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中华肝脏外科手术学电子杂志

中华肝脏外科手术学电子杂志 ›› 2023, Vol. 12 ›› Issue (01): 82 -86. doi: 10.3877/cma.j.issn.2095-3232.2023.01.016

临床研究

术前胆道引流对壶腹周围癌患者术后并发症和远期生存的影响
武帅1, 吴含雪2, 莫建涛1, 杨沛泽1, 程亚丽1, 仵正1,†()   
  1. 1. 710061　西安交通大学第一附属医院肝胆外科
    2. 710061　西安交通大学医学部
  • 收稿日期:2022-09-09 出版日期:2023-02-10
  • 通信作者: 仵正
  • 基金资助:
    陕西省科技资源开放共享平台(2022PT-35); 陕西省自然科学基础研究计划(2020JQ-510); 西安交通大学第一附属医院科研发展基金(2021QN-24)

Effect of preoperative biliary drainage on postoperative complications and long-term survival of patients with periampullary carcinoma

Shuai Wu1, Hanxue Wu2, Jiantao Mo1, Peize Yang1, Yali Cheng1, Zheng Wu1,†()   

  1. 1. Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
    2. Xi'an Jiaotong University Health Science Center, Xi'an 710061, China
  • Received:2022-09-09 Published:2023-02-10
  • Corresponding author: Zheng Wu
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目的

探讨术前胆道引流（PBD）对壶腹周围癌患者术后并发症和远期生存的影响。

方法

回顾性分析2016年1月至2018年6月在西安交通大学第一附属医院行胰十二指肠切除术的114例壶腹周围癌患者临床资料。其中男75例，女39例；年龄39~78岁，中位年龄62岁。壶腹癌55例，远端胆管癌52例，十二指肠乳头癌7例。患者均签署知情同意书，符合医学伦理学规定。根据术前是否进行PBD，将患者分为PBD组（36例）和未引流组（78例）。比较两组围手术期、术后并发症和远期生存情况。两组围手术期指标比较采用t检验或Mann-Whitney U检验，并发症发生率比较采用χ2检验。生存分析采用Kaplan-Meier法和Log-rank检验。

结果

PBD组术后TB中位数为110（132）μmol/L，明显小于未引流组的156（117）μmol/L（Z=-2.588，P<0.05）。PBD组术后TB变化值为43（163）μmol/L，明显大于未引流组的25（87）μmol/L（Z=2.140，P<0.05）。PBD组术后总并发症发生率为72%（56/78），未引流组为67%（24/36），差异无统计学意义（χ2=0.310，P>0.05）。生存分析显示，PBD组中位生存期为24个月，未引流组为20个月，两组总体生存率比较差异无统计学意义（χ2=0.551，P>0.05）。

结论

对于壶腹周围癌患者，术前PBD仅能明显改善黄疸情况，而对术后并发症和长期生存并无明显获益，不推荐常规PBD减黄。

关键词: 壶腹周围癌, 引流术, 黄疸，阻塞性, 手术后并发症, 预后
Objective

To evaluate the effect of preoperative biliary drainage (PBD) on postoperative complications and long-term survival of patients with periampullary cancer.

Methods

Clinical data of 114 patients with periampullary cancer who underwent pancreaticoduodenectomy in the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to June 2018 were retrospectively analyzed. Among them, 75 patients were male and 39 female, aged from 39 to 78 years, with a median age of 62 years. 55 patients were diagnosed with ampullary carcinoma, 52 cases of distal cholangiocarcinoma and 7 cases of carcinoma of the duodenal papilla. The informed consents of all patients were obtained and the local ethical committee approval was received. All patients were divided into the PBD (n=36) and non-drainage groups (n=78) according to whether preoperative PBD was performed. Perioperative and postoperative complications and long-term survival were compared between two groups. Perioperative parameters betweentwo groups were compared by t test or Mann-Whitney U test. The incidence of complications was compared byChi-square test. Survival analysis was performed by Kaplan-Meier method and Log-rank test.

