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Surgical Efficacy and Quality of Life of Total Pancreatectomy versus Pancreatico- duodenectomy for Pancreatic Cancer: A Retrospective Cohort Study Based on Propensity Score Matching
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摘要:目的
探究全胰切除术(total pancreatectomy, TP)与胰十二指肠切除术(pancreaticoduodenectomy, PD)治疗胰腺癌患者的术后短期并发症与长期预后差异。
方法回顾性收集北京协和医院2016年1月至2021年12月行TP(TP组)和2019年1月至2021年12月行PD(PD组)的胰腺癌患者临床资料。根据危险因素的不同, 将PD组患者分为胰瘘高风险PD组和复发高风险PD组。采用倾向性评分法匹配后, 比较TP组与胰瘘高风险PD组、复发高风险PD组术后短期手术疗效指标(术后并发症发生率、30 d死亡率、住院时间等)、长期手术疗效指标(总生存期)及生活质量差异。
结果共入选符合纳入与排除标准的TP组患者32例, PD组174例(胰瘘高风险PD组99例, 复发高风险PD组15例)。(1)TP组与胰瘘高风险PD组: 经倾向性评分匹配后, 最终纳入TP组患者29例、胰瘘高风险PD组患者56例。TP组无胰瘘发生, 胰瘘高风险PD组胰瘘发生率为19.64%(P=0.027), 两组其他术后并发症发生率、Clavien-Dindo分级、住院时间、ICU停留时间、30 d死亡率等短期手术疗效指标均无统计学差异(P均＞0.05)。中位随访时间36个月时, 两组生命质量核心量表(quality of life questionnaire-core 30, QLQ-C30)评分均无显著差异(P均＞0.05)。(2)TP组与复发高风险PD组: 由于两组基线资料均无统计学差异(P均＞0.05), 故TP组32例患者、复发高风险PD组15例患者均纳入分析。TP组无胰瘘发生, 复发高风险PD组胰瘘发生率为20.00%(P=0.028), 两组其他术后并发症发生率、Clavien-Dindo分级、住院时间、ICU停留时间、30 d死亡率等短期手术疗效指标亦无统计学差异(P均＞0.05)。截至末次随访, 与复发高风险PD组比较, TP组中位总生存期更长(37.68个月比15.24个月, HR=2.551, 95% CI: 1.144~5.689, P=0.018);多因素Cox回归分析显示, 复发高风险PD、术前合并梗阻性黄疸是胰腺癌患者长期预后不良的独立危险因素。
结论对于胰瘘高风险胰腺癌患者, TP可取得与PD相当的短期手术疗效和长期生活质量, 且术后无胰瘘负担。对于复发高风险胰腺癌患者, TP可在保证手术安全性的基础上显著延长患者生存期。
Abstract:ObjectiveTo investigate the differences in postoperative short-term complications and long-term prognosis of pancreatic cancer(PC) patients after total pancreatectomy(TP) and pancreaticoduodenectomy(PD).
MethodsClinical data of PC patients who underwent TP from January 2016 to December 2021(TP group) and PD from January 2019 to December 2021(PD group) at Peking Union Medical College Hospital were retrospectively collected. Patients in the PD group were divided into the pancreatic fistula(PF) high-risk PD group and the recurrence high-risk PD group according to risk factors. After propensity score matching, the differences in postoperative short-term surgical efficacy indicators(postoperative complication rate, 30 d mortality rate, length of hospital stay, etc.), long-term surgical efficacy indicators(overall survival), and quality of life were compared between the TP group and the PF high-risk PD group or the recurrence high-risk PD group.
