摘要
目的基于M-ANNHEIM评分系统评价慢性胰腺炎不同治疗方式的临床疗效。方法采用回顾性横断面研究方法。收集2008年7月至2018年7月2家医疗单位收治的177例慢性胰腺炎患者(四川省人民医院95例、四川大学华西医院82例)的临床病理资料;男100例,女77例;年龄为(49±5)岁,年龄范围为29~72岁。根据M-ANNHEIM慢性胰腺炎临床分期系统进行疾病分期。不同临床分期患者分别选择单纯药物、内镜以及手术治疗。观察指标:(1)患者总体情况及随访情况。(2)无症状期患者治疗情况。(3)Ⅰ期患者治疗情况。(4)Ⅱ期患者治疗情况。(5)Ⅲ期患者治疗情况。(6)Ⅳ期患者治疗情况。(7)糖尿病加重及新发情况。(8)并发症情况。采用门诊、电话、信件、问卷星方式进行随访,随访内容为M-ANNHEIM评分所需要的相关数据。随访时间截至2018年12月。正态分布的计量资料以±s表示,多组间比较采用单因素方差分析。重复测量资料采用重复测量方差分析。计数资料以绝对数表示,组间比较采用χ2检验。结果(1)患者总体情况及随访情况:177例患者治疗前M-ANNHEIM慢性胰腺炎分期无症状期、Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期分别为11、72、55、31、8例。177例患者施行单纯药物治疗、内镜治疗、手术治疗分别为49、49、79例。177例患者均获得随访,随访时间为(2.4±0.5)年。(2)无症状期患者治疗情况:11例无症状期患者均行单纯药物治疗,治疗前M-ANNHEIM评分为(1.91±0.21)分,治疗后1、12、24个月M-ANNHEIM评分分别为(1.27±0.14)分、(1.73±0.19)分、(2.09±0.16)分。(3)Ⅰ期患者治疗情况:72例Ⅰ期患者中,行单纯药物治疗13例,行内镜治疗26例,行手术治疗33例。患者行单纯药物治疗前,治疗后1、12、24个月M-ANNHEIM评分分别为(8.11±1.05)分,(6.31±0.31)分、(7.69±0.24)分、(10.00±0.23)分。行内镜治疗患者上述指标分别为(8.42±0.93)分、(5.13±0.25)分、(6.89±0.20)分、(8.27±0.24)分。行手术治疗患者上述指标分别为(8.13±0.77)分、(4.79±0.15)分、(5.42±0.22)分、(7.76±0.20)分。3种治疗方式治疗前M-ANNHEIM评分比较,差异无统计学意义(F=1.23,P>0.05)。Ⅰ期患者治疗后1个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=2.94,4.98,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异无统计学意义(F=1.26,P>0.05)。Ⅰ期患者治疗后12个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=2.43,5.99,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异有统计学意义(F=4.80,P<0.05)。Ⅰ期患者治疗后24个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=4.61,6.29,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异无统计学意义(F=1.63,P>0.05)。(4)Ⅱ期患者治疗情况:55例Ⅱ期患者中,单纯药物治疗8例,内镜治疗15例,手术治疗32例。患者单纯药物治疗前,治疗后1、12、24个月M-ANNHEIM评分分别为(12.61±1.16)分,(11.63±0.26)分、(12.57±0.30)分、(14.50±0.27)分。行内镜治疗患者上述指标分别为(12.42±1.43)分、(8.47±0.24)分、(11.07±0.21)分、(11.93±0.30)分。行手术治疗患者上述指标分别为(12.53±1.22)分、(8.78±0.15)分、(9.94±0.21)分、(11.00±0.24)分。3种治疗方式治疗前M-ANNHEIM评分比较,差异无统计学意义(F=1.38,P>0.05)。Ⅱ期患者治疗后1个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=8.37,8.48,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异无统计学意义(F=1.13,P>0.05)。Ⅱ期患者治疗后12个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=4.13,8.48,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异有统计学意义(F=3.33,P<0.05)。Ⅱ期患者治疗后24个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=5.61,6.83,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异有统计学意义(F=2.26,P<0.05)。(5)Ⅲ期患者治疗情况:31例Ⅲ期患者中,单纯药物治疗9例,内镜治疗8例,手术治疗14例。患者单纯药物治疗前,治疗后1、12、24个月的M-ANNHEIM评分分别为(17.25±0.89)分,(17.11±0.35)分、(18.44±0.41)分、(17.33±0.44)分。行内镜治疗患者上述指标分别为(17.38±1.06)分、(15.00±0.53)分、(16.50±0.33)分、(16.88±0.44)分。行手术治疗患者上述指标分别为(17.63±1.06)分、(14.64±0.34)分、(16.00±0.35)分、(16.57±0.33)分,3种治疗方式治疗前M-ANNHEIM评分比较,差异无统计学意义(F=1.19,P>0.05)。Ⅲ期患者治疗后1个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=3.37,4.82,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异无统计学意义(F=0.59,P>0.05)。Ⅲ期患者治疗后12个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均有统计学意义(F=3.63,4.48,P<0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异无统计学意义(F=0.95,P>0.05)。Ⅲ期患者治疗后24个月,单纯药物治疗分别与内镜治疗、手术治疗M-ANNHEIM评分比较,差异均无统计学意义(F=0.73,1.41,P>0.05);内镜治疗与手术治疗M-ANNHEIM评分比较,差异无统计学意义(F=0.55,P>0.05)。(6)Ⅳ期患者治疗情况:8例Ⅳ期患者均行单纯药物治疗,治疗前,治疗后1、6、12、24个月M-ANNHEIM评分分别为(17.94±0.59)分,(18.01±0.34)分、(17.54±0.19)分、(17.34±0.26)分、(17.88±0.43)分。(7)糖尿病加重及新发情况:49例内镜治疗患者中,治疗前17例合并糖尿病,治疗后糖尿病加重5例,治疗后新发糖尿病11例;79例手术治疗患者中,治疗前31例合并糖尿病,治疗后糖尿病加重21例,治疗后新发糖尿病7例;两种治疗方式糖尿病加重和新发糖尿病比较,差异均有统计学意义(χ2=2.07,2.04,P<0.05)。(8)并发症情况:49例单纯药物治疗患者中,未发生治疗相关并发症。49例内镜治疗患者中,支架相关并发症4例经内镜重新安置支架后治愈,急性胰腺炎6例,消化道出血2例(1例经内镜下止血治愈),其余并发症经对症支持治疗后好转。79例手术治疗患者中,术后胰瘘17例(生化漏11例、B级胰瘘5例、C级胰瘘1例),术后胃瘫3例,术后腹腔感染3例,深静脉血栓形成1例,术后出血2例(1例合并C级胰瘘经再次开腹止血缝合后好转、1例经介入治疗后好转),其余并发症经对症支持治疗后好转。结论慢性胰腺炎应根据不同病情分期制订个体化治疗方案,M-ANNHEIM评分系统可用于评价单纯药物、内镜及手术治疗的临床疗效。
