术前减黄对胆道低位梗阻行胰十二指肠切除术患者预后的影响

doi:10.3877/cma.j.issn.2095-3232.2018.05.014

目的

探讨术前减黄对胆道低位梗阻行胰十二指肠切除术（PD）患者预后的影响。

方法

回顾性分析2013年1月至2017年1月陆军军医大学附属新桥医院收治的183例低位梗阻性黄疸患者临床资料。患者均签署知情同意书，符合医学伦理学规定。其中男113例，女70例；平均年龄（63±12）岁。患者PD术前均行减黄治疗。根据减黄程度将患者分为减黄较差组和减黄较好组，另设15例无黄疸胰头癌患者为对照组。比较减黄较差组PD后腹腔感染患者和对照组患者T淋巴细胞亚群表达情况。减黄前后TB、DB比较采用t检验，手术并发症相关性分析采用χ²检验。

结果

减黄后3 d的TB、DB分别为（149±26）、（107±16）μmol/L，明显低于减黄前的（243±37）、（177±24）μmol/L（t=-3.255，-1.836；P<0.05）。减黄较差组PD后更易出现胆漏和腹腔感染（χ²=4.936，7.617；P<0.05）。腹腔感染患者CD4⁺CD25⁺Foxp3⁺ Tregs百分率为（5.89±0.28）%，明显高于对照组的（4.28±0.19）%（t=4.765，P<0.05）。

结论

术前减黄能快速降低胆道低位梗阻患者胆红素水平，可能通过改善免疫功能减少腹腔感染的发生。

关键词: 黄疸，阻塞性, 胰十二指肠切除术, 术前减黄, 预后

Objective

To evaluate the effect of preoperative biliary drainage on the prognosis of patients with low biliary obstruction undergoing pancreaticoduodenectomy (PD).

Methods

Clinical data of 183 patients with low obstructive jaundice admitted to Xinqiao Hospital Affiliated to Army Medical University from January 2013 to January 2017 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 113 patients were male and 70 female, aged (63±12) years on average. All patients received biliary drainage before PD. The patients were divided into 2 groups: better drainage group and poorer drainage group, and another 15 cases with pancreatic head carcinoma without jaundice were enrolled as control group. The expression of T lymphocytes subset in patients with abdominal infection in poorer drainage group and control group were compard. TB and DB before and after jaundice reduction were compared by t test, and the correlation with surgical complications was analyzed by Chi-square test.

Results

At 3 d after biliary drainage, the TB and DB levels were (149±26) and (107±16) μmol/L, significantly lower than the preoperative (243±37) and (177±24) μmol/L (t=-3.255, -1.836; P<0.05). The risk of bile leakage and abdominal infection was significantly higher in poorer drainage group after PD (χ2=4.936, 7.617; P<0.05). The percentage of CD4⁺CD25⁺Foxp3⁺ Tregs in patients with abdominal infection was (5.89±0.28)%, significantly higher compared with (4.28±0.19)% in control group (t=4.765, P<0.05).

Conclusions

Preoperative biliary drainage can rapidly reduce the bilirubin level in patients with low biliary obstruction, and decrease the incidence of abdominal infection probably by improving the immune function.

Key words: Jaundice, obstructive, Pancreaticoduodenectomy, Preoperative biliary drainage, Prognosis

图1 BD和PD前后胆红素变化

表1 术前减黄与PD后并发症相关性（例）

并发症		减黄较差组	减黄较好组	²值	值
胆漏		?	?	4.936	0.026
?	是	06	01	?	?
?	否	86	90	?	?
胰瘘		?	?	0.328	0.567
?	是	02	01	?	?
?	否	90	90	?	?
腹腔感染		?	?	7.617	0.005
?	是	12	02	?	?
?	否	80	89	?	?
肺部感染		?	?	0.085	0.770
?	是	07	08	?	?
?	否	85	83	?	?
腹腔内出血		?	?	0.350	0.554
?	是	01	02	?	?
?	否	91	89	?	?
消化道出血		?	?	0.328	0.567
?	是	02	01	?	?
?	否	90	90	?	?
胃肠排空障碍		?	?	0.400	0.527
?	是	06	04	?	?
?	否	86	87	?	?
切口愈合不良		?	?	0.000	1.000
?	是	04	04	?	?
?	否	88	87	?	?

表1 术前减黄与PD后并发症相关性（例）

并发症		减黄较差组	减黄较好组	²值	值
胆漏		?	?	4.936	0.026
?	是	06	01	?	?
?	否	86	90	?	?
胰瘘		?	?	0.328	0.567
?	是	02	01	?	?
?	否	90	90	?	?
腹腔感染		?	?	7.617	0.005
?	是	12	02	?	?
?	否	80	89	?	?
肺部感染		?	?	0.085	0.770
?	是	07	08	?	?
?	否	85	83	?	?
腹腔内出血		?	?	0.350	0.554
?	是	01	02	?	?
?	否	91	89	?	?
消化道出血		?	?	0.328	0.567
?	是	02	01	?	?
?	否	90	90	?	?
胃肠排空障碍		?	?	0.400	0.527
?	是	06	04	?	?
?	否	86	87	?	?
切口愈合不良		?	?	0.000	1.000
?	是	04	04	?	?
?	否	88	87	?	?

