术相关并发症总发生率分别为63.2%(43/68)和70.6%(24/34),差异无统计学意义(χ^(2)=0.54,P=0.461),其中胆漏、腹腔或消化道出血、腹腔感染、胃排空延迟、所有级别胰漏及B级和C级胰漏发生率差异均无统计学意义(均P>0.05),但短时引流组手术相关严重并发症发生率高于长时引流组[27.9%(19/68)比8.8%(3/34),χ^(2)=4.90,P=0.027]。多因素logistic回归分析显示,术前胆道长时引流是术后严重并发症发生的独立保护因素(长时引流比短时引流:OR=0.253,95%CI 0.066~0.975,P=0.046),而BMI(OR=1.174,95%CI 0.986~1.398,P=0.071)和肿瘤性质(良性或交界性比恶性:OR=0.247,95%CI 0.043~1.419,P=0.117)均不是术后严重并发症发生的独立影响因素。结论对于术前接受胆道引流的肝胰管壶腹周围肿瘤患者,短时胆道引流(≤14 d)是术后严重并发症发生的危险因素。术前胆道引流时间与术后总并发症发生及胰漏、胆漏、腹腔或消化道出血、腹腔感染、胃排空延迟等的发生无关。

Objective To investigate the effect of the duration of preoperative biliary drainage on postoperative complications after pancreaticoduodenectomy.Methods The clinical data of 102 patients with benign and malignant hepatopancreatic ductal periampullary tumors who underwent pancreaticoduodenectomy and preoperative biliary drainage in Beijing Friendship Hospital,Capital Medical University from January 2016 to July 2020 were retrospectively analyzed.According to the median duration of preoperative biliary drainage,the patients were divided into short-term drainage group(≤the median duration of biliary drainage)and long-term drainage group(>the median duration of biliary drainage).The general data,the effect of biliary drainage,inflammation-related indicators and postoperative complications were compared between the two groups.Multivariate logistic regression was used to screen the risk factors related to the postoperative severe complications.Results Of the 102 patients,68(66.7%)were males and 34(33.3%)were females,with a median age of 63 years(43-80 years).The median duration of preoperative biliary drainage was 14 d.There were 68 patients in short-term drainage group and 34 patients in long-term drainage group.There were no statistically significant differences in age,gender,body mass index(BMI),hypertension,diabetes mellitus,surgery history of upper abdominal,American Society of Anesthesiologists(ASA)grade,carcinoembryonic antigen,carbohydrate antigen 125,alpha-fetoprotein,prothrombin time,pancreaticojejunostomy method,operation time,and pathological type between the two groups(all P>0.05).However,patients in long-term drainage group had higher conversion rate,more blood loss and longer hospital stay compared with those in short-term drainage group(all P<0.05).Before biliary drainage,alanine aminotransferase(ALT)level in short-term drainage group was higher than that in long-term drainage group(Z=-2.59,P=0.009),and there were no statistically significant differences in aspartate aminotransferase(AST),albumin(ALB),total bilirubin(TB)and direct bilirubin(DB)levels between the two groups before biliary drainage(all P>0.05).After biliary drainage,DB in short-term drainage group was higher than that in long-term drainage group(Z=-3.34,P=0.001),and there was no statistically significant difference in ALT,AST,ALB,TB levels between the two groups(all P>0.05).There were no statistically significant differences in the levels of white blood cells,neutrophils,lymphocytes and the ratio of neutrophils to lymphocytes between the two groups on the 1st and 3rd day after the operation(all P>0.05).The total incidence of postoperative related complications in short-term drainage group and long-term drainage group was 63.2%(43/68),70.6%(24/34),respectively,and the difference was statistically significant(χ^(2)=0.54,P=0.461);the incidences of bile leakage,abdominal or gastrointestinal bleeding,intra-abdominal infection,delayed gastric emptying,all grades of pancreatic leakage,grade B and C pancreatic leakage were not statistically different between the two groups(all P>0.05);the incidence of severe postoperative related complications in short-term drainage group was higher than that in long-term drainage group[27.9%(19/68)vs.8.8%(3/34),χ^(2)=4.90,P=0.027].Multivariate logistic regression analysis showed that the long-term preoperative biliary drainage was an independent protective factor for postoperative severe complications(long-term drainage vs.short-term drainage:OR=0.253,95%CI 0.066-0.975,P=0.046),while BMI(OR=1.174,95%CI 0.986-1.398,P=0.071)and pathological type(benign or borderline vs.malignant tumor:OR=0.247,95%CI 0.043-1.419,P=0.117)were not independent influencing factors for postoperative severe complications.Conclusions Short-term biliary drainage(≤14 d)is a risk factor for postoperative severe complications in patients with hepatopancreatic ductal periampullary tumor undergoing preoperative biliary drainage.Preoperative biliary drainage time is not associated with postoperative total complications,pancreatic leakage,bile leakage,abdominal or gastrointestinal bleeding,intra-abdominal infection,delayed gastric emptying.