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北京大学学报（医学版） ›› 2021, Vol. 53 ›› Issue (6): 1152-1158. doi: 10.19723/j.issn.1671-167X.2021.06.024

• 论著 • 上一篇    下一篇

硬膜外阻滞与结直肠癌患者术后远期生存状态的关系:一项倾向性评分匹配的回顾性研究

穆东亮1,薛铖1,安彬2,王东信1,△()   

  1. 1.北京大学第一医院麻醉科,北京 100034
    2.航天中心医院麻醉科,北京 100049
  • 收稿日期:2019-12-26 出版日期:2021-12-18 发布日期:2021-12-13
  • 通讯作者: 王东信 E-mail:wangdongxin@hotmail.com

Epidural block associated with improved long-term survival after surgery for colorectal cancer: A retrospective cohort study with propensity score matching

MU Dong-liang1,XUE Cheng1,AN Bin2,WANG Dong-xin1,△()   

  1. 1. Department of Anesthesiology, Peking University First Hospital, Beijing 100034, China
    2. Department of Anesthesiology, Aerospace Center Hospital, Beijing 100049, China
  • Received:2019-12-26 Online:2021-12-18 Published:2021-12-13
  • Contact: Dong-xin WANG E-mail:wangdongxin@hotmail.com

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摘要：

目的:探索硬膜外阻滞对结直肠癌患者预后的影响。方法:本研究为一项回顾性队列研究,纳入2011年8月至2012年12月在北京大学第一医院接受择期结直肠癌切除术的患者。根据患者接受的麻醉和术后镇痛方式将患者分为单纯全身麻醉(general anesthesia,GA)组和硬膜外阻滞复合全身麻醉(epidural-general anesthesia, EGA)组。主要观察终点为患者远期生存状态,次要观察终点为住院期间并发症发生率和术后住院时间。采用倾向性评分进行病例匹配。术后生存时间采用Kaplan-Meier生存分析,组间比较采用Log-rank test;采用多因素Cox风险回归模型分析麻醉方式及其他变量对患者远期生存状态的影响。结果:对264例患者完成了术后随访,其中GA组166例,EGA组98例。患者平均年龄为(63.3±12.1)岁,平均生存时间为47.2(95%CI 45.7~48.7)个月。在倾向性评分前,EGA组患者死亡率为16.9%(28/166),而GA组死亡率为9.2%(9/98), 组间差异无统计学意义(P=0.091)。经倾向性评分匹配后,GA和EGA组共有87对匹配病例。EGA组死亡率低于GA组死亡率(5.7% vs.16.1%,HR=0.34,95%CI 0.12~0.96,P=0.041),平均生存时间长于GA组患者(50.3个月 vs. 42.9个月, P=0.032),术后整体并发症发生率低于GA组(8.0% vs.16.4%, P=0.044)。多因素Cox风险模型显示围术期使用硬膜外阻滞是降低患者远期死亡风险的独立因素之一(HR=0.33,95%CI 0.12~0.91,P=0.032), 而年龄(HR=1.04,95%CI 1.00~1.09,P=0.046)和术前淋巴结转移(HR=2.92,95%CI 1.16~7.36,P=0.023)分别是增加患者远期死亡风险的独立危险因素。结论:与单纯全身麻醉组相比,硬膜外阻滞复合全身麻醉组患者的远期生存时间延长,但仍需要进一步开展高质量研究进行验证。

关键词: 全身麻醉, 硬膜外阻滞, 结直肠癌, 远期, 生存状态

Abstract:

