基于倾向性评分匹配分析腹腔镜胰十二指肠切除术安全性及其学习曲线:一项高流量中心回顾性队列研究

Perioperative safety and learning curve of laparoscopic pancreaticoduodenectomy by propensity score matching:a cohort study of single high-volume center

目的 探讨腹腔镜胰十二指肠切除术(LPD)安全性并分析其学习曲线。方法 回顾性分析2018年1月至2020年12月华中科技大学同济医学院附属协和医院胰腺外科收治的行胰十二指肠切除术(PD)的415例病人的临床病理资料,按1∶3进行倾向性评分匹配后筛选出79例LPD病人和154例开放PD(OPD)病人,比较不同手术方式病人术中和术后情况,并分析LPD学习曲线。结果 (1)与OPD组比较,LPD组病人手术时间延长,术中输血量减少,术中输血比例降低(P<0.05);两组R0切除率、清扫淋巴结数目、术后并发症和30 d死亡、术后住院时间、住院费用、二次手术方面差异无统计学意义(P>0.05)。LPD组生化漏发生率高于OPD组,而B、C级胰瘘发生率低于OPD组(P<0.05)。(2)与LPD组比较,中转开放组病人血管切除比例、术中失血量和输血比例明显增高,但在淋巴结清扫数及恶性肿瘤的切缘阳性率差异无统计学意义(P>0.05)。术后并发症方面,中转开放组败血症发生率明显增高(P<0.05),其他并发症以及二次手术率、术后30 d死亡等指标差异无统计学意义(P>0.05)。中转开放病例术后出血发生率为35.4%(17/48),LPD病例为21.6%(21/89),OPD病例为16.2%(45/278),3组差异有统计学意义(P=0.023);而LPD与中转开放病例单独进行比较则差异无统计学意义(P>0.05)。通过绘制学习曲线发现,在第39例完成LPD的学习。结论 在高流量中心可早期开展LPD,其总体费用、术后总体并发症发生率、病死率、住院时间等与OPD相当,且LPD的B、C级胰瘘发生率更低。

Objective To compare the safety of laparoscopic pancreaticoduodenectomy(LPD)with open pancreaticoduodenectomy(OPD)at a high-volume pancreatic disease center,and analyze the learning curve of LPD.Methods A retrospective analysis of the clinical pathological data of patients undergoing PD at Pancreatic Disease Institute,Wuhan Union Hospital,from January 2018 to December 2020 was conducted.79 LPD and 154 OPD patients were grouped in a ratio of 1∶3 in LPD and OPD groups using propensity scores matching analysis(PSM).The perioperative safety of two groups was compared and the learning curve of LPD was analyzed.The learning curve for LPD was evaluated.Results(1)The LPD group took longer operative time,showed lower intraoperative blood transfusion volume and blood transfusion rate than the OPD group(P<0.05).And the R0 resection rate of malignancies,harvested lymph nodes,postoperative complications,the 30-day mortality rate,postoperative hospital stay,cost,reoperation and readmission showed no difference(P>0.05).(2)When compared with LPD,the conversion group demonstrated higher vascular resection rate,higher intraoperative blood transfusion volume and blood transfusion rate.And R0 resection rate of malignancies,harvested lymph nodes showed no difference(P>0.05).In terms of postoperative complications,the conversion group showed significant higher sepsis(P<0.05),the other complications,reoperation and the 30-day mortality rate showed no difference(P>0.05).The postoperative hemorrhage of the conversion group,the LPD group,the OPD group was 35.4%(17/48),21.6(21/89),16.2%(45/278),respectively(P=0.023).However,the LDP and the conversion group showed no difference(P>0.05).By drawing a learning curve,we found that approximately 39 LPD cases were required to complete the learning process in our center.Conclusion LPD is technically safe and feasible,and its incidence rate of complications,mortality and cost caused by surgical complications are equivalent to those of OPD.The incidence of pancreatic fistula of grade B and C in LPD is even lower.