裴大兵 張翼臻 張海平 盧榮 丁小兵 張旭華
[摘要] 目的 探討L3骨骼肌質(zhì)量指數(shù)在胃癌患者營養(yǎng)風險評估及術(shù)后并發(fā)癥的應(yīng)用價值。方法? 回顧性分析選擇2018年7月~2021年7月井岡山大學附屬醫(yī)院收治的92例胃癌行根治術(shù)患者作為研究對象,根據(jù)骨骼肌指數(shù)(SMI)高低分組,高SMI 69例,低SMI 23例,比較SMI高低組患者的年齡、性別、體質(zhì)量指數(shù)(BMI)、血紅蛋白、血清總蛋白、白蛋白、營養(yǎng)風險篩查2002評分(NRS 2002)、術(shù)前患者整體營養(yǎng)狀況主觀評定法(PG-SGA)評分、手術(shù)時間、手術(shù)方式、手術(shù)切除范圍、出血量、住院時間、術(shù)后并發(fā)癥的差異,并對患者術(shù)后并發(fā)癥相關(guān)因素進行單因素及Logistic回歸分析,篩選術(shù)后并發(fā)癥的危險因素。結(jié)果? 高骨骼肌患者的BMI、血清總蛋白、白蛋白、血紅蛋白分別為(23.38±3.13)kg/m2、(69.75±7.21)g/L、(43.13±3.81)g/L、(132.21±20.45)g/L,均分別高于低骨骼肌患者的(20.68±2.79)kg/m2、(67.19±8.32)g/L、(40.19±5.12)g/L、(124.57±22.56)g/L,高骨骼肌患者術(shù)后并發(fā)癥3例低于低骨骼肌患者的13例,差異有統(tǒng)計學意義(P<0.05)。高骨骼肌患者年齡、出血量[(58.72±10.13)歲、(155.49±133.59)ml]低于低骨骼肌患者[(62.65±10.91)歲、(160.19±125.49)ml],高骨骼肌患者手術(shù)時間、住院時間分別為(215.79±51.49)min、(19.39±4.49)d,高于低骨骼肌患者的(207.79±61.49)min、(12.89±6.39)d,但差異無統(tǒng)計學意義(P>0.05)。NRS2002評分高低SMI組間比較,差異有統(tǒng)計學意義(χ2=4.215,P=0.018);PG-SGA評分高低SMI組間比較,差異有統(tǒng)計學意義(χ2=27.680,P=0.037),L3-SMI可用于篩查胃癌患者術(shù)前營養(yǎng)風險。Logistic回歸分析結(jié)果顯示:低L3-SMI是影響胃癌術(shù)后并發(fā)癥的危險因素(OR=2.913,95%CI:2.513~3.732;P=0.046)。結(jié)論? L3-SMI可用于評估胃癌患者的營養(yǎng)風險,是胃癌術(shù)后并發(fā)癥的危險因素。
[關(guān)鍵詞] 骨骼肌質(zhì)量指數(shù);胃癌;營養(yǎng)風險;術(shù)后并發(fā)癥
[中圖分類號] R735.2;R730.6? ? ? ? ? [文獻標識碼] B? ? ? ? ? [文章編號] 1673-9701(2022)17-0047-04
Application value of L3 skeletal muscle mass index in nutritional risk assessment and postoperative complications for patients with gastric cancer
PEI Dabing1? ?ZHANG Yizhen2? ?ZHANG Haiping3? ?LU Rong3? ?DING Xiaobing1? ?ZHANG Xuhua1
1. Department of General Surgery, Affiliated Hospital of Jinggangshan University, Ji'an 343000, China; 2. Department of Pathology, Affiliated Hospital of Jinggangshan University, Ji'an 343000, China; 3. Department of Imaging, Affiliated Hospital of Jinggangshan University, Ji'an 343000, China
[Abstract] Objective To explore the application value of L3 skeletal muscle mass index in nutritional risk assessment and postoperative complications for patients with gastric cancer. Methods A total of 92 patients with gastric cancer who underwent radical gastrectomy in the Affiliated Hospital of Jinggangshan University from July 2018 to July 2021 were retrospectively analyzed as the research objects. According to the skeletal muscle index (SMI), they