中国实用外科杂志

中国实用外科杂志 ›› 2025, Vol. 45 ›› Issue (01): 113-120.DOI: 10.19538/j.cjps.issn1005-2208.2025.01.18

• 论著 • 上一篇    

基于年龄分层的胰腺导管内乳头状黏液性肿瘤手术指征再评估: 2023年版京都指南应用研究

李    勃a,b，史美龙a，康晓超a，袁    帅a，经    纬a，郑楷炼a，李鹏昊a，江爱俊b，周玉坤b，王蓓蕾a，时霄寒a，郭世伟a，金    钢a    

  1. 海军军医大学  a.长海医院肝胆胰外科  b.特色医学中心普外科,上海 200433
  • 出版日期:2025-01-01 发布日期:2025-01-27

  • Online:2025-01-01 Published:2025-01-27

摘要： 目的    2023年版《国际胰腺病协会京都指南：胰腺导管内乳头状黏液性肿瘤的管理》为胰腺导管内乳头状黏液性肿瘤（intraductal papillary mucinous neoplasm，IPMN）的诊疗提出了新的共识，但令人担忧特征（worrisome features，WF）-IPMN病人的手术指征仍不够明确，基于预期寿命的手术时机的把握还有待优化。根据病人年龄分层，探索个性化的手术决策具有重要意义。方法    回顾性分析2012年1月至2023年12月于海军军医大学长海医院行胰腺切除术且术后病理检查诊断为IPMN的542例病人资料。定义积极手术：预期病理检查诊断为中级别异型增生（intermediate-grade dysplasia，IGD）、高级别异型增生 （high grade dysplasia，HGD）或浸润性癌（invasive carcinoma，IC）；常规手术：预期病理检查诊断为HGD或IC；谨慎手术：预期病理检查诊断为IC。评价不同手术指征预测手术决策下预期病理效能的参数包括灵敏度、特异度、受试者工作特征曲线下面积（area under curve，AUC）、约登指数和F1值等。结果    542例IPMN病人，其中371例为WF。 积极手术决策与最大径≥30mm（OR=2.107，95%CI：1.297-3.425，P=0.003）和远端胰腺萎缩（OR=1.672，95%CI：1.032-2.708，P=0.037）独立相关；常规手术决策与CA19-9水平≥ 37kU/L（OR=2.226 ，95%CI：1.377-3.600，P=0.001）和远端胰腺萎缩（OR=2.807，95%CI：1.730-4.557，P <0.001）独立相关；谨慎手术决策与CA19-9≥ 37kU/L（OR=2.850，95%CI：1.687-4.817，P <0.001）、囊壁增厚或强化（OR=2.288，95%CI：1.368-3.828，P =0.002）和远端胰腺萎缩（OR=3.311，95%CI：1.947-5.629，P <0.001）独立相关。远端胰腺萎缩和（或）最大径≥30 mm 作为积极手术的指征，WF数量≥3 个作为谨慎手术的指征，分别预测对应术后预期病理诊断的效能最佳；而常规手术指征中，CA19-9水平 ≥ 37kU/L和（或）远端胰腺萎缩预测术后病理检查诊断的敏感性（0.628）和特异性（0.616）居中，F1值最大（0.535）；WF数量≥3个预测术后病理检查诊断的特异性（0.707）最大，AUC值最大（0.632）。结论    WF-IPMN积极手术指征为最大径≥30 mm和（或）远端胰腺萎缩。远端胰腺萎缩和（或）CA19-9水平≥ 37kU/L作为常规手术指征可避免恶变漏诊。而WF数量≥3个可避免过度手术治疗，适用于部分常规手术和谨慎手术。

关键词: 胰腺囊性肿瘤, 导管内乳头状黏液性肿瘤, 手术指征, 年龄分层, 京都指南

Abstract: The 2023 Kyoto Guidelines have proposed new consensus for the diagnosis and treatment of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. However, the surgical indications for patients with worrisome features (WF) remain unclear, and the timing of surgery based on life expectancy requires further optimization. This study aims to explore personalized surgical decision-making based on patient age stratification.Methods    A retrospective analysis was conducted on 542 patients who underwent pancreatic resection with postoperative pathology confirming IPMN at Changhai Hospital from January 2012 to December 2023. Active surgery was defined as the anticipated pathology diagnosis of intermediate-grade dysplasia (IGD), high-grade dysplasia (HGD), or invasive carcinoma (IC); routine surgery was defined as the anticipated pathology diagnosis of HGD or IC; and cautious surgery was defined as the anticipated pathology diagnosis of IC. Various parameters, including sensitivity, specificity, area under the receiver operating characteristic curve (AUC), Youden's index, and F1 score, were used to evaluate the predictive efficacy of different surgical indications.Results    Among the 542 IPMN patients, 371 had worrisome features (WF). Active surgery decisions were independently associated with maximum diameter ≥ 30 mm (OR = 2.107, 95% CI: 1.297-3.425, P = 0.003) and distal pancreatic atrophy (OR = 1.672, 95% CI: 1.032-2.708, P = 0.037). Routine surgery decisions were independently associated with CA19-9 ≥ 37 kU/L (OR = 2.226, 95% CI: 1.377-3.600, P = 0.001) and distal pancreatic atrophy (OR = 2.807, 95% CI: 1.730-4.557, P < 0.001). Cautious surgery decisions were independently associated with CA19-9 ≥ 37k U/L (OR = 2.850, 95% CI: 1.687-4.817, P < 0.001), cyst wall thickening or enhancement (OR = 2.288, 95% CI: 1.368-3.828, P = 0.002), and distal pancreatic atrophy (OR = 3.311, 95% CI: 1.947-5.629, P < 0.001). Distal pancreatic atrophy and/or maximum diameter ≥ 30 mm were the best predictors for active surgery, while WF count ≥ 3 was the best predictor for cautious surgery. For routine surgery indications, CA19-9 ≥ 37 kU/L and/or distal pancreatic atrophy had moderate sensitivity (0.628) and specificity (0.616), with the highest F1 score (0.535). WF count≥3 predicted the highest specificity (0.707) and AUC (0.632) for postoperative pathology diagnosis.Conclusion    The active surgery indication for WF-IPMN includes a maximum diameter≥30 mm and/or distal pancreatic atrophy. Distal pancreatic atrophy and/or CA19-9≥37 kU/L as routine surgery indications can help avoid missed diagnoses of malignancy. A WF count≥3 can help avoid overtreatment and is applicable to both routine and cautious surgical decisions.

Key words: pancreatic cystic neoplasm, intraductal papillary mucinous neoplasm, surgery indication, age-stratification, kyoto guidelines