胰十二指肠切除术后发生胰腺内外分泌功能不全的影响因素分析

Analysis of influencing factors for pancreatic endocrine and exocrine insufficiency after pancreaticoduodenectomy

    摘要
  • 摘要: 目的:探讨胰十二指肠切除术(PD)后发生胰腺内外分泌功能不全的影响因素。
    方法:采用回顾性病例对照研究方法。收集2016年1月至2017年12月南京大学医学院附属鼓楼医院收治的168例行PD患者的临床病理资料；男96例，女72例；年龄为(64±13)岁，年龄范围为38～75岁。168例患者中，术前胰腺内分泌功能不全36例，术前胰腺外分泌功能不全8例。所有患者行PD。观察指标：(1)手术和随访情况。(2)PD后发生内分泌功能不全的影响因素分析。(3)PD后发生外分泌功能不全的影响因素分析。采用门诊和电话方式进行随访，了解患者术后血糖控制情况、饮食及营养状况、肿瘤复发及转移情况。随访时间截至2018年6月。正态分布的计量资料以±s表示，组间比较采用独立样本t检验；偏态分布的计量资料以M(范围)表示，组间比较采用Mann-Whitney U检验。计数资料以绝对数或百分比表示，组间比较采用x2检验。单因素分析采用x2检验。多因素分析采用Logistic回归模型。
    结果:(1) 手术和随访情况：168例患者成功完成PD，术后恢复顺利，均完成术后6个月随访。168例患者术后空腹血糖为7 mmol/L(5～9 mmol/L)，餐后2 h血糖为10 mmol/L(7～14 mmol/L)，每天排便次数为(2.4±1.2)次/d。所有患者未出现肿瘤复发及转移。168例患者中，排除术前有胰腺内分泌功能不全的患者，实际132例患者纳入研究。术后6个月，132例患者中，47例发生胰腺内分泌功能不全，发生率为35.61%(47/132)。168例患者中，排除术前有胰腺外分泌功能不全的患者，实际160例患者纳入研究。术后6个月，160例患者中，68例发生胰腺外分泌功能不全，发生率为42.50%(68/160)。(2) PD后发生内分泌功能不全的影响因素分析：单因素分析结果显示为性别、代谢综合征、慢性胰腺炎、切离点、术后化疗是影响PD后发生胰腺内分泌功能不全的相关因素(x2=5.300，6.270，4.473，4.392，5.397，P<0.05)。多因素分析结果显示：男性、有代谢综合征是PD后发生内分泌功能不全的独立危险因素(风险比=5.252，5.364，95%可信区间为1.362～6.382，1.891～12.592， P<0.05)。(3)PD后发生外分泌功能不全的影响因素分析：单因素分析结果显示为体质量指数、慢性胰腺炎、总胆红素、切离点、术后胰瘘为B级或C级、胰腺纤维化是影响PD后发生胰腺外分泌功能不全的相关因素(x2=1.691，4.910，7.763，5.605，4.663，7.700，P<0.05)。多因素分析结果显示：体质量指数<18.5 kg/m2、慢性胰腺炎、总胆红素≥171 μmol/L是PD后发生外分泌功能不全的独立危险因素(风险比=3.695，5.231，7.623，95%可信区间为1.232～7.324，2.161～6.893，1.562～5.235，P<0.05)。
    结论:男性、有代谢综合征是PD后发生胰腺内分泌功能不全的独立危险因素。体质量指数<18.5 kg/m2、慢性胰腺炎、总胆红素≥171 μmol/L是PD后发生胰腺外分泌功能不全的独立危险因素。

     

    Abstract: Objective:To investigate the influencing factors for pancreatic endocrine and exocrine insufficiency after pancreaticoduodenectomy.
    Methods:The retrospective case-control study was conducted. The clinicopathological data of 168 patients who underwent pancreaticoduodenectomy in the Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from January 2016 to December 2017 were collected. There were 96 males and 72 females, aged (64±13)years, with a range from 38 to 75 years. Of the 168 patients, 36 had pancreatic endocrine insufficiency while 8 had pancreatic exocrine insufficiency preoperatively. All patients underwent pancreaticoduodenectomy. Observation indications: (1) surgical situations and follow-up; (2) analysis of influencing factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy; (3) analysis of influencing factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy. Follow-up using out-patient examination and telephone interview was performed to detect postoperative condition of blood glucose control, diet and nutrition, tumor recurrence and metastasis up to June 2018. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were expressed as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the chi-square test. Multivariate analysis was conducted using the Logistic regression model.
    Results:(1) Surgical situations and follow-up: all the 168 patients underwent pancreaticoduodenectomy successfully and recovered well after operation. All patients were followed up for 6 months. The level of fasting and postprandial blood glucose of the 168 patients after surgery were 7 mmol/L(range, 5-9 mmol/L) and 10 mmol/L(range, 7-14 mmol/L), respectively. The defecation frequency was (2.4±1.2)times per day. No tumor recurrence or metastasis occurred in either patient. One hundred and thirty-two of the 168 patients were included in the study excepting patients with pancreatic endocrine insufficiency before operation. At postoperative 6 months, 47 patients developed pancreatic endocrine insufficiency, with an incidence of 35.61%(47/132). One hundred and sixty of the 168 patients were included in the study excepting patients with pancreatic exocrine insufficiency before operation. At postoperative 6 months, 68 patients had pancreatic exocrine insufficiency, with an incidence rate of 42.50%(68/160). (2) Analysis of influencing factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy. Results of univariate analysis showed that gender, metabolic syndrome, chronic pancreatitis, excision point, and postoperative chemotherapy were the related factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy (x2=5.300, 6.270, 4.473, 4.392, 5.397, P<0.05). Results of multivariate analysis revealed that male and metabolic syndrome were independent risk factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy ［hazard ratio (HR)=5.252, 5.364, 95% confidence interval (CI): 1.362-6.382, 1.891-12.592, P<0.05)］. (3) Analysis of risk factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy. Results of univariate analysis showed that body mass index (BMI), chronic pancreatitis, total bilirubin, excision point, postoperative pancreatic fistula as grade B or C, and pancreatic fibrosis were related factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy (x2=1.691, 4.910, 7.763, 5.605, 4.663, 7.700, P<0.05). Results of multivariate analysis showed that BMI< 18.5 kg/m2, chronic pancreatitis, total bilirubin ≥171 μmol/L were independent risk factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy (HR=3.695, 5.231, 7.623, 95% CI: 1.232-7.324, 2.161-6.893, 1.562-5.235, P<0.05).
    Conclusions:Male and metabolic syndrome are risk factors for pancreatic endocrine insufficiency after pancreaticoduodenectomy. BMI<18.5 kg/m2, chronic pancreatitis, and total bilirubin ≥171 μmol/L are risk factors for pancreatic exocrine insufficiency after pancreaticoduodenectomy.

     

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