Results

In the PBD group, the median postoperative TB level was 110(132) μmol/L, significantly lower than 156(117) μmol/L in the non-drainage group (Z=-2.588, P<0.05). The change value of postoperative TB level in the PBD group was 43(163) μmol/L, significantly higher than 25(87) μmol/L in the non-drainage group (Z=2.140, P<0.05). In the PBD group, the total incidence of postoperative complications was 72%(56/78), and 67%(24/36) in the non-drainage group, where no significant difference was observed (χ2=0.310, P>0.05). Survival analysis showed that the median overall survival was 24 months in the PBD group and 20 months in non-drainage group, where no significant difference was observed between two groups (χ2=0.551, P>0.05).

Conclusions

For patients with periampullary cancer, preoperative PBD can significantly mitigate jaundice, whereas it brings no significant benefits for postoperative complications and long-term survival. Hence, PBD is not routinely recommended for patients with periampullary cancer complicated with obstructive jaundice.

Key words: Periampullary carcinoma, Drainage, Jaundice, obstructive, Postoperative complications, Prognosis
表1 PBD组和未引流组壶腹周围癌患者一般资料比较
组别 例数 年龄（岁，±s） 性别（例） 病理类型（例） TNM分期（例） TB[μmol/L，M（QR）] WBC[×109/L，M（QR）] ASA分级（例） 手术方式（例）
男 女 壶腹癌 远端胆管癌 十二指肠乳头癌 Ⅰ期 Ⅱ期 Ⅲ期 Ⅱ级 Ⅲ级 OPD LPD
PBD组 36 61±10 22 14 23 11 2 8 20 8 177（195） 6（3） 27 9 31 5
未引流组 78 63±9 53 25 32 41 5 9 55 14 173（120） 6（2） 53 25 68 10
统计值   t=-1.225 χ2=0.512 χ2=5.314 χ2=2.956 Z=0.463 Z=0.302 χ2=0.585 χ2=0.025
P值   0.159 0.474 0.070 0.228 0.643 0.763 0.444 0.875
表2 PBD组与未引流组壶腹周围癌患者围手术期情况比较
组别 例数 手术时间[min，M（QR）] 术中出血量（ml） 术后TB[μmol/L，M（QR）] TB变化值[μmol/L，M（QR）] 术后WBC[×109/L，M（QR）] 术后住院时间（d，±s） 住院费用（万元，±s） 二次手术（例）
PBD组 36 343（120） 400（400） 110（132） 43（163） 12（8） 19±9 13±4 1
未引流组 78 338（123） 400（300） 156（117） 25（87） 12（6） 18±7 12±4 4
统计值   Z=0.772 Z=0.808 Z=-2.588 Z=2.140 Z=0.079 t=0.784 t=0.931 χ2=0.324
P值   0.440 0.419 0.010 0.032 0.937 0.101 0.354 0.569
表3 PBD组与未引流组壶腹周围癌患者术后并发症发生情况比较（例）
组别 例数 腹腔感染 腹腔积液 胆漏 胃排空延迟 出血 胰瘘
B级 C级
PBD组 36 17 15 1 14 9 11 2
未引流组 78 41 27 1 44 12 17 3
χ2值   0.281 0.526 0.320 3.026 1.515 1.314
P值   0.596 0.468 0.572 0.082 0.218 0.518
图1 PBD组与未引流组壶腹周围癌患者Kaplan-Meier生存曲线 注：PBD为术前胆道引流
[1]
Lee H, Han Y, Kim JR, et al. Preoperative biliary drainage adversely affects surgical outcomes in periampullary cancer: a retrospective and propensity score-matched analysis[J]. J Hepatobiliary Pancreat Sci, 2018, 25(3):206-213.
[2]
Wang C, Xu Y, Lu X. Should preoperative biliary drainage be routinely performed for obstructive jaundice with resectable tumor?[J]. Hepatobiliary Surg Nutr, 2013, 2(5):266-271.
[3]
Sapisochin G, Ivanics T, Subramanian V, et al. Multidisciplinary treatment for hilar and intrahepatic cholangiocarcinoma: a review of the general principles[J]. Int J Surg, 2020(82S):77-81.
[4]
Nakai Y, Yamamoto R, Matsuyama M, et al. Multicenter study of endoscopic preoperative biliary drainage for malignant hilar biliary obstruction: E-POD hilar study[J]. J Gastroenterol Hepatol, 2018, 33(5):1146-1153.
