全腔镜与腹腔镜辅助全胃切除术后患者生活质量比较:基于倾向评分匹配的回顾性队列研究

Quality of life after totally laparoscopic versus laparoscopic-assisted total gastrectomy:a retrospective cohort study with propensity score matching

目的评价全腹腔镜全胃切除术(TLTG)后患者的生活质量。方法采用基于倾向评分匹配回顾性队列研究方法。研究对象纳入标准:(1)术后病理证实的原发性胃癌;(2)接受TLTG或腹腔镜辅助根全胃切除术(LATG);(3)R0切除;(4)完成12个月随访且随访资料完整。排除标准:(1)残胃癌;(2)合并其他部位肿瘤;(3)术中发现远处转移;(4)既往有上腹部手术史。纳入福建医科大学附属协和医院胃外科2014年1月至2018年4月期间施行腹腔镜根治性全胃切除手术的1182例胃癌患者的临床及随访资料,根据采用腹腔镜方式的不同,分为LATG组(1 076例)和TLTG组(106例),为消除两组之间临床基线资料由于缺乏平等分布而产生的潜在偏差,使用具有以下协变量的逻辑回归模型计算倾向评分,包括年龄、性别、体质指数、美国麻醉医师协会评分、肿瘤位置、肿瘤大小、病理类型和分期,采用1∶2倾向评分配比法对两组进行匹配,并指定了0.01标准差的卡尺宽度。主要观察指标为比较两组患者术后3、6、12个月生活质量,包括身体症状和社会功能情况;功能评分越高表示功能越好,而症状评分越高则表示症状越严重;生活质量评分=(100-躯体症状量表得分+社会功能量表得分)/2。次要观察指标为比较两组患者术后3、6、12个月的术后营养恢复情况以及患者对食物的耐受能力评估。分类变量以例(%)表示,采用χ^(2)检验或Fisher精确检验进行比较;符合正态分布的连续变量采用x±s表示,采用配对t检验进行比较。对组内术前、术后1、3、6和12个月的营养相关指标比较,采用重复测量方差分析。结果倾向性评分匹配后,TLTG组104例,LATG组208例;两组间临床基线资料的比较,差异均无统计学意义(均P>0.05)。TLTG组的术前及术后3、6、12个月躯体症状总评分分别为(8.6±5.8)分、(15.5±8.4)分、(10.1±5.9)分和(6.1±2.4)分,组内前后比较,差异有统计学意义(F=43.493,P<0.001);LATG组则分别为(9.7±6.9)分、(23.7±10.4)分、(13.3±8.3)分和(8.5±4.2)分,组内前后比较,差异也有统计学意义(F=112.588,P<0.001);与LATG组比较,TLTG组患者的术后3个月和6个月的躯体症状总评分更低,差异有统计学意义(分别为t=-3.653,P<0.001和t=-2.513,P=0.012),在术后12个月时,虽然TLTG组也低于LATG组,但差异无统计学意义(t=-1.487,P=0.138)。TLTG组的术前及术后3、6、12个月社会功能总评分分别为(90.3±8.9)分、(77.5±14.3)分、(87.4±10.3)分和(91.7±6.7)分,组内比较,差异有统计学意义(F=28.524,P<0.001);LATG组则分别为(92.5±6.3)分、(68.5±16.8)分、(79.8±14.7)分和(84.7±11.1)分,组内比较,差异有统计学意义(F=57.975,P<0.001);与LATG组比较,TLTG组患者的术后3个月、6个月以及12个月的总评分均更高(t=3.543,P<0.001;t=3.216,P=0.001;t=2.235,P=0.026)。TLTG组术后3、6、12个月生活质量评分分别为(81.0±15.6)分、(88.3±8.1)分、(93.3±9.1)分;LATG组分别为(72.4±13.6)分、(83.3±11.5)分和(88.1±7.7)分,两组各时间点的比较,差异均有统计学意义(均P<0.05)。TLTG组与LATG组术后12个月总的体质量变化比例为[(-8.4±1.4)%比(-13.2±1.6)%,t=2.273,P=0.024]、血清白蛋白变化比例为[(-5.1±0.7)%比(-7.4±0.8)%,t=2.095,P=0.037]、餐量变化比例为[(-15.6±4.7)%比(-24.1±6.0)%,t=2.885,P=0.004]及餐次变化比例为[(20.8±7.1)%比(30.6±11.5)%,t=3.043,P<0.001],TLTG组均显著低于LATG组(均P<0.05)。术后3、6及12个月,TLTG组患者的固体和软食的饮食比例均高于LATG组(均P<0.05)。结论与LATG相比,TLTG组患者表现出更优的术后生活质量和更快的术后营养状态恢复。

