内脏型肥胖对胃癌根治术后早期并发症的影响

Influence of visceral lipids obesity on the early postoperative complications after radical gastrectomy

目的探讨内脏脂肪面积(VFA)对胃癌根治术疗效及术后早期并发症的影响。方法采用回顾性队列研究的方法。分析2014年1月至2017年12月期间,于西安交通大学第一附属医院普通外科行胃癌D2根治术的195例患者的临床病理资料及术前影像资料。纳入标准:(1)临床病理及影像学资料完整;(2)术前病理为胃恶性肿瘤,且经术后病理证实为胃癌;(3)术前无出血、梗阻或穿孔等并发症,无远处转移。排除既往有腹部手术史者、合并其他部位恶性肿瘤或基础情况差者、行急诊手术或姑息性切除术者以及术前新辅助治疗者。通过软件计算VFA,根据日本肥胖协会标准,将VFA≥100 cm^(2)定义为内脏型肥胖。将患者分为VFA高值组(VFA-H组,96例)和VFA低值组(VFA-L组,99例)。比较两组患者的临床病理特征、手术效果及术后早期并发症等指标。采用单因素及多因素Logistic回归模型,分析影响胃癌根治术后早期并发症发生的危险因素;采用受试者工作特征(ROC)曲线分析VFA对胃癌根治术后早期并发症的预测能力;采用Pearsonχ^(2)检验分析体质指数(BMI)与VFA间的相关性。结果VFA-L组与VFA-H组患者在性别、年龄、美国麻醉医师协会分级、术前合并症、术前贫血、肿瘤TNM分期以及N分期、T分期和分化程度、手术方式、肿瘤切除范围、肿瘤位置等方面比较,差异均无统计学意义(P>0.05);但VFA-H组患者比VFA-L组具有更高的BMI、更大的肿瘤直径、更低的合并低白蛋白血症者比例和更高的皮下脂肪面积(SFA),差异均有统计学意义(均P<0.05)。VFA-H组手术时间显著长于VFA-L组,而淋巴结清扫数目显著少于VFA-L组,差异均有统计学意义(均P<0.05);但在术中出血量、中转开腹率及术后住院时间方面比较,差异无统计学意义(P>0.05)。本组患者术后30 d内发生Clavien-DindoⅡ级以上并发症主要为吻合口相关并发症(包括漏、出血、感染及狭窄)、肠梗阻和切口感染,VFA-H组比VFA-L组早期并发症发生率更高[24.0%(23/96)比10.1%(10/99),χ^(2)=6.657,P=0.010],术后吻合口相关并发症和切口感染发生率也均更高[10.4%(10/96)比3.0%(3/99),χ^(2)=4.274,P=0.039;7.3%(7/96)比1.0%(1/99),P=0.033]。Logistic多因素分析结果显示,高BMI(OR=3.688,95%CI:1.685~8.072,P=0.001)和高VFA(OR=2.526,95%CI:1.148~5.559,P=0.021)是本组胃癌根治术后早期并发症发生的独立危险因素。VFA预测胃癌根治术后发生早期并发症的ROC曲线下面积(AUC)值为0.645,高于体质量(0.591)、BMI(0.624)和SFA(0.626)。相关性分析显示,BMI与VFA值呈现显著正相关(r=0.640,P<0.001)。结论VFA≥100 cm2是胃癌根治术后早期并发症发生的独立危险因素;VFA能更好地预测胃癌根治术后早期并发症的发生。

Objective To investigate the effect of visceral fat area(VFA)on the surgical efficacy and early postoperative complications of radical gastrectomy for gastric cancer.Methods A retrospective cohort study method was used.Clinicopathological data and preoperative imaging data of 195 patients who underwent D2 radical gastric cancer surgery at the First Affiliated Hospital of Xi'an Jiaotong University from January 2014 to December 2017 were analyzed retrospectively.Inclusion criteria:(1)complete clinicopathological and imaging data;(2)malignant gastric tumor diagnosed by preoperative pathology,and gastric cancer confirmed by postoperative pathology;(3)no preoperative complications such as bleeding,obstruction or perforation,and no distant metastasis.Those who had a history of abdominal surgery,concurrent malignant tumors,poor basic conditions,emergency surgery,palliative resection,and preoperative neoadjuvant therapy were excluded.The VFA was calculated by software and VFA≥100 cm^(2) was defined as visceral obesity according to the Japan Obesity Association criteria.The patients were divided into high VFA(VFA-H,VFA≥100 cm^(2),n=96)group and low VFA(VFA-L,VFA<100 cm^(2),n=99)group.The clinicopathological characteristics,surgical outcomes and early postoperative complications were compared between the two groups.Univariate and multivariate Logistic regression models were used to analyze the risk factors of early complications.Receiver operating characteristic(ROC)curve was used to analyze predictive values of VFA for early complications.Pearson'sχ^(2) test was used to analyze the correlation between BMI and VFA.Results There were no significant differences in terms of gender,age,American Society of Anesthesiologists physical status classification,preoperative comorbidities,preoperative anemia,tumor TNM staging,N staging,T staging and tumor differentiation,surgical method,extent of resection,and tumor location between the VFA-L group and the VFA-H group(all P>0.05).However,patients in the VFA-H group had higher BMI,larger tumor,lower rate of hypoalbuminemia and greater subcutaneous fat area(SFA)(all P<0.05).The VFA-H group presented significantly longer operation time and significantly less number of harvested lymph nodes as compared to the VFA-L group(both P<0.05).However,there were no significant differences in intraoperative blood loss,conversion to laparotomy and postoperative hospital stay(all P>0.05).Complications of Clavien-Dindo grade II and above within 30 days after operation were mainly anastomosis-related complications(leakage,bleeding,infection and stricture),intestinal obstruction and incision infection.The VFA-H group had a higher morbidity of early complications compared to the VFA-L group[24.0%(23/96)vs 10.1%(10/99),χ^(2)=6.657,P=0.010],and the rates of anastomotic complications and incision infection were also higher in the VFA group[10.4%(10/96)vs.3.0%(3/99),χ^(2)=4.274,P=0.039;7.3%(7/96)vs.1.0%(1/99),P=0.033].Multivariate logistic analysis showed that high BMI(OR=3.688,95%CI:1.685-8.072,P=0.001)and high VFA(OR=2.526,95%CI:1.148-5.559,P=0.021)were independent risk factors for early complications.The area under the ROC curve(AUC)of VFA for predicting early complications was 0.645,which was higher than that of body weight(0.591),BMI(0.624)and SFA(0.626).Correlation analysis indicated that there was a significantly positive correlation between BMI and VFA(r=0.640,P<0.001).Conclusion VFA≥100 cm^(2) is an independent risk factor for early complications after radical gastrectomy for gastric cancer.It can better predict the occurrence of above early postoperative complications.