• 四川大學(xué)華西醫(yī)院肛腸外科(成都610041);

目的　 初步驗(yàn)證英國(guó)結(jié)直腸醫(yī)師協(xié)會(huì)結(jié)直腸癌術(shù)后風(fēng)險(xiǎn)評(píng)估模型(The colorectal cancer model of the Association of Coloproctology of Great Britain and Ireland,ACPGBI-CCM)的準(zhǔn)確性，探討其與臨床風(fēng)險(xiǎn)預(yù)測(cè)指標(biāo)間的關(guān)系。
方法 　回顧性分析2007年4月至2007年7月期間四川大學(xué)華西醫(yī)院肛腸外科治療組收治的診斷明確的結(jié)直腸癌患者。通過(guò)ACPGBI-CCM為每一位納入研究的患者計(jì)算死亡率預(yù)測(cè)值，并以死亡率預(yù)測(cè)值中位數(shù)為界，將納入患者分為低風(fēng)險(xiǎn)組與高風(fēng)險(xiǎn)組，比較2組間不同風(fēng)險(xiǎn)因子的差異; 然后對(duì)評(píng)估指標(biāo)進(jìn)行分層分析，探討其與術(shù)后死亡率預(yù)測(cè)值的關(guān)系。
結(jié)果 　研究期間本治療組共收治了99例診斷明確的結(jié)直腸癌患者，其中有67例符合納入條件，平均年齡60.09歲，男34例，女33例； 右半結(jié)腸癌15例，左半結(jié)腸癌9例，直腸癌43例; Dukes分期: A期0例，B期37例，C期24例，D期6例。術(shù)后30 d內(nèi)的實(shí)際死亡例數(shù)為0。ACPGBI-CCM預(yù)測(cè)的死亡率為0.77%～25.75%，中位值為3.36%，以預(yù)測(cè)死亡率≤3.36%為低風(fēng)險(xiǎn)組(34例)，預(yù)測(cè)死亡率 gt;3.36%為高風(fēng)險(xiǎn)組(33例)，高風(fēng)險(xiǎn)組的死亡率預(yù)測(cè)值明顯高于低風(fēng)險(xiǎn)組〔(8.86±4.51)% vs (1.76±0.68)%,P＜0.01〕。高風(fēng)險(xiǎn)組與低風(fēng)險(xiǎn)組間患者年齡、內(nèi)科合并癥、術(shù)前有無(wú)化療、ASA分級(jí)、術(shù)中腫瘤是否切除及手術(shù)持續(xù)時(shí)間差異均有統(tǒng)計(jì)學(xué)意義(P＜0.01)； 2組間腫瘤并發(fā)癥、Dukes分期、TNM分期及術(shù)后疼痛差異也均有統(tǒng)計(jì)學(xué)意義(P＜0.05); 2組間性別、既往腹部手術(shù)史、腫瘤距肛緣位置、腫瘤部位、分化程度、術(shù)后住院時(shí)間及總住院時(shí)間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P gt;0.05)。進(jìn)一步對(duì)各風(fēng)險(xiǎn)評(píng)估指標(biāo)進(jìn)行分析，發(fā)現(xiàn)不同年齡、有無(wú)內(nèi)科合并癥、術(shù)前化療、不同ASA分級(jí)及腫瘤是否切除會(huì)導(dǎo)致不同的死亡率，其差異具有統(tǒng)計(jì)學(xué)意義(P＜0.01); 不同Dukes分期和分化程度會(huì)引起不同的死亡率，其差異亦有統(tǒng)計(jì)學(xué)意義(P＜0.05); 而不同的性別、有無(wú)既往腹部手術(shù)史、腫瘤并發(fā)癥、不同TNM分期及不同腫瘤部位之間死亡率風(fēng)險(xiǎn)預(yù)測(cè)值差異均無(wú)統(tǒng)計(jì)學(xué)意義(P gt;0.05)。
結(jié)論 　ACPGBI-CCM的臨床適用性在單一大容量的醫(yī)療中心研究中得到肯定，但其預(yù)測(cè)效果會(huì)高估死亡率，這可能是由于地域和人文差異帶來(lái)的結(jié)果。進(jìn)一步分析發(fā)現(xiàn)，合并癥、是否行新輔助治療或輔助治療可能是結(jié)直腸癌患者術(shù)后生存質(zhì)量的獨(dú)立預(yù)測(cè)因子，這需要進(jìn)一步的臨床分層次研究來(lái)證實(shí)。

引用本文： 曹霖,汪曉東,陳珊珊,李立. ACPGBI結(jié)直腸癌術(shù)后風(fēng)險(xiǎn)評(píng)估模型臨床應(yīng)用的初步探索. 中國(guó)普外基礎(chǔ)與臨床雜志, 2008, 15(9): 646-651. doi: 復(fù)制

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1. 　Shike M, Winawer SJ, Greenwald PH, et al. Primary prevention of colorectal cancer. The WHO Collaborating Centre for the Prevention of Colorectal Cancer [Ｊ]. Bull World Health Organ, 1990; 68(3)∶377.
