胰臟切除對於慢性胰臟炎是安全的


  October 17, 2007(紐澳良訊)-慢性胰臟炎接受胰臟切除較癌症手術的全國死亡率低,這可能使得針對適合特定病患進行這種手術以治療慢性胰臟炎的併發症,包括疼痛以及/或是阻塞,是合乎道理的。
  
  這些新發現發表在美國外科醫學會第93屆年度臨床會議,由Joshua Hill醫師發表,他是伍思特市麻州大學醫學院外科住院醫師。
  
  Hill醫師向聽眾表示,在美國,每10萬位民眾就有2~10個慢性胰臟炎的案例,大約80%的病例是因為慢性飲酒的關係,治療選擇包括止痛療法、引流、與胰臟切除。
  
  研究者想要研究胰臟切除手術前後的高風險,這也是限制這項手術用途主要原因;他們透過1998年到2004年的國家住院樣本,以比較慢性胰臟炎患者胰臟切除後術後死亡率,以及因惡性腫瘤進行的手術死亡率。自該資料庫取得主要診斷為慢性胰臟炎或是胰臟癌病患的出院資料,以住院死亡率作為主要試驗終點,數據以變異數分析、卡方檢定、多變項邏輯式迴歸分析。
  
  在總共29,809位病患中,6,407位罹患慢性胰臟炎、2,3408位罹患胰臟癌;平均年齡分別為62.1歲,標準誤差(SE)為0.27,另一組平均年齡為50.9歲(SE,0.50)、65.2歲(SE,0.20)(P<.0001);各組男性病患的比例分別為51.9%、56.8%與50.6%(P<.0001);女性病患的比例分別為80.3%、79.5%與80.5%(P<.003);黑人病患比例為9.5%、12.7%與8.7%(P<.003)。
  
  相較於慢性延臟炎患者,胰臟癌比較可能接受切除手術(11.6%相較於2.1%):72.5%罹患癌症病患接受的是胰臟十二指腸切除、24.1%接受部分胰臟切除術、而3.5%接受全胰臟切除術(P<.001)。
  
  胰臟癌患者整體住院期間死亡率(切除或是未切除)為15.7%、慢性胰臟炎患者為0.6%,胰臟癌患者但未切除病患的住院死亡率為16.8%,慢性胰臟炎患者則是0.6%。
  
  胰臟炎接受切除患者的手術前後死亡率低於癌症患者(胰臟部分切除的死亡率為1.6比上6.1%;P<.0001;胰臟十二指腸切除的死亡率為2.3%比上7.4%;P<.0001);全胰臟切除但不同適應症下的差異,因為樣本數目太小而未達統計上顯著差異。
  
  相較於慢性胰臟炎患者,罹癌患者的死亡率較高(勝算比【OR】,1.8;95% CI為1.6-2.1),而女性相較於男性的死亡率低(OR,0.86;95% CI為0.8-0.9),死亡率經Cox比例風險模式校正。
  
  雖然整個態勢看起來,胰臟切除術對於慢性胰臟炎是安全的,但僅有少部份的患者接受這項手術。
  
  研究者的結論是,慢性胰臟炎患者接受胰臟切除術的死亡率是令人驚訝地低,這可能使得使用這項手術來治療該疾病併發症是合理的。
  
  Albert Lowenfels醫師對Medscape一般外科評論這項研究:這兩種疾病的死亡率差異是令人驚訝的,非常少數的中心進行胰臟切除,而死亡率僅有0.6%;除此之外,僅有少數中心針對非癌症疾病進行胰臟切除,因為可能會有發生不易治療糖尿病的併發症,特別是在酗酒病患身上。
  
  他認為少數病患可能會因此受益,如那些罹患遺傳性胰臟炎的患者;Lowenfels醫師是紐約醫學中心預防醫學與外科教授,也是威徹斯特醫學中心榮譽外科醫師,這兩個中心都在伍哈瓦。他並未參與這項研究。
  
  Hill醫師與Lowenfels醫師都表示無相關資金上的往來。Lowenfels是Medscape一般外科主編群的一員。

Pancreatectomy Safe for Chroni

By Lexa W Lee, ND
Medscape Medical News

October 17, 2007 (New Orleans) — The risk of death nationally after pancreatectomy for chronic pancreatitis is surprisingly low vs comparable operations for cancer. This may justify more use of this procedure in appropriately selected patients to treat complications of chronic pancreatitis, including pain and/or obstructive sequelae.