ResultsA total of 32 patients in the TP group and 114 patients in the PD group(99 patients in the PF high-risk PD group and 15 patients in the recurrence high-risk PD group) meeting the inclusion and exclusion criteria were enrolled.(1)TP group and PF high-risk PD group: after propensity score matching, 29 patients in the TP group and 56 patients in the PF high-risk PD group were finally included. There was no PF in the TP group, and the rate of PF in the PF high-risk PD group was 19.64%(P=0.027).There were no statistical differences in short-term surgical efficacy indicators such as other postoperative complication rates, Clavien-Dindo grading, length of stay, ICU stay, and 30 d mortality between the two groups(all P > 0.05). At the median follow-up time of 36 months, there was no significant difference in the quality of life questionnaire-core 30(QLQ-C30) scores between the two groups(P > 0.05).(2)TP group and recurrent high-risk PD group: Since there were no statistically significant differences between the baseline data of the two groups(P > 0.05), 32 patients in the TP group and 15 patients in the recurrent high-risk PD group were both included in the analysis. There was no PF in the TP group, and the rate of PF in the recurrent high-risk PD group was 20.00%(P=0.028).The other postoperative complication rates, Clavien- Dindo grading, length of hospital stay, ICU stay, 30 d mortality and other short-term surgical efficacy indicators were also not statistically different between the two groups(all P > 0.05). By the final follow-up, the median overall survival was longer in the TP group than the recurrent high-risk PD group(37.68 months vs. 15.24 months, HR=2.551, 95% CI: 1.144-5.689, P=0.018). Multifactorial Cox regression showed that recurrent high-risk PD and preoperative obstructive jaundice were independent risk factors in the poor long-term prognosis of patients with PC.
ConclusionsFor PC patients at high risk of PF, TP can achieve short-term surgical outcomes and long-term quality of life comparable to PD with no burden of postoperative pancreatic fistula. For patients with high-risk recurrence, TP can significantly prolong the survival of PC patients while ensuring surgical safety.