Objective: To investigate the effect of epidural anesthesia on the long-term prognosis of patients after selective colorectal cancer resection surgery. Methods: This was a retrospective cohort study and approved by local institution review board. Patients who underwent selective colorectal cancer resection surgery from August 2011 to December 2012 in Peking University First Hospital were enrolled. The patients were divided into general anesthesia (GA) group and combined epidural-general anesthesia (EGA) group according to anesthesia type. Primary outcome was patient’s long-term survival status. Secondary outcome included the overall incidence of in-hospital complications and length of postoperative in-hospital stay. Propensity score was used to match cases between the two groups based on the probability of receiving EGA. Survival was analyzed by Kaplan-Meier analysis and compared by Log-rank test between the two groups. Multivariate Cox regression analysis was used to investigate the relationship between epidural anesthesia and other variables with long-term survival status. Results: A total of 264 patients were entered into final analysis, including 166 cases in GA group and 98 cases in EGA group. Mean age of the patients was (63.3±12.1) years and mean survival time was 47.2 (95%CI 45.7-48.7) months. Before the propensity score match, the mortality in EGA group was 16.9% (28/166) and 9.2% (9/98) in GA group. But comparison between the two groups had no statistical significance (P=0.091). After the propensity score match,87 paired cases were matched and analyzed. The risk of long-term mortality in EGA group was lower than that of GA group by Kaplan-Meier analysis (5.7% vs.16.1%, HR=0.344, 95%CI 0.124-0.955, P=0.041). Mean survival time of EGA group was longer than that of GA group (50.3 months vs. 42.9 months, P=0.032). Multivariate Cox regression ana-lysis showed that EGA, in comparison with GA, was related with lower risk of long-term mortality (HR=0.326, 95%CI 0.117-0.909, P=0.032). Age (HR=1.042, 95%CI 1.001-1.085, P=0.046) and preoperative lymph node metastasis (HR=2.924, 95%CI 1.162-7.356, P=0.023) were also related with increased risk of long-term mortality. Conclusion: Present study found that perioperative use of epidural anesthesia and analgesia was associated with improvement of the patient’s long-term survival. Well-designed studies are needed to verify this hypothesis.

Key words: General anesthesia, Epidural anesthesia, Colorectal cancer, Long-term, Survival status

中图分类号: 

  • R614.4

表1

入选患者的基本资料"

Variables All patients
(n=264)		 Before matching After matching
GA group
(n=166)		 EGA group
(n=98)		 P GA group
(n=87)		 EGA group
(n=87)		 P
Age/year, $\overline{x}$±s 63.3±12.1 64.2±12.7 61.6±10.9 0.082 61.2±12.8 60.5±10.5 0.698
BMI, $\overline{x}$±s 23.8±3.3 23.8±3.6 23.7±2.8 0.749 24.2±3.7 23.7±2.8 0.360
Preoperative comorbidity, n (%)
CAD 37 (14.0) 29 (17.5) 8 (8.2) 0.035 4 (4.6) 5 (5.7) 1.000
Hypertension 117 (44.3) 82 (49.4) 35 (35.7) 0.031 38 (43.7) 29 (33.3) 0.161
Stroke 26 (9.8) 21 (12.7) 5 (5.1) 0.047 6 (6.9) 2 (2.3) 0.148
Diabetics 45 (17.0) 33 (19.9%) 12 (12.2) 0.111 11 (12.6) 8 (9.2) 0.466
CRF 6 (2.3) 6 (3.6) 0 (0) 0.057 2 (2.3) 0 (0) 0.155
COPD 6 (2.3) 2 (1.2) 4 (4.1) 0.130 2 (2.3) 3 (3.4) 1.000
ASA grade, n (%) 0.008 0.794
1 21 (8.0) 10 (6.0) 11 (11.2) 9 (10.3) 11 (12.6)
2 188 (71.2) 111 (66.9) 77 (78.6) 76 (87.4) 73 (83.9)
3 55 (20.9) 44 (26.5) 10 (10.2) 2 (2.3) 3 (3.4)
Surgery site, n (%) 0.759 0.762
Colon 118 (44.7) 73 (44.0) 45 (45.9) 45 (51.7) 43 (49.4)
Rectal 146 (55.3) 93 (56.0) 53 (54.1) 42 (48.3) 44 (50.6)
Anesthesia time/h, $\overline{x}$±s 5.5±1.7 5.4±1.8 5.5±1.7 0.877 5.7±1.6 5.5±1.6 0.595
Allogenic blood transfusion, n (%) 14 (5.3) 10 (6.0) 4 (4.1) 0.496 1 (1.1) 3 (3.4) 0.312
Tumor size, n (%) (n=259) (n=162) (n=97) 0.601 0.931
<2 cm 13 (4.9) 7 (4.2) 6 (6.1) 5 (5.7) 5 (5.7)
2-<3 cm 49 (18.6) 29 (17.5) 20 (20.4) 18 (20.7) 18 (20.7)
3-<5 cm 117 (44.3) 71 (42.8) 46 (46.9) 38 (43.7) 42 (48.3))
5-<7 cm 50 (18.9) 36 (21.7) 14 (14.3) 15 (17.2) 11 (12.6)
≥7 cm 30 (11.4) 19 (11.4) 11 (11.2) 11 (12.6) 11 (12.6)
Pathological grade, n (%) 0.158 0.346
Undifferentiation 1 (0.4) 0 (0) 1 (1.0) 0 (0) 1 (1.1)
Low differentiation 29 (11.0) 16 (9.6) 13 (13.3) 7 (8.0) 12 (13.8)
Medium differentiation 204 (77.3) 125 (75.3) 79 (80.6) 67 (77.0) 70 (80.5)
Well differentiation 5 (1.9) 1 (0.6) 4 (4.1) 1 (1.1) 4 (4.6)
Not available 25 (9.5) 24 (14.5) 1 (1.0) 12 (13.8) 0 (0)
Lymph node metastasis, n (%) 123 (46.6) 85 (51.2) 38 (38.8) 0.060 31 (35.6) 34 (39.1) 0.638
Postoperative radio-/chemotherapy, n (%) 132 (50.4)
(n=263)		 81 (48.8)
(n=166)		 51 (53.1)
(n=97)		 0.411 42 (48.3) 49 (56.3) 0.288