These new findings were presented here at the American College of Surgeons 93rd Annual Clinical Congress by Joshua Hill, MD, a surgical resident at the University of Massachusetts Medical School in Worcester.

"There are 2 to 10 cases of chronic pancreatitis per 100,000 people in the United States; about 80% of cases are due to chronic alcohol abuse," Dr. Hill told the audience. Treatment choices include analgesic therapy, drainage, and pancreatectomy.

The researchers wanted to investigate the presumed high perioperative risk of pancreatectomy, which has limited its use as a treatment. They used the Nationwide Inpatient Sample 1998 to 2004 to compare postoperative mortality of pancreatic resections performed for chronic pancreatitis with those performed for malignant neoplasm. Data about patient discharges with a primary diagnosis of chronic pancreatitis or pancreatic cancer were obtained from the database. Using in-hospital mortality as the primary outcome, data were analyzed by analysis of variance, chi-square, and multivariable logistic regression.

Of a total of 29,809 patients, 6407 had chronic pancreatitis, vs 23,408 with pancreatic cancer; mean age, respectively, was 62.1 with a standard error (SE) of 0.27, 50.9 (SE, 0.50), and 65.2 (SE, 0.20) (P < .0001); percentage of male patients in each group was 51.9%, 56.8%, and 50.6% (P < .0001); percentage of female patients was 48.1%, 43.2%, and 49.4% (P < .0001); percentage of white patients was 80.3%, 79.5%, and 80.5% (P < .003); and percentage of black patients was 9.5%, 12.7%, and 8.7% (P < .003).

Patients with pancreatic cancer were more likely to undergo resection compared with those with pancreatitis (11.6% vs 2.1%): 72.5% of those with neoplasms had pancreaticoduodenectomy, 24.1% had partial pancreatectomy, and 3.5% had total pancreatectomy (P < .001). Of those with chronic pancreatitis, 52% had partial pancreatectomy, 42.8% had total pancreatectomy, and 5.2% had total pancreatectomy (P < .001).

Overall in-hospital mortality (both resected and nonresected) was 15.7% for those with pancreatic cancer vs 0.6% for those with chronic pancreatitis. In-hospital mortality among just the nonresected patients with pancreatic cancer was 16.8% vs 0.6% for those with chronic pancreatitis.

Perioperative mortality was lower in those who underwent resection for pancreatitis vs cancer (partial resection: 1.6% vs 6.1%; P < .0001; pancreaticoduodenectomy: 2.3% vs 7.4%; P < .0001). Differences among those with total pancreatectomy were not significant because of the small sample size.

There was a higher mortality rate for those with neoplasm vs chronic pancreatitis (odds ratio [OR], 26.5; 95% confidence interval [CI], 21.2 – 33.7), for older vs younger patients (OR, 1.8; 95% CI, 1.6 – 2.1), and for women vs men (OR, 0.86; 95% CI, 0.9 – 0.8). Mortality rates were adjusted by Cox proportion hazards model.

Although the figures show that pancreatectomy is safe for those with chronic pancreatitis, only a small percentage of those patients undergo the procedure.

The researchers concluded that there is a surprisingly low mortality from pancreatectomy for those with chronic pancreatitis, which may justify less restrictive use of this procedure for the treating the complications of this disease.

Albert Lowenfels, MD, commented on the study for Medscape General Surgery: "The difference in mortality rates between the 2 diseases is surprising. Very few centers do pancreatic resection with a 0.6% mortality rate. Also, few centers perform pancreatectomy for nonmalignant disease because of problems with fragile diabetes, especially in alcoholics."

He did concede that "a few patients, such as the ones with hereditary pancreatitis, may benefit." Dr. Lowenfels is a professor of surgery and community preventive medicine at New York Medical Center, and emeritus surgeon in the Department of Surgery at Westchester Medical Center, both in Valhalla. He was not involved with the study.

Dr. Hill and Dr. Lowenfels have disclosed no relevant financial relationships. Dr. Lowenfels is a member of the Medscape General Surgery editorial board.

American College of Surgeons 93rd Annual Clinical Congress: Surgical Forum S81. Presented October 10, 2007.

    
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