胰瘘风险预测系统在胰十二指肠切除术术后胰瘘预测中的临床价值

The clinical value of pancreatic fistula risk predicting system after pancreaticoduodenectomy

目的 探讨日本国立癌症中心医院（NCCH）建立的胰十二指肠切除术（PD）术前胰瘘风险预测系统（简称NCCH预测系统）的临床应用价值.方法 回顾性分析安徽医科大学附属省立医院2008年2月至2014年2月收治的269例行胰十二指肠切除术的患者的临床资料.按照NCCH预测系统的5项指标（性别、胰腺癌、主胰管指数、腹腔脂肪厚度、门静脉侵犯）进行评分,其中＞4分者定义为术后胰瘘高危人群,≤4分者定义为术后胰瘘低危人群,并对影响术后胰瘘的非重复特征性因素进行临床分析.计数资料和计量资料的比较分别采用x2检验和t检验.通过单因素和多因素Logistic回归分析术后发生胰瘘的危险因素.应用ROC曲线分析NCCH预测系统预测患者术后胰瘘发生的灵敏度和特异度.结果 269例患者中,33例术后发生胰瘘,其中A级15例、B级11例、C级7例.PD术后胰瘘的单因素分析结果显示,PD术后胰瘘与性别、术前胆红素水平、是否胰腺癌、门静脉是否受侵犯、胰腺质地、主胰管直径和胰腺空肠吻合方式有关（P＜0.05）.多因素分析结果显示,性别、门静脉侵犯、胰腺质地、主胰管直径是影响PD术后胰瘘的独立危险因素（P＜0.05）.高危人群术后胰瘘发生率（53.8％,14/26）与低危人群术后胰瘘发生率（7.8％,19/243）相比,差异有统计学意义（x2 =46.231,P ＜0.01）.ROC曲线分析结果表明,NCCH预测系统预测PD术后胰瘘的灵敏度为87.9％,特异度为94.1％,曲线下面积为0.946（95％ CI：0.895 ～0.997）.结论 NCCH预测系统可以在术前预测胰瘘的发生,但仍需大样本、多中心、前瞻性随机对照研究进一步明确NCCH预测系统的临床价值.

Objective To evaluate the clinical value of a preoperative predictive scoring system which was established by the National Cancer Center Hospital（NCCH） for the postoperative pancreatic fistula （POPF） after pancreaticoduodenectomy.Methods The clinical data of 269 patients who underwent pancreaticoduodenectomy at the Affiliated Provincial Hospital of Anhui Medical University from February 2008 to February 2014 were studied retroprospectively.The five indexes which including gender,portal invasion,pancreatic cancer,main pancreatic duct index and intra abdominal fat thickness were calculated in the NCCH predictive score system.Patients with a score over 4 were defined as high risk of POPF,and those with score less than 4 were defined as low risk of POPF.Then the factors associated with POPF were analyzed by Logistic regression test.The enumeration data and measurement data were compared with x2 test and t test.Risk factors for postoperative pancreatic fistula were analyzed through single factor and multiple factors Logistic regression analysis.The sensitivity and specificity of the predictive scoring system were determined by receiver operating characteristic （ROC）curve analysis.Results A total of 33 patients were diagnosed as POPF,including 15 in grade A,11 in grade B and 7 in grade C.The univariate analysis showed that the factors associated with POPF are gender,total serum bilirubin level,pancreatic cancer,portal invasion,the pancreatic texture,main pancreatic duct diameter and the pancreaticojejunostomy.The multivariate analysis showed that gender,pancreatic texture,portal invasion and main pancreatic duct diameter were the independent risk factor of POPF.The rate of pancreatic fistula of high risk group was 53.8% （14/26）,and the rate of pancreatic fistula of the low risk group was 7.8% （19/243）.There were significant differences in the pancreatic fistula rate between the high risk and low risk of POPF（x2 =46.231,P 〈 0.01）.The results of ROC curve analysis showed that the sensitivity and specificity of the predictive scoring system were 87.9% and 94.1%,respectively.The area under the curve was 0.946 （95% CI：0.895-0.997）.Conclusions The NCCH preoperative predictive scoring system could accurately predict the occurrence of POPF.While large,multicenter prospective randomized controlled trials is still needed to further confirm it.