Department of Surgery, Emory University, Atlanta, GA.
Department of Surgery, Emory University, Atlanta, GA; Winship Cancer Institute, Emory University, Atlanta, GA.
J Am Coll Surg. 2020 Apr;230(4):393-402.e3. doi: 10.1016/j.jamcollsurg.2019.12.016. Epub 2020 Jan 23.
Literature is varied regarding risk factors associated with diabetes development after major pancreatic resection. The aim was to develop and validate a scoring index that preoperatively predicts the development of diabetes after pancreaticoduodenectomy and distal pancreatectomy.
In this prospective study, perioperative fasting and postprandial (OGTT, oral glucose tolerance test) plasma glucose, glycated hemoglobin A1c (HbA1c), insulin, and c-peptide were measured in select consecutive patients undergoing pancreaticoduodenectomy and distal pancreatectomy by the senior author, from 2007 to 2018. American Diabetes Association definitions were used for glycemic classifications. Statistical analyses included multivariate generalized estimated equation for factor identification and variable weighting; area under the receiver operating curve (ROC) c-statistic for predictive ability, and survival analysis risk score grouping.
Of 1,083 included patients with preoperative normoglycemia (253; 23.4%), prediabetes (362; 33.4%), and diabetes (468; 43.2%), the overall postoperative incidence of each diabetic class at 120 months was 152 (14.0%), 466 (43.0%), and 465 (42.9%), respectively. The development and validation groups included 1,023 and 60 patients, respectively. Five factors were identified predicting diabetes development, with a total possible score of 8. The C-statistics for development and validation groups were 0.727 (CI 0.696 to 0.759, p < 0.001) and 0.823 (CI 0.718 to 0.928, p < 0.001), respectively. At a cut point of 3 (sensitivity 0.691, specificity 0.644) the Post-pancreatectomy Diabetes Index (PDI) independently predicted diabetes in development (odds ratio [OR] 4.298, relative risk [RR] 2.486, CI 1.238 to 5.704, p < 0.001) and validation (OR 6.970, RR 2.768, CI 2.182 to 22.261, p < 0.001) groups. The PDI similarly predicted pre-diabetes in development (OR 1.961, RR 1.325, CI 1.202 to 2.564, p < 0.001) and validation (OR 4.255, RR 1.798, CI 1.247 to 14.492, p = 0.021) groups.
The Post-pancreatectomy Diabetes Index predicts the development of diabetes and pre-diabetes in patients undergoing major pancreatectomy using routine endocrine laboratories and pre-surgical clinical data.
有关主要胰腺切除术后发生糖尿病的危险因素，文献报道不一。本研究旨在建立并验证一种评分指数，以预测胰十二指肠切除术和胰体尾切除术患者术后糖尿病的发生。
在这项前瞻性研究中，由资深作者对 2007 年至 2018 年间连续进行胰十二指肠切除术和胰体尾切除术的患者进行围手术期禁食和餐后（OGTT，口服葡萄糖耐量试验）血浆血糖、糖化血红蛋白 A1c（HbA1c）、胰岛素和 C 肽测定。采用美国糖尿病协会的血糖分类标准进行血糖分类。统计分析包括多变量广义估计方程确定因素和变量权重；受试者工作特征曲线（ROC）下面积（C 统计量）预测能力，以及生存分析风险评分分组。
在术前血糖正常（253 例，23.4%）、糖尿病前期（362 例，33.4%）和糖尿病（468 例，43.2%）的 1083 例患者中，术后 120 个月时，每个糖尿病类别的总体发生率分别为 152 例（14.0%）、466 例（43.0%）和 465 例（42.9%）。发展和验证组分别纳入了 1023 例和 60 例患者。确定了 5 个预测糖尿病发生的因素，总得分可能为 8 分。发展组和验证组的 C 统计量分别为 0.727（CI 0.696 至 0.759，p<0.001）和 0.823（CI 0.718 至 0.928，p<0.001）。在 3 分（灵敏度 0.691，特异性 0.644）的切点时，胰切除术糖尿病指数（PDI）可独立预测发展组（比值比[OR]4.298，相对风险[RR]2.486，CI 1.238 至 5.704，p<0.001）和验证组（OR 6.970，RR 2.768，CI 2.182 至 22.261，p<0.001）的糖尿病。PDI 也可预测发展组的糖尿病前期（OR 1.961，RR 1.325，CI 1.202 至 2.564，p<0.001）和验证组（OR 4.255，RR 1.798，CI 1.247 至 14.492，p=0.021）。
胰切除术糖尿病指数可利用常规内分泌实验室和术前临床数据预测行胰十二指肠切除术和胰体尾切除术患者糖尿病和糖尿病前期的发生。
