术后白蛋白下降分数对直肠癌保肛术后并发症及长期预后的预测价值

Predictive values of proportional postoperative reduction of albumin for postoperative complications and long-term outcomes following sphincter-preserving surgery for rectal cancer

目的探讨术后白蛋白下降分数(△ALB)在预测直肠癌保肛术后并发症方面的临床价值,并且考察△ALB是否影响患者长期预后。方法采用病例-对照研究方案,回顾性分析2010年7月至2016年6月在本科行直肠癌保肛术的809例患者的临床资料,其中女性345例,男性464例,年龄(60.3±11.2)岁。按照Clavien-Dindo评价系统进行术后并发症分级,应用受试者工作特征曲线(ROC)评价△ALB的预测作用。根据△ALB水平的第一、第三四分位数将患者分为3组,采用χ^(2)趋势检验分析各组间并发症发生率的变化趋势,应用Logistic回归模型分析术后并发症的独立危险因素,应用Kaplan-Meier法绘制生存曲线,并计算总生存率、无病生存率,通过Log-rank法对比生存结果差异。结果在809例手术中,腹腔镜手术669例,腹腔镜中转开腹手术22例,中转率为3.2%,开腹手术118例。术后226例患者出现了并发症,并发症发生率为27.9%,术后并发症发生率在△ALB各分组间呈递增趋势(χ趋势2=7.955,P=0.005)。多因素分析显示:△ALB高水平组(△ALB≥34.7%)患者术后发生并发症的风险是△ALB低水平组(△ALB<21.9%)患者的1.791倍(OR=1.791,95%CI:1.139~2.817,P=0.012)。并发症组和无并发症组的5年总生存率分别为76.6%、81.6%,5年无病生存率分别是65.4%、74.7%,两组在总生存率方面差异无统计学意义(χ^(2)=2.836,P=0.092),两组无病生存率比较差异有统计学意义(χ^(2)=5.875,P=0.015)。△ALB各水平组患者在术后总生存率和无病生存率方面的差异均无统计学意义。结论△ALB是直肠癌保肛术患者术后发生并发症的独立危险因素,预测术后并发症经济、方便、术后反应快。术后并发症影响患者的远期生存状况,关注术后白蛋白变化可能有助于改善患者长期预后。

Objective To investigate clinical values of proportional postoperative reduction of albumin(ΔALB) in the prediction of postoperative complications following sphincter-preserving surgery for rectal cancer and evaluate whether it affects long-term outcomes. Methods A case-control trail was performed on 809 rectal cancer patients(345 females and 464 males, at an average age of 60.3±11.2 years) undergoing sphincter-preserving surgery in our department between July 2010 and June 2016. Postoperative complications were graded using Clavien-Dindo classification. Receiver operating characteristic(ROC) curve analysis was employed to assess the predictive values of ΔALB. The patients were divided into 3 groups based on the first and third quartiles of the ΔALB level. Chi-square test for trend was performed to analyze the change tendency in the incidence of postoperative complications among the 3 groups. Logistic regression analysis was conducted to identify independent risk factors for postoperative complications. Overall survival(OS) and disease-free survival(DFS) were calculated using Kaplan-Meier survival curve and compared by Log-rank test. Results Among the 809 surgical cases, laparoscopic surgery was accomplished in 669 cases, 22 cases required converted open surgery(a conversion rate of 3.2%), and 118 cases underwent open surgery. Postoperative complications occurred in 226 patients, with a rate of 27.9%, and an increased trend of the rate was displayed among the ΔALB groups(Chi-square=7.955, P=0.005). Multivariate analysis indicated that the risk for developing postoperative complications was 1.791 times higher in the patients with high ΔALB level(ΔALB≥34.7%) than those with low ΔALB level(ΔALB <21.9%)(OR=1.791, 95%CI: 1.139~2.817, P=0.012). The complication and non-complication groups had a 5-year OS rate of 76.6% and 81.6%(Chi-square=2.836, P=0.092), and a 5-year DFS rate of 65.4% and 74.7%, respectively(Chi-square=5.875, P=0.015). There were no statistical differences in OS and DFS rate among the ΔALB groups. Conclusion ΔALB is an independent risk factor for postoperative complications in rectal cancer patients after sphincter-preserving surgery, with advantages of low-cost, convenience, and rapid response in prediction of postoperative complications. Since postoperative complications will influence patients’ long-term survival, special attention should be paid to ΔALB to improve the long-term prognosis.