加速康复外科方案在肝细胞癌手术的失败因素分析及风险预测模型的建立

Influential factors for failure of enhanced recovery after surgery from hepatectomy for hepatocellular carcinoma and the establishment of risk prediction model

目的探讨接受肝切除手术的肝细胞癌患者行加速康复外科（ERAS）方案失败的预后因素，并建立风险预测模型。方法回顾性分析2016年1月至2017年6月在安徽医科大学附属省立医院肝脏外科行肝切除手术的180例肝细胞癌患者的临床资料。男性149例（82．8％），女性31例（17．2％），年龄（56．5±11．0）岁（范围：33-84岁）。所有患者术前Child．Pugh分级均为A级。通过单因素与多因素分析筛选肝细胞癌患者术后ERAS方案失败的预后因素，并采用独立预后因素及其统计值建立风险预测模型。结果180例患者中，23例患者ERAS方案失败（12．8％）。单因素和多因素分析结果显示．术前总胆红素（TBIL）、ALT、术中出血量均为肝切除手术后ERAS方案失败的独立预后因素（P值均〈0．05）；所得到的风险预测模型为：风险系数（R）=0．114×（TBIL）＋0．082×（ALT）＋0．008×（术中出血量）；R值的临界值为7．90时，其预测ERAS方案失败的ROC曲线下面积为0．866（95％CI：0．788-0．945，P〈0．01），敏感度和特异度分别为69．6％和91．1％。外部验证显示，该模型具有良好的区分度，ROC曲线下面积为0．889（95％CI：0．811-0．967，P〈0．01）。结论术前TBIL（〉21μmol／L）和ALT（〉50U／L）较高，术中出血量较大（〉400ml）是肝细胞癌患者术后ERAS方案失败的独立预后因素．所建立的风险预测模型对于早期风险评估有一定价值。

Objective To investigate the influential factors for failure of enhanced recovery after surgery（ERAS） from hepatectomy for hepatocellular carcinoma （HCC） patients and then to establish a risk prediction model. Methods The relevant clinical data of 180 patients with HCC undergoing hepateetomy at Department of Hepatic Surgery, Affiliated Provincial Hospital, Anhui Medical University from January 2016 to June 2017 were analyzed retrospectively. There were 149 male patients and 31 female patients aging of （56. 5_＋11.0）years（from 33 to 84 years old）. The factors affecting postoperative failure of ERAS of HCC patients were identified by univariate and multivariate analyses, and then, all the obtained factors and their statistical values were used to establish the risk prediction model. Results A total of 23 patients failed in the ERAS protocol（ 12. 8% ）.The preoperative total bilirubin （TBIL） , alanine aminotransferase （ALT） and amount of intraoperative bleeding were independent risk factors for failure of ERAS from hepatectomy（ all P〈 0. 05）. The obtained risk prediction model was presented as follows：risk coefficient（R） = 0. 114× （TBIL）＋ 0. 082x ×（ALT）＋0. 008x （amount of intraoperative bleeding）.At the cut of value of R = 7. 90, the area under the ROC curve of this model for predicting failure of ERAS was 0. 866（ 95%CI：0. 788-0. 945, P〈0. 01 ）, with the sensitivity and specificity of 69. 6% and 91.1%, respectively. External validation results indicated that the scoring system had good differential ability（ area under the ROC curve = 0. 889, 95% CI： O. 811- 0. 967, P〈0. 01）. Conclusions Higher level of preoperative TBIL（ 〉21μmol/L） and ALT（ 〉50 U/L） and the larger amount of intraoperative bleeding （more than 400 ml） are independent risk factors for failure of ERAS inpatients undergoing hepatectomy for HCC and the established prediction model may have certain value for risk assessment.