Objective To evaluate the clinical efficacy of different treatment methods for chronic pancreatitis based on M-ANNHEIM system.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 177 patients with chronic pancreatitis from two medical centers between July 2008 and July 2018 were collected,including 95 in the Sichuan Provincial People′s Hospital and 82 in the West China Hospital of Sichuan University.There were 100 males and 77 females,aged(49±5)years,with a range from 29 to 72 years.The M-ANNHEIM system was used to decide clinical stages of chronic pancreatitis.Patients in different clinical stages received drug,endoscopic or surgical treatment.Observation indicators:(1)general data and follow-up of patients;(2)treatment of patients in asymptomatic stage;(3)treatment of patients in stageⅠ;(4)treatment of patients in stageⅡ;(5)treatment of patients in stageⅢ;(6)treatment of patients in stageⅣ;(7)aggravation and new-onset of diabetes;(8)complications.Follow-up using outpatient examination,telephone,mail,and Sojump was performed to collect data for M-ANNHEIM system up to December 2018.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed by the AVONA.Repeated measurement data were analyzed using repeated ANOVA.Count data were described as absolute numbers,and comparison between groups was conducted using the chi-square test.Results(1)General data and follow-up of patients:there were 11,72,55,31,and 8 patients with chronic pancreatitis classified as asymptomatic stage,stageⅠ,stageⅡ,stageⅢ,stageⅣof M-ANNHEIM system before treatment.Of the 177 patients,49,49,and 79 patients underwent drug,endoscopic and surgical treatment,respectively.All the 177 patients were followed up for(2.4±0.5)years.(2)Treatment of patients in asymptomatic stage:11 patients in asymptomatic stage underwent drug treatment.The M-ANNHEIM score was 1.91±0.21 before treatment,and 1.27±0.14,1.73±0.19,2.09±0.16 at 1 month,12 months,24 months after treatment,respectively.(3)Treatment of patients in stageⅠ:of the 72 patients in stageⅠ,13 underwent drug treatment,26 underwent endoscopic treatment,and 33 underwent surgical treatment.The M-ANNHEIM score of patients undergoing drug treatment was 8.11±1.05 before treatment,and 6.31±0.31,7.69±0.24,10.00±0.23 at 1 month,12 months,24 months after treatment,respectively.The M-ANNHEIM score of patients undergoing endoscopic treatment was 8.42±0.93 before treatment,and 5.13±0.25,6.89±0.20,8.27±0.24 at 1 month,12 months,24 months after treatment,respectively.The M-ANNHEIM score of patients undergoing surgical treatment was 8.13±0.77 before treatment,and 4.79±0.15,5.42±0.22,7.76±0.20 at 1 month,12 months,24 months after treatment,respectively.There was no significant difference in M-ANNHEIM score before treatment between