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结肠癌是常见的消化道肿瘤，全球发病率以每年约2%的速度增长，而我国发病率的上升速度更为明显[1-2]。对于未出现远处转移的结肠癌患者，根治性手术是主要的治疗手段，其中已有淋巴结转移的Ⅲ期结肠癌患者更是一组与治疗密切相关的人群。近年来，腹腔镜结肠癌根治术发展迅速，不仅具有创伤小、恢复快等短期疗效优势，而且腹腔镜手术治疗结肠癌的长期生存率亦不劣于传统开腹手术[3-6]。但是，腹腔镜技术对于局部进展期结肠癌的肿瘤学疗效仅在既往研究中作为亚组分析，未见大宗病例报道。本研究旨在评价腹腔镜结肠癌根治性切除术治疗Ⅲ期结肠癌患者的临床疗效和长期预后。
资料和方法
临床资料
收集北京协和医院基本外科结直肠专业组2007年1月至2012年12月收治的Ⅲ期结肠癌手术患者资料，按手术方式分为腹腔镜组和开腹组。排除标准：(1)结肠癌因结肠穿孔或梗阻需要急诊手术；(2)多原发性癌。
所有患者术前通过结肠CT重建或者结肠镜明确肿瘤定位，根据胸部X线片、腹部超声或CT进行分期。术后病理均证实为TNM Ⅲ期结肠腺癌，均给予术后6个月的辅助化疗，方案为奥沙利铂+亚叶酸/5-氟尿嘧啶(FOLFOX-4)或奥沙利铂+卡培他滨(XELOX)。局部复发定义为影像学或组织学检查确定肿瘤位于吻合口及其附近肠管、Trocar孔、切口和盆壁。转移定义为肿瘤位于腹膜和肝脏、肺、脑等其他远隔组织器官。
手术方法
对于肿瘤部位相同的患者，腹腔镜组和开腹组肠管切除长度及淋巴结清扫范围一致。肿瘤位于盲肠及升结肠时行右半结肠切除术，根部结扎回结肠血管和右结肠血管或结肠中血管右支，清扫此区域内淋巴结。肿瘤位于横结肠中部时行横结肠切除术，根部结扎中结肠血管并清扫淋巴结。肿瘤位于降结肠时行左半结肠切除术，根部结扎肠系膜下血管，清扫相应区域淋巴结。肿瘤位于乙状结肠时行乙状结肠切除术，根部结扎乙状结肠血管并清扫相应区域淋巴结。腹腔镜手术行体外或体内(乙状结肠癌时)端-端肠吻合术。
随访情况
术后2年内每3个月随访一次，复查胸部X线、腹部B超、血癌胚抗原和CA19-9，每年复查1次结肠镜，并行胸腹盆增强CT代替X线和B超检查；术后2~5年每6个月随访一次，5年后每年随访一次。复查项目如有异常则进一步行全身骨扫描、MRI/CT、PET-CT等检查以明确复发或转移。本组患者末次随访时间为2014年6月。
统计学处理
采用SPSS 17.0软件进行数据分析。计数资料用卡方检验或者Fisher精确检验。计量资料采用均值±标准差表示，组间比较采用两独立样本t检验或秩和检验。用Kaplan-Meier法计算患者5年总体生存率、无病生存率，用Log-rank法进行组间比较。由手术结束累积至肿瘤死亡的时间为总生存时间；由手术结束累积至复发、转移或非肿瘤死亡的时间为无病生存时间。以双侧检验P＜0.05为差异有统计学意义。
结果
患者临床病理特征
共纳入169例Ⅲ期结肠癌患者，其中腹腔镜组75例，开腹组94例。两组患者在性别、年龄、手术方式、肿瘤分化程度、肿瘤分期上差异均无统计学意义(P＞0.05)。腹腔镜组手术时间显著长于开腹组[(171.3±43.2)min比(132.7±60.4)min，P＜0.001]，但术中出血量显著少于开腹组[(86.3±61.7)ml比(109.8±74.6)ml, P=0.030]。腹腔镜组检出淋巴结数目显著多于开腹组(23.3±12.2比19.3±9.6, P=0.022)(表 1)。
表 1 Ⅲ期结肠癌患者临床病理特征组别 性别(例) 年龄
(x±s，岁)术式(例) 手术时间
(x±s，min)出血量
(x±s，ml)组织分化程度(例) 淋巴结获取数目
(x±s)T分期(例) N分期(例) TNM分期(例) 男 女 右半结肠
切除术横结肠
切除术左半结肠
切除术乙状结肠
切除术高 中 低 T2 T3 T4 N1 N2 Ⅲa Ⅲb Ⅲc 腹腔镜组(n=75) 39 36 63.6±13.3 45 3 5 22 171.3±43.2 86.3±61.7 16 47 12 23.3±12.2 4 60 11 51 24 3 56 16 开腹组(n=94) 53 41 63.8±12.6 43 5 13 32 132.7±60.4 109.8±74.6 10 68 16 19.3±9.6 3 82 9 60 34 2 67 25 P值 0.680 0.929 0.341 ＜0.001 0.030 0.157 0.022 0.441 0.686 0.596 患者局部复发、转移情况及5年生存率
共纳入169例Ⅲ期结肠癌患者，其中腹腔镜组75例，开腹组94例。两组患者在性别、年龄、手术方式、肿瘤分化程度、肿瘤分期上差异均无统计学意义(P＞0.05)。腹腔镜组手术时间显著长于开腹组[(171.3±43.2)min比(132.7±60.4)min，P＜0.001]，但术中出血量显著少于开腹组[(86.3±61.7)ml比(109.8±74.6)ml, P=0.030]。腹腔镜组检出淋巴结数目显著多于开腹组(23.3±12.2比19.3±9.6, P=0.022)(表 1)。
腹腔镜组和开腹组患者的中位随访时间分别为38个月(6~88个月)和32.1个月(8~88.7个月)，差异无统计学意义(P=0.748)。腹腔镜组5例(6.7%)术后局部复发，开腹组8例(8.5%)术后局部复发，两组差异无统计学意义(P=0.876)。腹腔镜组和开腹组分别有21例(28%)和29例(30.9%)患者发生术后远处转移(P=0.815)(表 2)。
