Tol Johanna A M G, Busch Olivier R C, van Delden Otto M, van Lienden Krijn P, van Gulik Thomas M, Gouma Dirk J
Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
Surgery. 2014 Sep;156(3):622-31. doi: 10.1016/j.surg.2014.04.026. Epub 2014 Jul 10.
Operative complications after pancreatoduodenectomy can be managed by nonoperative or operative interventions. The aim of this study was to analyze the shift in management of five major complications and their success rates. An algorithm was developed according to predictors for type of intervention and failure of management.
From 1992-2012, patients with pancreaticojejunostomy, hepaticojejunostomy or gastroenterostomy leakage, postpancreatectomy hemorrhage, or primary abscess after pancreatoduodenectomy were selected from a prospectively maintained database. Complications were treated by nonoperative or operative intervention Two cohorts were created according to period of index operation. Pre- and postoperative characteristics were analyzed.
Of 1,037 patients, 263 (25%) experienced operative complications. The incidence of pancreatic fistula increased from 11 to 18%, accompanied by a shift from operative toward nonoperative management. This was also seen in the management of late hemorrhage. Success rates of interventions remained similar for all complications. The incidence of primary abscesses decreased. Early sepsis (odds ratio [OR] 17.8, 95% confidence interval [CI] 4.9-64.4) was associated with failure of nonoperative interventions in patients with pancreatic fistula. Hemodynamic instability (OR 17.2, 95% CI 1.8-160.1) and sepsis (OR 6.7, 95% CI 2.7-16.3) were predictive for operative intervention. Failure of nonoperative intervention (HR 3.95% CI 1.3-7.1) and operative intervention (HR 6.4 95% CI 3.2-12.8) were predictors for poor survival.
The shift towards nonoperative interventions was notable in patients suffering from pancreaticojejunostomy leakage and late hemorrhage. Anastomotic leakage, late hemorrhage, and primary abscesses can be managed nonoperatively however; hemodynamic instability and early sepsis are strong arguments to perform surgery.
胰十二指肠切除术后的手术并发症可通过非手术或手术干预进行处理。本研究的目的是分析五种主要并发症处理方式的转变及其成功率。根据干预类型和处理失败的预测因素制定了一种算法。
从1992年至2012年，从一个前瞻性维护的数据库中选取接受胰空肠吻合术、肝空肠吻合术或胃肠吻合术漏、胰十二指肠切除术后胰周出血或原发性脓肿的患者。并发症通过非手术或手术干预进行治疗。根据首次手术时间创建了两个队列。分析术前和术后特征。
在1037例患者中，263例（25%）出现手术并发症。胰瘘的发生率从11%增加到18%，同时处理方式从手术干预转向非手术干预。晚期出血的处理也出现了这种情况。所有并发症的干预成功率保持相似。原发性脓肿的发生率降低。早期脓毒症（比值比[OR]17.8，95%置信区间[CI]4.9 - 64.4）与胰瘘患者非手术干预失败相关。血流动力学不稳定（OR 17.2，95% CI 1.8 - 160.1）和脓毒症（OR 6.7，95% CI 2.7 - 16.3）是手术干预的预测因素。非手术干预失败（风险比[HR]3.9，95% CI 1.3 - 7.1）和手术干预失败（HR 6.4，95% CI 3.2 - 12.8）是生存不良 的预测因素。
对于胰空肠吻合术漏和晚期出血患者，向非手术干预的转变较为显著。然而，吻合口漏、晚期出血和原发性脓肿可以通过非手术方式处理；血流动力学不稳定和早期脓毒症是进行手术的有力依据。
