血栓弹力图测定对远端胆管癌胰十二指肠切除术后出血的预测价值

doi:10.3877/cma.j.issn.2095-3232.2023.02.017

目的

探讨远端胆管癌胰十二指肠切除术（PD）术后出血患者的临床特点及血栓弹力图（TEG）对术后出血的预测价值。

方法

回顾性分析2016年1月至2018年8月在西安交通大学第一附属医院行PD的162例远端胆管癌患者临床资料。其中男100例，女62例；年龄39~78岁，中位年龄64岁。患者均签署知情同意书，符合医学伦理学规定。根据患者是否发生术后出血分为出血组（29例）和未出血组（133例）。两组围手术期情况比较采用秩和检验或χ²检验。将患者肿瘤标志物、凝血功能和TEG相关指标纳入术后出血影响因素分析，采用单因素和多因素Logistic回归分析术后出血的独立影响因素；建立Logistic回归模型，采用ROC曲线判断该模型的预测价值。

结果

出血组患者术后发生胰瘘、胃排空障碍、90 d死亡分别为19、25、5例，未出血组分别为79、57、3例，差异有统计学意义（χ²=32.874，17.899，11.390；P<0.05）。出血组ICU时间、术后住院时间中位数分别为2（0，4）、22（17，34）d，明显长于未出血组的1（0，2）、16（14，19）d（Z=2.014，4.005；P<0.05）。多因素Logistic回归分析显示，TEG测定凝血形成时间K和Plt是远端胆管癌患者PD术后出血的独立影响因素（OR=0.193，0.298；P<0.05），以两者建立的模型预测术后出血的ROC曲线下面积为0.742（95%CI：0.637~0.847）。

结论

远端胆管癌PD术后出血患者容易出现胰瘘、胃排空障碍、早期死亡，基于术前TEG测定及Plt构建模型对术后出血有一定的预测价值。

关键词: 胆管肿瘤, 胰十二指肠切除术, 出血, 血栓弹力图

Objective

To investigate the clinical features of patients with distal cholangiocarcinoma who developed bleeding after pancreaticoduodenectomy (PD) and assess the predictive value of thromboelastography (TEG) in postoperative bleeding.

Methods

Clinical data of 162 patients with distal cholangiocarcinoma who underwent PD in the First Affiliated Hospital of Xi'an Jiaotong University from January 2016 to August 2018 were retrospectively analyzed. Among them, 100 patients were male and 62 female, aged from 39 to 78 years, with a median age of 64 years. The informed consents of all patients were obtained and the local ethical committee approval was received. All patients were divided into the bleeding group (n=29) and non-bleeding group (n=133) according to whether postoperative bleeding occurred. Perioperative conditions between two groups were compared by rank-sum test or Chi-square test. Patients' tumor markers, coagulation function and TEG-related indexes were included in the analysis of influencing factors of postoperative bleeding. The independent influencing factors of postoperative bleeding were identified by univariate and multivariate Logistic regression analyses. Logistic regression model was established, and predictive value of this model was evaluated by ROC curve.

Results

Pancreatic fistula, gastric emptying disturbance and 90-d mortality occurred in 19, 25 and 5 cases in the bleeding group, whereas 79, 57 and 3 cases in the non-bleeding group, significant differences were observed between two groups (χ²=32.874, 17.899, 11.390; P<0.05). In the bleeding group, the median length of ICU stay and length of postoperative hospital stay were 2(0, 4) d and 22(17, 34) d, significantly longer than 1(0, 2) d and 16(14, 19) din the non-bleeding group (Z=2.014, 4.005; P<0.05). Multivariate Logistic regression analysis showed that coagulation time K and Plt measured by TEG were the independent influencing factors of bleeding after PD in patients with distal cholangiocarcinoma (OR=0.193, 0.298; P<0.05). The area under the ROC curve of the model based on these two factors in predicting postoperative bleeding was 0.742 (95%CI:0.637-0.847).

