基于ERAS理念的腹腔镜胰十二脂肠切除术在老年壶腹周围癌患者治疗中的应用

Application of laparoscopic pancreaticoduodenectomy based on enhanced recovery after surgery concept in elderly patients with periampullary carcinoma

目的探讨加速康复外科(ERAS)围手术期管理下的腹腔镜胰十二指肠切除术(LPD)在老年壶腹周围癌患者治疗中应用的可行性。方法回顾性研究。纳入2015年1月—2019年12月蚌埠医学院第一附属医院肝胆外科壶腹周围癌患者127例,其中男71例、女56例,年龄17~81(62.2±11.5)岁。将患者按年龄分为老年组(>65岁,61例)和非老年组(≤65岁,66例)。2组患者均接受LPD治疗,并按照标准的ERAS围手术期管理方案进行个体化管理,术后随访1年以上。对比分析2组患者以下观察指标:(1)患者性别、体质量指数、美国麻醉协会(ASA)评分及合并基础疾病等基线资料;(2)肿瘤的部位、大小(长径)、数目、切缘阳性率,以及有无淋巴、血管和神经浸润等肿瘤病理学特征;(3)手术时间、住院时间、术中出血量等围术期指标,包括术后腹腔出血、胃延迟排空、腹腔感染、胆瘘和胰瘘等在内的术后主要并发症(Clavien-Dindo分级≥Ⅲ级)发生率,围手术期死亡率、患者生存率和生存时间等临床病理特征;(4)采用logistic多因素回归分析患者围手术期死亡的危险因素。结果2组患者均顺利完成LDP手术,围手术期均无心血管事件发生。患者术后出血、胃延迟排空、腹腔感染、术后胰瘘、术后胆瘘等主要并发症发生率组间比较,差异均无统计学意义(P值均>0.05)。非老年组患者肿瘤长径为2(2.0,3.6)cm,大于老年组的2(1.5,3.0)cm,差异有统计学意义(Z=-2.40,P=0.017);2组患者其余的肿瘤病理组织学特征、基线资料,以及包括术后主要并发症的各临床病理特征比较,差异均无统计学意义(P值均>0.05)。logistic多因素回归分析显示,术后腹腔出血是影响患者围手术期死亡的危险因素(比值比11.158,95%可信区间1.664~74.836,P=0.013),而包括年龄、性别、ASA评分和其他主要并发症等则不是患者围手术期死亡的危险因素(P值均>0.05)。结论ERAS理念下的老年壶腹周围癌患者腹腔镜胰十二指肠切除术安全可行,年龄不应成为腹腔镜胰十二指肠切除术的禁忌。

Objective This study aims to explore the feasibility of laparoscopic pancreaticoduodenectomy(LPD)under perioperative management of enhanced recovery after surgery(ERAS)in elderly patients with periampullary carcinoma.Methods A retrospective study design was adopted.A total of 127 patients with periampullary carcinoma in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Bengbu Medical College from January 2015 to December 2019 were enrolled,including 71 males and 56 females aged 17-81(62.2±11.5)years.The patients were divided into elderly group(>65 years old,61 patients)and non-elderly group(≤65 years old,66 patients).The patients in both groups received LPD treatment and were individually managed according to the standard ERAS perioperative management plan.The patients were followed up for more than 1 year.The following observation indicators of the two groups of patients were compared and analyzed:(1)baseline data such as gender,body mass index,American Society of Anesthesiology(ASA)score,and underlying diseases;(2)tumor location,size(long diameter),number,positive rate of resection margin,and tumor pathological characteristics such as lymphatic,vascular and nerve invasion;and(3)operation time,hospitalization time,intraoperative blood loss,including postoperative abdominal hemorrhage,delayed gastric emptying,intra-abdominal infection,and bile leakage.The incidence of major postoperative complications(Clavien-Dindo grade≥gradeⅢ)including pancreatic leakage,perioperative mortality,patient survival rate and survival time,and other clinicopathological characteristics were evaluated.(4)Logistic multivariate regression analysis was used to determine risk factors for perioperative mortality in patients.Results The LDP operation was successfully performed on all patients in 2 groups,and no cardiovascular events occurred during the perioperative period.There was no significant difference in postoperative bleeding,delayed gastric emptying,abdominal infection,postoperative pancreatic leakage,postoperative biliary leakage and major complications between the groups(all P values>0.05).The tumor diameter in the non-elderly group was 2(2.0,3.6)cm,which was greater than that in the elderly group[2(1.5,3.0)cm],and the difference was statistically significant(Z=-2.40,P=0.017).Results showed no significant difference in tumor histopathological characteristics,baseline data,and clinicopathological characteristics including major postoperative complications(all P values>0.05).Logistic multivariate regression analysis showed that postoperative abdominal hemorrhage was a risk factor for perioperative death[odds ratios=11.158(95%credibility interval 1.664~74.836),P<0.05],while age,gender,ASA score,and other major complications were not the risk factors for perioperative mortality death(all P values>0.05).Conclusion Laparoscopic pancreaticoduodenectomy is safe and feasible for elderly patients with periampullary carcinoma under the ERAS concept.Age should not be a contraindication to laparoscopic pancreaticoduodenectomy.