术后预后营养指数与肝细胞癌切除术后严重并发症的关系

Relation between postoperative prognostic nutritional index and severe complications after hepatectomy in patients with hepatocellular carcinoma

目的 探讨肝细胞癌(hepatocellular carcinoma,HCC)肝切除患者术后预后营养指数(prognostic nutritional index,PNI)与严重并发症即Clavien-Dindo并发症分级Ⅲ~Ⅴ级的关系。方法 按照制定的纳入和排除标准回顾性收集2009年1月至2016年1月期间在四川省肿瘤医院行肝切除的HCC患者。通过受试者操作特征曲线来评估术后PNI对术后并发症发生的预测能力并确定其最佳临界值,再根据最佳临界值将患者分为低术后PNI和高术后PNI;同时采用非条件logistic回归多因素分析影响HCC患者肝切除术后严重并发症的相关因素以及采用Cox比例风险回归分析影响HCC根治性切除患者总生存时间的相关因素。结果 最终纳入779例患者,术后发生并发症238例(30.6%),其中严重并发症68例(8.7%)。779例患者的术后PNI为35.8±4.9。受试者操作特征曲线分析显示术后PNI预测术后严重并发症的曲线下面积为0.735,其最佳临界值为35.7,敏感度和特异度分别为0.868、0.518。低术后PNI(≤35.7)患者397例、高术后PNI(>35.7)患者382例,相较于高术后PNI患者,低术后PNI患者的临床肝癌巴塞罗那分期B、C期患者占比更高(P<0.001),术前肝功能更差(P<0.05),切除肝体积更大(P<0.001),术中失血量更多(P<0.001),术中输血者占比更高(P<0.001),严重并发症率(P<0.001)和死亡率(P=0.039)更高。非条件logistic回归多因素分析结果显示,术前Child-Pugh评分分级B级、美国麻醉医师协会分级Ⅲ~Ⅳ级、术中输血及术前低血小板水平和术后PNI≤35.7增加HCC患者肝切除术后严重并发症发生的概率(P<0.05)。高术后PNI患者的总生存情况优于低术后PNI患者(P=0.007),但二者无瘤生存情况比较差异无统计学意义(P=0.073),并且在本研究中对HCC肝切除患者总生存时间影响的多因素分析中未发现术后PNI与其有关(P=0.276)。结论 本研究中确定的术后PNI预测术后严重并发症发生的最佳临界值为35.7时其预测价值较高,术后高和低PNI患者术后严重并发症发生情况有差异,并且高术后PNI患者的总生存情况优于低术后PNI患者。

Objective To discuss the relation between postoperative prognostic nutritional index(PNI) and serious complications(Clavien-Dindo complications classification Ⅲ to Ⅴ) after hepatectomy for patients with hepatocellular carcinoma(HCC). Methods According to the inclusion and exclusion criteria, the HCC patients who underwent hepatectomy in the Sichuan Cancer Hospital from January 2009 to January 2016 were retrospectively collected.The predictive ability of postoperative PNI for postoperative complications was evaluated by receiver operating characteristic(ROC) curve, and the optimal cutoff value was determined. At the same time, the related factors affecting the severe complications and overall survival after hepatectomy in the HCC patients were analyzed by non-conditional logistic regression and Cox proportional hazards regression analysis, respectively. Results A total of 779 patients were enrolled,and the postoperative complications occurred in 238(30.6%) cases, including 68(8.7%) cases of serious complications.The postoperative PNI of all patients was 35.8±4.9, the ROC curve analysis showed that the area under the ROC curve of postoperative PNI for predicting postoperative severe complications was 0.735, the optimal cutoff value was 35.7, and the sensitivity and specificity were 0.868 and 0.518, respectively. The patients were classified as a lower postoperative PNI(≤35.7,397 patients) and higher postoperative PNI(>35.7, 382 patients) based on the optimal cutoff value. Compared with patients with higher postoperative PNI, the patients with lower postoperative PNI had later stage of tumor(P<0.001), worse liver function(P<0.05), and larger volume of excised liver(P<0.001), more blood loss(P<0.001), and higher proportion of intraoperative blood transfusion(P<0.001), higher serious complication(P<0.001) and mortality(P=0.039). The multivariate logistic regression analysis found that the preoperative Child-Pugh score grade B, American Society of Anesthesiologists grade Ⅲ–Ⅳ, intraoperation blood transfusion, preoperative decreased platelet level, and lower postoperative PNI increased the probability of postoperative serious complications in the HCC patients(P<0.05). The overall survival of HCC patients with higher postoperative PNI was better than that of patients with lower postoperative PNI(P=0.007), but there was no statistical difference in tumor-free survival between the two(P=0.073), and it was not fount that the postoperative PNI was associated with the overall survival of HCC patients underwent hepatectomy by the Cox proportional hazards regression multivariate analysis(P=0.276). Conclusions The optimal cutoff value of postoperative PNI for predicting postoperative serous complications determined in this study is 35.7, which has a higher predictive value. Patients with higher postoperative PNI and lower postoperative PNI in incidence of postoperative serious complications are obviously different, patients with higher postoperative PNI has a better overall survival than those with lower postoperative PNI.