胰肠吻合和胰胃吻合对胰十二指肠切除术后胰瘘的影响：使用ISGPS 2016标准的单中心研究

发布时间：2018-09-13 16:56

【摘要】：目的胰十二指肠切除术(PD)是壶腹周围癌唯一有效的治疗方法。目前胰十二指肠切除术的主要问题是术后胰瘘(POPF)等并发症发生率仍较高,严重影响了病人的术后康复。胰胃吻合(PG)相对于传统的胰肠吻合(PJ)能否降低术后胰瘘的发生率一直是研究争论的热点。过去的研究所使用的术后胰瘘诊断标准存在缺陷。2016年国际胰腺外科小组对术后胰瘘诊断标准进行了重大更新。本研究首次使用新标准,比较胰肠吻合和胰胃吻合对胰十二指肠切除术后胰瘘等并发症的影响。方法回顾了本中心2012年1月至2016年12月期间接受胰十二指肠切除术的210名病人的临床数据,其中胰肠吻合组136例,胰胃吻合组74例,主要观察结局是术后胰瘘,次要观察结局包括其他并发症和再手术、围手术期死亡等临床结果。另外,还验证了术后胰瘘风险评分工具(FRS)的预测效果;并通过回归分析探索术后胰瘘的相关风险因素。结果210例胰十二指肠切除术总体的术后胰瘘发生率为16.2%,其中胰肠吻合为16.9%,胰胃吻合为14.9%,两者没有显著性差异,p=0.701;其他并发症方面,虽然胰肠吻合和胰胃吻合的胃排空延迟总发生率没有显著性差异(18.4%vs 14.9%,p=0.518),但胰胃吻合的严重等级显著低于胰肠吻合,p=0.012;另外,胰胃吻合的术后胆漏发生率显著低于胰肠吻合(18.9%vs33.8%,p=0.022)。尽管如此,胰肠吻合和胰胃吻合在主要临床结果方面没有发现显著差异,如死亡率(0.7%vs 0),总并发症率(45.6%vs 40.5%,p=0.481),严重并发症率(11.0%vs 13.5%,p=0.595)。根据术后胰瘘风险评分量表所划分的风险等级与实际术后胰瘘发生率相匹配,无风险的术后胰瘘发生率为0,低风险为5%,中风险为12%,高风险为48%。在对15项可能的术后胰瘘风险因素的单因素分析中,胰管直径与术后胰瘘的发生有显著相关性(OR:4.31,p0.001),在对胰腺质地、胰管直径、病理类型、术中出血4个风险因素的多因素分析中,同样得出胰管直径3mm显著增加术后胰瘘风险(OR:4.93,p0.001)。结论胰肠吻合和胰胃吻合都是胰十二指肠术后可选择的安全可靠的胰腺-消化道重建方法。胰肠吻合与胰胃吻合的术后胰瘘发生率和严重程度没有显著性差异。尽管胰胃吻合的胃排空延迟严重程度更低,而且胆漏发生率更低,但两种吻合方式的总并发症率、严重并发症率、死亡率等主要临床结果没有显著差异。术后胰瘘风险评分量表是有效的术后胰瘘风险预测工具。胰管直径3mm是术后胰瘘唯一的独立风险因素。
[Abstract]:Objective: pancreaticoduodenectomy (PD) is the only effective treatment for periampullary carcinoma. At present, the main problem of pancreaticoduodenectomy is that the incidence of postoperative complications such as pancreatic fistula (POPF) is still high, which seriously affects the postoperative rehabilitation of patients. Compared with the traditional pancreaticojejunostomy (PG) can reduce the incidence of postoperative pancreatic fistula. The diagnostic criteria for postoperative pancreatic fistula used in the past have been flawed. The 2016 International Panel of Pancreatic surgery has significantly updated the diagnostic criteria for postoperative pancreatic fistula. To compare the effects of pancreaticojejunostomy and pancreaticogastric anastomosis on pancreatic fistula after pancreaticoduodenectomy. Methods the clinical data of 210 patients undergoing pancreaticoduodenectomy from January 2012 to December 2016 were reviewed, including 136 cases of pancreaticojejunostomy group and 74 cases of pancreaticogastric anastomosis group. The main outcome was postoperative pancreatic fistula. Secondary outcomes include other complications and re-operation, perioperative death and other clinical outcomes. In addition, the predictive effect of postoperative pancreatic fistula risk scoring tool (FRS) was verified, and the risk factors of postoperative pancreatic fistula were explored by regression analysis. Results the overall incidence of pancreatic fistula in 210 cases of pancreaticoduodenectomy was 16.2.The pancreaticojejunostomy was 16.9 and pancreaticogastric anastomosis was 14.9. there was no significant difference between the two groups. Although there was no significant difference in the total incidence of delayed gastric emptying between pancreaticojejunostomy and pancreaticogastric anastomosis (18.4%vs 14.9), the severity of pancreaticogastric anastomosis was significantly lower than that of pancreaticojejunostomy (0.012), and the incidence of biliary leakage after pancreaticogastric anastomosis was significantly lower than that of pancreaticojejunostomy (18.9vs33.8p0.022). Nevertheless, there were no significant differences in the main clinical outcomes between pancreaticojejunostomy and pancreaticogastric anastomosis, such as mortality rate (0.7%vs 0), total complication rate (45.6%vs 40.5%) and severe complication rate (11.0%vs 13.5p 0.59%). According to the risk rating scale of postoperative pancreatic fistula, the incidence rate of postoperative pancreatic fistula was 0, low risk was 5, middle risk was 12, and high risk was 48. In the univariate analysis of 15 possible risk factors for postoperative pancreatic fistula, the diameter of pancreatic duct was significantly correlated with the occurrence of postoperative pancreatic fistula (OR:4.31,p0.001). In the multivariate analysis of four risk factors, pancreatic texture, diameter of pancreatic duct, pathological type and intraoperative hemorrhage, there was a significant correlation between the diameter of pancreatic duct and the occurrence of postoperative pancreatic fistula. It was also found that pancreatic duct diameter 3mm significantly increased postoperative pancreatic fistula risk (OR:4.93,p0.001). Conclusion both pancreaticojejunostomy and pancreaticoduodenostomy are safe and reliable methods for pancreaticoduodenal reconstruction. There was no significant difference in the incidence and severity of pancreatic fistula between pancreaticojejunostomy and pancreaticogastric anastomosis. Although the severity of gastric emptying delay was lower and the incidence of bile leakage was lower in pancreaticogastric anastomosis, there was no significant difference in total complication rate, severe complication rate and mortality rate between the two anastomoses. Postoperative pancreatic fistula risk scale is an effective tool for predicting postoperative pancreatic fistula risk. Pancreatic duct diameter 3mm is the only independent risk factor for postoperative pancreatic fistula.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R656

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