were divided into two groups: 69 patients with high SMI and 23 patients with low SMI. The following indicators were compared between the high SMI group and the low SMI group: age, gender, body mass index (BMI), hemoglobin, total serum protein, albumin, Nutritional Risk Screening 2002 (NRS 2002) score, preoperative Patient-Generated Subjective Global Assessment (PG-SGA), operation time, operation mode, resection scope, bleeding amount, length of hospital stay and postoperative complications. Univariate and Logistic regression analyses on the related factors for postoperative complications were carried out to screen the risk factors for postoperative complications. Results The BMI, serum total protein, albumin and hemoglobin of patients with high SMI [(23.38±3.13) kg/m2, (69.75±7.21) g/L, (43.13±3.81) g/L and (132.21±20.45) g/L respectively] were higher than those of patients with low SMI [(20.68±2.79) kg/m2, (67.19±8.32) g/L, (40.19±5.12) g/L and (124.57±22.56) g/L]. The postoperative complication in patients with high SMI (3 cases) was less than that in patients with low SMI (13 cases), with statistically significant differences (P<0.05). The age and bleeding amount of patients with high SMI [(58.72±10.13) years old, (155.49±133.59) ml] were lower than those of patients with low SMI [(62.65±10.91) years old, (160.19±125.49) ml]. The operation time and length of hospital stay in patients with high SMI [(215.79±51.49) min, (19.39±4.49) days] were longer than those in patients with low SMI [(207.79±61.49) min, (12.89±6.39) days], without statistically significant difference (P>0.05). There was a statistically significant difference in NRS 2002 score between the high SMI group and the low SMI group (χ2=4.215, P=0.018); there was a statistically significant difference in PG-SGA score between the high SMI group and the low SMI group (χ2=27.680, P=0.037). L3 SMI could be used to screen preoperative nutritional risks in patients with gastric cancer. Logistic regression analysis showed that low L3 SMI was a risk factor for postoperative complications of gastric cancer (OR=2.913, 95%CI:2.513-3.732; P=0.046). Conclusion L3 SMI can be used to evaluate the nutritional risks of patients with gastric cancer and is a risk factor for postoperative complications of gastric cancer.
