术后C反应蛋白对达芬奇机器人手术系统胃癌根治术后发生严重并发症的预测价值

Predictive value of postoperative C-reactive protein for serious complications after Da Vinci robotic surgical system radical gastrectomy of gastric cancer

目的探讨术后C反应蛋白对达芬奇机器人手术系统胃癌根治术后严重并发症的预测价值。方法采用回顾性病例对照研究方法。收集2017年1月至2019年6月中国人民解放军联勤保障部队第940医院收治的298例进展期胃癌行达芬奇机器人手术系统胃癌根治术病人的临床病理资料;男253例,女45例;中位年龄为60岁,年龄范围为24~86岁。298例病人中,275例术后无严重并发症,23例术后发生严重并发症。观察指标:(1)术后严重并发症发生情况。(2)影响达芬奇机器人手术系统胃癌根治术后发生严重并发症的危险因素分析。(3)预测指标效能评价。偏态分布的计量资料以M(范围)表示。计数资料以绝对数表示,组间比较采用χ^(2)检验或Fisher确切概率法。等级资料比较采用秩和检验。单因素分析采用χ2检验。多因素分析采用Logistic回归模型。绘制受试者工作曲线,以曲线下面积(AUC)判定和比较诊断标准的准确性,约登指数确定最佳截断值。结果 (1)术后严重并发症发生情况。298例病人中,23例出现≥Ⅲa级并发症。其中Ⅲa级并发症10例,Ⅲb级7例,Ⅳa级4例,Ⅳb级1例,Ⅴ级1例。(2)影响达芬奇机器人手术系统胃癌根治术后发生严重并发症的危险因素分析。单因素分析结果显示:手术时间、术后第1天C反应蛋白、术后第1天中性粒细胞计数、术后第3天C反应蛋白、术后第3天白细胞计数、术后第3天中性粒细胞计数、术后第3天血小板计数、病理学分期是影响进展期胃癌病人达芬奇机器人手术系统胃癌根治术后发生严重并发症的相关因素(χ^(2)=7.671,4.504,5.045,48.293,9.575,15.436,13.731,9.537,P<0.05)。多因素分析结果显示:手术时间≥250 min、术后第3天C反应蛋白≥16.65 mg/dL、术后第3天中性粒细胞计数≥8.167×10^(9)/L、术后第3天血小板计数≥218×10^(9)/L、病理学分期为Ⅱ期和Ⅲ期是影响进展期胃癌病人达芬奇机器人手术系统胃癌根治术后发生严重并发症的独立危险因素(比值比=3.721,16.084,6.056,6.893,12.455;95%可信区间为1.032~13.421,4.657~55.547,1.073~34.163,1.798~26.423,1.338~115.930,P<0.05)。(3)预测指标效能评价。术后第3天C反应蛋白AUC为0.851(95%可信区间为0.780~0.921,P<0.05),为高效能预测指标。术后第3天中性粒细胞计数和血小板计数AUC分别为0.659(95%可信区间为0.570~0.748,P<0.05)和0.666(95%可信区间为0.581~0.750,P<0.05),为低预测效能指标。结论达芬奇机器人手术系统胃癌根治术后第3天C反应蛋白≥16.65 mg/dL是预测术后发生严重并发症的高效能指标。

Objective To investigate the predictive value of postoperative C-reactive protein for serious complications after Da Vinci robotic surgical system radical gastrectomy of gastric cancer.Methods The retrospective case-control study was conducted.The clinicopathological data of 298 patients with advanced gastric cancer who underwent Da Vinci robotic surgical system radical gastrectomy in the 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army from January 2017 to June 2019 were collected.There were 253 males and 45 females,aged from 24 to 86 years,with a median age of 60 years.Of the 298 patients,275 cases underwent no serious postoperative complications and 23 cases underwent serious postoperative complications.Observation indicators:(1)serious postoperative complications;(2)analysis of risk factors for serious postoperative complications after Da Vinci robotic surgical system radical gastrectomy of gastric cancer;(3)performance evaluation of the predictive indicators.Measurement data with skewed distribution were represented as M(range).Count data were described as absolute numbers and comparison between groups was conducted using the chi-square test or Fisher exact probability.Comparison of ordinal data was conducted using the rank sum test.Univariate analysis was conducted using the chi-square test.Multivariate analysis was conducted using Logistic regression model.The receiver operating characteristic curve was drawn and the area under curve(AUC)was used to compare and estimate the efficiency of diagnostic criteria.The value of Youden index was used to determine the optimal cut-off point.Results(1)Serious postoperative complications:of the 298 patients,23 cases underwent complications classified≥gradeⅢ a of Clavien-Dindo classification,including 10 cases with grade Ⅲ a complications,7 cases with grade Ⅲb complications,4 cases with grade Ⅳa complications,1 case with grade Ⅳb complications and 1 case with grade Ⅴ complications.(2)Analysis of risk factors for serious postoperative complications after Da Vinci robotic surgical system radical gastrectomy of gastric cancer.Results of univariate analysis showed that operation time,indicators of C-reactive protein concentration and neutrophil count at postoperative day 1,and indicators of C-reactive protein concentration,white blood cells count,neutrophil count and platelet count at postoperative day 3 and pathological stage were related factors affecting serious complications for advanced gastric cancer after Da Vinci robotic surgical system radical gastrectomy(χ^(2)=7.671,4.504,5.045,48.293,9.575,15.436,13.731,9.537,P<0.05).Results of multivariate analysis showed that the operation time^250 minutes,the concentration of C-reactive protein at postoperative day 3≥16.65 mg/dL,the neutrophil count at postoperative day 3>8.167×10^(9)/L,the platelet count at postoperative day 3>218×10^(9)/L and the pathological stage of tumor as stage II and stage ID were independent risk factors affecting serious complications for advanced gastric cancer after Da Vinci robotic surgical system radical gastrectomy(odds ratio=3.721,16.084,6.056,6.893,12.455,95%confidence interval:1.032-13.421,4.657-55.547,1.073-34.163,1.798-26.423,1.338-115.930,P<0.05).(3)Performance evaluation of the predictive indicators:the C-reactive protein concentration at postoperative day 3 was a high-performance predictor with the AUC as 0.851(95%confidence interval:0.780-0.921,P<0.05)and neutrophil count and platelet count at postoperative day 3 were low-performance predictors with the AUC as 0.659 and 0.666(95%confidence interval:0.570-0.748 and 0.581-0.750,P<0.05).Conclusion The C-reactive protein concentration≥16.65 mg/dL at postoperative day 3 is a high performance predictive indicator for serious complications after Da Vinci robotic surgical system radical gastrectomy of gastric cancer.