老年病人胰十二指肠切除术后严重并发症发生的危险因素

doi:10.16139/j.1007-9610.2023.02.10

摘要/Abstract

摘要：

目的：研究老年病人胰十二指肠切除术(pancreaticoduodenectomy, PD)术后严重并发症发生的危险因素。方法：回顾性分析2016年1月至2020年12月本院行PD 399例≥65岁(65~91岁)老年病人的临床资料，其中≥75岁76例(19.0%)。Barthel指数低提示生活自理能力低下。用二元Logistic回归分析PD术后严重并发症的危险因素,构建预测模型。以受试者工作特征(ROC)曲线验证模型的预测效能。结果：399例老年PD病人中，术后并发症发生224例，总发生率56.14%。轻度并发症187例(46.87%)，严重并发症37例(9.27%)。年龄≥75岁(OR=2.78, P<0.05)、合并高血压(OR=4.20, P<0.05)和Barthel指数(提示生活自理能力）低(OR=0.96, P<0.05)为老年PD术后严重并发症发生的独立危险因素。以年龄、合并高血压、术前营养风险、手术形式、生活自理能力的Barthel指数、手术时间6项指标构建PD术后严重并发症的风险模型，回归方程拟合度0.93。ROC曲线显示，该模型曲线下面积AUC为0.76，灵敏度65%，特异度76%。结论：年龄≥75岁、合并高血压且生活自理能力低为老年病人PD术后严重并发症的独立性危险因素。以年龄等6项指标构建的模型能较好预测老年病人PD术后严重并发症的发生。

关键词: 老年, 胰十二指肠切除术, 术后严重并发症, 危险因素

Abstract:

Objective To investigate the risk factors of severe complications of elderly patients with pancreaticoduodenectomy (PD). Methods The clinical data of 399 elderly patients with PD and 65 years or more (65-91years) including 76 cases with 75 years or more （19.0%） in this hospital from January 2016 to December 2020, were retrospectively analyzed. Less Barthel index score was used to indicate lower activities of daily living. The risk factors of severe complications after PD were analyzed by binary Logistic regression and predictive model was established. Receiver operating characteristic (ROC) curve was used to verify the predictive efficiency of model. Results A total of 224 cases were found postoperative complications from 399 elderly PD cases with the rate 56.14% including 187 (46.87%) cases of mild complications and 37 (9.27%) cases of severe complications. Age ≥75 years (OR=2.78, P<0.05), combined with hypertension (OR=4.20, P<0.05) and less Barthel index score (OR=0.96, P<0.05) were independent risk factors for severe complications after PD in elderly patients. The risk prediction model of severe postoperative complications of PD was constructed using 6 indexes including age, hypertension, preoperative nutritional risk, operative type, Barthel index score in activities of daily living and operative time, and the fit of regression equation 0.93. ROC curve analysis showed that area under curve (AUC) was 0.76, the sensiti-vity 65%, and the specificity 76%. Conclusions Age 75 years or more, hypertension and low activities of daily living would be independent risk factors for severe complications after PD in elderly patients. The risk model constructed by age, hypertension, preoperative nutritional risk, operative type, Barthel index score in activities of daily living and operative time had certain predictive efficacy for severe complications after PD in elderly patients.

Key words: Elderly, Pancreaticoduodenectomy, Severe postoperative complication, Risk factor

中图分类号:

R735.9

于岚, 张永怡, 黄雷, 万歆, 姜胜耀, 唐思静, 张俊, 胡伟国. 老年病人胰十二指肠切除术后严重并发症发生的危险因素[J]. 外科理论与实践, 2023, 28(02): 139-146.

YU Lan, ZHANG Yongyi, HUANG Lei, WAN Xin, JIANG Shengyao, TANG Sijing, ZHANG Jun, HU Weiguo. Risk factors of severe postoperative complications in elderly patients with pancreaticoduodenectomy[J]. Journal of Surgery Concepts & Practice, 2023, 28(02): 139-146.

