术前肌肉减少症对胃癌患者根治术后临床结局的影响及其与术后认知功能障碍的关系

Impact of preoperative sarcopenia on clinical outcomes after radical surgery in gastric cancer patients and its relationship with postoperative cognitive dysfunction

背景与目的:术前肌肉减少症是一种与骨骼肌量减少和肌力下降相关的综合征,被认为与多种术后不良结局相关。胃癌患者术后可能出现短暂或持续的认知功能下降,严重影响患者生活质量和预后,该并发症是否与肌肉减少症有关联尚不明确。因此,本研究进一步验证术前肌肉减少症对接受根治性胃癌手术患者术后并发症及长期预后的影响,重点并分析患者术后认知功能障碍(POCD)与肌肉减少症的关系,以期为胃癌患者的术前评估和术后管理提供参考。方法:回顾性收集河北医科大学第四医院外三科2014年1月—2015年1月期间行根治性手术治疗后的胃癌患者的临床资料,根据术前L3骨骼肌指数、握力及步速测量结果将患者分为肌肉减少症组和非肌肉减少症组。分析肌肉减少症患者的临床病理特征、肌肉减少症对胃癌患者近期临床结局和远期预后的影响,并分析患者发生POCD的影响因素。结果:共纳入320例胃癌患者,其中59例(18.44%)诊断为肌肉减少症,与非肌肉减少症组比较,肌肉减少症组患者体质量指数、血清总蛋白、血清白蛋白、血红蛋白值更低,年龄≥60岁、NRS 2002评分≥3、合并肺疾病及开腹手术的比例更高(均P<0.05)。采用倾向性评分匹配(PSM)方法均衡两组基线资料后(每组各59例)的分析结果显示,肌肉减少症组术后总并发症发生率高于非肌肉减少症组(54.24%vs.32.20%,P=0.016),其中肌肉减少症组Clavien-Dindo并发症分级Ⅱ~Ⅳ级并发症与术后感染性并发症发生率明显高于非肌肉减少症组(27.12%vs.5.08%,P=0.001;33.90%vs.15.25%,P=0.019);肌肉减少症组患者平均住院时间明显长于非肌肉减少症组(12.54±4.7 vs.7.68±3.8,P=0.005);肌肉减少症组患者的5年总生存(OS)率与无进展生存(DFS)率均低于非肌肉减少症组(均P<0.05);Cox多因素分析显示,肌肉减少症、肿瘤pT分期、肿瘤pN分期是胃癌根治术后患者5年OS及DFS的独立危险因素,而术后辅助化疗是患者预后的保护性因素(均P<0.05)。PSM后的118例患者中,术后诊断为POCD共34例(28.81%),Logistic多因素回归分析显示,术前肌肉减少症以及术前合并症数量、麻醉时间≥2 h是术后发生POCD的独立危险因素,术中使用右美托咪定是预防POCD的保护因素(均P<0.05)。结论:术前肌肉减少症与胃癌根治术后患者的术后不良结局以及POCD的发生密切相关,临床医师应重视术前肌肉减少症的检测,进行积极的术前干预及术后管理,以改善患者的临床结局和长期生存率。

Background and Aims:Preoperative sarcopenia is a syndrome characterized by reduced skeletal muscle mass and strength,and it is associated with various adverse postoperative outcomes.Gastric cancer patients may experience transient or persistent postoperative cognitive dysfunction(POCD),which significantly impacts their quality of life and prognosis.However,it remains unclear whether this complication is linked to sarcopenia.Therefore,this study was conducted to investigate further the impact of preoperative sarcopenia on postoperative complications and long-term outcomes in patients undergoing radical gastric cancer surgery,with a particular focus on the relationship between sarcopenia and POCD,in order to provide insights for preoperative assessment and postoperative management of gastric cancer patients.Methods:The clinical data of gastric cancer patients who underwent radical surgery in the Third Department of Surgery at the Fourth Hospital of Hebei Medical University between January 2014 and January 2015 were retrospectively collected.Patients were divided into the sarcopenia and nonsarcopenia groups based on preoperative L3 skeletal muscle index,handgrip strength,and gait speed measurements.The clinicopathologic characteristics of sarcopenic patients,as well as the impact of sarcopenia on short-term clinical outcomes and long-term prognosis,were analyzed.Additionally,factors influencing the development of POCD were determined.Results:A total of 320 gastric cancer patients were included,of whom 59(18.44%)were diagnosed with sarcopenia.Compared with the non-sarcopenia group,sarcopenic patients had significantly lower bady mass index,serum total protein,serum albumin,and hemoglobin levels,with a higher proportion of patients aged≥60 years,NRS 2002 score≥3,comorbid pulmonary disease,and those undergoing open surgery(all P<0.05).After balancing the baseline characteristics of the two groups using propensity score matching(PSM),each group included 59 patients.The analysis revealed that the overall incidence of postoperative complications was higher in the sarcopenia group than in the non-sarcopenia group(54.24%vs.32.20%,P=0.016).The sarcopenia group also had a significantly higher incidence of ClavienDindo gradeⅡ-Ⅳcomplications and postoperative infectious complications(27.12%vs.5.08%,P=0.001;33.90%vs.15.25%,P=0.019).The average hospital stay was significantly longer for sarcopenic patients(12.54±4.7 d vs.7.68±3.8 d,P=0.005).Additionally,the 5-year overall survival(OS)and diseasefree survival(DFS)rates were lower in the sarcopenia group compared to the non-sarcopenia group(both P<0.05).Cox multivariate analysis showed that sarcopenia,tumor pT stage,and tumor pN stage were independent risk factors for 5-year OS and DFS.At the same time,adjuvant chemotherapy was a protective factor for prognosis(all P<0.05).Among the 118 patients after PSM,34(28.81%)were diagnosed with POCD.Logistic multivariate regression analysis indicated that preoperative sarcopenia,the number of preoperative comorbidities,and anesthesia duration of≥2 h were independent risk factors for POCD,while intraoperative use of dexmedetomidine was a protective factor(all P<0.05).Conclusion:Preoperative sarcopenia is closely associated with unfavorable postoperative outcomes and the development of POCD in patients undergoing radical gastric cancer surgery.Clinicians should emphasize the detection of sarcopenia during preoperative evaluation and implement proactive interventions and postoperative management strategies to improve clinical outcomes and long-term survival rates.