肥胖对腹腔镜结直肠癌根治术后肺部并发症的影响

Impact of obesity on the incidence of postoperative pulmonary complications following laparoscopic colorectal surgery

目的探讨肥胖对腹腔镜结直肠癌根治术后肺部并发症(PPCs)的影响。方法回顾性纳入2023年1至5月在中国医学科学院肿瘤医院行腹腔镜结直肠癌根治术的150例PPCs为中高风险[加泰罗尼亚外科患者呼吸风险评分(ARISCAT)≥26分]的患者。根据患者是否肥胖分为肥胖组和非肥胖组,利用倾向性评分匹配(1∶1)进行临床参数平衡,匹配因素包括年龄、性别、呼吸系统合并症以及术前ARISCAT评分,最终匹配成功的患者共96例,其中肥胖组48例、非肥胖组48例。另外,根据不同手术体位角度将患者分为25°~30°Trendelenburg亚组和±10°~15°Trendelenburg亚组。比较肥胖组和非肥胖组患者PPCs发生率、术中气道压和肺损伤标志物表达水平,包括术后1、3 d外周血可溶性高级糖基化终末产物受体(sRAGE)和血管生成素2(ANG2)。采用单因素Cox风险比例回归模型分析肥胖与术后30 d内发生PPCs的关系。结果肥胖组男35例,女13例,年龄[M(Q_(1),Q_(3))]为60(49,69)岁;非肥胖组男35例,女13例,年龄为60(52,67)岁。肥胖组患者PPCs发生率为50.0%(24/48),高于非肥胖组的20.8%(10/48);1级PPCs发生率、微小肺不张发生率分别为31.3%(15/48)、33.3%(16/48),均高于非肥胖组的12.5%(6/48)、12.5%(6/48)(均P<0.05)。肥胖组患者术中气道峰压和平台压分别为34.0(31.5,36.5)、30.0(27.0,32.0)cmH_(2)O(1 cmH_(2)O=0.098 kPa),高于非肥胖组的26.0(24.0,29.5)、22.0(21.0,26.5)cmH_(2)O(均P<0.001)。肥胖组患者术后3 d的ANG2水平为11.9(8.4,16.5)μg/L,高于非肥胖组的9.2(6.0,12.3)μg/L(P=0.045)。25°~30°Trendelenburg亚组中,肥胖组PPCs发生率为41.4%(12/29),高于非肥胖组的11.4%(4/35)(P=0.005);±10°~15°Trendelenburg亚组中,肥胖组和非肥胖组术后PPCs发生率分别为63.2%(12/19)和46.2%(6/13),差异无统计学意义(P=0.215)。单因素Cox风险比例回归模型结果显示,肥胖是腹腔镜结直肠癌根治术后30 d内发生PPCs的危险因素(HR=3.015,95%CI:1.438~6.321,P=0.001)。结论在接受腹腔镜结直肠癌根治术的PPCs中高风险患者中,肥胖因素增加患者术中气道压力,加剧肺内皮细胞损伤,是患者术后30 d内发生PPCs的危险因素。

Objective To evaluate the effects of obesity on the incidence of postoperative pulmonary complications(PPCs)following laparoscopic colorectal surgery.Methods A total of 150 patients with pathological diagnosis of colorectal cancer who accepted laparoscopic colorectal excision from January to May 2023 were retrospectively recruited.All the patients scored 26 points or more in the Assess Respiratory Risk in Surgical Patients in Catalonia(ARISCAT)model,making them all in intermediate to high risks of PPCs.Patients were divided into obesity group and non-obesity group depending on whether they were obese or not.Propensity score matching(1∶1)was performed to achieve the balance of clinicopathological characteristics with the matching factors of age,sex,respiratory complications and ARISCAT score.A total of 96 patients were eventually enrolled,with 48 patients in obesity group and 48 patients in non-obesity group.Besides,the patients were divided into 25°-30°Trendelenburg subgroup and±10°-15°Trendelenburg subgroup according to surgical sites for further analysis.The incidence of PPCs,the intraoperative airway pressure and blood biomarker expression of lung injury,including soluble receptor for advanced glycation end products(sRAGE)and angiopoietin-2(ANG2)at postoperative day(POD)1 and POD3 between the two groups were compared.The relationship between obesity and incidence of PPCs within 30 postoperative days were analyzed with unifactorial Cox proportional hazard model.Results The obesity group was comprised of 35 males and 13 females with a median age of 60(49,69)years,and the non-obesity group was comprised of 35 males and 13 females with a median age of 60(52,67)years.The incidence of PPCs was 50.0%(24/48)in the obesity group,which was higher than 20.8%(10/48)in the non-obesity group and the incidence of gradeⅠPPCs and microatelectasis were 31.3%(15/48)and 33.3%(16/48),higher than the 12.5%(6/48)and 12.5%(6/48)of the non-obesity group(all P<0.05).The peak airway pressure(Ppeak)and plateau airway pressure(Pplat)of patients in obesity group were 34.0(31.5,36.5)and 30.0(27.0,32.0)cmH_(2)O(1 cmH_(2)O=0.098 kPa),which were significantly higher than the 26.0(24.0,29.5)and 22.0(21.0,26.5)cmH_(2)O of the non-obesity group(all P<0.001).The ANG2 level of the obesity group at POD3 was 11.9(8.4,16.5)μg/L,which was higher than 9.2(6.0,12.3)μg/L of the non-obesity group(P=0.045).In 25°-30°Trendelenburg subgroup,the incidence of PPCs in obese patients were significantly higher than that of non-obese patients[41.4%(12/29)vs 11.4%(4/35),P=0.005].In±10°-15°Trendelenburg subgroup,no significant difference was found in PPCs incidence between obese and non-obese patients[63.2%(12/19)vs 46.2%(6/13),P=0.215].The unifactorial Cox proportional hazard model analysis showed that obesity was a risk factor of PPCs in 30 postoperative days(HR=3.015,95%CI:1.438-6.321,P=0.001).Conclusion In patients undergoing laparoscopic colorectal surgery with intermediate to high risk of PPCs,obesity raises intraoperative airway pressure and aggravates intraoperative lung endothelial injury.Obesity is a risk factor of PPCs in 30 postoperative days.