目的 探讨腹腔镜根治性全胃切除术治疗老年原发性胃癌患者的预后及其影响因素.方法 采用倾向评分配比及回顾性病例对照研究方法.收集2010年1月至2012年12月福建医科大学附属协和医院收治的338例老年原发性胃癌患者的临床病理资料.行腹腔镜根治性全胃切除术患者246例,行开腹根治性全胃切除术患者92例.采用门诊、家访、信件、电话方式进行随访,了解患者术后生存情况.随访时间截至2015年12月.观察指标包括:(1)患者临床病理资料:性别、年龄、BMI、术前伴发疾病查尔森指数、美国麻醉医师协会(ASA)分级、肿瘤部位、肿瘤直径、淋巴结清扫数量、肿瘤病理学分型、肿瘤pTNM分期.(2)采用倾向评分配比对行腹腔镜和开腹根治性全胃切除术患者进行配对.将配比后行腹腔镜根治性全胃切除术患者设为腹腔镜组,行开腹根治性全胃切除术患者设为开腹组.(3)预后指标:3年累积生存率.(4)预后因素分析指标:性别、肿瘤部位、肿瘤直径、手术方式、肿瘤病理学分型、肿瘤临床分期.(5)对独立预后因素的分层分析.正态分布的计量资料以x±s表示,组间比较采用LSD-t检验和配对t检验.计数资料比较采用x2检验.采用Logistic回归模型进行倾向评分配比.采用Kaplan-Meier法绘制生存曲线并计算生存率,Log-rank检验比较生存率.采用COX比例风险模型进行预后单因素和多因素分析.结果 338例患者中,共87对患者(腹腔镜组和开腹组患者各87例)完成配对.两组患者年龄、肿瘤pTNM分期由配比前差异有统计学意义(t=-1.692,x2=8.437,P＜0.05),经配比后,差异无统计学意义(t=-1.793,x2=0.074,P＞0.05).配比前338例患者中,306例获得随访,随访时间为2～ 67个月,中位随访时间为32个月.行腹腔镜根治性全胃切除术患者3年累积生存率为58.2％,行开腹根治性全胃切除术患者为45.3％,两者3年累积生存率比较,差异有统计学意义(x2=4.989,P＜0.05).配比后174例患者中,159例获得随访,随访时间为2～59个月,中位随访时间为36个月.腹腔镜组和开腹组患者3年累积生存率分别为51.4％和47.6％,两组3年累积生存率比较,差异无统计学意义(x2=0.483,P＞0.05).对配比后的174例患者进行预后单因素分析的结果显示:肿瘤直径和肿瘤临床分期是影响老年原发性胃癌患者行根治性全胃切除术后预后的相关因素(OR=2.697,4.493,95％可信区间:1.695 ～4.289,2.466 ～8.186,P＜0.05).多因素分析结果显示:肿瘤临床分期为Ⅲ期是影响老年原发性胃癌患者行根治性全胃切除术后预后不良的独立危险因素(OR=3.954,95％可信区间:2.122 ～7.367,P＜0.05).配比后的174例患者中,肿瘤临床分期为Ⅰ、Ⅱ、Ⅲ期的腹腔镜组患者3年累积生存率分别为90.6％、72.1％、38.7％,开腹组患者分别为100.0％、77.5％、30.6％,两组比较,差异均无统计学意义(x2=0.999,0.000,0.788,P＞0.05).结论 对于老年原发性胃癌患者,行腹腔镜根治性全胃切除术仍能获得与开腹手术相当的预后;年龄不应视为腹腔镜根治性全胃切除术的绝对禁忌证.肿瘤临床分期为Ⅲ期是影响老年原发性胃癌患者行根治性全胃切除术后预后不良的独立危险因素.%Objective To investigate the prognostic factors of laparoscopic radical total gastrectomy for elderly patients with primary gastric cancer.Methods The retrospective case-control study was adopted by using propensity score matching analysis.The clinicopathological data of 338 elderly patients with primary gastric cancer who were admitted to the Union Hospital of Fujian Medical University between January 2010 and December 2012 were collected,including 246 receiving laparoscopic radical total gastrectomy (LTG) and 92 receiving open radical total gastrectomy (OTG).The follow-up was performed to detect postoperative survival of patients by outpatient examination,home visit,correspondence and telephone interview till December 2015.Observation indicators included:(1) the clinicopathological data:gender,age,body mass index (BMI),Charlson scores of preoperative concomitant diseases,American Society of Anesthesiologists (ASA) grading,tumor location and diameter,number of lymph node dissected,pathologic classification of tumors and pathologic TNM (pTNM) stage.(2) All the patients were allocated into the LTG group and OTG group after a propensity score matching analysis.(3) Prognostic indicator included 3-year cumulative survival rate.(4) Prognostic analysis indicators included gender,tumors location and diameter,surgical procedures,pathological classification and tumor clinical staging.(5) Independent prognostic factors were done by the stratification analysis.Measurement data with normal distribution were presented as x-± s and comparison between groups was analyzed by LSD-t test and matching t test.Count data were analyzed using the chi-square test.The propensity score matching analysis was done using Logistic regression model.The survival curve was drawn by Kaplan-Meier method and survival rate was calculated using the Log-rank test.The univariate analysis and multivariate analysis were done using the COX proportional risk model.Results Of 338 patients,there were 87 matched pairs (87 patients in each group).There were significant differences in the age and pTNM stage before propensity score matching between the 2 groups (t =-1.692,x2=8.437,P ＜0.05) and no significant difference after propensity score matching (t =-1.793,x2 =0.074,P ＞ 0.05).Among 338 patients before propensity score matching,306 patients were followed up for a median time of 32 months (range,2-67 months).The 3-year cumulative survival rate was 58.2％ and 45.3％ in the LTG and OTG groups,respectively,showing a significant difference between the 2 groups (x2=4.989,P ＜0.05).After propensity score matching,159 of 174 matched patients were followed up for a median time of 36 months (range,2-59 months).The 3-year cumulative survival rate was 51.4％ and 47.6％ in the LTG and OTG groups,respectively,showing no significant difference between the 2 groups (x2=0.483,P ＞0.05).The results of univariate analysis in the 174 matched patients showed that tumor diameter and clinical staging were related factors affecting the prognosis of elderly patients undergoing radical total gastrectomy of primary gastric cancer [OR =2.697,4.493,95％ confidence interval (CI):1.695-4.289,2.466-8.186,P ＜ 0.05].The results of multivariate analysis showed that the stage Ⅲ of tumor was an independent risk factor affecting the poor prognosis of elderly patients undergoing radical total gastrectomy of primary gastric cancer (OR =3.954,95％ CI:2.122-7.367,P ＜ 0.05).Among 174 matched patients,3-year cumulative survival rates in the stage Ⅰ,Ⅱ and Ⅲ of tumor were 90.6％,72.1％,38.7％ in the LTG group and 100.0％,77.5％,30.6％ in the OTG group,respectively,with no significant difference (x2=0.999,0.000,0.788,P ＞0.05).Conclusions LTG for elderly patients with primary gastric cancer is equivalent to OTG in the prognosis,and the age is not an absolute contraindication.The stage Ⅲ of tumor is an independent risk factor affecting the poor prognosis of elderly patients undergoing radical total gastrectomy of primary gastric cancer.
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