Conclusions

Patients with distal cholangiocarcinoma presenting with postoperative bleeding after PD are prone to pancreatic fistula, gastric emptying disorder and early death. The prediction model based on preoperative TEG measurement and Plt yields certain predictive value for postoperative bleeding.

Key words: Bile duct neoplasms, Pancreaticoduodenectomy, Hemorrhage, Thrombelastography

表1 远端胆管癌PD术后出血患者的临床病理学特征

参数	出血组	未出血组	统计值	P值
年龄(岁，±s)	62±10	63±10	t=-0.081	0.777
男性(例)	17	83	χ²=0.144	0.704
BMI[kg/m²，M(Q_R)]	21(5)	23(5)	Z=-1.278	0.201
糖尿病(例)	3	18	χ²=0.215	0.643
吸烟(例)	12	38	χ²=1.830	0.176
饮酒(例)	3	16	χ²=0.065	0.798
AFP[μg/L，M(Q_R)]	2.7(1.4)	3.1(1.8)	Z=-1.355	0.175
CEA[μg/L，M(Q_R)]	2.3(2.6)	3.2(2.6)	Z=-1.327	0.184
CA125[kU/L，M(Q_R)]	17.8(10.1)	16.0(10.9)	Z=1.137	0.421
CA19-9[kU/L，M(Q_R)]	82(110)	100(349)	Z=-0.805	0.256
TNM分期(例)	29	133	χ²=0.216	0.643
Ⅰ期	9	26
Ⅱ期	13	82
Ⅲ期	7	25
手术时间[min，M(Q_R)]	330(157)	330(131)	Z=0.791	0.429
术中出血量[ml，M(Q_R)]	300(200)	400(400)	Z=-0.679	0.497
胰瘘(例)	19	79	χ²=32.874	0.002
生化胰瘘	3	45
B级胰瘘	10	34
C级胰瘘	6	0
胆漏(例)	1	1	χ²=1.420	0.236
胃排空障碍(例)	25	57	χ²=17.899	<0.001
术后住院时间[d，M(Q_R)]	22(17)	16(5)	Z=4.005	<0.001
ICU时间[d，M(Q_R)]	2(4)	1(2)	Z=2.014	0.044
30 d内再住院(例)	0	2	-	0.509
90 d死亡(例)	5	3	χ²=11.390	0.001

表1 远端胆管癌PD术后出血患者的临床病理学特征

参数	出血组	未出血组	统计值	P值
年龄(岁，±s)	62±10	63±10	t=-0.081	0.777
男性(例)	17	83	χ²=0.144	0.704
BMI[kg/m²，M(Q_R)]	21(5)	23(5)	Z=-1.278	0.201
糖尿病(例)	3	18	χ²=0.215	0.643
吸烟(例)	12	38	χ²=1.830	0.176
饮酒(例)	3	16	χ²=0.065	0.798
AFP[μg/L，M(Q_R)]	2.7(1.4)	3.1(1.8)	Z=-1.355	0.175
CEA[μg/L，M(Q_R)]	2.3(2.6)	3.2(2.6)	Z=-1.327	0.184
CA125[kU/L，M(Q_R)]	17.8(10.1)	16.0(10.9)	Z=1.137	0.421
CA19-9[kU/L，M(Q_R)]	82(110)	100(349)	Z=-0.805	0.256
TNM分期(例)	29	133	χ²=0.216	0.643
Ⅰ期	9	26
Ⅱ期	13	82
Ⅲ期	7	25
手术时间[min，M(Q_R)]	330(157)	330(131)	Z=0.791	0.429
术中出血量[ml，M(Q_R)]	300(200)	400(400)	Z=-0.679	0.497
胰瘘(例)	19	79	χ²=32.874	0.002
生化胰瘘	3	45
B级胰瘘	10	34
C级胰瘘	6	0
胆漏(例)	1	1	χ²=1.420	0.236
胃排空障碍(例)	25	57	χ²=17.899	<0.001
术后住院时间[d，M(Q_R)]	22(17)	16(5)	Z=4.005	<0.001
ICU时间[d，M(Q_R)]	2(4)	1(2)	Z=2.014	0.044
30 d内再住院(例)	0	2	-	0.509
90 d死亡(例)	5	3	χ²=11.390	0.001

