胰腺切除术、胰管引流术及二者联合治疗胰管结石的疗效和预后分析

Analysis of therapeutic effect and prognosis of pancreatectomy. pancreatic duct drainage and combined procedures for pancreatic ductal stones

目的 探讨胰腺切除术、胰管引流术及二者联合治疗慢性胰腺炎(CP)合并胰管结石的疗效及预后分析.方法 回顾性分析2008年1月至2017年6月间陆军军医大学附属第一医院行手术治疗的CP合并胰管结石296例患者的临床资料,按手术方式分为胰腺切除组(切除组,162例)、胰管引流组(引流组,104例)和胰腺切除+胰管引流联合手术组(联合组,30例),分析3组患者的临床特征以及外科治疗的近期和远期疗效.采用Kaplan-Meier法计算术后无疼痛复发的生存期,采用Log-rank检验及Cox比例风险模型分析影响患者术后无疼痛复发生存期的影响因素.结果 男性患者占比以切除组最高,胰腺外分泌功能不全发生率以引流组最高;296例患者中切除组和联合组均以Ⅰ型胰管结石为主(80.2%、70.0%),引流组则以Ⅲ型胰管结石较多(46.2%);切除组以中等结石为主(52.5%),引流组以中等及大结石为主(80.8%);胰腺明显萎缩者以引流组最多,胰头肿大、胆总管扩张或受压、合并胰腺及周围脏器其他并发症者均以切除组最多,差异均有统计学意义(P值均<0.05).近期疗效方面,术后总的疼痛缓解率为99.3%,3组间差异无统计学意义.引流组在手术时间、术中出血量、术后住院天数和术后并发症发生率方面较其他两组更具优势(P值均<0.05),但术后残留结石发生率(64.8%)较其余两组更高,差异均有统计学意义(P值均<0.05).远期疗效方面,3组间在疼痛复发、结石复发再手术、术后胰腺功能、体重和生活质量恢复等方面的差异均无统计学意义;胰管结石术后1、3、5年无疼痛复发生存率分别为89.0%、79.2%和68.9%.单因素及多因素分析结果均显示,CP病程≥5年(HR=2.113,95% CI1.160 ~3.848,P=0.014)、术后长期饮酒(HR=1.971,95% CI 1.073~3.620,P =0.029)是影响胰管结石术后无疼痛复发生存期的独立危险因素.结论 手术仍然是治疗胰管结石的重要手段,胰腺切除术、胰管引流术和二者联合治疗胰管结石的近、远期疗效确切,但均不能阻止部分患者术后胰腺功能继续丧失.依据术前临床特征制定个体化的手术策略,并重视术后健康指导和随访,有助于改善患者预后.

Objective To analyze the curative effect and prognosis of pancreatic ductal stone treated by pancreatectomy, pancreatic duct drainage or combined procedures. Methods The clinical data of 296 pancreatic ductal stone patients who received surgical treatment in First Affiliated Hospital of the Army Medical University between January 2008 and June 2017 were retrospectively analyzed. The cases were divided into pancreatectomy group (162 cases), pancreatic duct drainage group ( 104 cases) and combined procedures group ( 30 cases) according to their surgical procedures. The clinical characteristics and short-term and longterm outcomes of surgical treiitment between the three groups were analyzed. Kaplan-Meier method was used to estimate the survival rate of no recurrence of pain after operation. leg-rank test and Cox-proportional hazard model were used to analyze the influencing factors on the recurrent pain free survival after surgery. Results The ratio of male patients was highest in pancreatectomy group, and the incidence of pancreatic exocrine insufficiency was highest in pancreatic duct drainage group. Of 296 patients, I type pancreatic stone was most in pancreatectomy group and combined procedures group (80.2%, 7(). 0%), and HI type panc reatic stone was most in pancreatic duct drainage group (46. 2%). Medium size pancreatic stone was most in pancreatectomy group ( 52. 5%), and medium cind large size pancreatic stone was most in pancreatic duct drainage group (80. 8%). Obvious pancreatic atrophy was most in pancreatic duct drainage group. Pancreatic head swelling, bile ductal dilation or compression, combined with pancreatic or surrounding organ complications were most in pancreatectomy, and all the differences were statistically significant (all Pv0.05). In the short-term effect, the overall rate of pain relief was 99.3%, and there was no statistical difference among three groups. Pancreatic duct drainage group was superior to the other two groups in terms of operative time, bleeding volume, postoperative hospitalization days and postoperative complications ( all 0.05 ), but the total incidence of residual stones after operation in drainage group ( 64. 8%) was higher than that in the other two groups, and the difference was statistically significant ( all P < 0. 05 ). In the long-term effect, there were no significant differences in pain recurrence, stone recurrence reoperation, postoperative pan(?reatic function, body weight and quality of life recovery among the three groups. The 1 -year, 3-year and 5?year no recurrent pain after operation was 89. 0%, 79. 2% and 68. 9%, respectively. Univaricite and multivariate analysis showed that lhe course of CP M5 years(〃/?二 2. 113 , 95% 67 1. 160 - 3. 848 , P =().()14) and postoperative long - term alcohol consumption ( HR = 1.971 , 95% Cl 1.073 - 3. 620, P = 0. 029) were independent risk factors affecting pain recurrence after surgery. Conclusions Surgery is still an important means for the treatment of pancreatic ductal stone. The short-term and long-term effect of pancreatectomy, pancreatic duct drainage and combined procedures for pancreatic ductal stones are definitely effective. However, none of the three methods can prevent the continued loss of pancreatic function in some patients. According to the preoperative clinical features, surgery strategy should be formulated individually, and the postoperative health guidance and followup should be emphasized, which can help to improve the prognosis of the patients with pancreatic ductal stones.