2. 　Ries LAG, Eisner MP, Kosary CL, et al. SEER cancer statistics review, 1975-2002 [EB/OL]. http://seer.cancer.gov/csr/1975_2002/, 2005-04/2008-04-20.
3. 　Edwards BK, Howe HL, Ries LA, et al. Annual report to the nation on the status of cancer, 1973-1999, featuring implications of age and aging on U.S. cancer burden [Ｊ]. Cancer, 2002; 94(10)∶2766.
4. 　Aschele C, Lonardi S. Multidisciplinary treatment of rectal cancer: medical oncology [Ｊ]. Ann Oncol, 2007; 18(11)∶1908.
5. 　Tekkis PP, Poloniecki JD, Thompson MR, et al. Operative mortality in colorectal cancer: prospective national study[Ｊ]. BMJ, 2003; 327(7425)∶1196.
6. 　Metcalfe MS, Norwood MG, Miller AS, et al. Unreasonable expectations in emergency colorectal cancer surgery [Ｊ]. Colorectal Dis, 2005; 7(3)∶275.
7. 　Ferjani AM, Griffin D, Stallard N, et al. Newly devised scoring system for prediction of mortality in patients with colorectal cancer: a prospective study [Ｊ]. Lancet Oncol, 2007; 8(4)∶317.
8. 　Sobin LH, Wittekind C Eds. TNM classification of malignant tumours [M]. 6th ed. New York: Wiley, 2002∶55-87.
9. 　呂東昊, 汪曉東, 陽(yáng)川華, 等. 結(jié)直腸腫瘤多學(xué)科協(xié)作診治模式的數(shù)據(jù)庫(kù)初期建設(shè)現(xiàn)狀 [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2007; 14(6)∶713.
10. 　汪曉東, 曹霖, 羅德云, 等. 多學(xué)科協(xié)作診治模式下運(yùn)行結(jié)直腸癌綜合治療的臨床對(duì)照研究 [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2008; 15(1)∶63.
11. 　汪曉東, 馮碩, 游小林, 等. 結(jié)直腸腫瘤多學(xué)科協(xié)作診治模式下的隨訪(fǎng)體系建設(shè) [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2007; 14(6)∶709.
12. 　Valenti V, Hernandez-Lizoain JL, Baixauli J, et al. Analysis of POSSUM score and postoperative morbidity in patients with rectal cancer undergoing surgery [Ｊ]. Langenbecks Arch Surg, 2008; [Epub ahead of print].
13. 　Al-Homoud S, Purkayastha S, Aziz O, et al. Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models [Ｊ]. Surg Oncol, 2004; 13(2-3)∶83.
14. 　張建生. POSSUM、(P、Cr)-POSSUM、APGBI評(píng)分系統(tǒng)預(yù)測(cè)結(jié)直腸癌術(shù)后死亡率的研究 [Ｊ]. 大腸肛門(mén)病外科雜志, 2005; 11(2)∶102.
15. 　Bennett-Guerrero E, Hyam JA, Shaefi S, et al. Comparison of PPOSSUM risk-adjusted mortality rates after surgery between patients in the USA and the UK [Ｊ]. Br J Surg, 2003; 90(12)∶1593.
16. 　Piccirillo JF, Tierney RM, Costas I, et al. Prognostic importance of comorbidity in a hospital-based cancer registry [Ｊ]. JAMA, 2004; 291(20)∶2441.
17. 　Read WL, Tierney RM, Page NC, et al. Differential prognostic impact of comorbidity [Ｊ]. J Clin Oncol, 2004; 22(15)∶3099.
18. 　Yancik R, Ganz PA, Varricchio CG, et al. Perspectives on comorbidity and cancer in older patients: approaches to expand the knowledge base [Ｊ]. J Clin Oncol, 2001; 19(4)∶1147.
19. 　Ko C, Chaudhry S. The need for a multidisciplinary approach to cancer care [Ｊ]. J Surg Res, 2002; 105(1)∶53.
20. 　Brosens RP, Oomen JL, Glas AS, et al. POSSUM predicts decreased overall survival in curative resection for colorectal cancer [Ｊ]. Dis Colon Rectum, 2006; 49(6)∶825.