表2 远端胆管癌患者PD术后出血的Logistic回归分析

指标	单因素分析			多因素分析
指标	OR	95%CI	P	OR	95%CI	P
R (min)	0.291	0.104~0.816	0.019	0.477	0.134~1.700	0.351
K (min)	0.387	0.159~0.945	0.037	0.193	0.054~0.694	0.012
α(°)	0.346	0.043~2.775	0.318
MA (mm)	0.659	0.285~1.521	0.328
Plt (×10⁹/L)	0.312	0.136~0.719	0.006	0.298	0.092~0.967	0.044
FIB (g/L)	0.542	0.117~2.497	0.432
FDP (mg/L)	0.381	0.162~0.869	0.028	0.507	0.134~1.916	0.594
DD (mg/L)	0.361	0.154~0.845	0.019	0.677	0.185~2.165	0.494
AFP (μg/L)	0.393	0.160~0.968	0.042	0.632	0.185~2.165	0.112
CEA (μg/L)	0.353	0.148~0.840	0.019	0.572	0.188~1.744	0.128
CA125 (kU/L)	0.349	0.143~0.849	0.020	0.613	0.190~1.980	0.393
CA19-9(kU/L)	0.247	0.070~0.868	0.029	0.137	0.016~1.196	0.069

表2 远端胆管癌患者PD术后出血的Logistic回归分析

指标	单因素分析			多因素分析
指标	OR	95%CI	P	OR	95%CI	P
R (min)	0.291	0.104~0.816	0.019	0.477	0.134~1.700	0.351
K (min)	0.387	0.159~0.945	0.037	0.193	0.054~0.694	0.012
α(°)	0.346	0.043~2.775	0.318
MA (mm)	0.659	0.285~1.521	0.328
Plt (×10⁹/L)	0.312	0.136~0.719	0.006	0.298	0.092~0.967	0.044
FIB (g/L)	0.542	0.117~2.497	0.432
FDP (mg/L)	0.381	0.162~0.869	0.028	0.507	0.134~1.916	0.594
DD (mg/L)	0.361	0.154~0.845	0.019	0.677	0.185~2.165	0.494
AFP (μg/L)	0.393	0.160~0.968	0.042	0.632	0.185~2.165	0.112
CEA (μg/L)	0.353	0.148~0.840	0.019	0.572	0.188~1.744	0.128
CA125 (kU/L)	0.349	0.143~0.849	0.020	0.613	0.190~1.980	0.393
CA19-9(kU/L)	0.247	0.070~0.868	0.029	0.137	0.016~1.196	0.069

图1 Logistic回归模型预测远端胆管癌患者PD术后出血的ROC曲线注：PD为胰十二指肠切除术

表3 预测远端胆管癌患者PD术后出血的Logistic回归模型参数

参数	b	SE（b）	Wald χ²	P	OR	95%CI
K	-1.333	0.502	7.069	0.008	0.264	0.099~0.704
Plt	-1.503	0.483	9.702	0.002	0.222	0.086~0.573
常量	0.036	0.443	0.007	0.935	1.037	-

表3 预测远端胆管癌患者PD术后出血的Logistic回归模型参数

参数	b	SE（b）	Wald χ²	P	OR	95%CI
K	-1.333	0.502	7.069	0.008	0.264	0.099~0.704
Plt	-1.503	0.483	9.702	0.002	0.222	0.086~0.573
常量	0.036	0.443	0.007	0.935	1.037	-

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Predictive value of thromboelastography in bleeding after pancreaticoduodenectomy in patients with distal cholangiocarcinoma

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Predictive value of thromboelastography in bleeding after pancreaticoduodenectomy in patients with distal cholangiocarcinoma