老年腹部手术患者术前衰弱状态和手术转归的相关性研究及潜在机制探讨

Correlation between preoperative frailty and surgical overcome in elderly patients undergoing abdominal surgery and the underlying mechanisms

目的研究老年腹部手术患者术前衰弱状态与术后30 d严重并发症的相关性,并探讨潜在的线粒体机制。方法选择2019年9月至2020年10月于四川大学华西医院行择期腹部手术的患者256例。术前使用改良衰弱指数(modified frailty index,mFI)量表评估衰弱状态。同时进行包括年龄校正的Charlson合并症指数(age⁃ajusted Charlson comorbidity index,aCCI)评分等在内的术前基线资料的收集和评估,并提取外周血单个核细胞,使用Seahorse XF24分析仪进行线粒体压力测试,获取细胞生物能量健康指数(bioenergetic health index,BHI)。随访患者严重并发症等指标至术后30 d。研究首要结局指标为衰弱状态与术后30 d严重并发症的相关性。次要结局指标为:①衰弱患者与非衰弱患者在以下术后转归指标的差异,包括术后30 d严重并发症发生率、综合并发症指数(comprehensive complication index,CCI)评分、术后30 d病死率、术后住院时长、是否入住ICU及ICU住院时长、总体医疗耗费;②BHI及其与衰弱状态及术后30 d严重并发症的相关性。结果衰弱患者术前aCCI评分高于非衰弱患者(P<0.05),两组患者其余基线资料差异无统计学意义(P>0.05)。单因素Logistic回归分析提示衰弱状态是术后30 d严重并发症的危险因素(比值比5.89,95%CI 2.64~13.14,P<0.05)。调整变量后的多因素Logistic回归分析也表明衰弱状态(比值比5.86,95%CI 2.34~14.68,P<0.05)与术后30 d严重并发症相关。衰弱患者术后30 d严重并发症发生率、术后CCI评分、术后住院时长、总体医疗耗费均高于非衰弱患者(P<0.05),术后30 d病死率、是否入住ICU及ICU住院时长差异无统计学意义(P>0.05)。衰弱患者与非衰弱患者的BHI差异无统计学意义(P>0.05),且BHI与衰弱状态及术后30 d严重并发症均无相关性(P>0.05)。结论老年患者术前衰弱状态与术后30 d严重并发症相关,衰弱患者的手术转归较非衰弱患者差;此外,反映线粒体功能的BHI尚不能单独用于预测术后30 d严重并发症的发生。

Objective To explore the correlation between preoperative frailty and severe postoperative complications within postoperative 30 d after abdominal surgery in elderly patients and the underlying mitochondrial mechanisms.Methods A total of 256 patients who were scheduled for abdominal surgery at West China Hospital of Sichuan University from September 2019 to October 2020 were selected.A modified frailty index(MFI)scale was used to evaluate preoperative frailty.Meanwhile,their baseline informa⁃tion,including age⁃adjusted Charlson comorbidity index(aCCI),was calculated and peripheral blood mononuclear cells were collected.The bioenergetic health index(BHI)was measured by a Seahorse XF24 analyzer for the mitochondrial stress test.They were followed up on serious postoperative complications until 30 d after surgery.Primary outcome was the correlation between preoperative frailty and serious complications within postoperative 30 d.Secondary outcomes were:①Difference of the following postoperative overcome infor⁃mation between frailty and non⁃frailty patients,including the incidence of severe complications within postoperative 30 d,comprehen⁃sive complication index(CCI)scores,mortality with postoperative 30 d,the length of postoperative hospitalization/intensive care unit(ICU)stay,ICU admission and total medical expense.②The correlation between BHI and frailty and serious complications within post⁃operative 30 d.Results Frailty patients showed higher aCCI scores than non⁃frailty patients before surgery(P<0.05),and there was no statistical difference in other baseline data between the two groups(P>0.05).According to univariate Logistic regression,frailty was associated with severe complications within postoperative 30 d[odds ratio(OR)5.89(95%CI 2.64,13.14),P<0.05].The multivariate regression after adjusting for variables also showed that frailty was associated with severe complications within postoperative 30 d[OR 5.86(95%CI 2.34,14.68),P<0.05].The frailty patients had an increased incidence of severe complications within postoperative 30 d and CCI scores,extended length of postoperative hospitalization stay,and increased overall medical expense,compared with non⁃frailty patients(P<0.05).However,no statistical difference was found in mortality within postoperative 30 d,ICU admission,and length of ICU stay between the two groups(P>0.05).There was no significant difference in BHI between frailty and non⁃frailty patients(P>0.05).Al⁃so,BHI was not associated with frailty or serious complications within postoperative 30 d.Conclusions Preoperative frailty in elder⁃ly patients is related to serious complications within postoperative 30 d.The surgical outcome of frailty patients is worse than non⁃frailty patients.In addition,BHI,which reflects mitochondrial function,is not suitable for predicting serious complications within postopera⁃tive 30 d.