胰臟與壺腹周圍腫瘤病患術前惡病質與術後三個月內體能變化之相關性探討

Abstract

惡病質在胰臟與壺腹周圍腫瘤病患術前常見症候群，而術後面臨傷口癒合與體能復原過程，惡病質此症狀易被忽視，且其影響病患生活品質與存活率甚鉅。至今國際上仍未針對此族群，探查其惡病質與手術期間造成體能變化的相關研究。故本研究之目的為：(1)瞭解接受胰臟與壺腹周圍腫瘤患者於手術前惡病質發生率與嚴重度；(2)瞭解此族群於術前至術後三個月內體能狀態之變化；(3)瞭解此族群惡病質與術後三個月內體能狀態變化之相關性。 本研究自2015年11月25日至2016年6月21日於台北市某醫學中心外科門診進行收案，採縱貫式研究，分別於術前與術後一、二、三個月共四次資料收集，以預計接受胰臟切除腫瘤病患為收案對象，藉由結構式問卷收集資料，包括基本資料表、症狀困擾嚴重度量表、疲倦量表；而體能測試項目，包含身體組成測量、慣用手握力與30秒坐站次數測量。資料分析採描述性統計分析各變項現況，以相關性統計分析相關體能的重要因子，並藉由廣義推估方程式分析病患惡病質與手術期間體能變化的重要因子。 研究期間共完成46位個案，四次資料收集完成率分別為46(T0)、43(T1)、43(T2)、43(T3)份，故問卷部分流失率為6.5%。研究結果顯示：(1)惡病質發生率為44.1%，且惡病質組罹患糖尿病較高於非惡病質組；(2)脹氣為病患術前最為困擾之症狀，易飽為術後三個月內最困擾的症狀，而疲倦位居第二或第三，屬低中度疲倦範圍，且症狀困擾程度在術後二、 三個月顯著低於術前；(3)在體能方面，體重與脂肪量隨著手術三個月期間達顯著下降，其他各項體能均無顯著差異，影響術前體能重要因子包括：性別、年齡、KPS、血紅素、白蛋白與術前置入膽管支架；(4)術前惡病質並未在手術期間成為影響體能變化之重要因子，而男性在體重、骨骼肌與手握力下降量大於女性，尤其在男性族群，術前血紅素與白蛋白高者，其手術期間體能狀態越好；而女性則是年紀輕且術前身體功能越高者，其手術期間體能狀態越好。 惡病質在接受胰臟腫瘤手術病患發生率高，且其手術前後體能皆低於一般健康民眾，並在術後三個月內體重與脂肪量仍顯著低於術前。因此，術後照護期間，需加強監測男性病患，尤其在術前血紅素與白蛋白較差者，其在術後體能的變化，進而提供適當介入性措施：給予術後飲食衛教以提升營養攝取，鼓勵持續維持術後身體活動，減少體重持續下降，進而重建與促進手術期間原有的體能。

Cachexia is the common syndrome among the patients with pancreatic and periampullary tumor before surgery. Since the process of the wound healing and the recovery in physical fitness during the post-operation, cachexia is easily ignored. Consequently, cachexia strongly impacts the quality of life and even the survival rate. However, there is no study to explore the correlation between cachexia and the changes of physical fitness in the patients with pancreatic and periampullary tumor during operation. Therefore, the purpose of this study was to explore (1) the prevalence and severity of cachexia before operation, (2) the change of physical fitness during three months after operation, and (3) the correlation between cachexia and the change of physical fitness within three months. A longitudinal designed study was conducted on the patients with pancreatic and periampullary tumor undergoing the surgery in the surgery outpatient. The data were collected four times at peri-operation (T0) and post-operation 1, 2, 3 months (T1, T2, T3) from 25 November in 2015 to 21 June in 2016. A set of structured questionnaire was used to collect data including the demographic and clinical characteristic, the Symptom Severity Scale (SSS) and the Fatigue Symptom Inventory (FSI). Besides, patients were received the test of physical fitness including the body composition, the strength of hand grip and 30-second sit-to-stand test (STS-30). The descriptive statistics was used to analyze the each variable and the correlation statistics was used to explore the independent variable in the physical fitness. Lastly, the generalized estimating equations (GEE) was used to analyze cachexia and the change of physical fitness during operation. Totally, 46 patients completed this survey and the attribution rate was 6.5% during the period of data collecting. The results had shown that (1) the prevalence of cachexia was 44.1% and the group of cachexia had more DM than the group without cachexia; (2) the flatulence was the most severity symptom before operation and the early satiety was the most severity symptom within three months of post operation. Moreover, the fatigue was ranking second or third, which belonged to mild to moderate fatigue during three months after operation. However, the overall severity of symptom was significant lower in the second and third month of post-operation (T2, T3) than pre-operation (T0); (3) the body weight and the fat mass were significant decrease within three months after operation. Besides, the significant factors of physical fitness before surgery included gender, age, KPS, hemoglobin, albumin and implanting the bile stent before surgery, and (4) Even though cachexia was not independent factor in the physical fitness within three months after operation, the male decreased in the body weight, the skeletal muscle mass and the strength of hand grip more than the female. Besides, the population of the male with higher level of hemoglobin and albumin and the population of the female with younger and higher KPS’s scoring had better physical fitness performance during the recovery of operation. Cachexia is high prevalence among patients undergoing pancreatic surgery and these patients had worst level of physical fitness than the healthy people. The patients still significant lower in body weight and the fat mass within three months after surgery. Therefore, the health providers should put more attention to the population of the male on the change of physical fitness especially those were lower level of hemoglobin and albumin. These patients were received appropriate interventions to gain more nutritional supplement, maintain physical fitness and decrease the loss of body weight. Those multiple interventions lead to rebuild and promote the physical fitness after operation.