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标准胰颈横断下胰腺断面结构参数对胰十二指肠切除术后胰瘘的预测价值

周黎晨 谭震 唐娅萍 赵治戎 戴睿武

引用本文:
Citation:

标准胰颈横断下胰腺断面结构参数对胰十二指肠切除术后胰瘘的预测价值

DOI: 10.3969/j.issn.1001-5256.2022.12.022
基金项目: 

四川省科技厅重点研发项目 2022YFS0195;

四川省科技厅省院省校合作项目 18SYXHZ0024;

胰腺损伤与修复四川省重点实验室 41732152

伦理学声明:本研究方案于2021年6月24日经由中国人民解放军西部战区总医院伦理委员会审批,批号:2021EC3-42。
利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明:周黎晨参与对研究的设计、数据收集分析及文章撰写修改;谭震参与对研究思路的设计及数据收集;唐娅萍、赵治戎参与了研究数据的获取及分析;戴睿武负责课题设计,并进行指导。
详细信息
    通信作者:

    戴睿武,dairuiwu@swjtu.edu.cn

Value of pancreatic anatomic structure under standard pancreatic neck transection in predicting pancreatic fistula after pancreaticoduodenectomy

Research funding: 

the Sichuan Science and Technology Program 2022YFS0195;

Project of Science and Technology Department of Sichuan Province 18SYXHZ0024;

Pancreatic injury and repair Key laboratory of Sichuan Province 41732152

More Information
  • 摘要:   目的  探究标准胰颈横断下胰腺断面结构相关参数对胰瘘预测作用,并验证。  方法  回顾性收集2016年6月—2019年12月在中国人民解放军西部战区总医院行胰十二指肠切除术(PD)的患者140例作为预测组;2020年1月—2021年3月在中国人民解放军西部战区总医院行PD手术的患者82例为验证组。比较两组基线水平,通过预测组单因素分析筛选胰瘘危险因素,在验证组采用组内相关系数比较术前影像学与术中实际测量值的一致性,并分组验证胰瘘危险因素。符合正态分布的计量资料组间比较采用t检验;偏态分布的计量资料组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ2检验。采用单因素Logistic分析筛选胰瘘危险因素。计算约登指数,GraphPad Prism绘制受试者工作特征曲线,计算受试者工作特征曲线下面积(AUC)。对术前影像测量值与术中实际测量值采用组内相关系数进行可靠性分析。  结果  胰颈胰管直径(OR=0.347,95%CI:0.192~0.626,P<0.001)、胰颈实质长轴(OR=1.127,95%CI:1.031~1.231,P=0.008)及胰颈实质短轴(OR=1.350,95%CI:1.137~1.602,P=0.001)具有显著差异。胰颈胰管直径AUC=0.785(95%CI:0.128~0.302,P<0.001)、截断值为2.7 mm;胰颈实质长轴AUC=0.669(95%CI:0.564~0.774,P=0.006)、截断值为19.3 mm;胰颈实质短轴AUC=0.720(95%CI:0.627~0.813,P<0.001)、截断值为9.9 mm。验证组30例患者中,术前影像测量值与术中实际测量值具有高度一致性,组内相关系数均>0.75,P<0.001。截断值分组验证,以胰颈胰管直径划分的高危组与低危组之间胰瘘发生率存在显著差异(χ2=0.645,P=0.011);胰颈实质短轴划分的两组之间胰瘘发生率差异显著(χ2=5.901,P=0.015)。  结论  标准胰颈横断下胰颈断面结构特征是胰瘘发生的危险因素,通过术前CT影像可进行判别,方法在临床上简单易行。

     

