胰十二指肠切除术中改良胰肠吻合法的应用及术后胰瘘预后因素分析

Applicational value of modified pancreaticojejunostomy and risk factors of pancreatic fistula following pancreaticoduodenectomy

目的比较胰十二指肠切除术中改良胰肠吻合法和常规胰肠吻合法的效果,并探讨胰十二指肠切除术后胰瘘发生的危险因素。方法回顾性分析2017年10月至2018年10月海军军医大学附属东方肝胆外科医院胆道二科收治的68例行胰十二指肠切除术患者的临床资料。根据术中胰肠吻合方式不同分为改良组(34例)和常规组(34例)。改良组男性18例,女性16例,年龄(60.4±9.6)岁;常规组男性16例,女性18例,年龄(58.9±10.9)岁。比较两组患者胰瘘等主要术后并发症的发生情况,并通过单因素和多因素分析探讨术后胰瘘发生的预后因素。结果68例患者均成功实施手术,术后总体并发症发生率为51.5%(35/68)。其中胰瘘9例(13.2%),均为B级胰瘘;腹腔感染16例(23.5%);胃排空延迟11例(16.2%),其中A级1例(1.5%),B级1例(1.5%),C级9例(13.2%);术后出血9例(13.2%),其中轻度出血2例(2.9%),中度出血5例(7.4%),重度出血2例(2.9%);胆瘘1例(1.5%),乳糜瘘2例(2.9%)。两组相比,改良胰肠吻合能够降低术后出血的发生率(χ^2=4.610,P=0.032),其他并发症发生率的差异均无统计学意义(P值均>0.05)。单因素分析结果显示,年龄、术中出血和胰管直径是影响胰十二指肠切除术后发生胰瘘的预后因素(P=0.025,0.019,0.017);多因素回归分析结果显示,术中出血>400ml和胰管直径<3mm是术后发生胰瘘的独立预后因素(P=0.025,0.008)。结论改良胰肠吻合法有可操作性,具有降低术后出血发生率的优势。

Objective To compare the efficacy of modified pancreaticojejunostomy with traditional pancreaticojejunostomy following pancreaticoduodenectomy, and to investigate the risk factors of postoperative pancreatic fistula. Methods Clinical data of 68 patients who underwent pancreaticoduodenectomy between October 2017 and October 2018 at the Second Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital was retrospectively collected and analyzed.According to the method of pancreaticojejunostomy, the patients were divided into two groups: modified pancreaticojejunostomy group (34 patients) and traditional pancreaticojejunostomy group (34 patients). There were 18 males and 16 females, aged (60.4±9.6) years of modified pancreaticojejunostomy groups;there were 17 males and 18 females, aged (58.9±10.9) years of traditional pancreaticojejunostomy group. The major postoperative complications such as pancreatic fistula were compared between the two groups, and the risk factors of postoperative pancreatic fistula were analyzed by univariate and multivariate analyses. Results All of the 68 operations were successfully completed. The overall incidence of postoperative complications was 51.5%(35/68). The incidence of postoperative pancreatic fistula was 13.2%(9/68), of which all were cases of grade B.There were 16 patients (23.5%) occurred with abdominal infection, and 11 patients (16.2%) occurred with delayed gastric emptying, including 1 case of grade A, 1 case of grade B and 9 cases of grade C.And 9 patients (13.2%) occurred with postoperative bleeding was, including 2 cases of mild bleeding, 5 cases of moderate bleeding, and 2 cases of severe bleeding.Biliary leakage occurred in one patient (1.5%) and chylous leakage occurred in two patients (2.9%). The modified pancreaticojejunostomy could significantly reduce the incidence of postoperative bleeding compared with control group (χ^2=4.610, P=0.032). And there were no significant differences for other postoperative complications between the two groups (all P>0.05). According to the results of univariate analysis: age, intraoperative bleeding and diameter of pancreatic tube were related factors affecting postoperative pancreatic fistula (P=0.025, 0.019, 0.017, respectively). The results of multivariate analysis showed that intraoperative bleeding>400 ml and diameter of pancreatic tube <3 mm were independent risk factors of pancreatic fistula following pancreaticoduodenectomy (P=0.025, 0.008, respectively). Conclusion The modified pancreaticojejunostomy is feasible with advantages of reducing postoperative bleeding following pancreaticoduodenectomy.