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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2015, Vol. 09 ›› Issue (01) : 44 -50. doi: 10.3877/cma.j.issn.1674-0793.2015.01.012

所属专题： 文献；

论著

扩大胰十二指肠切除术后并发症及其危险因素分析
蔡建鹏1, 陈伟1, 黄力1, 殷晓煜1, 梁力建1, 张昆松1,†()   
  1. 1. 510080　广州，中山大学附属第一医院胆胰外科
  • 收稿日期:2014-11-18 出版日期:2015-02-01
  • 通信作者: 张昆松
  • 基金资助:
    广东省自然科学基金资助项目（2013-2015）(S2012040006299)

Analysis of postoperative complications and risk factors following extended pancreaticoduodenectomy

Jianpeng Cai1, Wei Chen1, Li Huang1, Xiaoyu Yin1, Lijian Liang1, Kunsong Zhang1,†()   

  1. 1. Department of Biliary and Pancreatic Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
  • Received:2014-11-18 Published:2015-02-01
  • Corresponding author: Kunsong Zhang
  • About author:
    Corresponding author: Zhang Kunsong, Email:
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蔡建鹏, 陈伟, 黄力, 殷晓煜, 梁力建, 张昆松. 扩大胰十二指肠切除术后并发症及其危险因素分析[J]. 中华普通外科学文献(电子版), 2015, 09(01): 44-50.

Jianpeng Cai, Wei Chen, Li Huang, Xiaoyu Yin, Lijian Liang, Kunsong Zhang. Analysis of postoperative complications and risk factors following extended pancreaticoduodenectomy[J]. Chinese Archives of General Surgery(Electronic Edition), 2015, 09(01): 44-50.

目的

探讨扩大胰十二指肠切除术(PD)对术后并发症的影响。

方法

回顾性分析2004年11月至2014年11月接受PD术的患者临床资料,根据手术方式不同将患者分成常规组和扩大组,对比两组间术后并发症发生情况,并分析并发症发生相关的危险因素。

结果

358例手术患者分为常规组(321例)和扩大组(37例);术后总并发症发生率41.1%(147/358),术后死亡率5.0%(15/358)。扩大组较常规组的腹腔内并发症率(P = 0.02)和胃排空功能障碍发生率(P = 0.01)差异具有统计学意义。多变量Logistic回归分析显示腹腔内并发症的独立危险因素包括年龄≥65岁(P < 0.01)、手术时间≥360 min(P = 0.03)、胰管直径< 3 mm(P < 0.01)、胰腺质软(P < 0.01)、扩大PD术(P = 0.02)和套入式吻合(P = 0.01);胃排空障碍的独立危险因素包括扩大切除(P = 0.03)、手术时间≥360 min(P < 0.01)、胰腺质软(P = 0.02)和胰管直径< 3 mm(P < 0.01)。

结论

扩大PD术是术后腹腔内并发症的独立危险因素,但并未增加术后的死亡率。

关键词: 扩大胰十二指肠切除术, 腹腔内并发症, 胃排空功能障碍, 独立危险因素
Objective

The present study aimed at investigating the complications following extended pancreaticoduodenectomy and analyzing risk factors.

Methods

Clinical data of patients undergoing pancreaticoduodenectomy between November 2004 and November 2014 were collected, and were divided into Standard Group and Extended Group retrospectively. The postoperative complications and risk factors were analyzed by uni-variate and multi-variate logistic analysis.

Results

Three hundred and fifty-eight patients were subjected to pancreaticoduodenectomy, 321 cases in Standard Group and 37 cases in Extended Group. The total morbidity was 41.1% and mortality was 5.0%. The differences of intra-abdominal complications (P = 0.02) and delayed gastric emptying (P = 0.01) were significant between the groups. Multi-variate logistic analysis revealed that age over 65 (P < 0.01), operation time more than 360 min (P = 0.03), pancreatic duct diameter less than 3 mm (P < 0.01), soft texture of remnant pancreas (P < 0.01), extended pancreaticoduodenectomy (P = 0.02) and invagination pancreaticojejunostomy (P = 0.01) were independent risk factors for intra-abdominal complications. And independent risk factors for delayed gastric emptying included extended pancreaticoduodenectomy (P = 0.03), operation time more than 360 min (P < 0.01), soft texture of remnant pancreas (P = 0.02) and pancreatic duct diameter less than 3 mm (P < 0.01).

Conclusion

Extended pancreaticoduodenectomy is the independent risk factor for intra-abdominal complications, while it does not increase the mortality.

