近端胃癌患者行近端胃切除术后反流性食管炎危险因素分析

Risk factors of reflux esophagitis after proximal gastrectomy for proximal gastric cancer

目的观察近端胃癌患者行近端胃切除术后反流性食管炎发生情况,探讨术后发生反流性食管炎的危险因素。方法189例近端胃癌患者均行近端胃切除术+食管残胃吻合术,术后6~12个月根据患者症状和胃镜检查判定是否发生反流性食管炎,并评估洛杉矶分级;其中发生反流性食管炎者39例为反流组,未发生反流性食管炎者150例为无反流组,比较2组体质量指数、手术时间、术中出血量、肿瘤位置等,采用多因素logistic回归分析近端胃癌患者术后发生反流性食管炎的影响因素;采用Mantel-Haenszelχ^(2)检验及Pearson相关法分析近端胃癌患者术后发生反流性食管炎危险因素个数与洛杉矶分级的相关性。结果189例患者术后发生反流性食管炎39例(20.6%),其中洛杉矶分级A级2例,B级7例,C级17例,D级13例。反流组手术时间[(259.49±22.47)min]长于无反流组[(248.80±22.40)min](t=2.652,P=0.009),术中出血量[(232.05±61.22)mL]多于无反流组[(203.00±55.93)mL](t=2.833,P=0.005),体质量指数≥24 kg/m^(2)、肿瘤位于贲门、食管切除长度≥2 cm、残胃容积1/2、吻合器型号29比率(74.4%、92.3%、71.8%、82.1%、71.8%)均高于无反流组(52.7%、75.3%、50.7%、65.3%、52.0%)(P<0.05),肿瘤直径、分化程度、术后TNM分期、术后留置胃管时间与无反流组比较差异均无统计学意义(P>0.05)。体质量指数≥24 kg/m^(2)(OR=3.644,95%CI:1.450~9.156,P=0.006)、食管切除长度≥2 cm(OR=4.374,95%CI:1.540~12.425,P=0.006)、残胃容积1/2(OR=12.109,95%CI:3.717~39.445,P<0.001)、吻合器型号29(OR=6.877,95%CI:2.467~19.169,P<0.001)是近端胃癌患者术后发生反流性食管炎的危险因素。近端胃癌患者术后发生反流性食管炎危险因素个数与洛杉矶分级存在线性关系(χ^(2)=8.941,P=0.003),危险因素个数与洛杉矶分级呈正相关(r=0.485,P=0.002)。结论体质量指数≥24 kg/m^(2)、食管切除长度≥2 cm、残胃容积1/2、吻合器型号29是近端胃癌患者术后发生反流性食管炎的危险因素,反流性食管炎严重程度随患者危险因素个数增加而增加。

Objective To observe the occurrence of reflux esophagitis(RE)after proximal gastrectomy in patients with proximal gastric cancer,and to investigate its risk factors.Methods Totally 189patients with proximal gastric cancer underwent proximal gastrectomy+esophagostomy.The RE was diagnosed 6to 12months after surgery according to the symptoms and gastroscopical findings,and the Los Angeles grading was evaluated.RE group(n=39)and no-RE group(n=150)were compared the body mass index,operation lasting time,intraoperative blood loss and tumor site.Multivariate logistic regression was done to analyze the influencing factors of postoperative RE in patients with proximal gastric cancer.Mantel-Haenszel Chi-square test and Pearson’s correlation coefficient were used to analyze the correlation between the number of risk factors of postoperative RE and the Los Angeles grading.Results In 189patients,39(20.6%)developed RE after operation,including 2cases of Los Angeles grade A,7of grade B,17of grade C,and 13of grade D.The operation lasting time was longer in RE group[(259.49±22.47)min]than that in no-RE group[(248.80±22.40)min](t=2.652,P=0.009).The intraoperative blood loss was larger in RE group[(232.05±61.22)mL]than that in no-RE group[(203.00±55.93)mL](t=2.833,P=0.005).The percentages of patients with body mass index≥24kg/m^(2),tumor locating at the cardiac,resected esophagus length≥2cm,gastric residual volume 1/2and stapler type 29were higher in RE group(74.4%,92.3%,71.8%,82.1%,71.8%)than those in no-RE group(52.7%,75.3%,50.7%,65.3%,52.0%)(P<0.05).There were no significant differences in the tumor diameter,differentiation degree,postoperative TNM stage and postoperative gastric tube indwelling time between two groups (P>0.05).Body mass index≥24kg/m^(2)(OR=3.644,95%CI:1.450-9.156,P=0.006),resected esophagus length≥2cm (OR=4.374,95%CI:1.540-12.425,P=0.006),gastric residual volume 1/2(OR=12.109,95%CI:3.717-39.445,P<0.001)and stapler type 29 (OR=6.877,95%CI:2.467-19.169,P<0.001)were the risk factors of postoperative RE.The number of risk factors of postoperative RE was linearly and positively correlated with the Los Angeles grading(χ^(2)=8.941,P=0.003;r=0.485,P=0.002).Conclusion BMI≥24kg/m^(2),resected esophagus length≥2cm,gastric residual volume 1/2and stapler type 29are the risk factors of postoperative RE in patients with proximal gastric cancer,and the more the number of risk factors is,the severer RE is.