Factors associated with postoperative complication after minimally invasive gastrectomy for elder gastric cancer patients
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摘要:背景 高龄是胃癌术后近期并发症的独立危险因素。近年来，微创胃癌手术已成为高龄胃癌患者的手术方式，但目前对于高龄患者微创胃癌根治术术后并发症影响因素的研究相对较少。目的 分析高龄胃癌患者微创胃癌根治术术后近期并发症及影响因素。方法 采用回顾性研究，收集2017年4月- 2021年4月492例于解放军总医院第一医学中心普通外科医学部行微创胃癌根治术且年龄≥70岁患者(包括2D腹腔镜、3D腹腔镜及机器人手术)的临床病历资料，通过单因素及多因素分析探究影响术后30 d并发症的独立危险因素。结果 492例中103例(20.9%)出现Clavien-Dindo分级≥Ⅱ级的术后并发症；24例出现Clavien-Dindo分级≥Ⅲa级的并发症，严重并发症发生率为4.9%；2例围术期死亡(1例腹腔出血，1例肺栓塞)，围术期死亡率0.4%。单因素分析结果显示，脉管侵犯、年龄≥80岁、术中出血量≥200 mL与高龄胃癌患者微创胃癌根治术术后30 d内并发症相关(P均＜0.05)，微创手术方式(腹腔镜、3D腹腔镜或机器人)与术后并发症无明显相关性(P=0.096)。多因素logistic分析结果显示，脉管侵犯(OR=1.985；95% CI：1.267 ~ 3.110；P=0.003)、术中出血量≥200 mL(OR=2.120；95% CI：1.193 ~ 3.769，P=0.010)与高龄胃癌患者微创胃癌根治术术后30 d内并发症独立相关。结论 高龄胃癌患者行微创胃癌根治术安全可行，近期疗效确切。脉管侵犯、术中出血量≥200 mL与高龄胃癌患者微创胃癌根治术术后30 d内并发症独立关联，应对此类患者加以重视，术前充分评估以降低并发症发生率。Abstract:Background Old age is an independent risk factor for the postoperative complications after gastrectomy. In recent years, minimally invasive gastrectomy has become the optional surgical approach for elderly gastric cancer patients, but few studies focus on the indicators affecting postoperative complications after minimally invasive gastrectomy in the elderly.Objective To analyze the short-term outcomes and factors influencing the postoperative complications of elder patients with gastric cancer under minimally invasive gastrectomy.Methods From April 2017 to April 2021, a retrospective study was conducted for the clinical data about 492 elder patients aged ≥70 years undergoing minimally invasive gastrectomy (including 2D laparoscopic, 3D laparoscopy, or robotic gastrectomy) in the department of general surgery, the First Medical Center of Chinese PLA General Hospital. Binary logistic regression analysis was used to explore the factors associated with the 30-day postoperative complication occurrence.Results Totally 103 patients (20.9%) had Clavien-Dindo classification ≥ grade Ⅱ postoperative complications, and 24 patients had Clavien-Dindo classification ≥ grade IIIa complications, with a serious complication rate of 4.9%. Two patients died before surgery (one patient with abdominal hemorrhage and the other with pulmonary embolism), with the mortality rate of 0.4%. Univariate analysis showed that vascular invasion, age ≥80 years, intraoperative blood loss ≥200 mL, and postoperative ICU transition were associated with the 30-day postoperative complications in elderly patients with gastric cancer under minimally invasive gastrectomy (P ＜ 0.05), while the minimally invasive surgical approaches (2D laparoscopic, 3D laparoscopic or robotic) were not significantly associated with the postoperative complication (P=0.096). Multivariate analysis showed that vascular invasion (OR=1.985; 95% CI: 1.267-3.110; P=0.003) and intraoperative blood loss≥200 mL (OR=2.120; 95% CI: 1.193-3.769, P=0.010) were independently associated with the 30-day postoperative complication in the elderly patients.Conclusion Minimally invasive gastrectomy is safe and feasible for elderly patients. Vascular invasion and intraoperative blood loss ≥200 mL are associated with 30-day postoperative complication. For patients with above these factors, surgeons need to pay more attention to avoiding complications by sufficient preoperative evaluation.
