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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胃癌是常见的恶性肿瘤之一。据全球癌症流行病学数据库(GLOBOCAN)最新数据统计,胃癌发病率在恶性肿瘤中位居第5位,死亡率位居第4位,造成严重的健康负担[1]。我国年龄80岁以上高龄癌症患者中,胃癌在男性癌症发病率中位居第2位,女性癌症发病率中位居第3位[2]。高龄患者由于合并症较多、脏器储备功能较差、机体免疫功能下降等因素,一定程度上增加了手术风险。既往研究报道,高龄是胃癌术后近期并发症发生的独立危险因素[3]。因此,高龄胃癌患者的手术方式及围术期管理应综合考量,合理决策。既往研究表明,高龄胃癌患者行腹腔镜、机器人与开腹手术的术后安全性相当[4-6]。一项Meta分析结果表明,与开腹手术相比,高龄胃癌患者行腹腔镜手术出血量更少、术后恢复更快、并发症发生率更低[7]。尽管目前微创胃癌根治术在高龄胃癌患者中的开展比例日趋增加,且相关前瞻性研究正在进行[8],但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。因此我们开展本研究,以探究高龄胃癌患者微创胃癌手术近期并发症的独立危险因素,为临床合理评估术式选择提供参考。
资料与方法
1 资料来源
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患者的临床病历资料,采用回顾性研究方式,纳入标准:1)年龄≥70岁胃癌患者[9-10];2)术前胃镜病理,超声内镜,腹部CT或PET-CT证实为原发性胃腺癌;3)术后病理分期为T0N0 ~ Ⅲ期。排除标准:1)术中任何原因导致中转开腹;2)ASA分级>Ⅲ级;残胃癌,既往行胃部手术;3)临床病理资料缺失。本研究符合《赫尔辛基宣言》的要求,经解放军总医院第一医学中心伦理委员会审批通过(审批号:S2021-605-01)。
2 手术方法
术者具有丰富的腹腔镜或机器人手术经验,机器人组手术医师均获得达芬奇机器人手术操作证书,并跨过学习曲线[11]。手术操作步骤分别参照《机器人胃癌手术专家共识(2015版)》[12]和《腹腔镜胃癌手术操作指南(2016版)》[13]进行。手术切除及淋巴结清扫范围依据《第五版日本胃癌诊疗指南》[14]规定统一标准进行。采用上腹正中小切口(切口长度≤7 cm)取出标本并行体外消化道重建。消化道重建依据外科医生喜好,符合标准化流程进行。
3 围术期观察指标
术前信息:性别,年龄,手术方式,手术切除范围,合并症aCCI评分,麻醉ASA分级,既往腹部手术史;术中情况:手术方式,消化道重建方式,术中估计出血量,手术时间;术后评价指标:术后总并发症率及严重并发症发生率,围术期死亡率;病理指标:肿瘤分化程度,肿瘤长径,淋巴结清扫数目,淋巴结转移数目,有无脉管侵犯,有无神经侵犯。
4 术后并发症定义及分级
依据Clavien-Dindo系统评估术后30 d内并发症发生情况及严重程度[15]。具体分级评估标准主要包括:1)Ⅰ级:任何偏离术后正常恢复过程,但不需药物、手术干预、内镜或介入治疗;2)Ⅱ级:包括输血,全肠外营养在内的药物治疗(除外止吐、退热、镇痛、利尿、补液等对症药物治疗);3)Ⅲ级:需要手术干预、内镜或介入治疗,其中Ⅲa级不需全身麻醉,Ⅲb级需要全身麻醉;4)Ⅳ级:危及生命,需在重症监护室处理,其中Ⅳa级为单器官功能衰竭,Ⅳb级为多器官功能衰竭,Ⅴ级为死亡。由于回顾性研究限制,术后30 d内并发症定义为Clavien-Dindo分级≥Ⅱ级的并发症,严重并发症定义为Clavien-Dindo分级≥Ⅲa级的并发症。
5 统计学方法
应用SPSS26.0统计软件进行分析。正态分布的计量资料以
$\bar x \pm s $ 表示,偏态分布的计量资料以Md(IQR)表示。计数资料以例数(百分比)表示。采用logistic回归分析术后并发症发生的相关危险因素。将单因素分析中差异有统计学意义的因素及临床提示具有潜在并发症风险的因素纳入多因素分析。P<0.05为差异有统计学意义。结 果
