衰弱亚型对老年胃癌患者不良结局的影响研究

Preoperative Frailty and Postoperative Adverse Outcomes among Elderly Patients with Gastric Cancer

背景老年胃癌患者在生理、心理、社会等方面均存在较大的异质性,可能导致不同维度的衰弱发生,形成不同的衰弱亚型,其术前各衰弱亚型对术后不良结局的影响有待探讨。目的探究老年胃癌患者术前各衰弱亚型对不良结局(总并发症、住院时间延长、生活质量低下及失能)的影响。方法采用便利抽样法,于2021年3—10月选取南京医科大学第一附属医院胃外科404例老年胃癌患者为研究对象,在术前采用一般资料调查表、Tilburg衰弱量表对其进行调查,通过电子病历系统收集患者总并发症和住院时间,术后1个月通过电话随访收集生活质量和失能信息。采用单因素Logistic回归分析探讨老年胃癌患者不良结局的影响因素。调整潜在的混杂因素后,使用多因素Logistic回归分析探讨不同衰弱亚型对老年胃癌患者不良结局的影响。结果404例老年胃癌患者术前衰弱分为8个衰弱亚型:仅生理衰弱77例(19.1%)、仅心理衰弱78例(19.3%)、仅社会衰弱23例(5.7%)、生理与心理衰弱63例(15.6%)、生理与社会衰弱13例(3.2%)、心理与社会衰弱16例(4.0%)、多维衰弱(生理、心理与社会衰弱)15例(3.7%)、非衰弱119例(29.5%)。单因素Logistic回归分析结果显示,年龄为老年胃癌患者总并发症的影响因素[OR=1.063,95%CI(1.021,1.106),P=0.003];药物服用史[OR=1.549,95%CI(1.016,2.362),P=0.042]、手术方式[OR=2.103,95%CI(1.191,3.712),P=0.010]为老年胃癌患者住院时间延长的影响因素;婚姻状况[OR=4.611,95%CI(1.079,19.706),P=0.039]、居住地为城市[OR=1.614,95%CI(1.009,2.582),P=0.046]、合并慢性病数量≥2种[OR=1.694,95%CI(1.038,2.766),P=0.035]为老年胃癌患者低生活质量的影响因素;居住地为城市[OR=0.601,95%CI(0.390,0.926),P=0.021]、药物服用史[OR=1.663,95%CI(1.082,2.558),P=0.020]、胃癌TNM分期Ⅲ期及以上[OR=1.659,95%CI(1.017,2.706),P=0.043]为老年胃癌患者失能的影响因素。多因素Logistic回归分析结果显示,调整年龄因素后,术前多维衰弱[OR=5.344,95%CI(1.715,16.656),P=0.004]为老年胃癌患者总并发症的影响因素;调整药物服用史、手术方式因素后,术前仅生理衰弱[OR=2.048,95%CI(1.078,3.891),P=0.029]、仅心理衰弱[OR=2.077,95%CI(1.103,3.913),P=0.024]、多维衰弱[OR=8.321,95%CI(2.400,28.848),P<0.001]为老年胃癌患者住院时间延长的影响因素;调整婚姻状况、居住地为城市、合并慢性病数量≥2种因素后,术前仅心理衰弱[OR=2.620,95%CI(1.267,5.418),P=0.009]、心理与社会衰弱[OR=11.122,95%CI(3.253,38.028),P<0.001]、多维衰弱[OR=11.579,95%CI(2.835,47.302),P<0.001]为老年胃癌患者低生活质量的影响因素。结论医护人员应关注老年胃癌患者的术前衰弱状况,将多维衰弱量表整合至术前临床评估中,并高度重视术前被评估为仅生理衰弱、仅心理衰弱、心理与社会衰弱及多维衰弱的患者,针对老年胃癌患者的具体情况,针对性地采取预康复干预措施,以预防不良结局的发生,改善其生活质量。