  1. 1. 　Shike M, Winawer SJ, Greenwald PH, et al. Primary prevention of colorectal cancer. The WHO Collaborating Centre for the Prevention of Colorectal Cancer [Ｊ]. Bull World Health Organ, 1990; 68(3)∶377.
  2. 2. 　Ries LAG, Eisner MP, Kosary CL, et al. SEER cancer statistics review, 1975-2002 [EB/OL]. http://seer.cancer.gov/csr/1975_2002/, 2005-04/2008-04-20.
  3. 3. 　Edwards BK, Howe HL, Ries LA, et al. Annual report to the nation on the status of cancer, 1973-1999, featuring implications of age and aging on U.S. cancer burden [Ｊ]. Cancer, 2002; 94(10)∶2766.
  4. 4. 　Aschele C, Lonardi S. Multidisciplinary treatment of rectal cancer: medical oncology [Ｊ]. Ann Oncol, 2007; 18(11)∶1908.
  5. 5. 　Tekkis PP, Poloniecki JD, Thompson MR, et al. Operative mortality in colorectal cancer: prospective national study[Ｊ]. BMJ, 2003; 327(7425)∶1196.
  6. 6. 　Metcalfe MS, Norwood MG, Miller AS, et al. Unreasonable expectations in emergency colorectal cancer surgery [Ｊ]. Colorectal Dis, 2005; 7(3)∶275.
  7. 7. 　Ferjani AM, Griffin D, Stallard N, et al. Newly devised scoring system for prediction of mortality in patients with colorectal cancer: a prospective study [Ｊ]. Lancet Oncol, 2007; 8(4)∶317.
  8. 8. 　Sobin LH, Wittekind C Eds. TNM classification of malignant tumours [M]. 6th ed. New York: Wiley, 2002∶55-87.
  9. 9. 　呂東昊, 汪曉東, 陽(yáng)川華, 等. 結(jié)直腸腫瘤多學(xué)科協(xié)作診治模式的數(shù)據(jù)庫(kù)初期建設(shè)現(xiàn)狀 [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2007; 14(6)∶713.
  10. 10. 　汪曉東, 曹霖, 羅德云, 等. 多學(xué)科協(xié)作診治模式下運(yùn)行結(jié)直腸癌綜合治療的臨床對(duì)照研究 [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2008; 15(1)∶63.
  11. 11. 　汪曉東, 馮碩, 游小林, 等. 結(jié)直腸腫瘤多學(xué)科協(xié)作診治模式下的隨訪(fǎng)體系建設(shè) [Ｊ]. 中國(guó)普外基礎(chǔ)與臨床雜志, 2007; 14(6)∶709.
  12. 12. 　Valenti V, Hernandez-Lizoain JL, Baixauli J, et al. Analysis of POSSUM score and postoperative morbidity in patients with rectal cancer undergoing surgery [Ｊ]. Langenbecks Arch Surg, 2008; [Epub ahead of print].
  13. 13. 　Al-Homoud S, Purkayastha S, Aziz O, et al. Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models [Ｊ]. Surg Oncol, 2004; 13(2-3)∶83.
  14. 14. 　張建生. POSSUM、(P、Cr)-POSSUM、APGBI評(píng)分系統(tǒng)預(yù)測(cè)結(jié)直腸癌術(shù)后死亡率的研究 [Ｊ]. 大腸肛門(mén)病外科雜志, 2005; 11(2)∶102.
  15. 15. 　Bennett-Guerrero E, Hyam JA, Shaefi S, et al. Comparison of PPOSSUM risk-adjusted mortality rates after surgery between patients in the USA and the UK [Ｊ]. Br J Surg, 2003; 90(12)∶1593.
  16. 16. 　Piccirillo JF, Tierney RM, Costas I, et al. Prognostic importance of comorbidity in a hospital-based cancer registry [Ｊ]. JAMA, 2004; 291(20)∶2441.
  17. 17. 　Read WL, Tierney RM, Page NC, et al. Differential prognostic impact of comorbidity [Ｊ]. J Clin Oncol, 2004; 22(15)∶3099.
  18. 18. 　Yancik R, Ganz PA, Varricchio CG, et al. Perspectives on comorbidity and cancer in older patients: approaches to expand the knowledge base [Ｊ]. J Clin Oncol, 2001; 19(4)∶1147.
  19. 19. 　Ko C, Chaudhry S. The need for a multidisciplinary approach to cancer care [Ｊ]. J Surg Res, 2002; 105(1)∶53.
  20. 20. 　Brosens RP, Oomen JL, Glas AS, et al. POSSUM predicts decreased overall survival in curative resection for colorectal cancer [Ｊ]. Dis Colon Rectum, 2006; 49(6)∶825.