图/表 5

表1

有无严重并发症两组老年PD病人临床资料比较分析[ x±s/n（%）/M（Q1,Q3）]

Item	Total（n=399）	Severe complication		χ²/Z/t value	P value
Item	Total（n=399）	Yes（n=37）	No（n=362）	χ²/Z/t value	P value
Gender
Male	233 (58.4)	24 (64.9)	209 (57.7)	0.70	0.40
Female	166 (41.6)	13 (35.1)	153 (42.3)
Age≥75 years	76 (19.0)	14 (37.8)	62 (17.1)	9.34	<0.001^a)
Age (years)	70.6 ± 4.7	72.7 ± 6.2	70.4 ± 4.4	2.22	0.03^a)
With diabetes	123 (30.8)	12 (32.4)	111 (30.7)	0.05	0.82
With hypertension	215 (53.9)	27 (73.0)	157 (43.4)	11.84	<0.001^a)
Domicile
Shanghai	197 (49.4)	24 (64.9)	173 (47.8)	4.14	0.24
Jiangsu	69 (17.3)	5 (13.5)	64 (17.7)
Zhejiang	56 (14.0)	4 (10.8)	52 (14.3)
Others	77 (19.3)	4 (10.8)	73 (20.2)
Barthel index score	77.8 ± 7.6	74.3 ± 14.4	78.2 ± 6.4	2.98	<0.001^a)
Operative type
Open pancreatoduodenectomy	329 (82.5)	34 (91.9)	295 (81.5)	2.51	0.11
Da Vinci robot operation	70 (17.5)	3 (8.1)	67 (18.5)
Surgical procedure
Pancreatoduodenectomy	351 (88.0)	29 (78.4)	322 (89.0)	3.55	0.06
Complex pancreatoduodenectomy	48 (12.0)	8 (21.6)	40 (11.0)
Operative time (min)	310 (265，365)	330 (290，393)	305 (261，360)	1.91	0.05
Intraoperative blood loss（mL）	400 (300，600)	500 (300，800)	400 (300，600)	1.32	0.19
Tumor location
Pancreas	311 (77.9)	30 (81.1)	281 (77.6)	0.23	0.62
Others	88 (22.1)	7 (18.9)	81 (22.4)
Pathological classification
Adenocarcinoma	337 (84.5)	33 (89.2)	304 (84.0)	0.70	0.40
Others	62 (15.5)	4 (10.8)	58 (16.0)
Preoperative nutritional risk	286 (71.7)	29 (78.4)	257 (71.0)	0.90	0.34
ALB on admission (g)	37.3 ± 5.3	36.4 ± 5.6	37.4 ± 5.3	0.89	0.37
HB on admission (g)	124.1 ± 17.8	122.0 ± 21.8	124.3 ± 17.4	0.63	0.53
Postoperative hospital stay (d)	21.8 ± 11.9	28.4 ± 15.4	21.1 ± 11.3	2.84	<0.001^a)
Total hospital stay (d)	29.2 ± 12.8	37.4 ± 16.3	28.3 ± 12.2	4.42	<0.001^a)
Cost in hospital stay (×10 000 RMB)	10.9 ± 4.5	15.1 ± 6.1	10.4 ± 4.1	4.50	<0.001^a)

