胰十二指肠切除术后早期生化漏进展为B级胰瘘的预后因素分析

Risk factors for biochemical leak progressing to grade B pancreatic fistula after pancreaticoduodenectomy early

目的探讨胰十二指肠切除术(PD)后早期生化漏进展为B级胰瘘的预后因素。方法回顾性分析2014年11月至2017年4月于中国医科大学附属第一医院肝胆外科暨器官移植科接受PD术后的190例患者的病历资料。男性112例,女性78例,年龄(73±6)岁(范围:22~77岁)。对可能与生化漏进展为B级胰瘘有关的指标进行单因素及Logistic多因素分析,再选择能够绘制受试者工作特征(ROC)曲线,且经Logistic多因素分析后具有统计学意义的术前指标绘制ROC曲线,计算曲线下面积(AUC),评价该指标的预测价值,针对具有中等预测价值以上的指标设计不同切割点值,计算约登指数等指标,找出具有最大预测效能的临界值。结果190例PD患者术后共发生生化漏81例,其中未进展36例,生化漏进展为B级胰瘘41例,B级进展为C级4例。各临床指标的单因素分析结果显示,术前胰体部平扫CT值及急性胰腺炎、术后3~4 d血小板计数(PLT)、血清前白蛋白和ALT是生化漏进展为B级胰瘘的预后因素。多因素分析结果显示,术前胰体部平扫CT值、急性胰腺炎、术后3~4 d PLT为生化漏进展为B级胰瘘独立预后因素,且术后发生生化漏患者若术前存在急性胰腺炎易进展为B级胰瘘,以及术前胰体部平扫CT值、术后3~4 d PLT越低越易进展为B级胰瘘。术前胰体部平扫CT值的AUC为0.734,CT值界定在39.8 HU时,灵敏度为73.2%,特异度为75.0%,约登指数为0.482,预测效能最高。结论通过对术前胰体部平扫CT值进行分析可判断胰腺质地,术前急性胰腺炎的合理治疗及围手术期适当给予患者提高血小板相关药物可分别预测及预防术后早期生化漏进展为B级胰瘘。

Objective To analyze the risk factors for biochemical leak progressing to grade B pancreatic fistula after pancreaticoduodenectomy(PD)early.Methods Retrospective analysis was conducted in the whole clinical data of 190 patients who had incurred biochemical leak from November 2014 to April 2017 at the First Hospital of China Medical University.There were 112 males and 78 females,aging of(73±6)years(range:22 to 77 years).And all the potential factors for progressing from biochemical leak to grade B were analyzed with univariate and logistic regression multivariate model.These statistically significant preoperative indicators which enabled the plotting of the receiver operation characteristic(ROC)curves were selected for plotting the ROC curves,calculating the area under the curve(AUC)and evaluating the forecast values.With pertinence to indicators with the forecast values above the medium level,the maximum predictive performance of the critical value was determined by using the different cut-off values to calculate the Youden index and other indicators.Results Among the 190 cases of PD patients,there were 81 cases had incurred biochemical leak including 36 cases with no progression,41 cases progressing to grade B and 4 cases progressing from grade B to grade C.Univariate analysis showed CT value of pancreatic body,acute pancreatitis preoperatively,and the platelet(PLT),prealbumin,ALT on postoperative 3-4 days were risk factors for progressing from biochemical leak to grade B.Multivariate analysis showed CT value,acute pancreatitis preoperatively,and the PLT on postoperative 3-4 days were independent risk factors.Postoperatively patients with biochemical leak got acute pancreatitis before surgery were more likely to progress to grade B as well as those with the lower CT value before surgery or the lower PLT at 3-4 days after surgery.The AUC of CT value was 0.734.Using 39.8 HU as CT value,the sensitivity,specificity and Youden index were 73.2%,75.0%and 0.482,with the highest performance prediction.Conclusion The analysis of CT value of pancreatic body for standardized judgment of pancreas texture,the rational treatments of acute pancreatitis preoperatively and appropriate administration of patients with platelet-related drugs during perioperative period can respectively forecast and prevent progressing from biochemical leak to grade B.