[Key words] Skeletal muscle mass index; Gastric cancer; Nutritional risk; Postoperative complications
胃癌(gastric cancer,GC)是全球惡性腫瘤第二致死原因[1]。胃癌治療以手術(shù)切除為主,術(shù)后并發(fā)癥影響患者的預(yù)后[2]。術(shù)前營養(yǎng)狀況與術(shù)后并發(fā)癥發(fā)生密切相關(guān),嚴重營養(yǎng)不良導(dǎo)致術(shù)后并發(fā)癥增加[3,4]。營養(yǎng)風險篩查2002評分(nutritional risk screening 2002,NRS 2002)、患者整體營養(yǎng)狀況主觀評定法(scored patient-generated subjective global assessment,PG-SGA)評分、體質(zhì)量指數(shù)(body-mass index,BMI)、白蛋白是常用的營養(yǎng)評價工具及指標。近年來,第三腰椎(third lumbar spine,L3)平面CT圖像骨骼肌指數(shù)(skeletal muscle index,SMI)被用來評估胃癌患者的營養(yǎng)狀況,有研究認為骨骼肌減少與惡性腫瘤患者的術(shù)后并發(fā)癥顯著相關(guān)[4]。本研究旨在通過回顧性分析L3-SMI高低組患者的營養(yǎng)評價表得分及指標情況,探討SMI指標與胃癌患者的營養(yǎng)狀態(tài)的關(guān)系及研究SMI對胃癌手術(shù)指標如手術(shù)方式、術(shù)后并發(fā)癥等的影響。
1 資料與方法
1.1 一般資料
回顧性分析選擇2018年7月~2021年7月井岡山大學附屬醫(yī)院收治的92例行胃癌根治術(shù)患者作為研究對象,收集患者的臨床病歷資料、影像資料。納入及排除標準參考Huang DD、Kamarajah SK文獻[10,19]。納入標準:①年齡≥18周歲;②術(shù)前胃鏡證實為胃癌行根治術(shù);③術(shù)前未行任何治療,術(shù)前1個月內(nèi)在井岡山大學附屬醫(yī)院行腹部CT檢查;④本研究需要的基本病歷資料完整病例。排除標準:①有慢性疾病者;②腹部CT檢查不符合要求者;③有營養(yǎng)疾病者。其中男57例,女35例,平均年齡(60.62±10.89)歲。本研究經(jīng)井岡山大學附屬醫(yī)院醫(yī)學倫理委員會審批。
1.2 方法
1.2.1 患者營養(yǎng)評估? 入院12 h內(nèi),由有經(jīng)驗的醫(yī)師與護士各1名進行NRS2002、PG-SGA營養(yǎng)評估。(1)NRS2002評估表[6]:①年齡評分:年齡<70歲為0分,年齡≥70歲加1分;②現(xiàn)患疾病的嚴重程度評分:不同疾病嚴重程度分別加0~3分;③營養(yǎng)狀況的受損情況評分:0~3分。參考指標:近期飲食攝入的減少量、體重的丟失量及BMI大小??傇u分為7分,患者總分≥3分為有營養(yǎng)風險,<3分為營養(yǎng)正常。(2)PG-SGA評估表[7]:①患者自評:患者自身進食情況、體重、自感癥狀、活動能力和身體功能進行自我評估。②醫(yī)護人員評估:醫(yī)護人員根據(jù)患者的疾病狀態(tài)、代謝狀態(tài)及體格檢查結(jié)果進行評估。總評分分為定量和定性評分,定量評分結(jié)果為四個等級:0~1分為營養(yǎng)狀況良好,2~3分為可疑營養(yǎng)不良,4~8分為中度營養(yǎng)不良,≥9分為重度營養(yǎng)不良。
1.2.2 L3-SMI測定? 分析術(shù)前GE公司lightspeed VCT機掃描的圖像,選用L3平面成像,選取兩個連續(xù)圖像,計算骨骼?。òㄘQ脊肌、腰大肌、腰方肌、腹直肌、腹內(nèi)斜肌、腹橫肌、腹外斜?。┑臋M截面積之和(圖1)并取平均值。SMI(cm2/m2)=骨骼肌面積(cm2)/身高2(m2),取四分位數(shù)為分組的截止值[8]。女性SMI值≥30 cm2/m2為高SMI組,SMI值<30 cm2/m2為低SMI組;男性SMI值≥38.3 cm2/m2為高SMI組,SMI值<38.3 cm2/m2為低SMI。根據(jù)計算的SMI數(shù)值,參照四分位數(shù)為分組的截止值,基于SMI分為高低組。
1.3 觀察指標及評價標準
①根據(jù)SMI分組,比較兩組患者的年齡、性別、BMI、白蛋白、血清總蛋白、血紅蛋白、手術(shù)方式、手術(shù)切除范圍、手術(shù)時間、出血量、住院時間、術(shù)后并發(fā)癥情況;②根據(jù)PG-SGA及NRS2002評分比較兩組的SMI,評價患者的營養(yǎng)風險;③比較一般指標及營養(yǎng)指標,單因素分析篩選與術(shù)后并發(fā)癥有關(guān)因素,多因素分析篩選出術(shù)后并發(fā)癥危險因素。
1.4 統(tǒng)計學方法
采用SPSS 22.0統(tǒng)計學軟件進行數(shù)據(jù)分析,計量資料以均數(shù)±標準差(x±s)表示,組間比較采用t檢驗,計數(shù)資料以[n(%)]表示,組間比較采用χ2檢驗,采用Logistic回歸分析確定術(shù)后并發(fā)癥的危險因素,P<0.05為差異有統(tǒng)計學意義。
