胃癌根治术围手术期并发症危险因素分析及其对预后的影响

Analysis of risk factor of perioperative complications in patients with radical gastrectomy for gastric cancer and its influence on prognosis

目的探讨接受胃癌根治术治疗的胃癌患者发生围手术期并发症的危险因素及其对预后的影响。方法回顾性收集天津医科大学附属肿瘤医院2009年1月至2011年8月期间行胃癌根治术的1148例胃癌患者的临床、病理及随访资料，对影响胃癌根治术患者围手术期并发症发生的危险因素进行Х^2检验和多因素Logistic回归分析，Cox回归分析围手术期并发症的发生对预后的影响。结果全组1148例患者中男性851例，女性297例，年龄19～89（平均数59．9）岁；发生围手术期并发症312例（27．2％），其中肺部感染140例，腹腔感染53例。多因素Logistic回归分析显示，年龄≥65岁（DJR：0．736，95％CI：0．558—0．971，P：0．030）、血清白蛋白〈35g／L（OR：2．626．95％C1：1．479~4．665，P=0．001）、Borrmann分型为Ⅳ型（OR：0．748，95％CI：0．610—0．917，P=0．005）、肿瘤位于胃上1／3（OR：1．326，95％CI：1．167—1．506，P=0．000）以及联合脏器切除（OR：0．624，95％CI：0．428—0．909，P=0．014）是胃癌根治术患者围手术期并发症发生的独立危险因素；年龄≥65岁（OR：0．548，95％CI：0．379～0．792，P=0．001）、肿瘤位于胃上1／3（OR：1．649，95％CI：1．368～1．988，P=0．000）、未术中化疗（OR：1．671，95％CI：1．146—2．437，P=O．008）是胃癌根治术患者围手术期发生肺部感染的独立危险因素：Borrmann分型为Ⅳ型（OR：0．576，95％CI：0．369—0．900，P=0．015）、进行术中化疗（OR：0．431，95％CI：0．230—0．810，P=0．009）、术中失血量≥400ml（OR：0．411，95％CI：0．176～0．959，P=0．040）以及联合脏器切除（OR：0．412，95％CI：0．215～0．789，P=0．008）是胃癌根治术患者围手术期发生腹腔感染的独立危险因素。全组患者中位生存时间为35个月，5年总生存率为38．7％。围手术期并发症组与无并发症组患者中位生存时间分别为28．0和36．5个月，5年总生存率分别为37．2％和39．3％，两者差异无统计学意义（P=0．259）。多因素Cox回归分析结果显示，未进行术中化疗、行近端次全或全胃切除术、TNM分期Ⅲ期、N，期淋巴结转移、淋巴结外软组织阳性、联合脏器切除以及有脏器衰竭是影响胃癌根治术患者预后的独立危险因素（均P〈0．05）；而围手术期并发症的发生并不是患者的预后影响因素（P=0．259）。结论老年、术前低血清白蛋白水平、肿瘤位于胃上1／3、BorrmannIV型以及术中联合脏器切除的患者发生围手术期并发症的风险较高，但围手术期并发症的发生对患者远期生存并无明显影响。

Objective To study the risk factor of perioperative complication in gastric cancer patients with radical therapy and its influence on prognosis. Methods Clinical, pathological and follow- up data of 1 148 gastric cancer patients undergoing radical gastrectomy at Tianjin Medical University Affiliated Tumor Hospital between January 2009 and August 2011 were retrospectively collected. Pearson 2 test and Logistic regression analysis were used to analyze the risk factor of perioperative complication. Cox regression analysis was used to evaluate the influence of perioperative complications on the prognosis in patients after radical gastrectomy. Kaplan-Meier survival curve was applied to calculate the survival. Results Of 1 148 patients, 851 were male, 297 were female, age ranged from 19 to 89 （average 59.9） years. Perioperative complication occurred in 312 cases （27.2%）, including 140 cases of pulmonary infection and 53 cases of abdominal infection. Multivariate Logistic regression analysis showed that ≥ 65 years old （OR：0.736, 95%CI： 0.558 to 0.971, P=0.030）, serum albumin less than 35 g/L（OR ： 2.626, 95%CI： 1.479 to 4.665, P = 0.001）, Borrmann type Ⅳ （OR ： 0.748, 95%CI： 0.610 to 0.917, P = 0.005）, tumor site at upper 1/3 of stomach （OR：1.326, 95%CI： 1.167 to 1.506, P = 0.000）, combined organ resection （OR ：0.624, 95%CI： 0.428 to 0.909, P = 0.014） were independent risk factors of perioperative complication. Tumor site at upper 1/3 of stomach （OR：1.649, 95%CI： 1.368 to 1.988, P=0.000）, 〉165 years old （OR：0.548, 95%C1：0.379 to 0.792, P=0.O01）, without intraoperative chemotherapy （OR：1.671, 95%CI：1.146 to 2.437, P= 0.008） were independent risk factors of perioperative pulmonary infection; Borrmann type Ⅳ （OR：0.576, 95%CI：0.369 to 0.900, P= 0.015）, with intraoperative chemotherapy （OR：0.431, 95% C1：0.230 to 0.810, P = 0.009）, intraoperative blood loss I〉 400 ml （OR：0.411, 95%C1：0.176 to 0.959, P= 0.040） and combined organ resection （OR：0.412, 95%CI：0.215 to 0.789, P= 0.008） were independent risk factors of perioperative intraperitoneal infection. Cox regression analysis revealed that without intraoperative chemotherapy, proximal subtotal or total gastrectomy, TNM stage III, N3 stage lymph node metastasis, positive soft tissue outside lymph node, combined organ resection and organ failure were independent risk factors affecting the prognosis of gastric cancer patients after radical resection （all P 〈 0.05）, however the perioperative complication was not independent risk factor affecting the prognosis （P = 0.259）. The median survival time was 35 months, and 5-year survival rate was around 38.7%. The median survival time of gastric cancer patients with operative complications and without complications were 28.0 and 36.5 months, and the 5-year survival rates were 37.2% and 39.3%, whose difference was not statistically significant （P = 0.259）. Conclusion There is a higher risk of perioperative complication in those gastric cancer patients with old age, preoperative low serum albumin level, tumor site at upper 1/3 of stomach, Borrmann type IV, intraoperative combined organ resection, while the perioperative complication has no significant effects on the long-term survival.