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目的 探讨60岁以上胃癌患者行胃癌根治术后发生肺部感染的危险因素.方法 采用病例对照研究的方法,回顾性收集北京大学肿瘤医院胃肠中心四病区2009年4月至2016年12月期间行胃癌根治术的60岁以上373例患者的临床病理资料,采用独立样本t检验(符合正态分布,采用x±s表示)和Mann?Whitney U检验[不符合正态分布,采用中位数(四分位数间距)表示]进行计量资料的组间比较;χ2检验或Fisher精确概率法检验进行计数资料(用例数及百分率表示)组间比较,分析术后出现肺部感染(含术后肺不张)与未出现肺部感染两组患者的临床病理特征,采用logistic回归多因素分析影响胃癌术后肺部感染的危险因素.术后肺部感染定义为:术后患者出现体温升高(>38.0℃)并持续24 h以上;伴咳嗽咳痰,痰细菌培养阳性;胸部影像学检查提示有新近出现的浸润、实变或肺不张.结果 373例患者中,术后出现肺部感染50例(13.4%,肺部感染组),未出现肺部感染323例(86.6%,无肺部感染组).肺部感染组患者术前合并基础疾病(包括高血压、糖尿病以及心肺疾病等)39例(78.0%),无肺部感染组为178例(55.1%),两组比较,差异有统计学意义(χ2=9.325,P=0.002).术前低白蛋白血症发生率肺部感染组也明显高于无肺部感染组[10.0%(5/50)比3.1% (10/323),χ2=4.098,P=0.048].肺部感染组与无肺部感染组相比,全胃切除率[54.0%(27/50)比34.4%(111/323),χ2=12.501,P=0.002]、术后伤口疼痛率[34.0%(17/50)比11.8%(38/323),χ2=16.928, P<0.001]、二次手术比率[6.0%(3/50)比0.6%(2/323),χ 2=6.032 ,P=0.014]以及胃管拔除超过7 d的比率[96.0%(48/50)比84.5%(273/323),χ2=4.811,P=0.028]均明显升高,术后住院天数亦明显延长[中位数(四分位数间距):16.0(9.5)d比12.0(5.0)d,U=4 275.0,P<0.001].多因素logistic回归分析显示,术前合并内科基础疾病(OR=4.008,95%CI :1.768~9.086,P=0.001)、腹腔感染(OR=3.164,95% CI:1.075~9.313,P=0.037)以及伤口疼痛(OR=3.428,95% CI:1.557~7.548,P=0.002)是60岁以上胃癌患者术后肺部感染的独立危险因素.进一步对肺部感染组的50例患者按感染潜伏期长短和感染类型分类,将肺部感染潜伏期≤3 d者归为早发感染组(34例,68.0%),潜伏期≥4 d者归为迟发感染组(16例,32.0%);将肺部感染合并外科感染(包括吻合口漏、腹腔感染、十二指肠残端漏、伤口感染等)与不合并外科感染者分别归为混合感染组(13例,26.0%)与单纯感染组(37例,74.0%).分析结果发现,混合感染组肺部感染均发生在外科感染前0~12(中位数3)d;早发感染组既往慢性阻塞型肺病发生率明显高于迟发感染组[17.6%(6/34)比0,χ2=5.005,P=0.025];迟发感染组混合感染发生率明显高于早发感染组[50.0%(8/16)比14.7%(5/34),χ2=6.730,P=0.009],而两组术后住院天数的差异无统计学意义[中位数(四分位数间距):17.0(9.8)d比14.0(9.5)d,U=224.0,P=0.317].结论 60岁以上胃癌患者术后肺部感染多发;术前合并内科基础疾病、术后腹腔感染和伤口疼痛是患者术后肺部感染的独立危险因素.术后3d以内出现的肺部感染术前多合并慢性阻塞型肺病,而术后4d以后出现的肺部感染需警惕有无合并腹部感染及吻合口漏.