  • 图  1  胰颈横断面示意图

    注:红色线段代表胰颈实质长轴,绿色线段代表胰颈实质短轴。PV,门静脉;SV,脾静脉;SMV,肠系膜上静脉。

    Figure  1.  Transection of pancreatic neck

    图  2  胰颈参数在CT中的标记

    注:a, 横断面胰颈;b, 白色线段表示胰颈胰管直径,橙色代表胰颈短轴;c, 冠状面胰颈;d, 白色线段表示胰颈长轴。

    Figure  2.  marker of pancreatic neck parameters in CT

    图  3  胰颈参数的ROC曲线

    Figure  3.  ROC curve of parameters of pancreatic neck

    表  1  两组基线水平和围手术期资料对比

    Table  1.   Comparison of baseline and perioperative data between two groups

    变量 总计(n=222) 预测组(n=140) 验证组(n=82) 统计值 P
    年龄(岁) 60.0(51.0~66.0) 59.5(51.0~65.0) 60.0(51.0~67.0) Z=-1.161 0.246
    性别[例(%)] χ2=0.753 0.385
      男 138(62.2) 84(60.0) 54(65.9)
      女 84(37.8) 56(40.0) 28(34.1)
    BMI(kg/m2) 22.3±3.1 22.5±3.1 22.0±3.1 t=1.305 0.193
    体质量下降(kg) 0(0~5.0) 0(0~5.0) 0(0~5.0) Z=-0.086 0.932
    吸烟史[例(%)] 85(38.3) 54(38.6) 31(37.8) χ2=0.013 0.910
    饮酒史[例(%)] 71(32.0) 43(30.7) 28(34.1) χ2=0.280 0.597
    高血压[例(%)] 40(18.0) 27(19.3) 13(15.9) χ2=0.412 0.521
    糖尿病[例(%)] 33(14.9) 18(12.9) 15(18.3) χ2=1.207 0.272
    ASA分级[例(%)] χ2=0.971 0.325
      Ⅰ~Ⅱ 203(91.4) 130(92.9) 73(89.0)
      Ⅲ 19(8.6) 10(7.1) 9(11.0)
    术前[例(%)]
      总胆红素(μmol/L) 149.0(41.6~240.5) 172.9(56.1~245.4) 131.6(19.8~228.3) Z=-1.443 0.149
      CA19-9(U/mL) 69.0(21.9~244.0) 87.4(28.1~262.4) 48.2(13.5~226.1) Z=-1.759 0.079
      C反应蛋白(mg/L) 32.4(5.8~89.0) 41.9(8.0~90.2) 23.4(3.4~90.1) Z=-1.837 0.066
      白蛋白(g/L) 40.4±4.0 40.6±3.9 40.0±4.1 t=1.163 0.246
      血红蛋白 125.8±17.7 127.0±18.7 123.8±15.5 t=1.300 0.195
    手术方式[例(%)] χ2=0.243 0.622
      腹腔镜 66(29.7) 40(28.6) 26(31.7)
      开腹 156(70.3) 100(71.4) 56(68.3)
    手术时间(min) 437.6±118.9 445.8±117.8 422.8±116.0 t=1.350 0.178
    失血量(mL) 400.0(300.0~500.0) 400.0(300.0~500.0) 300.0(200.0~500.0) Z=-1.187 0.235
    输血量(mL) 0(0~700.0) 0(0~700.0) 0(0~500.0) Z=-0.989 0.323
    术后住院时间(d) 15.0(12.0~21.0) 15.0(12.0~21.0) 15(13.0~21.0) Z=-0.090 0.928
    术后病理[例(%)] χ2=0.166 0.920
      胰腺癌 51(23.0) 32(22.8) 19(23.2)
      胆总管下段癌 97(43.7) 60(42.9) 37(45.1)
      十二指肠癌 74(33.3) 48(34.3) 26(31.7)
    注:ASA分级,美国麻醉医师协会分级。
    下载: 导出CSV

    表  2  预测组临床相关性胰瘘的单因素分析

    Table  2.   univariate analysis of CR-POPF in prediction group

    变量 OR 95%CI P
    年龄(岁) 0.967 0.922~1.013 0.157
    性别 0.702 0.290~1.698 0.433
    BMI(kg/m2) 1.017 0.888~1.165 0.810
    体质量下降(kg) 1.019 0.902~1.151 0.762
    吸烟史 1.084 0.455~2.582 0.855
    饮酒史 0.473 0.199~1.122 0.089
    高血压 0.799 0.287~2.224 0.667
    糖尿病 2.405 0.811~7.130 0.114
    ASA分级 2.250 0.273~18.562 0.451
      Ⅰ~Ⅱ
      Ⅲ
    总胆红素(μmol/L) 1.001 0.996~1.006 0.653
    CA199(U/mL) 1.000 1.000~1.000 0.306
    C反应蛋白(mg/L) 1.004 0.998~1.010 0.235
    白蛋白(g/L) 0.935 0.842~1.037 0.204
    手术方式 1.179 0.455~3.052 0.735
    手术时间(min) 0.999 0.995~1.003 0.530
    失血量(mL) 1.000 0.998~1.002 0.969
    输血量(mL) 1.001 1.000~1.001 0.138
    胰颈胰管直径(mm) 0.347 0.192~0.626 <0.001
    胰颈长轴(mm) 1.069 0.973~1.174 0.165
    胰颈短轴(mm) 1.118 0.943~1.324 0.200
    胰颈实质长轴(mm) 1.127 1.031~1.231 0.008
    胰颈实质短轴(mm) 1.350 1.137~1.602 0.001
    下载: 导出CSV

    表  3  术前影像测量值与术中实际测量值的一致性分析

    Table  3.   Consistency analysis between preoperative imaging measurements and intraoperative actual measurements

    变量 术前影像测量值 术中实际测量值 ICC值 P
    胰颈胰管直径(mm) 4.7±2.4 4.5±2.1 0.945 <0.001
    胰颈长轴(mm) 22.7±4.2 23.1±4.7 0.970 <0.001
    胰颈短轴(mm) 14.2±2.9 14.0±2.7 0.947 <0.001
    胰颈实质长轴(mm) 18.0±5.3 18.5±5.3 0.967 <0.001
    胰颈实质短轴(mm) 9.5±3.4 9.5±3.0 0.926 <0.001
    下载: 导出CSV

    表  4  胰颈胰管直径及胰颈实质验证

    Table  4.   Verification of diameter of pancreatic neck duct and pancreatic neck parenchyma

    变量 总计(n=82) 无CR-POPF组
    (n=67)
    CR-POPF组
    (n=15)
    χ2 P
    胰颈胰管直径[例(%)] 6.457 0.011
      >2.7 mm 46(56.1) 42(62.7) 4(26.7)
      ≤2.7 mm 36(43.9) 25(37.3) 11(73.3)
    胰颈实质长轴[例(%)] 3.394 0.065
      ≥19.3 mm 32(39.0) 23(34.3) 9(60.0)
      <19.3 mm 50(61.0) 44(65.7) 6(40.0)
    胰颈实质短轴[例(%)] 5.901 0.015
      ≥9.9 mm 37(45.1) 26(38.8) 11(73.3)
      <9.9 mm 45(54.9) 41(61.2) 4(26.7)
    下载: 导出CSV
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