1 患者一般情况
492例患者中,男性376例(76.4%),女性116例(23.6%),中位年龄75(70 ~ 89)岁,体质量指数(23.46±3.17) kg/m2。492例患者中,108例接受腹腔镜胃癌根治术,299例接受3D腹腔镜胃癌根治术,85例接受机器人胃癌根治术。31例患者术前行新辅助化疗,2例术后病理完全缓解。全组患者术后病理分期T0N0期2例,Ⅰ期125例,Ⅱ期131例,Ⅲ期234例,患者临床病理特征见表1。
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 gastrectomyCharacteristic 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) 2 术后并发症发生情况
492例中,103例出现Clavien-Dindo分级≥Ⅱ级的并发症,总体并发症发生率为20.9%。其中,发生率较高的并发症包括贫血(18/103)、低蛋白血症(15/103)、呼吸系统相关并发症(8/103)、心脑系统相关并发症(9/103)及吻合口漏(8/103)。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%,以胸腔积液为主(7/24)。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%。见表2。
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 gastrectomyComplication 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 3 术后并发症危险因素分析
1)单因素logistic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)与术后并发症发生无明显相关性(P=0.096)。2)多因素分析:将单因素分析中有统计学意义(P<0.05)的指标纳入多因素logistic回归,采用逐表后退法。由于ASA分级及aCCI评分有助于评估高龄患者术前基础状态,单因素分析结果提示高ASA分级及aCCI评分患者并发症发生风险较高,因此一并纳入多因素分析。结果显示,脉管侵犯、术中出血量≥200 mL是高龄胃癌患者微创胃癌根治术术后30 d内并发症的独立危险因素(P均<0.05)。而年龄≥80岁、ASA分级>Ⅱ级、aCCI评分>4分不是其独立危险因素(P>0.05)。见表3。
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 gastrectomyVariable 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) 讨 论
随着我国人口老龄化问题的逐步显现,高龄人群比例逐年增加,胃癌年龄分布也呈现老龄化趋势[16]。高龄胃癌患者具有独特的临床特征,如男性为主、多组织学分化类型、肿瘤多位于胃上1/3、肿瘤体积大、术后病理分期较晚等[17]。此外,随着年龄增长,脏器生理功能发生变化,因此需全面权衡身体状态,采取个体化治疗方案[18-19]。本研究纳入年龄≥70岁高龄胃癌患者,以期对该类人群微创手术安全性进行评估,为微创手术方式的合理选择提供依据。
高龄患者基础疾病较多,且由于微创手术建立CO2气腹会加重肺、心、脑等重要脏器负担,一定程度增加了手术风险及术后并发症发生率[20]。因此,合理评估术前合并症对预测术后并发症尤为重要。CCI评分是目前应用较广的合并症分级工具。Lin等[21]的研究证实基于年龄调整的CCI评分(aCCI评分)可预测胃癌患者术后并发症。然而,对于高龄胃癌患者,aCCI评分能否预测微创胃癌根治术术后并发症仍不清楚。本研究单因素分析结果表明,aCCI评分>4分的患者术后总体并发症发生率高于aCCI评分≤4分的患者(26.3% vs 19.3%),aCCI评分与术后并发症发生无明显相关[OR(95% CI):1.492(0.915~2.433),P=0.109]。尽管差异无统计学意义,但仍可看到aCCI评分对高龄胃癌患者微创胃癌根治术术后并发症的潜在预测能力。
