胰十二指肠切除术后胰瘘发生的危险因素分析

Analysis of risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy

目的探讨胰十二指肠切除术后胰瘘发生的危险因素。方法采用回顾性病例对照研究方法。收集2014年9月至2016年7月大连医科大学附属第一医院收治的196例行胰十二指肠切除术患者的临床病理资料。患者均行胰十二指肠切除术。观察指标：（1）术中及术后情况。（2）随访情况。（3）影响胰十二指肠切除术后胰瘘发生的危险因素分析。采用电话和门诊方式进行随访，了解患者发生胰瘘和腹腔积液情况，随访时间截至2017年3月。正态分布的计量资料以露±s表示，组间比较采用t检验；偏态分布的计量资料采用肘（范围）表示。计数资料比较和单因素分析采用驴检验。多因素分析采用Logistic回归模型。结果（1）术中及术后情况：196例患者均成功完成手术，手术时间为（439±136）min，术中出血量为（686±280）mL，术中输血45例，未输血151例；术后首次排气、首次排便、首次进食时间分别为（4．1±2．1）d、（5．1±2．9）d、（3．1±2．0）d。76例患者术后第1天腹腔引流液淀粉酶含量为614U／L（31—30215U／L）、术后第3天血清降钙素原为（0．7±0．4）ng／mL。196例患者腹腔引流管拔出时间为（14．6±7．1）d。196例患者中，54例术后发生并发症，其中肠梗阻15例、胃排空延迟12例、腹腔感染11例、切口感染9例、出血7例，经对症治疗后均好转。196例患者术后住院时间为（17．1±4．2）d。196例患者术后病理学诊断：胰腺癌121例，胰腺导管内乳头状黏液性肿瘤50例，壶腹癌7例，胆管下端癌15例，十二指肠癌3例；胰腺质地：胰腺质地硬101例，胰腺质地软95例；胰管直径：≥3mm101例，〈3mm95例。（2）随访情况：196例患者均获得随访，随访时间为4～30个月，中位随访时间为18个月。随访期间37例患者发生B级或C级胰瘘，其中发生胰瘘相关腹腔积液16例，再入院10例，经对症支持治疗后均好转。（3）影响胰十二指肠切除术后胰瘘发生的危险因素分析：单因素分析结果显示：术后第1天腹腔引流液淀粉酶含量、术后第3天血清降钙素原、胰腺质地是影响胰十二指肠切除术后胰瘘发生的相关因素（χ2=6．569，5．902，13．517．P〈0．05）。多因素分析结果显示：术后第1天腹腔引流液淀粉酶含量≥600U／L是影响胰十二指肠切除术后胰瘘发生的独立危险因素（OR=9．135，95％可信区间：2．247～37．130，P〈0．05）。结论术后第1天腹腔引流液淀粉酶含量≥600U／L是影响胰十二指肠切除术后胰瘘发生的独立危险因素。

Objective To investigate the risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy （PD）. Methods The retrospective case-control study was adopted. The clinicopathological data of 196 patients with PD who were admitted to First Affiliated Hospital of Dalian Medical University from September 2014 to July 2016 were collected. All the patients underwent PD. Observation indicators ： （ 1 ） intra- and post- operative situations ; （2） follow-up ; （3） analysis of risk factors of pancreatic fistula after PD. All patients were followed up by outpatient examination and telephone interview to detect pancreatic fistula and peritoneal fluid collection up to March 2017. Measurement data with normal distribution were represented as x±s and comparison between groups was analyzed by t test. Measurement data with skewed distribution were represented as median （range）. Count data and univariate analysis were done using the chi-square test. Logistic regression model was used for multivariate analysis. Results （1） Intra- and post-operative situations： all the 196 patients underwent surgeries successfully. The operation time, volume of intraoperative blood loss, number of intraoperative blood transfusion and non intraoperative blood transfusion were （439± 136） minutes, （686±280） mL, 45 and 151 cases, respectively. Time to initial anal exsufflation, time of initial defecation and time for first diet after operation were （ 4.1± 2.1 ） days, （ 5.1 ± 2.9） days and （ 3.1±2.0） days. Of 76 patients, the content of diastase in the intraperitoneal drainage was 614 U/L （31-30 215 U/L） at postoperative day 1 and level of serum procalciton in was （0.7± 0.4） ng/mL at postoperative day 3. Time for drainage tube removal of 196 patients was （ 14.6±7.1 ）days. Fifty four of 196 patients with postoperative complications were improved by symptomatic treatment, including 15 with intestinal obstruction, 12 with delayed gastric emptying, 11 with abdominal infection, 9 with incision infection, 7 with bleeding. Duration of postoperative hospital stay was （17.1±4.2） days. Results of pathological diagnosis of 196 patients showed 121 cases of pancreatic cancer, 50 of intraductal papillary mucinous tumors of the pancreas, 7 ampullary carcinoma, 15 of carcinoma of the lower end of the bile duct, and 3 of duodenum cancer. Pancreatic findings： pancreatic texture： 95 cases were with soft pancreas and 101 with hard pancreas. Diameter of main pancreatic duct duct： 101 cases had diameter of pancreatic duct duct ≥3 mm and 95 cases 〈3 mm. （2）Followup： all the 196 patients were followed up for 4-30 months, with a median follow-up time of 18 months. During follow-up time, the grade B/or C pancreatic fistula occurred in 37 cases. Of 16 patients with pancreatic fistula- ralated ascites, 10 had readmission and were improved by symptomatic treatment. （3） Analysis of risk factors of pancreatic fistula after PD： the results of univariate analysis showed that the content of diastase in the intraperitoneal drainage at postoperative day 1, level of serum procalcitonin at postoperative day 3 and pancreatic texture were related factors affecting the pancreatic fistula after PD （χ2 = 6.569, 5.902, 13.517, P〈0.05）. The results of multivariate analysis showed that the content of diastase in the intraperitoneal drainage at postoperative day 1 ≥600 U/L was an independent risk factor affecting the pancreatic fistula after PD （ OR = 9. 135, 95% confidence interval： 2.247-37.130, P〈0.05）. Conclusion The content of diastase in the intraperitoneal drainage at postoperative day 1 ≥600 U/L is an independent risk factor affecting the pancreatic fistula after PD.