表 2 Ⅲ期结肠癌患者术后复发、转移情况(例)组别 局部复发 远处转移 吻合口 腹腔内 总计 肝 骨 肺 脑 卵巢 腹膜后 总计 腹腔镜组(n=75) 0 5 5 15 1 3 1 0 1 21 开腹组(n=94) 1 7 8 21 2 5 0 1 2 29 本组患者5年总生存率和5年无病生存率分别为63.9%和58.7%。其中腹腔镜组和开腹组患者5年累积总生存率分别为73.6%和58.8%(P=0.317)(图 1)；5年累积无病生存率分别为61.6%和56.3% (P=0.544)，差异均无统计学意义(图 2)。
讨论
早在九十年代初腹腔镜技术就开始应用于结肠癌手术中。初期由于腹腔镜结肠癌切除术后切口肿瘤复发以及Trocar孔种植发生率较高[7]，使得人们对于腹腔镜结肠癌手术的肿瘤学安全性产生了疑虑。但是，随着腹腔镜技术的进步和器械的更新，腹腔镜技术在结肠癌治疗中的应用也越来越广泛，其长期的肿瘤学疗效也逐渐被接受[4-6]。
根治性结肠癌切除术至少应该做到：(1)完整系膜切除(complete mesocolic excision, CME)原则以及系膜根部淋巴结的清扫；(2)操作过程中不能造成肿瘤细胞的转移或播散。对于Ⅲ期结肠癌，手术的根治性对于提高预后尤为重要，大量研究也显示，Ⅲ期结肠癌患者的生存率随着检出淋巴结数目的增多而提高[8-10]。本研究中，腹腔镜组获取淋巴结总数为(23.3±12.2)个，而开腹组获取的淋巴结数目为(19.3±9.6)个，两组之间的差异具有统计学意义，检出淋巴结数目与以往文献报道相似[5, 11]。由此可见腹腔镜手术在区域淋巴结清扫上更优于开腹手术，这可能是导致5年总生存率优于开腹手术(73.6%比58.8%)的原因之一，虽然这种差异还没有达到统计学意义。
两组患者的局部复发/远处转移率相当(34.7%比39.4%), 其中开腹组有1例吻合口复发，其余均为腹腔内复发。本研究中两组均无手术切口或Trocar孔复发发生。曾有学者认为腹腔镜操作中气体流动、器械进出和更换等可能会造成脱离的肿瘤细胞种植于穿刺孔而降低腹腔镜结肠癌切除术的肿瘤学安全性[7]。可见随着腹腔镜技术的进步，避免结肠损伤以及常规使用切口保护装置可以有效减少腹腔镜手术中切口或者Trocar孔的复发[12]。
既往研究针对Ⅲ期结肠癌亚组的长期生存分析显示，腹腔镜手术组的5年总生存率(P=0.048)、无病生存率(P=0.048)和肿瘤相关生存率(P=0.02)均显著高于开腹手术组[13]。而在其他研究中，Ⅲ期结肠癌腹腔镜手术组的5年总生存率和无病生存率为72%~77.5%和67%~74.2%, 略高于开腹手术组，但差异无统计学意义[5, 11, 14]。在本研究中，腹腔镜组的5年总生存率和5年无病生存率均高于开腹手术组(73.6%比58.8%和61.6%比56.3%)，但是二者差异均无统计学意义，与文献报道结果相当。这一结果可能得益于腹腔镜手术能够获取更多的淋巴结。
综上，本研究显示，在Ⅲ期结肠癌根治性手术中，腹腔镜手术可以获得不劣于开腹手术的长期预后结果，腹腔镜技术是安全有效的。
作者贡献：李天宇主要完成资料整理、统计学分析及论文撰写；赵邦博、李泽儒、赵宇彤辅助完成资料整理及论文撰写；张太平、戴梦华、郭俊超、韩显林负责研究资料收集；王维斌负责选题、研究设计及论文修订。利益冲突：所有作者均声明不存在利益冲突 -
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图 1 TP组和复发高风险PD组Kaplan-Meier生存曲线
TP、PD：同表 1
Figure 1. Kaplan-Meier survival curves for the TP group and the recurrence high-risk PD group
表 1 TP组和胰瘘高风险PD组基线资料比较
Table 1 Baseline data of the TP group and the pancreatic fistula high-risk PD group
指标 总体(n=131) TP组(n=32) 胰瘘高风险PD组(n=99) P值 年龄(x±s, 岁) 61.14±8.80 61.38±6.54 61.06±9.45 0.861 BMI[M(P25, P75), kg/m2] 22.68(21.19, 24.87) 22.04(19.81, 24.43) 22.99(21.47, 24.87) 0.277 性别[n(%)] 0.339 女 60(45.80) 17(53.12) 43(43.43) 男 71(54.20) 15(46.88) 56(56.57) 新辅助治疗[n(%)] ＞0.999 是 6(4.58) 1(3.12) 5(5.05) 否 125(95.42) 31(96.88) 94(94.95) 高血压[n(%)] 0.377 是 41(31.30) 8(25.00) 33(33.33) 否 90(68.70) 24(75.00) 66(66.67) 糖尿病[n(%)] 0.024 是 44(33.59) 16(50.00) 28(28.28) 否 87(66.41) 16(50.00) 71(71.72) 冠心病[n(%)] 0.418 是 10(7.63) 4(12.50) 6(6.06) 否 121(92.37) 28(87.50) 93(93.94) 胰腺炎[n(%)] 0.965 是 10(7.63) 3(9.38) 7(7.07) 