收稿日期: 2024-03-05
网络出版日期: 2024-07-30
基金资助
国家自然科学基金面上项目(82072635)
Discussion on prevention and treatment strategies of pancreatic fistula and pancreatic fistula complicated with hemorrhage after pancreatoduodenectomy
Received date: 2024-03-05
Online published: 2024-07-30
目的 探讨胰十二指肠切除术后胰瘘及胰瘘合并出血的预防及治疗策略。 方法 选取广东省人民医院自2019年8月至2022年12月收治的90例拟行胰十二指肠切除术的患者为研究对象。根据是否发生术后胰瘘将患者分为术后胰瘘组（n = 35）与术后无胰瘘组（n = 55）；根据是否合并出血将35例术后胰瘘患者分为胰瘘合并出血组（n = 10）与胰瘘无出血组（n = 25）。采用χ2检验或Fisher精确检验进行单因素分析，有统计学差异的变量进一步行逐步回归变量筛选，多因素logistic回归分析确定发生胰瘘和术后胰瘘合并出血的独立危险因素。 结果 90例患者均顺利完成胰十二指肠切除术，术后胰瘘发生率为38.9%（35/90）。两组患者胰管直径（P = 0.013）、术中失血量（P = 0.045）、吻合方式（P = 0.045）、残余胰腺质地（P = 0.010）比较，差异均有统计学意义（P < 0.05）。多因素logistic回归分析结果显示，胰腺质地软、胰腺导管直径< 3 mm、术中出血量≥ 300 mL以及胰肠吻合方式为胰十二指肠切除术后胰瘘的独立危险因素。在发生术后胰瘘的患者中，多因素logistic回归分析结果显示，胰瘘量> 100 mL/d、术后胰瘘持续时间> 7 d是胰十二指肠切除术后胰瘘合并出血的独立危险因素。 结论 胰十二指肠切除术后胰瘘的发生风险较高，重视关注术前胰管直径及规范化判断胰腺质地，有助于预防术后胰瘘。术中仔细止血，尽量避免术后早期出血，可以降低术后B、C级胰瘘的发生率。胰瘘患者当胰瘘量> 100 mL/d、术后胰瘘持续时间＞7 d时要警惕出血的发生。
陈裕斌 , 张传钊 , 侯宝华 . 胰十二指肠切除术后胰瘘及胰瘘合并出血的预防及治疗策略[J]. 实用医学杂志, 2024 , 40(15) : 2084 -2091 . DOI: 10.3969/j.issn.1006-5725.2024.15.007
Objective To explore the prevention and treatment strategies for pancreatic fistula and pancreatic fistula combined with hemorrhage after pancreaticoduodenectomy. Methods We retrospectively reviewed 90 cases of pancreaticoduodenectomy at Guangdong Provincial People's Hospital from August 2019 to December 2022. According to whether postoperative pancreatic fistula occurred， the 90 patients were divided into a postoperative pancreatic fistula group （n = 35） and a postoperative non-pancreatic fistula group （n = 55）. Among the 35 patients with postoperative pancreatic fistula， they were further categorized into two subgroups based on the presence of hemorrhage： the pancreatic fistula with hemorrhage group （n = 10） and the pancreatic fistula without hemorrhage group （n = 25）. Chi-square test or Fisher's exact test was used for univariate analysis. Variables with statistical differences were selected for stepwise regression variable screening. Multivariate Logistic regression analysis was used to determine the independent risk factors for the occurrence of pancreatic fistula and postoperative pancreatic fistula with hemorrhage. Results All 90 patients successfully completed the pancreaticoduodenectomy. The incidence of postoperative pancreatic fistula was 38.9% （35/90）. Significant differences were observed in pancreatic duct diameter （P = 0.013）， intraoperative blood loss （P = 0.045）， anastomosis type （P = 0.045）， and residual pancreatic texture （P = 0.10） between the two groups （P < 0.05）. Multivariate logistic regression analysis revealed that soft pancreas texture， pancreatic duct diameter < 3 mm， intraoperative blood loss ≥ 300 mL， and pancreaticojejunostomy were independent risk factors for postoperative pancreatic fistula. Among patients with postoperative pancreatic fistula， multivariate logistic regression analysis identified pancreatic fistula volume > 100 mL and duration of postoperative pancreatic fistula > 7 days as independent risk factors for hemorrhage. Conclusions The risk of pancreatic fistula after pancreatoduodenectomy is relatively high. Attention to preoperative pancreatic duct diameter and standardized evaluation of pancreatic texture can help identify postoperative pancreatic fistula. Careful hemostasis during operation and avoidance of early postoperative hemorrhage can reduce the incidence of grade B and C pancreatic fistulas. Patients with pancreatic fistula should be warned of the occurrence of combined hemorrhage when the fistula volume is greater than 100ml and the duration of postoperative pancreatic fistula is greater than 7 days.
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