Background Due to great differences in physiological reserve,psychological status and social functioning,frailty in elderly patients with gastric cancer may present various subtypes.The relationship between preoperative frailty and postoperative adverse outcomes in them still remains to be further explored.Objective To explore the relationship between preoperative frailty subtypes and postoperative adverse outcomes[total complications,prolonged length of stay(PLOS),low quality of life(QOL),and disability]among elderly patients with gastric cancer.Methods From March to October 2021,404 elderly gastric cancer patients were selected from Department of Gastric Surgery,the First Affiliated Hospital with Nanjing Medical University by convenience sampling.The General Demographic Data Questionnaire and Tilburg Frailty Indicator were used to collect demographics and frailty status before surgery.Total complications and PLOS were collected from the electronic medical records,and the status of disability and QOL were obtained using a telephone follow-up at one month after discharge.Univariate Logistic regression was performed to explore the influencing factors of postoperative adverse outcomes.Multivariate Logistic regression analysis was performed to analyze the association of preoperative frailty subtypes with postoperative adverse outcomes,with potential confounders adjusted.Results Two hundred and eighty-five cases were found with preoperative frailty,and the frailty subtypes in them were classified into eight classes:exclusive physical frailty[77(19.1%)],exclusive psychological frailty[78(19.3%)],exclusive social frailty[23(5.7%)],physical and psychological frailty[63(15.6%)],physical and social frailty[13(3.2%)],psychological and social frailty[16(4.0%)],multidimensional frailty(physical,psychological,and social frailty)[15(3.7%)].The other 119(29.5%)cases had no preoperative frailty.In the univariate Logistic regression,age was the factor influencing total complications[OR=1.063,95%CI(1.021,1.106),P=0.003].History of pharmacological treatment[OR=1.549,95%CI(1.016,2.362),P=0.042]and surgical approach[OR=2.103,95%CI(1.191,3.712),P=0.010]were the factors influencing PLOS.Marital status[OR=4.611,95%CI(1.079,19.706),P=0.039],living in an urban area[OR=1.614,95%CI(1.009,2.582),P=0.046],having at least two comorbidities[OR=1.694,95%CI(1.038,2.766),P=0.035]were the factors influencing postoperative low QOL.Living in an urban area[OR=0.601,95%CI(0.390,0.926),P=0.021],history of pharmacological treatment[OR=1.663,95%CI(1.082,2.558),P=0.020],and advanced TNM stages[OR=1.659,95%CI(1.017,2.706),P=0.043]were the factors influencing postoperative disability.In the multivariate Logistic regression,the preoperative multidimensional frailty was independently associated with total complications,with age adjusted[OR=5.344,95%CI(1.715,16.656),P=0.004].The preoperative physical frailty[OR=2.048,95%CI(1.078,3.891),P=0.029],preoperative psychological frailty[OR=2.077,95%CI(1.103,3.913),P=0.024]and preoperative multidimensional frailty[OR=8.321,95%CI(2.400,28.848),P<0.001]were independently associated with PLOS,with history of pharmacological treatment and surgical approach adjusted.Preoperative psychological frailty[OR=2.620,95%CI(1.267,5.418),P=0.009],preoperative psychological and social frailty[OR=11.122,95%CI(3.253,38.028),P<0.001]and preoperative multidimensional frailty[OR=11.579,95%CI(2.835,47.302),P<0.001]were independently associated with postoperative low QOL,with marital status,living in an urban area,and having at least two comorbidities adjusted.Conclusion Medical professionals should pay attention to preoperative frailty prevalence in elderly gastric cancer patients,and assess preoperative frailty in these patients using tools with the multidimensional frailty scale included,and attach great importance to those with exclusive physical frailty,exclusive psychological frailty,psychological and social frailty,and multidimensional frailty before surgery.A targeted prerehabilitation intervention program can be delivered to those with preoperative frailty according to their subtypes of frailty to improve postoperative adverse outcomes and QOL.