表1

表2

表3

表4

图1

参考文献 33

[1]	CHAPMAN B C, GLEISNER A, IBRAHIM-ZADA I, et al. Laparoscopic pancreaticoduodenectomy: changing the management of ampullary neoplasms[J]. Surg Endosc, 2018, 32(2):915-922. doi: 10.1007/s00464-017-5766-8 pmid: 28779245
[2]	王志灼, 谷莉, 周谋望. 中国老年人跌倒风险因素识别及评估工具应用的研究进展[J]. 中国康复医学杂志, 2021, 36(11):1440-1444.
	WANG Z Z, GU L, ZHOU M W. Research progress in the identification of fall risk factors and the application of assessment tools in the elderly in China[J]. Chin J Rehabil Med, 2021, 36(11):1440-1444.
[3]	SAHORA K, MORALES-OYARVIDE V, THAYER S P, et al. The effect of antecolic versus retrocolic reconstruction on delayed gastric emptying after classic non-pylorus-preserving pancreaticoduodenectomy[J]. Am J Surg, 2015, 209(6):1028-1035. doi: 10.1016/j.amjsurg.2014.04.015 URL
[4]	LAI E C, YANG G P, TANG C N. Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy—a comparative study[J]. Int J Surg, 2012, 10(9):475-479. doi: 10.1016/j.ijsu.2012.06.003 URL
[5]	郭得兴, 左仲强, 谭宏涛, 等. 非糖尿病性术后高血糖对胰十二指肠切除术后并发症的影响[J]. 中华外科杂志, 2019, 57 (10):750-756.
	GUO D X, ZUO Z Q, TAN H T, et al. Effect of non-diabetic postoperative hyperglycemia on complications after pancreaticoduodenectomy[J]. Chin J Surg, 2019, 57(10):750-756.
[6]	JIANG J, UPFILL-BROWN A, DANN A M, et al. Association of hospital length of stay and complications with readmission after open pancreaticoduodenectomy[J]. JAMA Surg, 2019, 154(1):88-90. doi: 10.1001/jamasurg.2018.3213 pmid: 30325979
[7]	薛鸿, 颜锡洋, 陈江明, 等. 胰十二指肠切除术后并发症与预后的相关分析[J]. 肝胆外科杂志, 2020, 28(3):194-200.
	XUE H, YAN X Y, CHEN J M, et al. Correlation analysis of complications and prognosis after pancreaticoduodenectomy[J]. J Hepatobiliary Surg, 2020, 28(3):194-200.
[8]	吴浩然, 张恒, 段小辉, 等. 腹腔镜胰十二指肠切除术后并发症发生的危险因素分析及术后胰瘘风险预测模型的建立[J]. 中华普通外科杂志, 2020(11):838-842.
	WU H R, ZHANG H, DUAN X H, et al. Complications after laparoscopic pancreaticoduodenectomy and establishment of predicting model for postoperative pancreatic fistula[J]. Chin J Gen Surg, 2020, 35(11):838-842.
[9]	LUBRANO J, BACHELIER P, PAYE F, et al. Severe postoperative complications decrease overall and disease free survival in pancreatic ductal adenocarcinoma after pancreaticoduodenectomy[J]. Eur J Surg Oncol, 2018, 44(7):1078-1082. doi: S0748-7983(18)30993-4 pmid: 29685757
[10]	DENT E, HOOGENDIJK E O, VISVANATHAN R, et al. Malnutrition screening and assessment in hospitalised older people: a review[J]. J Nutr Health Aging, 2019, 23(5):431-441. doi: 10.1007/s12603-019-1176-z pmid: 31021360
[11]	LI Q X, ZHAO X J, WANG Y, et al. Value of the Barthel scale in prognostic prediction for patients with cerebral infarction[J]. BMC Cardiovasc Disord, 2020, 20(1):14. doi: 10.1186/s12872-019-01306-1
[12]	DINDO D, DEMARTINES N, CLAVIEN P A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey[J]. Ann Surg, 2004, 240(2):205-213. doi: 10.1097/01.sla.0000133083.54934.ae pmid: 15273542
[13]	SHIIHARA M, HIGUCHI R, IZUMO W, et al. Impact of the controlling nutritional status score on severe post-oprative complications of pancreaticoduodenectomy for pancreatic cancer[J]. Langenbecks Arch Surg, 2021, 406(5):1491-1498. doi: 10.1007/s00423-021-02151-7
[14]	ITOYAMA R, OKABE H, NAKAO Y, et al. The pivotal predictor of severe postoperative complications of pancreatoduodenectomy: complex links of bacterial contamination from preoperative biliary drainage[J]. Surg Today, 2020, 50(12):1594-1600. doi: 10.1007/s00595-020-02061-z
[15]	王贺彬, 熊光冰, 朱峰, 等. 腹腔镜胰十二指肠切除术后并发症的Clavien-Dindo分级及影响因素分析[J]. 中华外科杂志, 2018, 56(11):828-832.
	WANG H B, XIONG G B, ZHU F, et al. Clavien-Dindo classification and influencing factors analysis of complications after laparoscopic pancreaticoduodenectomy[J]. Chin J Surg, 2018, 56(11):828-832.
[16]	ZHANG W, HUANG Z, ZHANG J, et al. Effect of laparoscopic pancreaticoduodenectomy in elderly people: a meta-analysis[J]. Pancreas, 2021, 50(8):1154-1162. doi: 10.1097/MPA.0000000000001900 URL