patients receiving different treatments(F=1.23,P>0.05).For patients in M-ANNHEIM stageⅠ,at 1 month after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment(F=2.94,4.98,P<0.05);there was no significant difference in M-ANNHEIM score between patients receiving endoscopic treatment and patients receiving surgical treatment(F=1.26,P>0.05).At 12 months after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment,between patients receiving endoscopic treatment and patients receiving surgical treatment(F=2.43,5.99,4.80,P<0.05).At 24 months after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment(F=4.61,6.29,P<0.05);there was no significant difference in M-ANNHEIM score between patients receiving endoscopic treatment and patients receiving surgical treatment(F=1.63,P>0.05).(4)Treatment of patients in stageⅡ:of the 55 patients in stageⅡ,8 underwent drug treatment,15 underwent endoscopic treatment,and 32 underwent surgical treatment.The M-ANNHEIM score of patients undergoing drug treatment was 12.61±1.16 before treatment,and 11.63±0.26,12.57±0.30,14.50±0.27 at 1 month,12 months,24 months after treatment,respectively.The above indicators of patients undergoing endoscopic treatment was 12.42±1.43,8.47±0.24,11.07±0.21,11.93±0.30,respectively.The above indicators of patients undergoing surgical treatment was 12.53±1.22,8.78±0.15,9.94±0.21,11.00±0.24,respectively.There was no significant difference in M-ANNHEIM score before treatment between patients receiving different treatments(F=1.38,P>0.05).For patients in M-ANNHEIM stageⅡ,at 1 month after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment(F=8.37,8.48,P<0.05);there was no significant difference in M-ANNHEIM score between patients receiving endoscopic treatment and patients receiving surgical treatment(F=1.13,P>0.05).At 12 months after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment,between patients receiving endoscopic treatment and patients receiving surgical treatment(F=4.13,8.48,3.33,P<0.05).At 24 months after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment,between patients receiving endoscopic treatment and patients receiving surgical treatment(F=5.61,6.83,2.26,P<0.05).(5)Treatment of patients in stageⅢ:of the 31 patients in stageⅢ,9 underwent drug treatment,8 underwent endoscopic treatment,and 14 underwent surgical treatment.The M-ANNHEIM score of patients undergoing drug treatment was 17.25±0.89 before treatment,and 17.11±0.35,18.44±0.41,17.33±0.44 at 1 month,12 months,24 months after treatment,respectively.The above indicators of patients undergoing endoscopic treatment was 17.38±1.06,15.00±0.53,16.50±0.33,16.88±0.44,respectively.The above indicators of patients undergoing surgical treatment was 17.63±1.06,14.64±0.34,16.00±0.35,16.57±0.33,respectively.There was no significant difference in M-ANNHEIM score before treatment between patients receiving different treatments(F=1.19,P>0.05).For patients in M-ANNHEIM stageⅢ,at 1 month after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment(F=3.37,4.82,P<0.05);there was no significant difference in M-ANNHEIM score between patients receiving endoscopic treatment and patients receiving surgical treatment(F=0.59,P>0.05).At 