2 結(jié)果
2.1 高低SMI組患者的一般指標、營養(yǎng)指標比較
根據(jù)資料92例患者中高SMI患者69例,低SMI患者23例,兩組患者的術(shù)后并發(fā)癥、BMI、白蛋白、血清總蛋白、血紅蛋白比較,差異有統(tǒng)計學意義(均P<0.05),兩組患者的年齡、性別、手術(shù)方式、手術(shù)切除范圍、手術(shù)時間、出血量、住院時間比較,差異無統(tǒng)計學意義(均P>0.05)。見表1。
2.2 高低SMI組患者營養(yǎng)方法評分比較
根據(jù)PG-SGA評分,低SMI組營養(yǎng)狀況低于高SMI組,組間比較,差異有統(tǒng)計學意義(χ2=27.68,P=0.037)。NRS2002評分,組間比較差異有統(tǒng)計學意義(χ2=4.215,P=0.018),SMI可用于篩查患者術(shù)前營養(yǎng)風險。見表2。
2.3 單因素分析胃癌術(shù)后并發(fā)癥相關(guān)因素
對一般指標及營養(yǎng)指標單因素分析顯示,手術(shù)方式及低L3-SMI是影響胃癌術(shù)后并發(fā)癥發(fā)生的相關(guān)因素(P<0.05)。見表3。
2.4 Logistic回歸分析術(shù)后并發(fā)癥危險因素
將表3結(jié)果顯示有統(tǒng)計學意義的因素納入自變量并賦值。見表4。將胃癌術(shù)后是否出現(xiàn)并發(fā)癥作為因變量(1=出現(xiàn),0=未出現(xiàn)),經(jīng)Logistic回歸分析得出:手術(shù)方式和低L3-SMI是影響胃癌術(shù)后并發(fā)癥的危險因素。見表5。
3 討論
胃癌患者的營養(yǎng)狀況評估有BMI、血紅蛋白、血清總蛋白、白蛋白等指標及NRS 2002、PG-SGA評分工具。本研究顯示兩組患者的BMI、血紅蛋白、白蛋白、血清總蛋白比較,差異有統(tǒng)計學意義(P<0.05),表明患者術(shù)前存在營養(yǎng)風險可能。
胃癌患者行根治術(shù)后由于禁食及手術(shù)應(yīng)激使營養(yǎng)缺乏加重,導(dǎo)致術(shù)后并發(fā)癥發(fā)生增加,本研究發(fā)現(xiàn)高SMI組患者術(shù)后并發(fā)癥3例,低SMI組患者術(shù)后并發(fā)癥13例,組間比較,差異有統(tǒng)計學意義(P=0.025),低SMI患者的并發(fā)癥更嚴重。主要原因:低SMI患者急性期蛋白合成不足、免疫細胞活性下降,導(dǎo)致患者對感染的抵抗力減弱;腸道缺乏谷氨酰胺出現(xiàn)細菌移位也增加術(shù)后感染風險,谷氨酰胺減少導(dǎo)致腸黏膜萎縮腸道吸收功能下降且氨基酸供應(yīng)不足使組織愈合能力差,兩者導(dǎo)致腸瘺風險增加[9,10]。
PG-SGA、NRS2002及人體成分營養(yǎng)指標對預(yù)測胃癌根治性切除患者術(shù)前的營養(yǎng)狀態(tài)有一定的意義,但PG-SGA及NRS2002一致性較差,說明兩者單獨使用有各自的優(yōu)缺點[11]。所以本研究分析SMI高低組的PG-SGA及NRS2002情況,結(jié)果顯示:低SMI組營養(yǎng)狀況的PG-SGA評分低于高SMI組,組間比較差異有統(tǒng)計學意義(χ2=27.680,P=0.037)。對NRS2002評分,組間比較差異有統(tǒng)計學意義(χ2=4.215,P=0.018),表明L3-SMI可用于篩查患者的手術(shù)前營養(yǎng)風險。Sieber等[12]報道,營養(yǎng)不良是肌肉減少癥的主要原因。肌肉減少癥的發(fā)生還與患者的內(nèi)分泌及代謝變化、骨骼肌線粒體功能下降、胰島素抵抗等有關(guān)[13,14]。骨骼肌減少癥更容易出現(xiàn)在營養(yǎng)不良的胃癌患者中。有研究表明,術(shù)前有肌肉減少癥的胃癌患者術(shù)后擁有更差的總生存期[15]。因此,臨床上對肌肉減少癥患者的及時識別及干預(yù)意義重大,以期改善臨床結(jié)局。
肌肉減少癥能增加胃癌患者術(shù)后并發(fā)癥的發(fā)生。Zhuang等[16]研究發(fā)現(xiàn),肌肉減少癥是胃癌根治術(shù)后嚴重并發(fā)癥的獨立危險因素(OR=3.010,P<0.001);Lou等[17]研究認為,肌肉減少癥是超重或肥胖胃癌患者(BMI≥23 kg/m2)根治術(shù)后并發(fā)癥的獨立危險因素(OR=6.071,P=0.002)。本研究對患者一般指標及營養(yǎng)指標單因素分析顯示,手術(shù)方式及低L3-SMI是影響胃癌術(shù)后并發(fā)癥發(fā)生的相關(guān)因素(P<0.05),進一步通過Logistic回歸分析顯示,手術(shù)方式(OR=1.613, 95%CI:1.398~2.128;P=0.021)和低L3-SMI(OR=2.913,95%CI:2.513~3.732;P=0.046)是影響胃癌術(shù)后并發(fā)癥的危險因素。
綜上所述,L3-SMI可用于評估胃癌患者的營養(yǎng)風險,是影響胃癌術(shù)后并發(fā)癥的危險因素。
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