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Keywords:
- gastric cancer /
- the aged /
- minimally invasive surgery /
- risk factor /
- complications
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表 1 492例高龄胃癌微创胃切除术患者临床病理特征
Table 1 Clinicopathological characteristics for 492 elderly patients who accepted minimally invasive gastrectomy
Characteristic Value Characteristic Value Male (n, %) 376(76.4) Vascular invasion (n, %) Age/yrs 74.67±3.90 Yes 179(36.4) BMI/kg·m-2 23.46±3.17 No 313(63.6) Abdominal surgery (n, %) Tumor differentiation (n, %) No 388(78.9) Well/moderate 336(68.3) Yes 104(21.1) Poor/undifferentiation 156(31.7) ASA score (n, %) Tumor diameter/(cm, Md[IQR]) 4.0(2.8-6.0) Ⅰ 4(0.8) Operation time/min 224.67±52.48 Ⅱ 360(73.2) Estimated blood loss/(mL, Md[IQR]) 100(50-200) Ⅲ 128(26.0) Retrieved lymph nodes (n) 27.89±11.38 aCCI score (n, %) Tumor resection (n, %) ≤4 378(76.8) Proximal 95(19.3) ＞4 114(23.2) Distal 197(40.0) Neoadjuvant chemotherapy (n, %) 31(6.3) Total 200(40.7) Pathological stage Surgical approach (n, %) pT stage (n, %) 2D-laparoscopy 108(22.0) T0 2(0.4) 3D-laparoscopy 299(60.8) T1 85(17.3) Robot 85(17.3) T2 81(16.5) Anastomosis type (n, %) T3 235(47.8) BillrothⅠ 25(5.1) T4 89(18.1) Billroth Ⅱ+ braun 40(8.1) pN stage (n, %) Roux-en-Y 317(64.4) N0 176(35.8) Uncut-Roux-en-Y 15(3.0) N1 72(14.6) Esophagogastric anastomosis (n, %) 89(18.1) N2 100(20.3) Double-tract reconstruction (n, %) 6(1.2) N3 144(29.3) Fist flatus days (n, Md [IQR]) 4.0(3.0-5.0) pTNM stage (n, %) Postoperative days (n, Md [IQR]) 8.8(7.0-10.0) T0N0 2(0.4) Postoperative overall morbidity (n, %) 103(20.9) Ⅰ 125(25.4) Clavien-Dindo grade Ⅱ 79 Ⅱ 131(26.6) Clavien-Dindo grade Ⅲa 14 Ⅲ 234(47.6) Clavien-Dindo grade Ⅲb 2 Nerve invasion (n, %) Clavien-Dindo grade Ⅳ 6 Yes 164(33.3) Clavien-Dindo grade Ⅴ 2 No 328(66.7) Postoperative severe morbidity (n, %) 24(4.9) Perioperative mortality (n, %) 2(0.4) 
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表 2 492例高龄胃癌微创胃切除术患者术后并发症发生情况
Table 2 Postoperative complications for 492 elderly patients who accepted minimally invasive gastrectomy
Complication Case number Complication Case number Clavien-Dindo grade Ⅱ Clavien-Dindo grade Ⅲa Anastomosis leakage 8 Pleural effusion 7 Anastomosis bleeding 1 Seroperitoneum 1 Abdominal infection 1 Abdominal infection 1 Gastroplegia 2 Abdominal bleeding 2 Ileus 3 Anastomosis leakage 2 Duodenal stump leakage 2 Duodenal stump leakage 1 Pancreatic fistula 2 Clavien-Dindo grade Ⅲb Lymphatic leakage 1 Incisional hernia 1 Venous thrombosis 2 Intestinal fistula 1 Fever 6 Clavien-Dindo grade Ⅳa Cardiovascular and cerebrovascular diseases 9 Anastomosis leakage 1 Respiratory-related complications 8 Congestive heart failure 1 Hypoproteinemia 13 Abdominal bleeding 1 Anemia 15 Cardiogenic pulmonary edema 1 Incisional infection 3 Clavien-Dindo grade Ⅳb Electrolyte disturbance 2 Cerebral embolism 1 Silting bravery 1 Abdominal bleeding 1 Clavien-Dindo grade Ⅴ Abdominal bleeding 1 Pulmonary embolism 1
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表 3 高龄胃癌患者发生术后并发症的关联因素分析
Table 3 Factors associated with postoperative complications in the elderly patients with minimally invasive gastrectomy
Variable Univariate analysis Multivariate analysis OR (95% CI) P OR (95% CI) P Sex 0.219 Male 1.000 Female 1.360(0.832-2.223) Age 0.046 0.129 ＜80 yrs 1.000 1.000 ≥80 yrs 1.777(1.010-3.127) 1.645(0.865-3.128) BMI 0.249 ＜25 kg·m-2 1.000 ≥25 kg·m-2 0.745(0.452-1.228) ASA score 0.070 0.161 ≤2 1.000 1.000 ＞2 1.546(0.965-2.479) 1.434(0.866-2.375) aCCI score 0.109 0.760 ≤4 1.000 1.000 ＞4 1.492(0.915-2.433) 1.094(0.615-1.945) Abdominal surgery 0.307 No 1.000 Yes 0.746(0.425-1.309) Surgical approach 0.096 2D-laparoscopy 1.000 3D-laparoscopy 0.616(0.365-1.038) Robot 0.998(0.522-1.909) Estimated blood loss 0.004 0.010 ＜200 mL 1.000 1.000 ≥200 mL 2.254(1.288-3.946) 2.120(1.193-3.769) Operation time 0.332 ≤240 min 1.000 ＞240 min 1.244(0.796-1.944) Neoadjuvant chemotherapy 0.492 No 1.000 Yes 1.340(0.581-3.090) Tumor resection 0.998 Proximal 1.000 Distal 0.986(0.540-1.798) Total 0.997(0.547-1.815) Pathological stage 0.597 T0N0-Ⅰ 1.000 Ⅱ 1.174(0.632-2.180) Ⅲ 1.324(0.767-2.285) Differentiation 0.302 Well/moderate 1.000 Poor/undifferentiated 1.272(0.806-2.008) Tumor diameters 0.492 ≤5 cm 1.000 ＞5 cm 0.848(0.530-1.358) Nerve invasion 0.875 No 1.000 Yes 1.037(0.655-1.642) Vascular invasion 0.001 0.003 No 1.000 1.000 Yes 2.103(1.354-3.268) 1.985(1.267-3.110)
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