胰十二指肠切除术后围手术期并发症的风险因素

目的 探讨胰十二指肠切除术后围手术期并发症的风险因素及防治措施.方法 回顾性研究北京大学第一医院2000年1月至2006年12月连续146例胰十二指肠切除术的临床资料,单因素和多因素分析影响围手术期并发症的风险因素,比较不同因素对术后并发症的影响.结果 该组病人术后围手术期并发症发生率为54.1%(79/146),死亡率为4.79%(6/146).年龄>70岁病人与70岁以下病人比较.其术后总体并发症发生率分别为66.7%及50.6%(P=0.094),其中非手术部位并发症如心肺功能不全、肺部感染等二者差异存在统计学意义(P=0.001);手术部位并发症二者无差异.术中出血>600 ml术后并发症发生率77.8%,手术部位并发症发生率71.1%,均显著高于出血<600 ml组(P值分别为0.032,0.038).术后手术部位并发症以胃排空延迟及胰肠吻合口漏最多见,保留幽门胰十二指肠切除术后胃排空延迟发生率为35.7%,较不保留幽门者显著增加(P=0.031);胰漏发生率为19.9%,由胰漏导致感染或腹腔出血并致病人死亡率为10.3%(3/29).多因素Logistic分析示胰肠吻合方式为影响术后胰漏率的独立风险因素.术前白蛋白水平,胆红素水平,术前减黄引流,手术时间,预防性应用生长抑素等均对术后并发症的发生无显著影响.结论 年龄非为手术禁忌证,但其对术后非手术部位并发症有显著影响,围手术期应重视对心肺功能的评估与监护.胰腺质地,术中失血量为术后并发症及手术部位并发症的独立危险因素.保留幽门胰十二指肠切除病人宜术中行空肠造瘘术,以术后提供肠内营养支持.根据胰管直径可采用不同的胰肠吻合方式.术前引流减黄对术后并发症的发生无显著影响.

Risk factors for perioperative complicatgions of pancreaticoduodenectomy

Objective Pancreaticoduodenectomy has been used for curing a variety of benign andmalignant diseases of periampullary region. Since it has been firstly introduced by Wipple,this proce-dure has been associated with high morbidity. We reviewed 146 consecutive patients undergoing pan-ereaticoduodenectomy,examined the type and severity of complications and explored their related fac-tors. Methods Between January 2000 and December 2006,146 consecutive curative pancreaticoduode-nectomies were performed in our hospital for various diseases of periamputlary region. We studied thecases retrospectively, using univariate and multivariate logistic regression model to identify the risk fac-tors related to occurrence of postoperative complications. Results Postoperative morbidity was 54.1(79/146) ,mortality 4.79% (6/146) and reoperation rate 2.73% (4/146). Age>70 was a risk factordetermining non-surgical site complications (P=0. 001). The amount of intra-operative blood loss o-ver 600ml and soft pancreatic texture were more risky for total postoperative complications and surgi-cal site complications. Delayed gastric emptying and pancreatic fistula were the most common surgical site complications with occurring rate of 23.3% and 19.9%,respectively. DGE occurrence of PPPD(35.7%) was higher than that of SPD (18.3%) significantly (P= 0. 031). Mortality related to pan-creatic fistula was 10.3% (3/29). Pancreatic-enteric anastomosis, pancreatic duct diameter and pan-creatic texture had effects on postoperative pancreatic fistula statistically. Pancreatic-enteric anastomo-sis was an independent variable for pancreatic fistula. Neither the use of prophylactic octreotide nor preoperative biliary drainage improved postoperative outcome. Conclusion Age determines non-surgi-cal site complication rate following pancreaticoduodenectomy,which implies the more attention should be paid on the evaluation and monitoring of cardiopulmonary functions. The amount of intra-operativeblood loss and pancreatic texture are independent risk factors for total postoperative complications and surgical site complications. Jejunostomy should be undergone in PPPD to provide enteral nutrition postoperatively. Pancreatic-enteric anastomosis should be decided on pancreatic duct diameter. Preop-erative biliary drainage doesn't improve postoperative outcome.