胰十二指肠联合静脉切除重建术后早期血管栓塞的床旁超声诊断及危险因素分析

doi:10.16139/j.1007-9610.2024.01.009

摘要/Abstract

摘要：

目的：探讨胰十二指肠联合静脉切除重建术后早期血管栓塞的相关危险因素。方法：回顾性分析2018年1月至2021年9月上海交通大学医学院附属瑞金医院完成的90例胰十二指肠联合静脉切除重建术后7 d的病人的临床资料。根据术后门静脉血流床旁超声的检查结果通畅情况将病人分为门静脉通畅组及门静脉栓塞组，比较分析床旁超声诊断术后门静脉栓塞的血流动力学差异及影响血栓形成的相关危险因素。结果：90例病人经床旁超声诊断有8例出现胰十二指肠联合静脉切除重建术后血管栓塞，其发生率为8.89%（8/90）。床旁超声显示，术后发生门静脉栓塞病人门静脉流速以及流量明显降低（P<0.001）。围术期相关危险因素中既往吸烟史以及酗酒史在门静脉通畅组及门静脉栓塞组中差异有统计学意义，进一步的研究结果显示既往吸烟史是门静脉栓塞的独立危险因素（P=0.003）。研究转归显示胰十二指肠联合静脉切除重建安全可行，但早期门静脉栓塞合并其他严重并发症提示不良的预后。结论：既往吸烟及酗酒史是胰十二指肠联合静脉切除重建术后门静脉血栓形成的高危因素，应进行术前宣教予以预防。而床旁超声能有效安全地评估术后早期血管的通畅情况,为早期临床介入提供帮助。

关键词: 床旁超声, 门静脉栓塞, 胰十二指肠切除术, 静脉重建, 临界可切除胰腺癌

Abstract:

Objective To investigate the risk factors of early thromboembolism after pancreaticoduodenectomy with vein reconstruction. Methods The results of bedside ultrasonography and clinical data of 90 patients from Ruijin Hospital, Shanghai Jiao Tong University School of Medicine who underwent pancreaticoduodenectomy with vein reconstruction within 7 days after operation between Janurary 2018 and September 2021 were analyzed retrospectively. According to the results of bedside ultrasound examination of the patency of portal vein, the postoperative patients were divided into portal vein patency group and portal vein embolization group. The hemodynamic differences of bedside ultrasound and the influencing factors of postoperative portal vein thromboembolism were compared. Results Among 90 patients underwent bedside ultrasound, 8 patients had portal vein thromboembolism after pancreaticoduodenectomy with vein reconstruction, and the incidence rate was 8.89%. Bedside ultrasound showed that the velocity and flow of portal vein in patients with portal vein thromboembolism decreased significantly (P<0.001). Among the perioperative related risk factors, there was a statistically significant difference in the smoking history and alcohol abuse history between the portal vein patency group and portal vein thromboembolism group. Further, previous smoking history was an independent risk factor for portal vein thromboembolism (P=0.003). The outcomes showed that the pancreaticoduodenectomy with vein reconstruction was safe and feasible, however early portal vein thromboembolism with severe complications indicated a poor prognosis. Conclusions The history of smoking and alcohol abuse are the high risk factors of portal vein thromboembolism after pancreaticoduodenectomy with vein reconstruction, which should be prevented by preoperative education. Bedside ultrasound can effectively and safely evaluate the patency of portal vein after pancreaticoduodenectomy with vein reconstruction, which contributes to early clinical intervention.

Key words: Bedside ultrasound, Portal vein thromboembolism, Pancreaticoduodenectomy, Vein reconstruction, Borderline resectable pancreatic cancer

中图分类号:

王美文, 傅宁稹, 王伟珅, 任新平. 胰十二指肠联合静脉切除重建术后早期血管栓塞的床旁超声诊断及危险因素分析[J]. 外科理论与实践, 2024, 29(01): 54-60.

WANG Meiwen, FU Ningzhen, WANG Weishen, REN Xinping. Bedside ultrasound diagnosis and risk factors of early thromboembolism after pancreaticoduodenectomy with vein reconstruction[J]. Journal of Surgery Concepts & Practice, 2024, 29(01): 54-60.

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Variables	PV patency group（n=82）	PV thromboembolism group （n=8）	P value
Inner diameter of PV main trunk after reconstruction（mm）	9.77±1.76	8.00±3.93	0.247
Flow rate of PV after reconstruction（cm/s）	24.18±9.84	9.04±6.11	<0.001
Flow volume of PV after reconstruction（mL/min）	1 111.90±588.69	304.13±232.80	<0.001
Age（years）	60.12±11.35	60.13±10.29	0.999
Gender [n（%）]			0.145
Male	37 (45.12)	6 (75.00)
Female	45 (54.88)	2 (25.00)
BMI (kg/m²)	22.06±3.06	21.62±2.91	0.693
Hypertension [n（%）]			1.000
Yes	15 (18.29)	2 (25.00)
No	67 (81.71)	6 (75.00)
Diabetes [n（%）]			0.555
Yes	9 (10.98)	2 (25.00)
No	73 (89.02)	6 (75.00)
Previous surgical history [n（%）]			0.868
Yes	13 (15.85)	2 (25.00)
No	69 (84.15)	6 (75.00)
Preoperative CA125 （U/mL） [n（%）]			0.805
≤24	63 (76.83)	7 (87.50)
>24	19 (23.17)	1 (12.50)
Preoperative CA19-9（U/mL） [n（%）]			1.000
≤25	11 (13.41)	1 (12.50)
>25	71 (86.59)	7 (87.50)
Preoperative CEA （μg/L） [n（%）]			1.000
≤5	65 (79.27)	6 (75.00)
>5	17 (20.73)	2 (25.00)
Smoking history [n（%）]			0.014
Yes	9 (10.98)	4 (50.00)
No	73 (89.02)	4 (50.00)
Alcohol abuse history [n（%）]			0.004
Yes	7 (8.54)	4 (50.00)
No	75 (91.46)	4 (50.00)

Variables	PV patency group（n=82）	PV thromboembolism group （n=8）	P value
Operation time (min)	381.40±103.12	384.38±98.18	0.938
Blood loss (mL)	839.63±722.08	625.00±357.57	0.410
Transfusion (mL)	1 318.29±902.14	875.00±979.43	0.191
T stage			0.057
T1/2	18	5
T3	44	2
T4	20	1
N stage			1.000
N-	27	3
N+	55	5
PV invasion [n（%）]			0.728
Yes	45 (54.88)	5 (62.50)
No	37 (45.12)	3 (37.50)
SMV invasion [n（%）]			0.465
Yes	37 (45.12)	5 (62.50)
No	45 (54.88)	3 (37.50)
Use of artificial blood vessels [n（%）]			0.374
Yes	23 (28.05)	4 (50.00)
No	59 (71.95)	4 (50.00)

Variables	PV patency group（n=82）	PV thromboembolism group（n=8）	P value
Postoperative pancreatic fistulas [n（%）]			1.000
Yes	13 (15.85)	1 (12.50)
No	69 (84.15)	7 (87.50)
Postoperative bile leak [n（%）]			0.961
Yes	6 (7.32)	0
No	76 (92.68)	8 (100.00)
Re-operation [n（%）]			0.151
Yes	4 (4.88)	2 (25.00)
No	78 (95.12)	6 (75.00)
Hospital stay (d)	30.23±11.89	28.13±11.89	0.633
Postoperative death within 90 d [n（%）]			0.007
Yes	0	2(25.00)
No	82（100.00）	6(75.00)