[5]
Lai EC, Lau SH, Lau WY. The current status of preoperative biliary drainage for patients who receive pancreaticoduodenectomy for periampullary carcinoma: a comprehensive review[J]. Surgeon, 2014, 12(5):290-296.
[6]
Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after[J]. Surgery, 2017, 161(3):584-591.
[7]
Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition[J]. Surgery, 2007, 142(1):20-25.
[8]
Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)[J]. Surgery, 2007, 142(5):761-768.
[9]
Iacono C, Ruzzenente A, Campagnaro T, et al. Role of preoperative biliary drainage in jaundiced patients who are candidates for pancreatoduodenectomy or hepatic resection: highlights and drawbacks[J]. Ann Surg, 2013, 257(2):191-204.
[10]
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.
[11]
Wu JM, Ho TW, Yen HH, et al. Endoscopic retrograde biliary drainage causes intra-abdominal abscess in pancreaticoduodenectomy patients: an important but neglected risk factor[J]. Ann Surg Oncol, 2019, 26(4): 1086-1092.
[12]
Lin SC, Shan YS, Lin PW. Adequate preoperative biliary drainage is determinative to decrease postoperative infectious complications after pancreaticoduodenectomy[J]. Hepatogastroenterology, 2010, 57(101):698-705.
[13]
Saxena P, Kumbhari V, Zein ME, et al. Preoperative biliary drainage[J]. Dig Endosc, 2015, 27(2):265-277.
[14]
Cho JH, Yoon YS, Kim EJ, et al. A multicenter prospective randomized controlled trial for preoperative biliary drainage with uncovered metal versus plastic stents for resectable periampullary cancer[J]. J Hepatobiliary Pancreat Sci, 2020, 27(10):690-699.
[15]
Bonin EA, Baron TH. Preoperative biliary stents in pancreatic cancer[J]. J Hepatobiliary Pancreat Sci, 2011, 18(5):621-629.
[16]
Rungsakulkij N, Thongchai V, Suragul W, et al. Association of the rate of bilirubin decrease with major morbidity in patients undergoing preoperative biliary drainage before pancreaticoduodenectomy[J]. SAGE Open Med, 2021(9):20503121211039667.
[17]
Fujiwara Y, Haruki K, Hamura R, et al. A novel prognostic score combining preoperative biliary drainage and inflammatory status for patients with periampullary cancers[J]. J Gastrointest Surg, 2020, 24(4):813-822.
[18]
王锦程, 余佩和, 苏松, 等. 经内镜鼻胆管引流术与经内镜胆道支架置入术在低位恶性梗阻性黄疸术前胆道引流效果比较的Meta分析[J]. 临床肝胆病杂志, 2021, 37(4):863-867.
[19]
Ito Y, Nakai Y, Isayama H, et al. Impact of preoperative biliary drainage on surgical outcomes in periampullary and hilar malignancy: a single-center experience[J]. Surg Laparosc Endosc Percutan Tech, 2016, 26(2):150-155.
[20]
Shabunin AV, Lebedev SS, Tavobilov MM, et al. Preoperative biliary drainage for malignant biliary obstruction: to drain or not to drain? and if drain, in what way?[J]. Khirurgiia, 2021(6):101-105.
[21]
Tol JA, van Hooft JE, Timmer R, et al. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer[J]. Gut, 2016, 65(12):1981-1987.
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