否 121(92.37) 29(90.62) 92(92.93) 梗阻性黄疸[n(%)] 0.078 是 50(38.17) 8(25.00) 42(42.42) 否 81(61.83) 24(75.00) 57(57.58) 低白蛋白血症[n(%)] 0.171 是 14(10.69) 6(18.75) 8(8.08) 否 117(89.31) 26(81.25) 91(91.92) ASA分级≥3级[n(%)] 0.935 是 19(14.50) 4(12.50) 15(15.15) 否 112(85.50) 28(87.50) 84(84.85) 腹腔镜手术[n(%)] 0.087 是 31(23.66) 4(12.50) 27(27.27) 否 100(76.34) 28(87.50) 72(72.73) 手术时间[M(P25, P75)), h] 6.10(5.10, 7.10) 6.25(5.65, 7.00) 6.00(5.10, 7.50) 0.742 术中出血量[M(P25, P75)), mL] 450.00(300.00, 800.00) 600.00(375.00, 800.00) 400.00(250.00, 700.00) 0.116 输血量≥400 mL[n(%)] 0.512 是 63(48.09) 17(53.12) 46(46.46) 否 68(51.91) 15(46.88) 53(53.54) 静脉切除重建[n(%)] 0.026 是 19(14.50) 9(28.12) 10(10.10) 否 112(85.50) 23(71.88) 89(89.90) 保留幽门[n(%)] ＞0.999 是 12(9.16) 3(9.38) 9(9.09) 否 119(90.84) 29(90.62) 90(90.91) PD(pancreaticoduodenectomy)：胰十二指肠切除术；TP(total pancreatectomy)：全胰切除术；BMI(body mass index): 体质量指数；ASA(American Society of Anesthesiologists)：美国麻醉医师协会 
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表 2 TP组和复发高风险PD组基线资料比较
Table 2 Baseline data of the TP group and the recurrence high-risk PD group
指标 总体(n=47) TP组(n=32) 复发高风险PD组(n=15) P值 年龄(x±s, 岁) 61.91±8.06 61.38±6.54 63.07±10.81 0.582 BMI[M(P25, P75)), kg/m2] 22.23(19.92, 24.95) 22.04(19.81, 24.43) 23.20(21.05, 24.95) 0.486 性别[n(%)] 0.659 女 26(55.32) 17(53.12) 9(60.00) 男 21(44.68) 15(46.88) 6(40.00) 新辅助治疗[n(%)] 0.541 是 2(4.26) 1(3.12) 1(6.67) 否 45(95.74) 31(96.88) 14(93.33) 高血压[n(%)] 0.994 是 11(23.40) 8(25.00) 3(20.00) 否 36(76.60) 24(75.00) 12(80.00) 糖尿病[n(%)] 0.132 是 20(42.55) 16(50.00) 4(26.67) 否 27(57.45) 16(50.00) 11(73.33) 冠心病[n(%)] 0.923 是 5(10.64) 4(12.50) 1(6.67) 否 42(89.36) 28(87.50) 14(93.33) 胰腺炎[n(%)] ＞0.999 是 4(8.51) 3(9.38) 1(6.67) 否 43(91.49) 29(90.62) 14(93.33) 梗阻性黄疸[n(%)] 0.806 是 13(27.66) 8(25.00) 5(33.33) 否 34(72.34) 24(75.00) 10(66.67) 低白蛋白血症[n(%)] 0.965 是 8(17.02) 6(18.75) 2(13.33) 否 39(82.98) 26(81.25) 13(86.67) ASA分级≥3级[n(%)] ＞0.999 是 6(12.77) 4(12.50) 2(13.33) 否 41(87.23) 28(87.50) 13(86.67) 腹腔镜手术[n(%)] 0.431 是 8(17.02) 4(12.50) 4(26.67) 否 39(82.98) 28(87.50) 11(73.33) 手术时间[M(P25, P75)), h] 6.10(5.50, 7.00) 6.25(5.65, 7.00) 6.00(5.25, 6.30) 0.303 术中出血量[M(P25, P75)), mL] 500.00(400.00, 800.00) 600.00(375.00, 800.00) 400.00(400.00, 650.00) 0.339 输血量≥400 mL[n(%)] 0.680 是 24(51.06) 17(53.12) 7(46.67) 否 23(48.94) 15(46.88) 8(53.33) 静脉切除重建[n(%)] ＞0.999 是 13(27.66) 9(28.12) 4(26.67) 否 34(72.34) 23(71.88) 11(73.33) 保留幽门[n(%)] ＞0.999 是 4(8.51) 3(9.38) 1(6.67) 否 43(91.49) 29(90.62) 14(93.33) 肿瘤分期[n(%)]* 0.880 Ⅰ 3(6.38) 2(6.25) 1(6.67) Ⅱ 30(63.83) 21(65.62) 9(60.00) Ⅲ 14(29.79) 9(28.12) 5(33.33) TP、PD、BMI、ASA：同表 1；*采用Fisher精确概率法