图2 减黄较差组PD术后腹腔感染患者与对照组患者T淋巴细胞亚群比较

[1]	Moole H, Bechtold M, Puli SR. Efficacy of preoperative biliary drainage in malignant obstructive jaundice: a meta-analysis and systematic review[J]. World J Surg Oncol, 2016, 14(1):182.
[2]	Phoa SS, Reeders JW, Rauws EA, et al. Spiral computed tomography for preoperative staging of potentially resectable carcinoma of the pancreatic head[J]. Br J Surg, 1999, 86(6):789-794.
[3]	van der Gaag NA, Kloek JJ, de Castro SM, et al. Preoperative biliary drainage in patients with obstructive jaundice: history and current status[J]. J Gastrointest Surg, 2009, 13(4):814-820.
[4]	Fang Y, Gurusamy KS, Wang Q, et al. Meta-analysis of randomized clinical trials on safety and efficacy of biliary drainage before surgery for obstructive jaundice[J]. Br J Surg, 2013, 100(12):1589-1596.
[5]	Fang Y, Gurusamy KS, Wang Q, et al. Pre-operative biliary drainage for obstructive jaundice[J]. Cochrane Database Syst Rev, 2012(9):CD005444.
[6]	Xu C, Huang XE, Wang SX, et al. Comparison of infection between internal-external and external percutaneous transhepatic biliary drainage in treating patients with malignant obstructive jaundice[J]. Asian Pac J Cancer Prev, 2015, 16(6):2543-2546.
[7]	Zhao XQ, Dong JH, Jiang K, et al. Comparison of percutaneous transhepatic biliary drainage and endoscopic biliary drainage in the management of malignant biliary tract obstruction: a meta-analysis[J]. Dig Endosc, 2015, 27(1):137-145.
[8]	Chan C, Franssen B, Domínguez I, et al. Impact on quality of life after pancreatoduodenectomy: a prospective study comparing preoperative and postoperative scores[J]. J Gastrointest Surg, 2012, 16(7):1341-1346.
[9]	贺学荣，张宝华，龚建平．术前胆道引流对胰十二指肠切除术后影响的Meta分析[J]．临床肝胆病杂志，2017, 33(9):1749-1753.
[10]	Morris S, Gurusamy KS, Sheringham J, et al. Cost-effectiveness of preoperative biliary drainage for obstructive jaundice in pancreatic and periampullary cancer[J]. J Surg Res, 2015, 193(1):202-209.
[11]	王介营，李芹，王玉虎，等．恶性梗阻性黄疸患者黄疸程度对胰十二指肠切除术后并发症的影响[J]．疑难病杂志，2013, 12(10):773-775.
[12]	Chowdhury AH, Camara M, Martinez-Pomares L, et al. Immune dysfunction in patients with obstructive jaundice before and after endoscopic retrograde cholangiopancreatography[J]. Clin Sci, 2016, 130(17):1535-1544.
[13]	White JS, Hoper M, Parks RW, et al. Patterns of bacterial translocation in experimental biliary obstruction[J]. J Surg Res, 2006, 132(1):80-84.
[14]	Rigato O, Salomao R. Impaired production of interferon-gamma and tumor necrosis factor-alpha but not of interleukin 10 in whole blood of patients with sepsis[J]. Shock, 2003, 19(2):113-116.
[15]	Sharabi AB, Aldrich M, Sosic D, et al. Twist-2 controls myeloid lineage development and function[J]. PLoS Biol, 2008, 6(12):e316.
[16]	Tang Y, Xu X, Guo S, et al. An increased abundance of tumor-infiltrating regulatory T cells is correlated with the progression and prognosis of pancreatic ductal adenocarcinoma[J]. PLoS One, 2014, 9(3):e91551.
[17]	Yamamoto T, Yanagimoto H, Satoi S, et al. Circulating CD4⁺CD25⁺ regulatory T cells in patients with pancreatic cancer[J]. Pancreas, 2012, 41(3):409-415.
[18]	Campbell DJ, Koch MA. Phenotypical and functional specialization of FOXP3⁺ regulatory T cells[J]. Nat Rev Immunol, 2011, 11(2):119-130.
[19]	Daker C, Van Someren N, Besherdas K. PMO-097 Surgery for pancreatic cancer without preoperative biliary drainage: fiction in reality?[J]. Gut, 2012, 61 Suppl 2:A112-113.
[20]	van der Gaag NA, Rauws EA, van Eijck CH, et al. Preoperative biliary drainage for cancer of the head of the pancreas[J]. N Engl J Med, 2010, 362(2):129-137.

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Effect of preoperative biliary drainage on prognosis of patients with low biliary obstruction undergoing pancreaticoduodenectomy

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Effect of preoperative biliary drainage on prognosis of patients with low biliary obstruction undergoing pancreaticoduodenectomy