Key words: Extend pancreaticoduodenectomy, Intra-abdominal complications, Delayed gastric emptying, Independent risk factors
表1 常规组和扩大组的一般临床资料
项目 总例数 常规组(321例) 扩大组(37例) 统计值 P值
性别（男：女） 1.8 2.0 1.0 4.5 0.03a
平均年龄（岁， ± s） 59.3 ± 12.3 59.1 ± 12.4 61.2 ± 10.9 -1.0 0.35
术前资料 ? ? ? ? ?
? 高血压病[例(%)] 65(18.2) 53(16.5) 12(32.4) 5.7 0.02a
? 糖尿病[例(%)] 35(9.8) 29(9.0) 6(16.2) 1.9 0.23
? 冠心病[例(%)] 10(2.8) 9(2.8) 1(2.7) < 0.01 0.97
? 白蛋白(g/L， ± s） 38.8 ± 5.0 38.9 ± 4.9 37.9 ± 5.5 0.9 0.41
? 胆红素（μmol/L， ± s） 111.2 ± 95.2 110.6 ± 96.3 116.1 ± 85.8 -0.9 0.46
? 胆管引流[例(%)] 101(28.3) 91(28.3) 10(27.0) < 0.05 0.86
术中资料 ? ? ? ? ?
? 手术时间(min， ± s） 368.8 ± 105.9 362.6 ± 104.7 422.4 ± 101.7 -3.3 < 0.01a
? 中位术中出血量(ml)b 600.0 500.0 900.0 -2.4 0.02a
? 术中输血(U) b 6 5 8 -2.8 0.01a
胰管直径[例(%)] ? ? ? 1.2 0.27
? < 3 mm 166(46.4) 152(47.4) 14(37.8) ? ?
? ≥3 mm 192(53.6) 169(52.6) 23(62.2) ? ?
胰腺质地[例(%)] ? ? ? 0.5 0.49
? 质软 203(56.7) 184(57.3) 19(51.4) ? ?
? 质硬 155(43.3) 137(42.7) 81(48.6) ? ?
吻合方式[例(%)] ? ? ? < 0.01 1.00
? 套入式 300(83.8) 269(83.8) 31(83.8) ? ?
? 胰管空肠式 58(16.8) 52(16.2) 6(16.2) ? ?
术后资料 ? ? ? ? ?
? 使用生长抑素[例(%)] 210(58.7) 184(57.3) 26(70.3) 2.3 0.13
? 术后住院天数(d， ± s） 23.3 ± 18.5 23.6 ± 19.2 20.9 ± 10.5 0.2 0.90
病理[例(%)] ? ? ? 26.5 < 0.01 a
? 壶腹癌 134(37.4) 131(40.8) 3(8.1) ? ?
? 胰腺肿瘤 114(31.9) 94(29.3) 20(54.1) ? ?
? 十二指肠癌 40(11.2) 35(10.9) 5(13.5) ? ?
? 胆管癌 37(10.3) 35(10.9) 2(5.4) ? ?
? 其他恶性肿瘤 10(2.8) 7(2.2) 3(8.1) ? ?
? 慢性胰腺炎 9(2.5) 6(1.9) 3(8.1) ? ?
? 其他良性肿物 14(3.9) 13(4.0) 1(2.7) ? ?
经皮置管引流[例(%)] 61(17.0) 55(17.1) 6(16.2) 0.02 0.89
再次手术[例(%)] 24(6.7) 22(6.9) 2(5.4) 0.1 0.74
并发症发生率[例(%)] 147(41.1) 127(39.6) 20(54.1) 2.9 0.09
死亡率[例(%)] 18(5.0) 15(4.7) 3(8.1) 0.82 0.42
表2 常规手术组和扩大手术组的术后并发症[例次(%)]
并发症 总例数(358例) 常规组(321例) 扩大组(37例) P值
腹腔内并发症 120(33.5) 101(31.5) 19(51.4) 0.02a
? 胃排空功能障碍 56(15.6) 45(14.0) 11(29.7) 0.01a
? 腹腔感染 48(13.4) 41(12.8) 7(18.9) 0.31
? 术后胰漏 41(11.5) 38(11.8) 3(8.1) 0.78
? 术后出血 35(9.8) 31(9.7) 4(10.8) 0.77
? 胆漏 10(2.8) 10(3.1) 0(0) -
腹腔外并发症 38(10.67) 18(9.38) 20(12.20) 0.30
? 肺部感染 9(2.5) 7(2.2) 2(5.4) 0.24