Objective To investigate the risk factors of postoperative pulmonary infection (PPI) in patients over 60 years of age with gastric cancer after radical gastrectomy. Methods Clinicopathological data of 373 patients over 60 years of age who underwent radical gastrectomy at Department IV of Gastrointestinal Cancer Center,Peking University Cancer Hospital, from April 2009 to December 2016 were retrospectively collected in this case?control study. The clinicopathological characteristics of patients with postoperative pulmonary infection (including postoperative atelectasis) and those without pulmonary infection were compared. A Student t?test(reported as Mean±SD if data matching normal distribution)or Mann?Whitney U test[reported as median(quartile)if data did not conform to normal distribution]was used to analyze continuous variables. A χ2 test or Fisher exact tests (reported as number and percentage)was used for categorical variables. Multivariable logistic regression was used to analyze the risk factors for pulmonary infection after operation of gastric cancer. PPI was defined as postoperative patients with elevated body temperature (>38.0℃) for more than 24 hours;cough and expectoration; positive sputum bacteria culture;recent infiltration,consolidation or atelectasis confirmed by chest imaging examination. Results Among 373 patients,50 cases had PPI(13.4%,PPI group),323 cases had no PPI(86.6%,non?PPI group). There were 39 (78.0%) and 178(55.1%) patients with comorbidities (including hypertension, diabetes and cardiopulmonary disease) preoperatively in PPI and non?PPI group, respectively. The difference between two groups was statistically significant (χ2=9.325,P=0.002). The incidence of preoperative hypoalbuminemia in PPI group was also significantly higher than that in non?PPI group[10.0%(5/50)vs. 3.1%(10/323),χ2=4.098,P=0.048]. Compared to non?PPI group,the rate of total gastrectomy[54.0%(27/50)vs. 34.4% (111/323),χ2=12.501,P=0.002],postoperative wound pain[34.0%(17/50)vs. 11.8%(38/323),χ2=16.928,P<0.001],secondary operation [6.0%(3/50) vs. 0.6%(2/323),χ2=6.032,P=0.014]and the rate of gastric tube removal later than 7 days postoperatively[96.0%(48/50)vs. 84.5%(273/323),χ2=4.811,P=0.028]were significantly higher in PPI group,respectively. The postoperative hospital stay was also prolonged in PPI group [16.0(9.5) days vs. 12.0(5.0) days, U=4 275.0, P<0.001]. Multivariate logistic regression analysis showed that preoperative comorbidities (OR=4.008,95%CI:1.768?9.086,P=0.001),abdominal infection(OR=3.164,95%CI:1.075?9.313,P=0.037),and wound pain(OR=3.428,95%CI:1.557?7.548,P=0.002)were independent risk factors for PPI in patients over 60 years of age with gastric cancer. Furthermore,50 patients with pulmonary infection were classified according to the length of latency and the type of infection. The patients with PPI latency ≤ 3 days were classified as early onset (34 cases,68.0%),and those with latency ≥ 4 days as delayed onset (16 cases,32.0%);PPI combined with surgical infection(including anastomotic leakage,abdominal infection, duodenal stump leakage, wound infection, etc.) was classified into mixed infection group(13 cases,26.0%),with non?surgical infection as simple infection group (37 cases,74.0%). The results showed that the pulmonary infection occurred 0 to 12 days(median 3 days)before surgical infection in mix infection group. The incidence of previous chronic obstructive pulmonary disease (COPD)in patients with early onset was significantly higher than that in patients with delayed onset [17.6%(6/34) vs. 0,χ2=5.005,P=0.025],and the incidence of mixed infection in patients with delayed onset was significantly higher than that in patients with early onset[50%(8/16)vs. 14.7%(5/34), χ2=6.730,P=0.009],but there was no significant difference in postoperative hospital stay between the two groups[17.0(9.8)days vs. 14.0(9.5)days,U=224.0,P=0.317]. Conclusions Postoperative pulmonary infection is common in gastric cancer patients over 60 years of age. Preoperative comorbidities, abdominal infection and wound pain are independent risk factors for postoperative pulmonary infection. Pulmonary infection within 3 days after operation is associated with preoperative COPD. For patients suffering from PPI after the 4th day,attentions should be paid to abdominal infection and anastomotic leakage.