中国实用外科杂志

中国实用外科杂志 ›› 2025, Vol. 45 ›› Issue (07): 819-825.DOI: 10.19538/j.cjps.issn1005-2208.2025.07.17

• 论著 • 上一篇    下一篇

胰十二指肠切除术围手术期胰腺外分泌功能不全影响因素分析

王    爽，时国东，尹    杰，吴鹏飞，涂    敏，陈建敏，郭    峰，陈国胜，肖    斌，李    强，张    凯，冯    旭，卫积书，高文涛，吴峻立，陆子鹏，蒋奎荣   

  1. 南京医科大学第一附属医院（江苏省人民医院）胰腺中心  南京医科大学胰腺研究所，江苏南京210029
  • 出版日期:2025-07-01 发布日期:2025-07-27

  • Online:2025-07-01 Published:2025-07-27

摘要： 目的    分析胰头区肿瘤病人行胰十二指肠切除术（PD）围手术期胰腺外分泌功能不全（PEI）的影响因素。方法    前瞻性纳入2023年8月至2024年11月南京医科大学第一附属医院胰腺中心收治的拟行PD治疗的266例胰头区肿瘤病人，检测术前和术后1个月病人粪便弹性蛋白酶-1（FE-1）水平，以FE-1 <200 μg/g诊断为PEI。结合病人基线指标、病理类型、手术并发症及术后营养指标等资料，采用单因素及多因素Logistic回归分析PEI的危险因素。结果    （1）术前PEI：发生率为32.2%（57/177），其中胰头癌病人为45.2%（42/93）。多因素Logistic回归分析结果示，术前合并糖尿病（OR=11.49，95%CI 2.36-67.45，P=0.004）、胰头癌（OR=3.16，95%CI 1.28-8.26，P=0.015）、肿瘤体积≥6 cm3（OR=2.99，95%CI 1.23-7.57，P=0.017）、男性（OR=3.05，95%CI 1.20-8.25，P=0.022）、术前主胰管直径≥6 mm（OR=2.86，95%CI 1.11-7.60，P=0.031）、术前BMI<24（OR=2.96，95%CI 1.17-8.07，
P=0.027）是胰头区肿瘤病人PD术前发生PEI的独立危险因素。（2）术后PEI：发生率为85.5%（178/208），其中胰头癌病人为93%（93/100）。多因素Logistic回归分析结果示，术前FE-1≥500 μg/g（OR=4.03，95%CI 1.23-15.80，P=0.028）和术后胰瘘（OR=0.24，95%CI 0.07-0.73，P=0.015）是胰头区肿瘤病人PD术后发生PEI的独立影响因素。（3）围手术期指标变化：术后FE-1水平、体重、BMI、总胆固醇、白蛋白、血钙、血镁、血红蛋白、25-羟维生素D及维生素B12均较术前显著下降，差异有统计学意义（P<0.05）。结论    胰头区肿瘤病人PD术后PEI发生率较术前升高；合并糖尿病、主胰管扩张、肿瘤体积较大、术前低水平BMI、胰头癌及男性病人是术前发生PEI的高危因素；对于术前FE-1水平较低及术后非胰瘘病人，也应警惕术后PEI的发生，必要时应予以胰酶替代治疗；PD病人术后营养指标全面恶化，建议早期强化营养治疗。

关键词: 胰十二指肠切除术, 胰腺外分泌功能不全, 粪便弹性蛋白酶-1, 危险因素

Abstract: To investigate the incidence and influencing factors of exocrine pancreatic insufficiency (PEI) during the perioperative period in patients undergoing pancreaticoduodenectomy（PD）. Methods    A prospective study was conducted, enrolling 266 patients who underwent PD at the Pancreas Center of the First Affiliated Hospital with Nanjing Medical University between August 2023 and November 2024. Fecal elastase-1 (FE-1) levels were measured preoperatively and one month postoperatively, with PEI defined as FE-1<200 μg/g. Based on the patient's pathological type, postoperative complications, and nutritional indicators, risk factors for PEI were analyzed using univariate and multivariate logistic regression. Results    (1) Preoperative PEI（n=177）：The incidence was 32.2% (57/177), highest in pancreatic head carcinoma patients (45.2%, 42/93). Multivariate logistic regression analysis indicated that preoperative diabetes mellitus （OR=11.49，95%CI 2.36-67.45，P=0.004），pancreatic head carcinoma（OR=3.16，95%CI 1.28-8.26，P=0.015），tumor volume ≥6 cm3（OR=2.99，95%CI 1.23-7.57，P=0.017），male gender（OR=3.05，95%CI  1.20-8.25，P=0.022），preoperative main pancreatic duct diameter ≥6 mm（OR=2.86，95%CI 1.11-7.60，P=0.031），and preoperative BMI<24（OR=2.96，95%CI 1.17-8.07，P=0.027） were independent risk factors for preoperative PEI in PD patients. (2) Postoperative PEI（n=208）：The incidence increased to 85.5%（178/208），reaching 93%（93/100） in pancreatic head carcinoma patients. Multivariate logistic regression analysis indicated that preoperative FE-1≥500 μg/g（OR=4.03，95%CI 1.23-15.80，P=0.028） and postoperative pancreatic fistula（OR=0.24，95%CI 0.07-0.73，P=0.015） reduced the risk of postoperative PEI. (3) Perioperative changes：FE-1 levels, body weight, BMI, total cholesterol, albumin, serum calcium, serum magnesium, hemoglobin, 25-hydroxyvitamin D, and vitamin B12 all decreased significantly postoperatively compared with preoperative levels (P<0.05). Conclusion    The incidence of PEI increased after PD compared to preoperatively. Diabetes mellitus, main pancreatic duct dilation, larger tumor size, lower preoperative BMI, pancreatic head carcinoma, and male sex are high-risk factors for preoperative PEI; whereas patients with lower preoperative FE-1 levels and those without postoperative pancreatic fistula should also be monitored for postoperative PEI，pancreatic enzyme replacement therapy should be initiated when necessary. The comprehensive deterioration of nutritional indicators in PD patients postoperatively indicates the need for early intensified nutritional therapy.

Key words: pancreaticoduodenectomy, pancreatic exocrine insufficiency, fecal elastase-1, risk factors