机器人辅助胃癌根治术后腹腔感染的危险因素及预后分析

Analysis of risk factors and prognosis of intra-abdominal infection after robotic-assisted radical gastric cancer resection

摘要:

背景与目的 腹腔感染是胃癌根治术后常见的并发症，但目前有关机器人辅助胃癌根治术后发生腹腔感染的影响因素及相关预后研究报道较少。本研究旨在分析和探讨机器人辅助胃癌根治术后发生腹腔感染的危险因素及预后，以期为临床提供参考。方法 回顾甘肃省人民医院普外一科2017年1月—2021年3月行机器人辅助胃癌根治术的262例胃癌患者临床资料，分析患者术后腹腔感染的发生情况及其影响因素，以及术后腹腔感染对患者治疗结局与预后的影响。结果 在262例患者中，14例（5.34%）术后发生腹腔感染，感染原因分别为腹腔脓肿12例（4.58%）、横结肠瘘1例（0.38%）、胰瘘1例（0.38%）；Clavien-Dindo分级包括II级9例（3.44%），IIIa级4例（1.53%），IIIb级1例（0.38%）。单因素分析结果显示，体质量指数（BMI）、术前白蛋白、术前贫血、肿瘤直径、术中联合脏器切除、术中出血量、pTNM分期、N分期、肿瘤淋巴血管侵犯、神经侵犯和术后第3天中性粒细胞百分比（NEUT%）与机器人辅助胃癌根治术后发生腹腔感染有关（均P<0.05）；多因素Logistic回归分析结果表明，BMI<18.5 kg/m²（OR=11.160，95% CI=2.289~54.410，P=0.003）、术前白蛋白<30 g/L（OR=6.612，95% CI=1.630~26.820，P=0.008）、术中联合脏器切除（OR=5.236，95% CI=1.068~25.661，P=0.041）、肿瘤淋巴血管侵犯（OR=8.151，95% CI=1.771~37.52，P=0.007）和术后第3天NEUT%（OR=1.208，95% CI=1.069~1.366，P=0.003）是机器人辅助胃癌根治术后患者发生腹腔感染的独立危险因素。对术后第1、3、7天NEUT%行ROC曲线分析，结果表明，术后第3天NEUT%诊断术后腹腔感染的AUC（0.805）最大，其最佳截断值为82.65%，敏感度为71.4%，特异度为84.7%。与无术后腹腔感染的患者比较，有感染患者术后首次通气时间、首次进流食时间、术后1~7 d腹腔引流量、腹腔引流管拔除时间、术后住院时间及住院总费用均明显增加（均P<0.05）。生存分析结果显示，术后腹腔感染患者的总生存率低于无腹腔感染患者（45.4% vs. 67.8%，P=0.046）。结论 对于有以上危险因素的患者，在行机器人辅助胃癌根治术后要积极预防腹腔感染的发生，从而促进患者术后恢复、改善患者术后生存。术后第3天NEUT%对于预测机器人辅助胃癌根治术后腹腔感染有一定的价值。

Abstract:

Background and Aims Intra-abdominal infection is a common complication after radical gastrectomy for gastric cancer. However, there are few studies concerning the influencing factors for intra-abdominal infection after robotic-assisted radical gastrectomy and the associated prognosis. Therefore, this study was conducted to analyze the risk factors for intra-abdominal infection after robotic-assisted radical gastrectomy and the associated prognosis, so as to provide a reference for clinical practice.Methods The clinical data of 262 gastric cancer patients undergoing robotic-assisted radical gastrectomy from January 2017 to March 2021 in the First Department of General Surgery, Gansu Provincial Hospital were reviewed. The incidence of postoperative intra-abdominal infection and its influencing factors as well as the influence of postoperative intra-abdominal infection on the treatment outcomes and prognosis of the patients were analyzed.Results Among the 262 patients, postoperative intra-abdominal infection occurred in 14 cases (5.34%). The causes for infection were intraperitoneal abscess in 12 cases (4.58%), transverse colon fistula in one case (0.38%) and pancreatic fistula in one case (0.38%), respectively; the Clavien-Dindo classification included grade II in 9 cases (3.44%), grade IIIa in 4 cases (1.53%), and grade IIIb in one case (0.38%). The results of univariate analysis showed that body mass index (BMI), preoperative albumin, preoperative anemia, tumor diameter, synchronous other organ resection, intraoperative blood loss, pTNM stage, N stage, lymphovascular invasion, nerve invasion and the percentage of neutrophils (NEUT%) on postoperative day (POD) 3 were significantly associated with the occurrence of intra-abdominal infection after robotic-assisted radical gastrectomy (all P<0.05). the results of multiple logistic regression analysis revealed that BMI <18.5 kg/m² (OR=11.160, 95% CI=2.289-54.410, P=0.003), preoperative albumin <30 g/L (OR=6.612, 95% CI=1.630-26.820, P=0.008), synchronous other organ resection (OR=5.236, 95% CI=1.068-25.661, P=0.041), tumor lymphovascular invasion (OR=8.151, 95% CI=1.771-37.52, P=0.007) and NEUT% on POD 3 (OR=1.208, 95% CI=1.069-1.366, P=0.003) were independent risk factors for intro-abdominal infection in patients after robotic-assisted radical gastrectomy. The results ROC curve analysis of the NEUT% on POD 1, 3 and 7 demonstrated that the NEUT% on POD 3 had the largest AUC (0.805) for diagnosis of intra-abdominal infection, with the cut-off value of 82.65%, sensitivity of 71.4% and specificity of 84.7%. In patients with postoperative intro-abdominal infection compared with those without intro-abdominal infection, the time to first gas passage, time to first food intake, volumes of abdominal drainage on POD 1 to 7, time to drainage tube removal, length of postoperative hospital stay and total medical cost were all significantly increased (all P<0.05). The results of survival analysis indicated that the overall survival rate of patients with intro-abdominal infection was lower than that of patients without intro-abdominal infection (45.4% vs. 67.8%, P=0.046).Conclusion For patients with above risk factors, aggressive preventive measures against intro-abdominal infection should be implemented after robotic-assisted radical gastrectomy, and thereby promotes the postoperative recovery and improves the postoperative prognosis of them. The NEUT% on POD 3 has certain application value for predicting intro-abdominal infection after robotic-assisted radical gastrectomy.