ACPGBI结直肠癌术后风险评估模型临床应用的初步探索

Preliminary Application of Colorectal Cancer Model of ACPGBI

目的初步验证英国结直肠医师协会结直肠癌术后风险评估模型(The colorectal cancer model of the Association of Coloproctology of Great Britain and Ireland,ACPGBI-CCM)的准确性,探讨其与临床风险预测指标间的关系。方法回顾性分析2007年4月至2007年7月期间四川大学华西医院肛肠外科治疗组收治的诊断明确的结直肠癌患者。通过ACPGBI-CCM为每一位纳入研究的患者计算死亡率预测值,并以死亡率预测值中位数为界,将纳入患者分为低风险组与高风险组,比较2组间不同风险因子的差异;然后对评估指标进行分层分析,探讨其与术后死亡率预测值的关系。结果研究期间本治疗组共收治了99例诊断明确的结直肠癌患者,其中有67例符合纳入条件,平均年龄60.09岁,男34例,女33例;右半结肠癌15例,左半结肠癌9例,直肠癌43例;Dukes分期:A期0例,B期37例,C期24例,D期6例。术后30d内的实际死亡例数为0。ACPGBI-CCM预测的死亡率为0.77%～25.75%,中位值为3.36%,以预测死亡率≤3.36%为低风险组(34例),预测死亡率>3.36%为高风险组(33例),高风险组的死亡率预测值明显高于低风险组〔(8.86±4.51)%vs(1.76±0.68)%,P<0.01〕。高风险组与低风险组间患者年龄、内科合并症、术前有无化疗、ASA分级、术中肿瘤是否切除及手术持续时间差异均有统计学意义(P<0.01);2组间肿瘤并发症、Dukes分期、TNM分期及术后疼痛差异也均有统计学意义(P<0.05);2组间性别、既往腹部手术史、肿瘤距肛缘位置、肿瘤部位、分化程度、术后住院时间及总住院时间差异均无统计学意义(P>0.05)。进一步对各风险评估指标进行分析,发现不同年龄、有无内科合并症、术前化疗、不同ASA分级及肿瘤是否切除会导致不同的死亡率,其差异具有统计学意义(P<0.01);不同Dukes分期和分化程度会引起不同的死亡率,其差异亦有统计学意义(P<0.05);而不同的性别、有无既往腹部手术史、肿瘤并发症、不同TNM分期及不同肿瘤部位之间死亡率风险预测值差异均无统计学意义(P>0.05)。结论ACPGBI-CCM的临床适用性在单一大容量的医疗中心研究中得到肯定,但其预测效果会高估死亡率,这可能是由于地域和人文差异带来的结果。进一步分析发现,合并症、是否行新辅助治疗或辅助治疗可能是结直肠癌患者术后生存质量的独立预测因子,这需要进一步的临床分层次研究来证实。

Objective To validate the accuracy of the colorectal cancer model of the Association of Coloproctology of Great Britain and Ireland （ACPGBI-CCM）, and to find out the relationship between clinical risk factors and the predictive value produced by ACPGBI-CCM. Methods The patients diagnosed definitely as coloreetal cancer in the department of anal-colorectal surgery, West China hospital from April 2007 to July 2007 were analyzed retro spectively. And the predictive value of mortality for each patient was calculated by ACPGBI-CCM, then the differ enee of risk factors was compared by classifying the patients into lower risk group and higher risk group by making the median predictive mortality as a cut point. Results From April 2007 to July 2007, a total of 99 patients diagnosed definitely as colorectal cancer accepted treatment, and among which 67 patients included in this study were ad mitted whose average age was 60.09 years. And there were 34 male and 33 female patients; 15 right hemicolon cancer, 9 left hemicolon cancer, 43 rectal cancer; Dukes staging. A 0 case, B 37 cases, C 24 cases, D 6 cases. The observed mortality 30 days after operation was 0, whereas the predictive mortality was 0.77 % -25.75 % with a median value of 3.36 %. Then the patients whose predictive mortality were ≤3.36 % were grouped as lower risk group （34 cases）, the others higher risk group （33 cases）, and there was strikingly different predictive mortality between two groups （（8.86±4.51）% vs （1.76±0.68）%, P〈0.01]. And between two groups, the age, internal medicine complications, preoperative chemotherapy, ASA grading, cancer resected, and operative time made predominant differences （P〈0. 01）; and the neoplastic complications, Dukes staging, TNM classification, postoperative pain showed differences, too （P〈0.05） ; however, the gender, history of abdominal operation, the distance of the neoplasm to anal edge, the cancer location, differentiated degree, postoperative hospitalization time, and total hospitali- zation time didn＇t have any differences （P〉0.05）. Furthermore, stratification analysis was made for risk factors, and it came out that there were great differences of predictive mortality for different age groups and ASA grading, having internal medicine complications or not, having chemotherapy or not, and for cancer resected or not, and the differences were statistically significant （P〈0.01） ; also different Dukes staging or differentiation could cause different mortality （P〈0.05） ; but the difference of mortality didn＇t make any sense according to gender, having abdominal operative history or not, having neoplastic complications or not, different TNM staging and cancer location （P〉 0.05）. Conclusion The clinical applicability of the ACPGBI-CCM is ascertained in such a large volume single medical centre, but the ACPGBI CCM overpredicts the mortality in this study which may be attributed to the different areas, nations, or the different cultures. The complications and the neo adiuvant or adjuvant therapy are further found out that they may be independent predictive factors of survival, and more research will be needed to prove this.