比較胰臟全切除術與胰十二指腸切除術之術後糖尿病患者之疲倦、自我照顧行為與生活品質之相關性

Abstract

背景：胰臟全切除術之術後胰源性糖尿病是現今此手術執行率低的原因之一。然而，隨著治療進步，患者的內外分泌障礙能得到更好的控制；此外，由於對胰臟良性腫瘤、神經內分泌瘤等研究及了解增加，診斷出瀰漫性胰臟腫瘤人數日漸增加，使胰臟全切除術的需求也增加，而患者術後與胰源性糖尿病共存之生活品質是否比部分胰臟切除術後糖尿病患者差，是目前具爭議的議題。 目的：本研究目的為探討胰臟術後糖尿病患者之疲倦、自我照顧行為及生活品質之相關性，並比較胰臟全切除術後及胰頭十二指腸切除術後糖尿病患者的差異。 方法：採相關性、比較性之橫斷式研究設計，以結構式問卷收集資料，採立意取樣，於2016年11月30日至2017年5月31日，於北部某醫學中心之胰臟外科門診追蹤之胰臟全切除或胰頭十二指腸切除術後糖尿病患者為收案對象，有效問卷共50份。以IBM SPSS Statistics 24.0版分析資料，並以傾向分數1:2配對。統計方法包含描述性統計、曼─惠特尼U檢定、卡方檢定或費雪精確檢定、廣義估計方程式、史丕曼等級相關及逐步複迴歸分析。 結果: (1)胰臟全切除術後組疲倦持續時間統計上顯著高於胰頭十二指腸切除術後組(β = 2.36, p = .019)；胰臟全切除術後組疲倦干擾統計上顯著高於胰頭十二指腸切除術後組(β = 1.52, p = .035)，尤其在一般活動(β = 2.13, p = .009)、工作活動(β = 2.17, p = .009)、專注能力(β = 1.37, p = .012)、人際關係 (β = 1.31, p = .013)、享受生活(β = 2.66, p = .005)等面向。(2)在自我照顧行為中，胰臟全切除術後組一週中，一天所吃的蔬菜水果加起來超過5份的平均天數為統計上顯著低於胰頭十二指腸切除術後組。(3)兩組整體生活品質沒有統計上顯著差異；胰臟全切除術後組之身體功能平均分數統計上顯著低於胰頭十二指腸切除術後組(β = -22.64, p= .001)；胰臟全切除術後組之失眠平均分數統計上顯著高於胰頭十二指腸切除術後組(β = 54.88, p < .001)，其他常見症狀則未發現統計上顯著的結果。(4)在整體生活品質與疲倦之分析中，疲倦總分(rs = -0.62, p < .01)、疲倦強度(rs = -0.58, p < .01)、疲倦干擾(rs = -0.63, p < .01)及疲倦時間(rs = -0.56, p < .01)與生活品質有統計上顯著的負相關；自我照顧行為總分(rs = 0.32, p < .05)、運動行為(rs = 0.41, p < .01)與生活品質有統計上顯著的正相關。疲倦總分及自我照顧行為總分是整體生活品質的顯著相關因素，共可解釋43.5%的變異量；在分項分析中，疲倦干擾及運動是整體生活品質的顯著相關因素，共可解釋38.8%的變異量。 結論：本研究發現胰臟全切除術後及胰頭十二指腸切除術後糖尿病患者之整體生活品質沒有統計上顯著差異，但在疲倦、自我照顧行為、常見症狀等有差異，且自我照顧行為及疲倦為影響生活品質之重要因素。依本研究結果，將糖尿病自我照顧行為相關衛教與疲倦症狀處理整合，並依據病人需要提供建議，能幫助胰臟術後糖尿病患者的整體生活品質提升。國內外目前尚未見此族群之疲倦、自我照顧行為及生活品質之研究，本研究之發現能提供臨床上照顧此族群之醫護人員參考。

Background: Pancreatogenic diabetes resulted from total pancreatectomy (TP) is one of the reason why this form of surgery technique is seldom performed. However, with the progress of medical and surgical care nowadays, patients undergone TP could receive better care in endocrine and exocrine insufficiency. In addition, with better understanding of benign pancreatic tumors and pancreatic neuroendocrine tumors, more patients with diffused pancreatic disease are diagnosed; hence, the performance of TP may rise. Nevertheless, the quality of life of patients with pancreatogenic diabetes after TP is still currently controversial. Purpose: The purposes of this study were to (1) explore the association of fatigue, self-care activities and quality of life in patients with pancreatogenic diabetes after pancreatic surgey; (2) compare the data between diabetic patients after TP and pancreaticoduodenectomy (PD). Methods: A correlational and comparative cross-sectional approach was used. The data was collected with a structured questionnaire via purposive sampling of 50 subjects in an outpatient pancreatic surgical department. The data went through propensity score 1:2 matching and was analyzed by IBM SPSS Statistics 24.0 using descriptive statistics, Mann-Whitney U Test, Chi-squared Test or Fisher’s Exact Test, Generalized Estimating Equation, Spearman’s correlation, and Stepwise multiple regression. Results: (1) The TP group had longer period of fatigue time than PD group (β = 2.36, p = .019)；the TP group reported more fatigue interference than PD group (β = 1.52, p = .035), especially in general activities (β = 2.13, p = .009), work activities (β = 2.17, p = .009), ability to focus (β = 1.37, p = .012), relationships(β = 1.31, p = .013), and enjoying life (β = 2.66, p = .005). (2) The TP group reported less days in a week of consuming at least 5 portions of fruits and vegetables than PD group (β = -2.30, p < .001). (3) The two groups showed no statistical significant difference in overall quality of life; however, TP group had lower physical function (β = -22.64, p = .001) and higher level of insomnia (β = 54.88, p < .001) than PD group. (4) In overall patients recruited, total fatigue (rs = -0.62, p < .01), fatigue intensity (rs = -0.58, p < .01), fatigue interference (rs = -0.63, p < .01), and fatigue duration (rs = -0.56, p < .01) were negatively correlated with overall quality of life. Total self-care activities (rs = 0.32, p < .05), exercise behavior (rs = 0.41, p < .01) were positively correlated with overall quality of life. Fatigue and self-care activities were significant factors of quality of life and could explain 43.5% of the variance of quality of life; in subgroup analysis, fatigue interference and exercise could explain 38.8% of the variance of overall quality of life. Conclusions: The present study suggested no difference in quality of life in TP and PD patients; however, there were differences in fatigue characteristics, self-care activities, and common symptoms between the two groups; additionally, fatigue characteristics and self-care activities were significant factors that influence quality of life. According to this study, to improve patients’ quality of life, self-care education and fatigue management should be integrated and provided to this population according to individual needs. This is one of the first studies on fatigue, self-care, and quality of life in diabetic patients post pancreatic surgery; the findings in this study may provide healthcare providers with some reference regarding the care for patients with pancreatogenic diabetes after pancreatic surgery.