[17]	BOURGOUIN S, EWALD J, MANCINI J, et al. Predictive factors of severe complications for ampullary, bile duct and duodenal cancers following pancreaticoduodenectomy: multivariate analysis of a 10-year multicentre retrospective series[J]. Surgeon, 2017, 15(5):251-258. doi: 10.1016/j.surge.2015.11.003 URL
[18]	FUTAGAWA Y, KANEHIRA M, FURUKAWA K, et al. Study on the validity of pancreaticoduodenectomy in the elderly[J]. Anticancer Res, 2017, 37(9):5309-5316. pmid: 28870969
[19]	RENZ B W, KHALIL P N, MIKHAILOV M, et al. Pancreaticoduodenectomy for adenocarcinoma of the pancreatic head is justified in elderly patients: a retrospective cohort study[J]. Int J Surg, 2016, 28:118-125. doi: 10.1016/j.ijsu.2016.02.064 pmid: 26906329
[20]	ZHANG W, HUANG Z, ZHANG J, et al. Safety and effectiveness of open pancreaticoduodenectomy in adults aged 70 or older: A meta-analysis[J]. J Geriatr Oncol, 2021, 12(7):1136-1145. doi: 10.1016/j.jgo.2021.02.004 pmid: 33610506
[21]	YUAN F, ESSAJI Y, BELLEY-COTE E P, et al. Post-operative complications in elderly patients following pancreaticoduodenectomy lead to increased postoperative mortality and costs. A retrospective cohort study[J]. Int J Surg, 2018, 60:204-209. doi: 10.1016/j.ijsu.2018.11.016 URL
[22]	王丽敏, 陈志华, 张梅, 等. 中国老年人群慢性病患病状况和疾病负担研究[J]. 中华流行病学杂志, 2019, 40(3):277-283.
	WANG L M, CHEN Z H, ZHANG M, et al. Study of the prevalence and disease burden of chronic disease in the elderly in China[J]. Chin J Epidemiol, 2019, 40(3):277-283.
[23]	杜汉明, 陈伟, 黄力, 等. 胰十二指肠切除术后胰瘘发生的危险因素分析[J]. 中华消化外科杂志, 2018, 17(7):724-728.
	DU H M, CHEN W, HUANG L, et al. Risk factors analysis of pancreatic fistula after pancreaticoduodenectomy[J]. Chin J Dig Surg, 2018, 17(7):724-728.
[24]	谭小荣, 宗明, 张永杰, 等. 胰十二指肠切除术后出血的危险因素分析[J]. 中国普通外科杂志, 2010, 19(3):282-286.
	TAN X R, ZONG M, ZHANG Y J, et al. Risk factors for post-pancreaticoduodenectomy hemorrhage[J]. Chin J Gen Surg, 2010, 19(3):282-286.
[25]	FLOORTJE VAN OOSTEN A, SMITS F J, VAN DEN HEUVEL D A F, et al. Diagnosis and management of postpancreatectomy hemorrhage: a systematic review and meta-analysis[J]. HPB (Oxford), 2019, 21(8):953-961. doi: 10.1016/j.hpb.2019.02.011 URL
[26]	高红桥, 李宝毅, 马永蔌, 等. 胰十二指肠切除术后出血的危险因素分析及治疗策略[J]. 中华消化外科杂志, 2022, 21(4):492-499.
	GAO H Q, LI B Y, MA Y S, et al. Risk factors analysis and treatment of postpancreaticoduodenectomy hemorrhage[J]. Chin J Dig Surg, 2022, 21(4):492-499.
[27]	KATANO S, YANO T, OHORI K, et al. Barthel index score predicts mortality in elderly heart failure- a goal of comprehensive cardiac rehabilitation[J]. Circ J, 2021, 86(1):70-78. doi: 10.1253/circj.CJ-21-0584 URL
[28]	UCHINAKA E I, HANAKI T, MORIMOTO M, et al. The Barthel index for predicting postoperative complications in elderly patients undergoing abdominal surgery: a prospective single-center study[J]. In Vivo, 2022, 36(6):2973-2980. doi: 10.21873/invivo.13041 pmid: 36309389
[29]	MIMA K, KOSUMI K, MIYANARI N, et al. Impairment of activities of daily living is an independent risk factor for recurrence and mortality following curative resection of stage Ⅰ-Ⅲ colorectal cancer[J]. J Gastrointest Surg, 2021, 25(10):2628-2636. doi: 10.1007/s11605-021-04990-7
[30]	史瑞特, 沈柏用, 邓侠兴, 等. 胰十二指肠切除术后腹腔严重并发症发生的相关危险因素分析[J]. 外科理论与实践, 2015(4):346-351.
	SHRESTHA A K, SHEN B Y, DENG X X, et al. Factors indicating severe intra-abdominal complications after pancreatoduodenectomy[J]. J Surg Concepts Pract, 2015(4):346-351.
[31]	CHIPAILA J, KATO H, IIZAWA Y, et al. Prolonged operating time is a significant perioperative risk factor for arterial pseudoaneurysm formation and patient death following hemorrhage after pancreaticoduodenectomy[J]. Pancreatology, 2020, 20(7):1540-1549. doi: 10.1016/j.pan.2020.08.021 pmid: 32943343
[32]	王伟艺, 王巍, 袁祖荣, 等. 胰体尾肿瘤患者微创与传统手术效果比较[J]. 中华肝胆外科杂志, 2016, 22 (1):40-44.
	WANG W Y, WANG W, YUAN Z R, et al. A comparative study between minimally invasive and traditional open surgery in treating patients with pancreatic body or tail lesions[J]. Chin J Hepatobiliary Surg, 2016, 22(1):40-44.
[33]	LIU Q, ZHAO Z, ZHANG X, et al. Robotic pancreaticoduodenectomy in elderly and younger patients: a retrospective cohort study[J]. Int J Surg, 2020, 81:61-65. doi: S1743-9191(20)30584-7 pmid: 32750491