表2

主要研究终点和次要研究终点"

Variables Before matching After matching
GA group
(n=166)		 EGA group
(n =98)		 P GA group
(n =87)		 EGA group
(n =87)		 HR, OR or difference
(95%CI)		 P
Primary outcome
Overall survival, death, n (%) 28 (16.9) 9 (9.2) 0.091 14 (16.1) 5 (5.7) HR=0.34 (0.12, 0.96) 0.041
Secondary outcome, n (%)
Total incidence of complications 32 (19.3) 10 (10.2) 0.052 16 (18.4) 7 (8.0) OR=0.39 (0.15, 1.00) 0.044
Individualized complications
Ischemic cardiac events 2 (1.2) 0 (0) 0.531 1 (1.1) 0 (0) OR=0.99 (0.97, 1.01) 1.000
Hypertension 24 (14.5) 5 (5.1) 0.019 12 (13.8) 4 (4.6) OR=0.30 (0.09, 0.97) 0.036
Heart failure 3 (1.8) 0 (0) 0.297 2 (2.3) 0 (0) OR=0.98 (0.95, 1.10) 0.497
Arrythmia 4 (2.4) 3 (3.1) 0.713 0 (0) 1 (1.1) OR=1.01 (0.99, 1.04) 1.000
Atelectasis 1 (0.6) 0 (0) 1.000 1 (1.1) 0 (0) OR=0.99 (0.97, 1.01) 1.000
Pneumonia 2 (1.2) 1 (1.0) 1.000 1 (1.1) 1 (1.1) OR=1.00 (0.06, 16.25) 0.751
Hydrothorax 5 (3.0) 0 (0) 0.161 3 (3.4) 0 (0) OR=0.97 (0.93, 1.01) 0.246
Deep venous thrombi 0 (0) 2 (2.0) 0.137 0 (0) 2 (2.3) OR=1.02 (0.99, 1.06) 0.497
Postoperative LOS/day, median (IQR) 11 (9, 14) 11 (9, 14) 0.810 11 (9, 13) 11 (9, 14) Difference=0 (-1.0, 1.0) 0.783

图1

Kaplan-Meier分析"

表3

多因素Cox风险回归分析"

Variables Before matching After matching
Univariate analysis Multivariate analysis Univariate analysis Multivariate analysis
HR (95%CI) P HR (95%CI) P HR (95%CI) P HR (95%CI) P
Agea 1.04 (1.01, 1.07) 0.005 1.04 (1.02, 1.07) 0.001 1.04 (1.00, 1.08) 0.070 1.04 (1.00, 1.09) 0.046
Body mass indexb 0.88 (0.79, 0.98) 0.015
Coronary artery diseasec 2.25 (1.06, 4.77) 0.035
Diabeticsc 1.86 (0.90, 3.84) 0.095
Chronic renal failurec 4.32 (1.32, 14.10) 0.015 4.27 (1.49, 12.27) 0.007
ASA physical graded 2.28 (1.29, 4.41) 0.004
EGA groupe 0.52 (0.25, 1.11) 0.091 0.53 (0.28, 0.98) 0.044 0.34 (0.12, 0.96) 0.041 0.33 (0.12, 0.91) 0.032
Pathological gradef 0.49 (0.24, 1.03) 0.061 0.42 (0.24, 0.72) 0.002
Tumor sizeg 1.02 (1.00, 1.04) 0.076
Lymph node metastasisc 2.23 (1.11, 4.49) 0.024 2.81 (1.48, 5.34) 0.02 2.44 (0.98, 6.06) 0.056 2.92 (1.16, 7.36) 0.023
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ISSN 1671-167X
CN 11-4691/R
主管单位：中华人民共和国教育部
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