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表 3 倾向性评分匹配后TP组和胰瘘高风险PD组短期手术疗效比较
Table 3 Comparison of short-term surgical outcomes between the TP group and the pancreatic fistula high-risk PD group after propensity score matching
指标 总体(n=85) TP组(n=29) 胰瘘高风险PD组(n=56) P值 Clavien-Dindo分级≥Ⅲa[n(%)] 0.440 是 10(11.76) 5(17.24) 5(8.93) 否 75(88.24) 24(82.76) 51(91.07) 胰瘘[n(%)] 0.027 是 11(12.94) 0(0) 11(19.64) 否 74(87.06) 29(100) 45(80.36) 胃排空障碍[n(%)] 0.657 是 20(23.53) 6(20.69) 14(25.00) 否 65(76.47) 23(79.31) 42(75.00) 胆瘘[n(%)] ＞0.999 是 3(3.53) 1(3.45) 2(3.57) 否 82(96.47) 28(96.55) 54(96.43) 乳糜瘘[n(%)] 0.220 是 4(4.71) 3(10.34) 1(1.79) 否 81(95.29) 26(89.66) 55(98.21) 腹腔感染[n(%)] 0.926 是 7(8.24) 3(10.34) 4(7.14) 否 78(91.76) 26(89.66) 52(92.86) 术后出血[n(%)] 0.350 是 4(4.71) 0(0) 4(7.14) 否 81(95.29) 29(100) 52(92.86) 30 d死亡[n(%)]* 0.341 是 1(1.18) 1(3.45) 0(0) 否 84(98.82) 28(96.55) 56(100) 住院时间[M(P25, P75)), d] 21.00(17.00, 28.00) 21.00(18.00, 25.00) 21.00(17.00, 30.25) 0.690 ICU停留时间[M(P25, P75)), d] 1.00(0.00, 1.00) 1.00(0.00, 2.00) 1.00(0.00, 1.00) 0.141 呼吸机使用时间[M(P25, P75))，h] 4.00(0.00, 10.00) 4.00(0.00, 15.00) 3.00(0.00, 8.00) 0.208 TP、PD：同表 1；*采用Fisher精确概率法
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表 4 倾向性评分匹配后TP组和胰瘘高风险PD组长期QLQ-C30评分比较[M(P25, P75)), 分]
Table 4 Comparison of long-term QLQ-C30 scores between the TP and pancreatic fistula high-risk PD groups after propensity score matching[M(P25, P75)), score]
指标 总体(n=43) TP组(n=12) 胰瘘高风险PD组(n=31) P值 总体健康状况 75.00(75.00, 83.00) 75.00(75.00, 83.00) 75.00(75.00, 83.00) 0.895 功能相关指标 身体功能 80.00(60.00, 80.00) 60.00(56.75, 80.00) 80.00(60.00, 80.00) 0.224 角色功能 67.00(50.00, 67.00) 67.00(33.00, 67.00) 67.00(50.00, 67.00) 0.697 情绪功能 75.00(67.00, 75.00) 75.00(67.00, 75.00) 75.00(67.00, 75.00) 0.735 认知功能 83.00(67.00, 83.00) 83.00(67.00, 83.00) 83.00(67.00, 83.00) 0.650 社会功能 67.00(50.00, 67.00) 58.50(50.00, 67.00) 67.00(67.00, 67.00) 0.229 症状相关指标 恶心与呕吐 33.00(17.00, 50.00) 33.00(33.00, 54.25) 17.00(17.00, 41.50) 0.065 疼痛 17.00(17.00, 33.00) 17.00(17.00, 