? 胸腔积液 9(2.5) 8(2.5) 1(2.7) 1.00
? 切口感染 17(4.7) 17(5.3) 0(0) -
表3 腹腔内并发症及腹腔外并发症的危险因素分析
因素 IACs EACs
单因素分析 多因素分析 单因素分析 多因素分析
P值 P值 OR(95% CI) P值 P值 OR(95% CI)
男性 0.56 ? ? 0.32 ? ?
年龄≥65岁 0.04 < 0.01 a 2.4(1.4 ~ 4.1) 0.32 ? ?
术前资料 ? ? ? ? ? ?
? 高血压病 0.20 ? ? 0.08 ? ?
? 糖尿病 0.41 ? ? 0.51 ? ?
? 冠心病 0.27 ? ? 0.92 ? ?
? 白蛋白< 35 g/L 0.02 0.06 1.8(0.9 ~ 3.4) 0.03 0.06 2.1(0.9 ~ 4.6)
? 黄疸 0.25 ? ? 0.33 ? ?
? 胆管引流 0.09 ? ? 0.27 ? ?
术中资料 ? ? ? ? ? ?
? 手术时间≥360 min 0.008 0.03 a 1.7(1.1 ~ 2.9) 0.26 ? ?
? 术中出血≥600 ml 0.009 0.51 1.2(0.7 ~ 2.2) 0.85 ? ?
? 术中输血≥6 U 0.02 0.16 1.5(0.9 ~ 2.5) 0.14 ? ?
? 胰管直径< 3 mm < 0.01 < 0.01 a 3.0(1.8 ~ 5.1) 0.10 ? ?
? 胰腺质软 < 0.01 < 0.01 a 2.6(1.5 ~ 4.5) 0.10 ? ?
? 扩大切除 0.02 0.02 a 2.5(1.1 ~ 5.5) 0.56 ? ?
? 套入式吻合 0.002 0.01 a 3.2(1.4 ~ 7.5) 0.32 ? ?
? 胰管支架管 0.08 ? ? 0.26 ? ?
术后资料 ? ? ? ? ? ?
? 生长抑素 0.10 ? ? 0.94 ? ?
? 病理 0.39 ? ? 0.20 ? ?
表4 胃排空功能障碍和腹腔感染的危险因素分析
因素 胃排空功能障碍 腹腔感染
单因素分析P值 多因素分析 单因素分析P值 多因素分析
P值 OR(95% CI) P值 OR(95% CI)
男性 0.24 ? ? 0.75 ? ?
年龄≥65岁 0.99 ? ? 0.24 ? ?
白蛋白< 35 g/L 0.30 ? ? 0.01 0.15 1.80(0.8 ~ 3.9)
黄疸 0.18 ? ? 0.81 ? ?
手术时间≥360 min < 0.01 < 0.01 a 4.2(2.2 ~ 8.1) 0.25 ? ?
术中出血≥600 ml < 0.01 0.32 1.5(0.7 ~ 3.1) 0.24 ? ?
术中输血≥6 U 0.35 ? ? 0.38 ? ?
胰管直径< 3 mm 0.01 < 0.01 a 2.5(1.3 ~ 4.7) < 0.01 < 0.01 a 3.87(1.8 ~ 8.4)
胰腺质软 0.03 0.02 a 2.3(1.2 ~ 4.7) < 0.01 0.04 a 2.30(1.0 ~ 5.3)
扩大切除 0.01 0.03 a 2.5(1.1 ~ 5.8) 0.31 ? ?
套入式吻合 0.02 0.18 2.4(0.7 ~ 8.3) 0.06 ? ?
表5 术后出血和胰漏的危险因素分析
因素 术后出血 胰漏
单因素分析 多因素分析 单因素分析 多因素分析
P值 P值 OR(95% CI) P值 P值 OR(95% CI)
男性 0.82 ? ? < 0.01 < 0.01 a 3.5(1.4 ~ 8.6)
年龄≥65岁 0.32 ? ? 0.18 ? ?
白蛋白< 35 g/L 0.03 0.53 1.4(0.5 ~ 3.4) 0.52 ? ?
黄疸 < 0.01 < 0.01 a 5.8(1.7 ~ 20.1) 0.04 0.20 0.6(0.3 ~ 1.3)
手术时间≥360 min 0.87 ? ? < 0.01 < 0.01 a 3.3(1.5 ~ 7.2)
术中出血≥600 ml 0.24 ? ? < 0.01 0.34 1.5(0.7 ~ 3.2)
术中输血≥6 U 0.02 < 0.01 a 2.9(1.4 ~ 6.1) 0.31 ? ?
胰管直径< 3 mm 0.10 ? ? < 0.01 0.01 a 2.8(1.2 ~ 6.1)
胰腺质软 < 0.01 < 0.01 a 6.4(2.4 ~ 17.5) < 0.01 0.03 a 2.5(1.1 ~ 5.8)
扩大切除 0.83 ? ? 0.49 ? ?
套入式吻合 0.46 ? ? 0.09 ? ?
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