胰十二指肠切除术后胰瘘的危险因素

目的：探讨胰十二指肠切除术（PD）后胰瘘（PF）发生的危险因素及处理措施。方法：回顾性分析近12年来连续完成的218例PD的临床资料，并对围手术期可能与PF有关的16个因素进行单因素及非条件Logistic多因素分析。结果：全组术后并发症发生率为29.8%（65/218），病死率4.1%（9/218）。PF30例，发生率为13.8%，占总并发症的46.1％。PF中25例经引流通畅或B超或CT定位下穿刺引流处理后均痊愈;5例继发腹腔感染者，其中2例拒绝再手术者均死于多器官功能衰竭，1例死于迟发性腹腔大出血，2例经再手术腹腔引流后1例痊愈，1例死亡;PF病死率为13.3%（4/30），占总病死率的44.4％。PF组并发症发生率及病死率均显著高于无PF组（P＜0.01，P＜0.05）。单因素分析结果显示胰腺质地、胰管直径、胰管引流、手术时间、营养支持及应用生长抑素等6个因素与PF有关，多因素分析结果显示胰腺质地（正常）、胰管直径（细小）是PF的独立危险因素（OR 分别为9.394和4.232）。结论：胰腺质地正常、胰管细小是PD后PF发生的危险因素。根据胰腺质地、胰管直径及术者的经验，合理选择胰腺残端处理和吻合方式，是降低PF发生率的关键。早期诊断、早期处理PF及其他相关并发症对改善PF的预后至关重要。

Risk factors of pancreatic fistula after pancreaticoduodenectomy

Abstract:Objective：To investigate the risk factors and management of pancreatic fistula(PF) after pancreaticoduodenectomy（PD）. Methods：Two hundred and eighteen patients who underwent PD consecutively at our hospital from February 1994 to December 2005 were reviewed retrospectively. The management and outcomes of patients with PF were also evaluated. Sixteen factors which potentially affect the incidence of PF were analyzed with univariate and multivariate logistic regression model. Results：Of the 218 patients, the overall morbidity and hospital mortality were 29.8%（65/218）and 4.1%（9/218）respectively, and PE occurred in 30 patients(13.8%). PE was account for 46.1% in the overall morbidity. Of the 30 patients with PE, 25 had successful management conservatively with effective drainage including under B-ultrasonography guided or CT-guided percutaneous drainage. In the other 5 patients who had intra-abdominal abscess, two patients refused reoperation died of multiple organ failure, and one died of combination of intra-abdominal massive hemorrhage; the other two underwent reoperation for wide drainage, one survived, another died. The mortality of PF was 13.3%(4/30), which was account for 44.4% of overall mortality. Patients with PF had significantly higher morbidity（P＜0.01）and in-hospital mortality（P＜0.05）than those without PF. In univariate analysis, texture of the remnant pancreas, pancreatic duct size, drainage of pancreatic duct, duration of operation，perioperative nutrition support and use of prophylactic somatostatin analogues were related to occurrence of PF. Multivariate logistic regression analysis revealed that normal texture of the remnant pancreas and pancreatic duct size(≤3mm) were independent risk factors(OR=9.394 and 4.232). Conclusions：Pancreatic duct size and texture of the remnant pancreas are the independent risk factors of occurrence of PF after PD. If the optimal pancreatojejunal anastomotic technique is selected according to pancreatic duct size, texture of the remnant pancreas and experience of the surgeon, the incidence of PF can be reduced effectively. Early diagnosis and management of PE and other severe complications associated with PF are important to improve its outcome.