基于大数据分析的胰体尾部肿瘤手术方式与术后结局的临床研究

发布时间：2018-06-01 23:20

本文选题：胰体尾肿瘤 + 微创手术　；参考：《北京协和医学院》2017年博士论文

【摘要】：研究背景消化系统肿瘤WHO分类将胰腺肿瘤主要分为以下八类:浆液性囊性肿瘤、粘液性囊性肿瘤、导管内乳头状粘液性肿瘤、神经内分泌肿瘤、实性假乳头状瘤、导管腺癌、腺泡细胞癌和转移癌。根据其生物学行为不同通常又将前5类肿瘤列为良性及低度恶性肿瘤;后3种列为典型的恶性肿瘤。近年来,随着人们健康体检意识的增强以及影像学技术的进步与普及,胰腺肿瘤性疾病的检出率逐年升高,其中胰腺囊性肿瘤尤为明显。胰体尾部的肿瘤约占所有胰腺肿瘤的50%;对于该部分病例,大都需行胰腺体尾部切除术。研究目的1、建立北京协和医院胰体尾切除病例电子数据库,实现病例统一管理和随访。2、研究比较微创与开腹胰体尾切除的手术相关指标和术后短期并发症。3、研究胰体尾切除中脾脏保留与术后并发症的关系,以及脾脏保留的影响因素。4、研究胰体尾切除术后远期的并发症及其影响因素。5、研究胰体尾部导管腺癌手术方式及其与预后的相关性。研究方法通过建立北京协和医院胰体尾切除病例的电子数据库,基于大数据分析对上述五方面的问题分别进行探讨。采用倾向性评分匹配(PSM)和意向性(ITT)的统计学处理方法,尽可能降低选择偏倚和术中组间中转对研究结果的影响;采用单因素和多因素分析筛选影响胰体尾切除术后新发糖尿病的潜在危险因素;采用Logistics回归模型拟合胰体尾术后糖尿病综合风险评分公式;采用Cox回归模型分析胰体尾部导管腺癌病例生存期的影响因素。研究结果1、成功建立北京协和医院胰体尾切除病例电子数据库,为后续研究提供了统一平台;胰体尾切除病例中,良性及低度恶性肿瘤占65%,导管腺癌等恶性肿瘤占35%;最常见的5种病理类型为导管腺癌、神经内分泌肿瘤、粘液性囊腺瘤、浆液性囊腺瘤和实性假乳头状瘤。2、对于胰体尾切除术,微创手术较开腹具有手术出血少、术中输血比例低、术后恢复进食早和住院时间短的特点,可减少手术创伤、加速病人术后康复;BMI高和肿瘤直径偏大是微创手术中转开腹的独立危险因素。3、保留脾脏胰体尾切除术的手术时间、手术出血量和术中输血比例明显小于联合脾脏切除组;但二者在术后短期并发症方面无显著差异;肿瘤直径3cm可作为脾脏血管保留的独立预测因素。4、年龄、BMI、手术出血量、是否保留脾脏、肿瘤部位和切除胰腺总长度为胰体尾切除术后新发糖尿病的独立危险因素;首次在大型队列研究中证实胰体尾切除中保留脾脏有利于降低病人术后糖尿病的发生风险;首次建立糖尿病风险评分公式可较好地预测胰体尾切除后糖尿病的发生。5、根治性顺行模块胰体尾加脾切除术可提高胰体尾导管腺癌的手术切缘阴性率,增加淋巴结清扫数目,降低局部复发率,并且显著延长病人的无病生存期和总体生存期;与开腹胰体尾癌切除术相比,微创手术可加速患者术后康复,但并未降低其肿瘤切除的安全性。研究结论电子病例数据库的建立可为临床研究提供了统一规范的平台;微创技术可促进胰体尾切除病人的快速恢复,但并未降低胰体尾导管腺癌的肿瘤切除安全性;良性和低度恶性肿瘤中保留脾脏可减少手术创伤,并降低术后新发糖尿病风险;糖尿病风险评分公式可较好地预测胰体尾切除后糖尿病的发生;根治性顺行模块胰体尾加脾切除术安全可行,可降低胰体尾癌的局部复发率,并显著延长病人的总体生存期。
[Abstract]:Background WHO classification of tumors in the digestive system divides pancreatic tumors into eight main categories: serous cystic tumors, mucinous cystic tumors, intraductal papillary mucinous tumors, neuroendocrine tumors, real pseudopapillary tumors, ductal adenocarcinoma, acinar cell carcinoma and metastatic carcinoma. According to their biological behavior, the first 5 types of tumors are commonly used. In recent years, with the enhancement of health examination consciousness and the progress and popularization of imaging technology, the detection rate of pancreatic tumor disease is increasing year by year, especially the cystic tumor of pancreas is more obvious. The tumor of the tail of pancreas accounts for about 50% of all pancreatic tumors. In this part of the cases, most of the cases of pancreatectomy are required. Objective 1 to establish an electronic database of the cases of the tail resection of pancreas in Peking Union Medical College Hospital, to realize the unified management of cases and follow up.2, to compare the related indexes of minimally invasive and open pancreatectomy and to study the short-term postoperative onset of.3. The relationship between the complications and the factors affecting the retention of the spleen.4. The long-term complications and its influencing factors after the tail of the pancreatectomy were studied.5. The surgical methods and the correlation with the prognosis of the duct adenocarcinoma of the body and tail of the pancreas were studied. The five aspects of the above-mentioned problems were discussed respectively. The statistical methods of PSM and ITT were used to reduce the effect of selection bias and inter group transfer on the results of the study. Logistics regression model was used to fit the comprehensive risk score formula of diabetes after body and tail surgery, and Cox regression model was used