摘要
目的 探讨不同麻醉方式、麻醉时间及术后镇痛等麻醉相关因素对膀胱癌初发行膀胱部分切除术患者术后1年内复发是否产生影响,为临床麻醉方式选择及麻醉中需关注问题提供参考.方法 采用双向队列研究方法.历史性队列为2009年1月5日至2011年1月4日的连续病例,前瞻性队列为2011年1月5日—12月31日的连续病例,随访终止时间2012年12月31日,每例均随访至术后满1整年.共402例确诊为膀胱癌初发、行膀胱部分切除术患者入选.根据其不同麻醉方法分为静吸复合麻醉组和椎管内麻醉组.经随访确定患者术后1年内的复发情况.分别对性别,年龄,血型,吸烟史,饮酒史,肿瘤数目,肿瘤大小,病理分期,麻醉方式,麻醉时间,术后12 h视觉模拟量表（VAS）评分是否〈3分,肿瘤相关因子Ki67、P53、CK20、VEGF是否两项以上阳性共12项临床因素与膀胱癌1年内是否复发的相关性进行分析.在单因素分析的基础上进行多因素分析.单因素分析采用χ2或秩和检验,多因素分析采用Logistic回归模型,用最大似然法拟合分析.结果 402例患者中获得随访结果396例,随访率为98.51％.其中,1年内复发211例,复发率为53.28％.单因素分析显示,年龄,血型,麻醉时间,术后12 h VAS评分〈3分,肿瘤分期,吸烟史,饮酒史,肿瘤相关因子Ki67、P53、CK20、VEGF两项以上阳性与膀胱癌术后1年内复发相关（P〈0.01）,而麻醉方式与膀胱癌术后1年内复发无相关性（P〉0.05）.多因素Logistic回归模型分析显示,年龄（RR=0.371,95％CI：0.183～0.752）,饮酒史（RR=0.348,95％CI：0.161～0.752）,术后12 h VAS评分〈3分（RR=0.023,95％CI：0.011～0.050）,麻醉时间（RR=3.042,95％CI：1.495～6.192）,肿瘤相关因子Ki67、P53、CK20、VEGF两项以上阳性（RR=8.676,95％CI：4.018～18.733）为膀胱癌术后1年内复发的独立预测因子（P〈0.01）.其中麻醉时间、肿瘤相关因子Ki67、P53、CK20、VEGF中两项以上阳性是影响复发的危险因素;而饮酒史、年龄、术后12 h VAS评分〈3分是影响术后复发的保护因素.结论 对于膀胱癌初发行膀胱部分切除术患者,静吸复合麻醉与椎管内麻醉两种麻醉方式对术后1年内复发的影响不显著;麻醉时间依赖于手术时间,与术后1年内复发相关;术后镇痛完善（术后12 h VAS评分〈3分）为保护因素;年龄与饮酒史亦为保护因素.
Objective To explore the impact of different anesthesia methods and anesthesia-related factors in initial bladder cancer patients with partial cystectomy, and to provide a reference for clinical anesthesia choice and the questions that should be concerned. Methods Ambispective cohort study was performed in consecutive case of illness with initial occurrence bladder cancer patients treatedwith partial cystectomy from 2009 to 2012. A historical cohort was from January 5, 2009 to January 4, 2011. A prospective cohort was from January 5, 2011 to December 31, 2011. Follow-up was terminated in December 31, 2012. All cases were followed up to one full year after surgery. The 402 cases who were diagnosed of initial occurrence bladder cancer and partial cystectomy patients, according to different anesthesia method, were divided into general anesthesia group and intraspinal anesthesia group. Postoperative recurrence was determined within 1 year of follow-up. Multivariate analysis was carried out based on univariate analysis to analyze the causal connection factors for one year recurrence in initial occurrence bladder cancer patients with partial cystectomy. Variables included gender, age, blood type, smoking history, drinking history , number of tumors, tumor size, pathologic TNM stage, anesthesia method, duration of anesthesia, postoperative visual analog scale （VAS） score at 12 h, tumor-associated factor Ki67, P53, CK20, VEGF （whether two or more positive）. Tumor recurrence was considered the dependent variable （outcome）. Univariate analysis used χ2 or rank sum test, and multivariate analysis used Logistic regression model fitting analysis and the maximum likelihood method. SPSS 16.0 software package was used for data analysis and processing. Results Four hundred and two patients were followed up and got a result of 396 cases （98.51％）. Two hundred and eleven cases showed recurrence within one year （53.28％）. Univariate analysis showed that age, smoking history, drinking history, duration of anesthesia, pathologic stage, postoperative VAS scores at 12 h less than 3 scores, blood type, tumor-associated factor Ki67, P53, CK20, VEGF （two or more positive） were associated with one year recurrence in initial occurrence bladder cancer patients （P 0.05）. Multivariate Logistic regression model analysis showed that the following factors were associated with postoperative recurrence within a year in initial occurrence bladder cancer patients with partial cystectomy： age （RR = 0.371, 95％ CI 0.183-0.752）, drinking history （RR=0.348, 95％CI 0.161-0.752）, postoperative VAS scores at 12 h less than 3 scores （RR=0.023, 95％CI 0.011-0.050）, duration of anesthesia （RR=3.042, 95％CI 1.495-6.192）, and tumor-associated factor Ki67, P53, CK20, VEGF of two or more positive（RR=8.676, 95％CI 4.018-18.733）. Among these, duration of anesthesia and tumor-associated factors Ki67, P53, CK20, VEGF of two or more positive were risk factors, and drinking history, age, and postoperative VAS scores at 12 h less than 3 scores were protection factors. Conclusions The impact of general anesthesia and intraspinal anesthesia on one year recurrence in initial occurrence bladder cancer patients with partial cystectomy is not statistically significant. Duration of anesthesia depends on the part of the surgical time which is associated with the postoperative recurrence within a year. Postoperative analgesic perfect （VAS score at 12 h less than 3 scores） is the protective factor. Age and drinking history are also the protective factors for one year recurrence in initial occurrence bladder cancer patients of partial cystectomy.
作者
王怡
黄泽清
马虹
Wang Yi Huang Zeqing Ma Hong(Department of Anesthesiology, the First Affiliated Hospital of China Medical University, Shenyang 110042, China)
出处
《中国医师进修杂志》
2017年第9期828-833,共6页
Chinese Journal of Postgraduates of Medicine
关键词
膀胱肿瘤
麻醉方式
复发
Urinary bladder neoplasms
Anesthesia methods
Recurrence
