术后早期血脂代谢水平、C反应蛋白与白蛋白比值对食管癌术后吻合口瘘的预测效果分析

Analysis of the predictive effect of early postoperative blood lipid metabolism and ratio of C-reactive protein to albumin on postoperative anastomotic fistula of esophageal cancer

目的探讨术后血脂代谢水平、C反应蛋白/白蛋白比值(C-reactive protein to albumin ratio,CAR)对食管癌根治术后发生吻合口瘘的预测效果。方法选取2017年1月至2020年12月于郑州大学第二附属医院胸外科行食管癌根治术的256例食管鳞状细胞癌患者(年龄均>50岁)为研究对象,进行回顾性病例对照研究。收集患者术后总胆固醇、甘油三酯、高密度脂蛋白胆固醇(high-density lipoprotein cholesterol,HDL-C)、低密度脂蛋白胆固醇(low density lipoprotein cholesterol,LDL-C)、CAR、血红蛋白检验学指标。根据术后是否有吻合口瘘将患者分为吻合口瘘组和非吻合口瘘组。正态分布的计量资料组间比较采用t检验;非正态分布的计量资料以M(Q1,Q3)表示,组间比较采用Mann-WhitneyU检验。计数资料以[例(%)]表示,组间比较采用χ^(2)检验。Logistic回归模型进行多因素分析,采用ROC曲线及Kappa值评估总胆固醇、CAR对术后吻合口瘘的预测价值。结果吻合口瘘组患者术前体质量指数(body mass index,BMI)[(18.71±1.90)kg/m2]低于非吻合口瘘组[(20.59±2.88)kg/m2],两组比较差异有统计学意义(t=3.48,P=0.001);吻合口瘘组患者的术后总胆固醇[(5.44±1.09)mmol/L]、LDL-C[(3.82±1.15)mmol/L]及CAR[0.64(0.41,0.95)]均高于非吻合口瘘组[(4.54±0.94)mmol/L、(2.92±0.76)mmol/L、0.27(0.13,0.45)],两组比较差异均有统计学意义(统计量值分别为4.84、5.69、5.16;均P<0.001)];吻合口瘘组患者血红蛋白浓度[103.20(84.94,110.48)g/L]低于非吻合口瘘组[107.68(99.20,125.20)g/L],两组比较差异有统计学意义(Z=2.82,P=0.005)。BMI偏低(OR=0.652,95%CI 0.482~0.882)、术后总胆固醇浓度升高(OR=3.240,95%CI 1.430~7.340)、血红蛋白浓度降低(OR=0.837,95%CI 0.777~0.902)及CAR升高(OR=2.161,95%CI 1.597~2.925)是影响食管鳞状细胞癌术后吻合口瘘发生的危险因素(P值分别为0.006、0.005、<0.001、<0.001)。ROC曲线分析显示:术后总胆固醇及CAR的曲线下面积分别为0.742(95%CI:0.643~0.841,P<0.001)、0.790(95%CI:0.690~0.890,P<0.001),截断值分别为4.915 mmol/L、0.605,灵敏度分别为80.0%、80.0%,特异度分别为82.3%、92.5%,Kappa值分别为0.418、0.625(均P<0.001)。结论食管癌根治术后总胆固醇、CAR对食管鳞状细胞癌患者术后并发吻合口瘘有一定的预测价值,CAR预测结果优于总胆固醇。

Objective To investigate the predictive effect of postoperative blood lipid metabolism and C-reactive protein/albumin ratio(CAR)on anastomotic fistula after radical resection of esophageal cancer.Methods A retrospective case-control study was conducted on 256 patients with esophageal squamous cell carcinoma(all aged>50 years)who underwent radical esophagectomy in the thoracic surgery of the Second Affiliated Hospital of Zhengzhou University from January 2017 to December 2020.Total cholesterol,triglyceride,high density lipoprotein cholesterol(HDL-C)and low density lipoprotein cholesterol(LDL-C),ratio of C-reactive protein to albumin(CAR)and hemoglobin test index were collected.According to whether there was anastomotic fistula after operation,the patients were divided into anastomotic fistula group and non-anastomotic fistula group.The measurement data of normal distribution were compared by t-test,the measurement data of non-normal distribution were expressed by M(Q1,Q3),the comparison between groups was expressed by Mann-Whitney U test,and the counting data were expressed by(case(%)).The comparison between groups was performed byχ^(2) test.Logistic regression model was used for multivariate analysis.ROC curve and Kappa value were used to evaluate the predictive value of total cholesterol and CAR in postoperative anastomotic fistula.Results The preoperative body mass index(BMI)((18.71±1.90)kg/m2)in anastomotic fistula group was higher than that in non-anastomotic fistula group((20.59±2.88)kg/m2),and the difference was statistically significant(t=3.48,P=0.001).The postoperative total cholesterol((5.44±1.09)mmol/L),LDL-C((3.82±1.15)mmol/L)and CAR(0.64(0.41,0.95))in anastomotic fistula group were higher than those in non-anastomotic fistula group((4.54±0.94)mmol/L,(2.92±0.76)mmol/L,0.27(0.13,0.45)).There were significant differences between the two groups(the statistical values were t=4.84,t=5.69,Z=5.16,all P<0.001)).The hemoglobin concentration of 103.20(84.94,110.48)g/L was lower than that of non anastomotic fistula group(107.68(99.20,125.20)g/L),the difference was statistically significant(Z=2.82,P=0.005).Lower BMI(OR=0.652,95%CI 0.482-0.882),higher total cholesterol(OR=3.240,95%CI 1.430-7.340),lower hemoglobin(OR=0.837,95%CI 0.777-0.902)and higher CAR(OR=2.161,95%CI 1.597-2.925)were the risk factors of anastomotic fistula in esophageal squamous cell carcinoma(P values were 0.006,0.005,<0.001 and<0.001,respectively).ROC curve analysis showed that the areas under the curve of total cholesterol and CAR were 0.742(95%CI:0.643-0.841,P<0.001)and 0.790(95%CI:0.690-0.890,P<0.001)respectively.The cutoff values were 4.915 mmol/L and 0.605,the sensitivity were 80.0%and 80.0%,the specificity were 82.3%and 92.5%,respectively,and the Kappa values were 0.418 and 0.625 respectively(all P<0.001).Conclusion Total cholesterol and CAR after radical resection of esophageal cancer have a certain predictive value for postoperative anastomotic fistula in patients with esophageal squamous cell carcinoma.The predictive result of CAR is better than that of total cholesterol.