to analyze the influencing factors of the survival period of pancreatic duct adenocarcinoma cases. Results 1, the electronic database of the case of pancreatic body tail resection in Peking Union Medical College Hospital was successfully established, which provided a unified platform for the follow-up study. Benign and low grade malignant tumors accounted for 65%, and malignant tumor of ductal adenocarcinoma accounted for 35%; the most common 5 pathological types were ductal adenocarcinoma, neuroendocrine tumor, mucinous cystadenoma, serous cystadenoma and real pseudopapillary tumor.2, for caudal pancreatectomy, minimally invasive surgery had less bleeding, lower intraoperative blood transfusion, and lower postoperative blood transfusion. The characteristics of early recovery and short hospitalization can reduce the surgical trauma and accelerate the recovery of the patients. The BMI height and the large diameter of the tumor are the independent risk factor.3 for the minimally invasive surgery, preserving the operation time of the splenectomy, and the amount of bleeding and intraoperative blood transfusion is significantly lower than that of the combined splenectomy group; but the two are in the operation. There was no significant difference in the post short-term complications. The tumor diameter 3cm could be used as an independent predictor of the retention of the spleen,.4, age, BMI, the amount of bleeding, the retention of the spleen, the site of the tumor and the total length of the pancreas as an independent risk factor for new onset diabetes after the tail resection of the pancreas; the first in a large cohort study to confirm the tail cut of the body. In addition, the retention of spleen is beneficial to reduce the risk of postoperative diabetes. The first establishment of the diabetes risk score formula can better predict the incidence of diabetes after the tail of the pancreatectomy.5. The radical resection of the pancreatic body tail plus splenectomy can improve the negative rate of the surgical margin, increase the number of lymph node dissection and decrease the number of lymph node dissection. The low local recurrence rate, and significantly prolongs the patient's disease-free life and the overall life period; compared with the operation of the open caudal carcinoma of the pancreas, minimally invasive surgery can accelerate the postoperative recovery of the patients, but does not reduce the safety of the tumor resection. The technique can promote the rapid recovery of the patients with pancreatic tail resection, but it does not reduce the safety of the tumor resection of the caudal duct adenocarcinoma of the pancreas. The retention of the spleen in benign and low malignant tumors can reduce the surgical trauma and reduce the risk of new onset diabetes after the operation; the diabetes risk score formula can be used to predict the occurrence of diabetes after the tail of pancreatic body and tail excision; Treatment of antegrade pancreatic body tail and splenectomy is safe and feasible, which can reduce the local recurrence rate of the carcinoma of the body and tail of the pancreas, and significantly prolong the overall survival of the patients.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R735.9

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