胃癌手术中,以腹腔镜为代表的微创技术已逐步替代开腹手术,在高龄胃癌患者中亦是如此。既往研究表明,对于高龄胃癌患者,腹腔镜胃癌根治术与开腹手术的短期疗效和远期预后相当,腹腔镜可通过降低呼吸道疾病死亡率而提升远期生存[22-24]。同时,与非高龄患者相比,高龄胃癌患者腹腔镜操作仍安全可行[4]。近年来,微创平台与技术的不断发展为外科医生提供更加清晰的操作术野,带来更加立体的视觉感受。3D腹腔镜与机器人是目前比较先进的腹腔镜技术。张珂诚等[25]和李家新等[26]的研究结果表明,3D腹腔镜胃癌根治术相比2D腹腔镜胃癌根治术可缩短手术时间、减少术中出血量。一项回顾性分析结果表明,相比高龄患者腹腔镜手术及年轻患者机器人手术,高龄患者机器人手术近期疗效相当,操作安全可行[27]。本研究结果提示,微创手术方式与高龄胃癌患者术后并发症无明显相关性,初步表明行机器人/3D腹腔镜胃癌根治术高龄胃癌患者与行2D腹腔镜胃癌根治术高龄胃癌患者的并发症发生率相当,与既往研究结果相似,考虑原因如下:1)随着微创技术的普及应用,外科医生大多跨过学习曲线及技术壁垒,微创技术的差异对手术操作影响较小,操作安全可靠;2)由于机器人与3D腹腔镜可为术者带来更加立体且高清放大的视觉体验,可一定程度降低误操作概率[25],对总体并发症发生率影响较小,且可能在减少术中出血、降低关键淋巴结(如第8p,10组淋巴结)清扫难度、应对肥胖人群等方面存在优势[28]。不同微创手术方式对高龄胃癌患者近期疗效的影响有待进一步研究,以筛选特定人群制定适宜的微创手术方案。
目前,对年龄≥80岁的超高龄胃癌患者是否适宜行手术治疗仍存在争议,部分研究认为年龄≥80岁是高龄胃癌患者近期并发症的独立危险因素[29]。Sakurai等[30]的研究纳入年龄≥80岁与年龄60 ~ 69岁的胃癌患者,结果表明两者手术近期并发症发生率差异无统计学意义。本研究将高龄胃癌患者分为70 ~ 79岁组及80 ~ 89岁组,单因素分析结果表明年龄≥80岁组术后并发症发生率较70 ~ 79岁组显著升高(30.0% vs 19.4%,P=0.046)。多因素分析显示年龄≥80岁不是高龄胃癌微创术术后并发症的独立危险因素(P=0.129)。基于此结果,笔者建议对超高龄胃癌患者在基础身体状态可行的条件下行微创手术治疗,术中需注意控制出血量及手术时间,以期减少术后并发症发生。
本研究存在以下不足:回顾性研究存在选择偏倚,随着微创外科技术在高龄胃癌患者中的应用逐渐普及,应开展多中心或前瞻性研究以提供高级别的循证医学证据;既往研究指出老年营养风险指数(geriatric nutritional risk index,GNRI)是高龄胃癌患者术后并发症和整体生存的重要预测指标[31],本研究受回顾性研究限制,未纳入术前GNRI以全面评估高龄患者术前状态,有待开展更深入的研究以明确GNRI对高龄胃癌手术并发症的价值与意义。本研究仅关注高龄胃癌患者微创切除术后近期疗效的影响因素,应开展进一步研究以评价其远期疗效。
综上所述,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是高龄胃癌患者微创胃癌根治术术后30 d内并发症的独立危险因素,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。对超高龄(年龄≥80岁)患者可开展微创胃癌根治术。
利益冲突:所有作者声明不存在利益冲突。
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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) 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 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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