Objective To evaluate the postoperative quality of life in patients after totally laparoscopic total gastrectomy(TLTG).Methods A retrospective cohort study based on propensity score matching was performed.Clinical and follow-up data of patients who underwent laparoscopic radical gastrectomy at Union Hospital of Fujian Medical University from January 2014 to May 2015 were collected.Case indusion criteria:(1)primary gastric cancer confirmed by postoperative pathology;(2)receiving TLTG or laparoscopic-assisted total gastrectomy(LATG);(3)R0 resection;(4)completing follow-up for 12 months and complete follow-up data.Exclusion criteria:(1)gastric stump cancer;(2)concurrent tumor;(3)distal metastasis found during operation;(4)history of upper abdominal operation.According to surgical procedures,patients were divided into the LATG group(1076 cases)and the TLTG group(106 cases).To eliminate potential bias in baseline data between the two groups,the propensity score was calculated using a logistic regression model with the following covariates,including age,sex,body mass index,American Society of Anesthesiologists score,tumor location,tumor size,pathology type,and stage.The two groups were matched using a 1:2 propensity assessment ratio and a caliper width of 0.01 standard deviation was specified.The primary outcomes were the quality of life of the two groups at 3,6 and 12 months after gastrectomy,including physical symptoms and social function.Higher function score indicated better function,and higher symptom score presented worse symptoms.Quality of life score=(100-somatic symptom scale score+social function scale score)/2.The secondary outcomes were postoperative nutritional recovery and food tolerance at 3,6 and 12 months after gastrectomy.The categorical variables were expressed as n(%),and compared using theχ^(2) test or Fisher exact test.The continuous variables conforming to the normal distribution were represented by Mean±SD and compared with the paired t-test.Repeated measurement of variance was used to compare nutrition-related indicators within the group among pre-operation,postoperative 1,3,6,12 months.Results After PSM,there were no significant differences in clinicopathological baseline data between the TLTG group(n=104)and the LATG group(n=208)(all P>0.05).The physical symptoms scores in the TLTG group before operation and 3,6 and 12 months after operation were 8.6±5.8,15.5±8.4,10.1±5.9 and 6.1±2.4 respectively(F=43.493,P<0.001).In the LATG group,the above mentioned scores were 9.7±6.9,23.7±10.4,13.3±8.3 and 8.5±4.2 respectively(F=112.588,P<0.001).Compared with the LATG group,the symptom scores in the TLTG group were lower at 3 and 6 months after operation,and the differences were statistically significant(t=-3.653,P<0.001;t=-2.513,P=0.012).At 12 months after operation,although the physical symptom score in the TLTG group was also lower than that in LATG group,the difference was not statistically significant(t=-1.487,P=0.138).The social function scores in the TLTG group before operation and 3,6 and 12 months after operation were 90.3±8.9,77.5±14.3,87.4±10.3 and 91.7±6.7 respectively(F=28.524,P<0.001).In the LATG group,the above mentioned scores were 92.5±6.3,68.5±16.8,79.8±14.7 and 84.7±11.1 respectively(F=57.975,P<0.001).Compared with the LATG group,the social function scores of patients in the LATG group were higher at 3,6 and 12 months after operation(t=3.543,P<0.001;t=3.216,P=0.001;t=2.235,P=0.026).The total scores of quality of life at 3,6 and 12 months after operation in the TLTG group were 81.0±15.6,88.3±8.1 and 93.3±9.1 respectively,and the above mentioned scores in the LATG group were 72.4±13.6,83.3±11.5 and 88.1±7.7 respectively,whose differences at corresponding time point were all significant between the two groups(all P<0.05).The change of total body mass[(-8.4±1.4)%vs.(-13.2±1.6)%,t=2.273,P=0.024],serum albumin[(-5.1±0.7)%vs.(-7.4±0.8)%,t=2.095,P=0.037],meal quantity[(-15.6±4.7)%vs.(-24.1±6.0)%,t=2.885,P=0.004]and meal times[(20.8±7.1)%vs.(30.6±11.5)%,t=3.043,P<0.001]in the TLTG group were significantly lower than those in the LATG group one year after operation(all P<0.05).At 3,6 and 12 months after operation,the diet proportions of solid and soft food in the TLTG group were higher than those in the LATG group(all P<0.05).Conclusions Compared with LATG,patients with gastric cancer undergoing TLTG have better health-related quality of life and faster recovery of nutrition.