腹腔镜结直肠癌手术中转开腹列线图预测模型的构建

Establishment of nomogram risk prediction model for conversion to open surgery in laparoscopic colorectal neoplams resections

目的分析腹腔镜结直肠癌手术发生中转开腹的危险因素,建立列线图预测模型指导临床决策,并分析其短期预后影响。方法收集2017年5月至2020年5月西安交通大学第一附属医院行腹腔镜手术的764例结直肠癌患者的病例资料,分为中转开腹组(60例)及腹腔镜组(704例)。采用Logistic回归分析中转开腹的独立危险因素,并用R语言构建中转开腹列线图预测模型。通过受试者工作特征曲线(ROC)下面积评估列线图预测模型效能。通过绘制校准图进行一致性检验。并比较两组患者术中及术后恢复情况。结果本研究共纳入患者764例,其中60例发生中转开腹,中转开腹率为7.9%(60/764)。肿瘤位置位于直肠[比值比(OR)=1.846,P<0.05)]、美国麻醉医生协会(ASA)评分Ⅲ、Ⅳ级(OR=2.381,P<0.05)、腹部手术史(OR=3.652,P<0.01)、肿瘤长径≥5 cm(OR=2.704,P<0.05)和体重指数(OR=1.109,P<0.05)是发生中转开腹的独立危险因素,上述数据差异均有统计学意义。成功构建列线图预测模型,模型ROC曲线下面积为0.794。校正曲线显示预测结果与实际结果有较好的重合度。中转开腹组手术时间高于腹腔镜组(210 min比190 min,Z=-2.670,P<0.05);中转开腹组出血量高于腹腔镜组(170 ml比120 ml,Z=-6.018,P<0.01);中转开腹组术后住院天数高于腹腔镜组(10 d比9 d,Z=-2.134,P<0.05)。中转开腹组肠梗阻发生率高于腹腔镜组[10.0%(6/60)比4.3%(15/704),χ^(2)=4.055,P<0.05];伤口感染率高于腹腔镜组[15.0%(9/60)比4.7%(33/704),χ^(2)=11.318,P<0.05],上述数据差异均有统计学意义。结论肿瘤位置位于直肠、ASA评分Ⅲ、Ⅳ级、腹部手术史、肿瘤长径≥5 cm和体重指数是腹腔镜结直肠癌手术发生中转开腹的独立危险因素,据此建立的预测模型具有可靠的预测能力。

Objective To investigate the risk factors and short-term prognosis of patients who underwent conversion to open surgery in laparoscopic colorectal neoplams resections and to construct a nomogram to guide clinical decision-making.Methods Data of 764 patients with colorectal cancer(CRC)who underwent laparoscopic surgery in the First Affiliated Hospital of Xi′an Jiaotong University from May 2017 to May 2020 were collected.Patients were divided into the conversion group and the laparoscopic group.Logistic regression analysis was used to determine the independent risk factors associated with conversion to open surgery.R language was used to establish a nomogram.The area under receiver operating characteristic(ROC)curve was used to evaluate the predictive ability of the nomogram.The calibration curve was used to assess the calibration of prediction model.The intraoperative and postoperative recovery of the two groups was also compared.Results A total of 764 patients were included in this study.The incidence of conversion to open surgery was 7.9%(60/764).In the multivariate analysis,tumor location in the rectum[odd ratio(OR)=1.846,P<0.05],American Society of Anesthesiologists(ASA)gradeⅢor gradeⅣ(OR=2.381,P<0.05),history of abdominal surgery(OR=3.652,P<0.01),tumor length≥5 cm(OR=2.704,P<0.05)and body mass index(OR=1.109,P<0.05)were independent risk factors for conversion to open surgery in laparoscopic colorectal neoplams resections.The nomogram was successfully constructed.The area under the ROC curve was 0.794.The calibration curve of the nomogram showed high consistence between predictions and actual results.In conversion group,the operation time(210 min vs.190 min,Z=-2.670,P<0.05),intraoperative blood loss(170 vs.120 ml,Z=-6.018,P<0.01)and postoperative hospital stay(days)(10 vs.9,Z=-2.134,P<0.05)increased as compared with those in the laparoscopic group.The intestinal obstruction rate in the conversion group was significantly higher[10.0%(6/60)vs.4.3%(15/704),χ^(2)=4.055,P<0.05],and wound infection rate was significantly higher than that in the laparoscopic group[15.0%(9/60)vs.4.7%(33/704),χ^(2)=11.318,P<0.05].Conclusion Tumor location in the rectum,ASA gradeⅢorⅣ,history of abdominal surgery,tumor length≥5 cm,and body mass index were independent risk factors for conversion to open surgery in laparoscopic colorectal neoplams resections.The nomogram prediction model established based on the above findings has reliable prediction performance.