Variables	β	SE	Wald χ²	P value	OR（95%CI）
Interaction between surgical procedure and operative type	-0.026	0.344	0.006	0.940	0.974（0.497-1.912）
Interaction between surgical procedure and operative time	0.002	0.001	3.045	0.081	1.002（1.000-1.004）
Interaction between surgical procedure and intraoperative blood loss	0.000	0.000	0.244	0.621	1.000（0.999-1.001）
Interaction between operation type and operative time	-0.002	0.002	1.098	0.295	0.998（0.995-1.002）
Interaction between operative type and intraoperative blood loss	0.000	0.001	0.239	0.625	1.000（0.998-1.001）
Interaction between operative time and intraoperative blood loss	0.000	0.000	1.949	0.163	1.000（1.000-1.000）

Variables	OR（95%CI）	P value
Age		0.01^a
≥75 years	2.67 (1.24-5.74)
<75 years	1 (reference)
With hypertension		0.00^a
Yes	3.85 (1.74-8.53)
No	1 (reference)
Preoperative nutritional risk		0.09
Yes	2.13 (0.89-5.13)
No	1 (reference)
Operative type		0.13
Da Vinci robot operation	0.38 (0.11-1.31)
Open pancreatoduodenectomy	1 (reference)
Barthel index score	0.97 (0.94-1.00)	0.03^a)
Operative time	1.00 (1.00-1.01)	0.04^a)