Clavien-Dindo分级与并发症综合指数评估胃癌根治术后早期并发症的应用价值

Application value of Clavien-Dindo classification and comprehensive complication index in evaluating early postoperative complications for radical gastric cancer surgery

目的探讨Clavien-Dindo分级(CDC)与并发症综合指数(CCI)评估胃癌根治术后早期并发症的应用价值.方法采用回顾性队列研究方法.收集2016年1月至2018年12月南京大学医学院附属鼓楼医院收治的1484例行胃癌根治术患者的临床病理资料;男1086例,女398例;年龄为(60±17)岁.根据CDC对患者术后早期并发症划分等级,并计算CCI.正态分布的计量资料以(x)±s表示,计数资料以绝对数表示.单因素分析采用x2检验,多因素分析采用Logistic回归分析.采用Spearman秩相关分析CDC、CCI与术后住院时间和住院总费用的相关性.采用多重线性回归分析CDC、CCI与术后住院时间和住院总费用的相关性.结果(1)术后早期并发症的CDC与CCI分布.1484例患者中,432例出现术后早期并发症,其中322例为单一并发症,110例伴有多种并发症.432例患者CDCⅠ、Ⅱ、Ⅲa、Ⅲb、Ⅳ、Ⅴ级并发症分别为231、137、45、13、3、3例.432例患者CCI为17.2±11.7,CCI峰值为8.7和20.9.(2)胃癌根治术后早期并发症的影响因素分析.多因素分析结果显示:女性、年龄≥70岁以及术前血清白蛋白<35 g/L是影响胃癌根治术后早期并发症的独立危险因素(风险比=1.391,1.535,1.521,95%可信区间为1.083~1.786,1.187~1.985,1.055~2.192,P<0.05).(3)CDC、CCI与术后住院时间和住院总费用的相关性分析.432例术后早期并发症患者中,CDC、CCI与术后住院时间均呈正相关(r=0.574,0.576,P<0.05);两者与住院总费用均呈正相关(r=0.413,0.438,P<0.05).110例伴有多种术后并发症患者中,CDC、CCI与术后住院时间均呈正相关(r=0.514,0.537,P<0.05);两者与住院总费用均呈正相关(r=0.427,0.474,P<0.05).(4)CDC、CCI与术后住院时间和住院总费用的回归分析.术后住院时间多重线性回归分析结果显示:CDC≥3级、年龄≥70岁、术前C反应蛋白≥10g/L和美国麻醉医师协会(ASA)分级≥3级会延长术后住院时间;CCI越大,术后住院时间越长.CCI标准b值0.467高于CDC≥3级标准b值0.212.住院总费用多重线性回归分析结果显示:CDC分级≥3级、年龄≥70岁、术前血清白蛋白<35 g/L、ASA分级≥3级及病理学分期Ⅲ~Ⅳ期增加了患者住院总费用,而女性会减少住院总费用;CCI越大,住院总费用越高.CCI标准b值0.449高于CDC≥3级标准b值0.061.结论CDC与CCI均能较好地反映胃癌根治术后并发症严重程度.与CDC比较,CCI可更好预测术后住院时间和住院总费用.

Objective To investigate the application value of Clavien-Dindo classification(CDC)and comprehensive complication index(CCI)in evaluating early postoperative complications for radical gastric cancer surgery.Methods The retrospective cohort study was conducted.The clinicopathological data of 1484 patients who underwent radical gastric cancer surgery in Affiliated Drum Tower Hospital,Medical School of Nanjing University from January 2016 to December 2018 were collected.There were 1086 males and 398 females,aged(60±17)years.The early complica-tions of patients were classified by the CDC and the CCI was calculated.Measurement data with normal distribution were represented as Mean±SD.Count data are expressed as absolute numbers.Univariate analysis was performed using the chi-square test.Multivariate analysis was conducted using Logistic regression analysis.Correlation analysis between CDC,CCI and duration of postopera-tive hospital stay,total hospital expenses was performed using the Spearman rank correlation.Multiple linear regression analysis was conducted to compare the correlation analysis between CDC,CCI and duration of postoperative hospital stay,total hospital expenses.Results(1)Distribution of early postoperative complications by CDC and CCI.Among the 1484 patients,432 patients developed early postoperative complications,of which 322 cases had a single complication,and 110 cases had multiple complications.Among the 432 patients with complications,the numbers of patients with gradesⅠ,Ⅱ,Ⅲa,Ⅲb,Ⅳ,andⅤof CDC were 231,137,45,13,3,and 3 cases,respectively.The CCI in the 432 patients with complications was 17.2±11.7,with peak values of 8.7 and 20.9.(2)Analysis of factors influencing early postoperative complications in patients undergoing radical gastric cancer surgery.Results of multivariate analysis showed that female,age≥70 years,and preoperative serum albumin<35 g/L were independent risk factors for early postoperative complications in patients undergoing radical gastric cancer surgery(odds ratios=1.391,1.535,1.521,95%confidence intervals as 1.083-1.786,1.187-1.985,1.055-2.192,P<0.05).(3)Correlation analysis between CDC,CCI and duration of postoperative hospital stay,total hospital expenses.Among the 432 patients with post-operative complications,both CDC and CCI were positively correlated with duration of postoperative hospital stay(r=0.574,0.576,P<0.05),and both were positively correlated with total hospital expenses(r=0.413,0.438,P<0.05).Among the 110 patients with multiple postoperative complications,both CDC and CCI were positively correlated with duration of postoperative hospital stay(r=0.514,0.537,P<0.05),and both were positively correlated with total hospital expenses(r=0.427,0.474,P<0.05).(4)Regression analysis between CDC,CCI,and duration of postoperative hospital stay,total hospital expenses.Multiple linear regression analysis of duration of postoperative hospital stay showed that CDC≥grade 3,age≥70 years,preoperative C-reactive protein≥10 g/L,and American Society of Anesthesiology(ASA)classification≥grade 3 were associated with prolonged duration of postopera-tive hospital stay.The higher CCI indicated longer duration of postoperative hospital stay.The standard b value of CCI was higher than that of CDC≥grade 3(0.467 versus 0.212).The regression analysis of total hospital expenses showed that CDC≥grade 3,age≥70 years,preoperative serum albumin<35 g/L,ASA classification≥grade 3,and pathological stageⅢ-Ⅳincreased total hospital expenses,while gender of female reduced the expenses.The higher CCI indicated higher hospital expenses.The standard b value of CCI was higher than that of CDC≥grade 3(0.449 versus 0.061).Conclusions Both the CDC and CCI can effectively reflect the severity of postoperative complica-tions following radical gastric cancer surgery.Compared to the CDC,the CCI can better predict post-operative hospital stay and total hospital expenses.