12 months after treatment,there was a significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment(F=3.63,4.48,P<0.05);there was no significant difference in M-ANNHEIM score between patients receiving endoscopic treatment and patients receiving surgical treatment(F=0.95,P>0.05).At 24 months after treatment,there was no significant difference in M-ANNHEIM score between patients receiving drug treatment and patients receiving endoscopic treatment,between patients receiving drug treatment and patients receiving surgical treatment,between patients receiving endoscopic treatment and patients receiving surgical treatment(F=0.73,1.41,0.55,P>0.05).(6)Treatment of patients in stageⅣ:8 patients in stageⅣunderwent drug treatment.The M-ANNHEIM score of patients was 17.94±0.59 before treatment,and 18.01±0.34,17.54±0.19,17.34±0.26,17.88±0.43 at 1 month,6 months,12 months,24 months after treatment,respectively.(7)Aggravation and new-onset of diabetes:of 49 patients undergoing endoscopic treatment,17 had diabetes before treatment,5 had aggravated diabetes and 11 had new-onset of diabetes after treatment.Of 79 patients undergoing surgical treatment,31 had diabetes before treatment,21 had aggravated diabetes and 7 had new-onset of diabetes after treatment.There were significant differences in the aggravation and new-onset of diabetes between the two groups(χ2=2.07,2.04,P<0.05).(8)Complications:49 patients undergoing drug treatment had no treatment related complications.Of 49 patients undergoing endoscopic treatment,4 patients with stent related complications were cured after replacing stent under endoscopy,6 patients had acute pancreatitis,2 had gastrointestinal bleeding including 1 patient was cured after endoscopic hemostasis,other patients with complications were improved after symptomatic and supportive treatment.Of 79 patients undergoing surgical treatment,17 had pancreatic leakage(including 11 of biochemical leakage,5 of grade B pancreatic leakage,and 1 of grade C pancreatic leakage),3 had postoperative gastroparesis,3 had intraabdominal infection,1 had deep venous thrombosis,2 had hemorrhage of which 1 combined with grade C pancreatic leakage was improved after open hemostasis and 1 was improved after interventional treatment,other patients with complications were improved after symptomatic and supportive treatment.Conclusions For chronic pancreatitis,individualized treatment should be formulated according to the different stages.M-ANNHEIM score system can be used the evaluate clinical efficacies of drug treatment,endoscopic treatment,and surgical treatment.
作者
向光明
邹海波
姚豫桐
骆乐
罗兰云
刘续宝
黄孝伦
Xiang Guangming;Zou Haibo;Yao Yutong;Luo Le;Luo Lanyun;Liu Xubao;Huang Xiaolun(Department of Hepato-pancreato-biliary Surgery,Cell Transplantation Center,Sichuan Provincial People′s Hospital,Affiliated Hospital of School of Medicine of University of Electronic Science and Technology of China,Chengdu 610000,China;Department of Pancreatic Surgery,West China Hospital of Sichuan University,Chengdu 610000,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2020年第4期401-407,共7页
Chinese Journal of Digestive Surgery
基金
四川省卫计委科研课题(16PJ430)
四川省科技厅重大研究计划(2018SZ0110)。
