竞争风险模型在肠造口旁疝发病风险及影响因素分析中的应用

Application of competitive risk model in the analysis of risk and influencing factors of parastomal hernia

目的应用竞争风险模型评估肠造口旁疝(parastomal hernia,PSH)的发病风险及影响因素。方法回顾性分析2015年至2019年735例行肠造口术患者的临床资料。通过Cox模型评估PSH的累计发生率。当死亡和回纳作为竞争事件出现时,采用Fine-Gray模型进行分析。结果中位随访17.1个月,其间,136例(18.5%)发生PSH,PSH出现的中位时间为10个月。单因素Cox回归分析和单因素Gray检验显示,年龄、术前体质指数(BMI)、高血压、前列腺肥大、造口途径与PSH的发生相关。多因素Cox回归分析和多因素Fine-Gray模型均显示,年龄≥60岁、术前BMI≥25 kg/m2和经腹膜外造口术是PSH发生的独立影响因素。此外,多因素Fine-Gray模型显示,乙状结肠造口也是PSH的独立影响因素。使用Kaplan-Meier法分析发现,肠造口患者随访1年、2年和5年的PSH累计发生率分别为20.5%、29.8%和37.6%;使用Fine-Gray模型分析发现,肠造口患者随访1年、2年和5年的PSH累计发生率分别为13.69%、20.07%和25.31%。与Kaplan-Meier或Cox法相比,Fine-Gray模型对PSH累计发生率的估计始终较低。结论在存在竞争风险的情况下,相比于Kaplan-Meier和Cox模型,Fine-Gray模型能更准确地评估与PSH发生相关的高危因素以及PSH的累计发生率。

Objective To evaluate the risk and influencing factors of parastomal hernia(PSH)by competitive risk model.Methods Clinical data of 735 patients with enterostomy from 2015 to 2019 were analyzed retrospectively.The cumulative incidence of PSH was evaluated by Cox model.When death and reversal occurred as competitive events,Fine-Gray model was used for analysis.Results During the median follow-up of 17.1 months,136 cases(18.5%)developed PSH,and the median time of PSH was 10 months.Univariate Cox regression analysis and univariate gray test showed that age,preoperative body mass index(BMI),hypertension,prostate hypertrophy and stoma pathway were related to the occurrence of PSH.Multivariate Cox regression analysis and multivariate Fine-Gray model showed that age≥60 years old,preoperative BMI≥25 kg/m2 and extraperitoneal stoma were independent influencing factors of PSH.In addition,the multivariate Fine-Gray model showed that sigmoid colostomy was also an independent influencing factor of PSH.When Kaplan-Meier method was used,the cumulative incidence of PSH in patients with enterostomy were 20.5%,29.8%and 37.6%,respectively;when using Fine-Gray model,they were 13.69%,20.07%and 25.31%respectively.Compared with Kaplan-Meier or Cox method,the estimation of cumulative incidence of PSH by Fine-Gray model was always low.Conclusions In the case of competitive risk,compared with Kaplan-Meier and Cox models,Fine-Gray model can more accurately evaluate the high-risk factors related to the occurrence of PSH and the cumulative incidence of PSH.These results may provide reference value for clinical medical staff to evaluate the occurrence of PSH more objectively.