33.00) 33.00(17.00, 50.00) 0.323 疲劳 33.00(11.00, 33.00) 33.00(11.00, 35.75) 33.00(22.00, 33.00) 0.895 单项指标 呼吸困难 33.00(0.00, 33.00) 33.00(0.00, 33.00) 33.00(0.00, 33.00) 0.975 失眠 33.00(33.00, 33.00) 33.00(33.00, 41.50) 33.00(16.50, 33.00) 0.256 食欲丧失 33.00(33.00, 50.00) 33.00(33.00, 67.00) 33.00(33.00, 33.00) 0.533 便秘 33.00(0.00, 33.00) 16.50(0.00, 33.00) 33.00(0.00, 33.00) 0.546 腹泻 33.00(33.00, 33.00) 33.00(24.75, 67.00) 33.00(33.00, 33.00) 0.477 经济困难 33.00(33.00, 33.00) 33.00(33.00, 67.00) 33.00(33.00, 33.00) 0.286 QLQ-C30(quality of life questionnaire-core 30)：生命质量核心量表；TP、PD：同表 1
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表 5 TP组和复发高风险PD组短期手术疗效比较
Table 5 Comparative analysis of short-term surgical outcomes between the TP group and the recurrence high-risk PD group
变量 总体(n=47) TP组(n=32) 复发高风险PD组(n=15) P值 Clavien-Dindo分级≥Ⅲa[n(%)] ＞0.999 是 8(17.02) 5(15.62) 3(20.00) 否 39(82.98) 27(84.38) 12(80.00) 胰瘘[n(%)] 0.028 是 3(6.38) 0(0) 3(20.00) 否 44(93.62) 32(100) 12(80.00) 胃排空障碍[n(%)] ＞0.999 是 11(23.40) 7(21.88) 4(26.67) 否 36(76.60) 25(78.12) 11(73.33) 术后出血[n(%)] 0.235 是 3(6.38) 1(3.12) 2(13.33) 否 44(93.62) 31(96.88) 13(86.67) 胆瘘[n(%)] 0.541 是 2(4.26) 1(3.12) 1(6.67) 否 45(95.74) 31(96.88) 14(93.33) 乳糜瘘[n(%)] 0.923 是 5(10.64) 4(12.50) 1(6.67) 否 42(89.36) 28(87.50) 14(93.33) 腹腔感染[n(%)] ＞0.999 是 6(12.77) 4(12.50) 2(13.33) 否 41(87.23) 28(87.50) 13(86.67) 30 d死亡[n(%)]* ＞0.999 是 1(2.13) 1(3.12) 0(0) 否 46(97.87) 31(96.88) 15(100) 住院时间[M(P25, P75)), d] 22.00(18.00, 29.50) 21.00(18.00, 26.00) 28.00(20.00, 31.00) 0.137 ICU停留时间[M(P25, P75)), d] 1.00(0.50, 2.00) 1.00(0.00, 2.00) 1.00(1.00, 1.00) 0.971 呼吸机使用时间[M(P25, P75))，h] 7.00(1.00, 16.00) 4.00(0.00, 17.50) 8.00(3.50, 11.00) 0.721 TP、PD：同表 1；*采用Fisher精确概率法
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表 6 TP组和复发高风险PD组患者长期预后影响因素的Cox比例风险模型分析结果
Table 6 Results of Cox proportional hazards model analysis of factors influencing long-term prognosis in the TP group and the recurrence high-risk PD group
指标 单因素分析 多因素分析 HR(95% CI) P值 HR(95% CI) P值 肿瘤分期(以Ⅰ期为参照) Ⅱ 1.47(0.32~6.70) 0.619 1.11(0.22~5.49) 0.903 Ⅲ 5.34(1.08~26.45) 0.040 4.45(0.87~22.76) 0.073 复发高风险PD(以TP为参照) 2.55(1.14~5.69) 0.022 2.65(1.17~6.02) 0.020 术前合并梗阻性黄疸(以否为参照) 2.32(1.05~5.09) 0.037 2.76(1.18~ 6.49) 0.020 TP、PD：同表 1
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