摘要
腹腔镜结直肠癌手术术后神经认知恢复延迟(DNR)的发生率较高且严重影响患者康复。因此,本研究分析腹腔镜结直肠癌手术术后DNR的危险因素并构建风险预测模型,以期为防治术后DNR的发生提供循证参考。
回顾性分析2018年3月—2020年7月在中南大学湘雅医院行腹腔镜手术且术中行局部脑组织氧饱和度(rScO2)监测的227例结直肠癌患者的临床资料。将影响术后DNR的常见因素及潜在因素作为分析变量,逐步进行单因素分析和多因素分析以确定模型的预测因子,构建风险预测模型。通过受试者工作曲线(ROC)评估模型的预测性能,校准曲线评估模型与数据的拟合程度,并绘制列线图。另抽取2021年1月—2021年7月符合纳入、排除标准的30例患者,对预测模型进行外部验证。
建模组患者术后DNR的发生率为15.4%(35/227)。多因素分析显示,年龄、受教育年限、合并糖尿病、术中rScO2最低值是术后DNR的独立影响因素(均P<0.05)。据此构建腹腔镜结直肠癌手术术后DNR的风险预测模型,模型ROC曲线下面积为0.757(95% CI=0.676~0.839,P<0.001),校准曲线中Hosmer-Lemeshow检验提示模型拟合良好(P=0.516);行外部验证的C指数为0.617。
China Journal of General Surgery, 2024, 33(4):603-611.
结直肠癌是一种常见的严重危害人类健康的消化系统恶性肿瘤,其发病率和病死率分别居恶性肿瘤第3位和第2
对于术后认知功能障碍的研究,目前多集中在年龄、受教育水平、合并基础疾病、手术时长等风险因素的探
本研究回顾性收集术中行rScO2监测的腹腔镜结直肠癌手术患者的临床资料、rScO2数据及术后DNR发生情况,分析腹腔镜结直肠癌手术术后DNR的危险因素,构建可靠的预测模型并进行验证,旨在为DNR的早期识别和精准干预提供可靠的循证依据。
回顾性收集中南大学湘雅医院2018年3月—2020年7月227例择期行腹腔镜结直肠癌手术的患者作为预测模型的建模组。纳入标准:⑴ 年龄≥50岁;⑵ 美国麻醉医师协会(American association of anesthesiologists,ASA)分级Ⅱ~Ⅲ级;⑶ 择期行全身麻醉下腹腔镜结直肠癌手术;⑷ 术中行连续rScO2监测。排除标准:⑴ 急诊手术或昏迷患者;⑵ 术前有卒中、短暂性脑缺血发作、精神分裂、帕金森、癫痫及痴呆病史;⑶ 严重的心脏疾病,包括术前左心室射血分数<30%或者带起搏器的心律失常;⑷ 需进行肝移植或者肝功能Child-Pugh分级C级的肝功能障碍;⑸ 术前已需透析的肾功能障碍;⑹ 因设备原因导致rScO2数据缺失;⑺ 临床资料不全。收集2021年1月—2021年7月符合纳入标准的患者30例作为验证组,用于预测模型的外部验证。DNR组定义为患者术后第7天围术期简易智力状态检查量表(Mini-mental State Examination,MMSE)得分比术前下降≥1个标准
收集患者的一般资料,包括年龄、性别、体质量指数(BMI)、受教育年限(小学毕业为受教育6年,如果小学辍学,则记为3年,更高水平的受教育年限计算方法以此类推
采用SPSS 24.0统计软件分析。对所有连续变量首先进行正态分布检验,对于服从正态分布的变量以均数±标准差()描述,非正态分布的变量以中位数(四分位间距)[M(IQR)]进行描述;分类变量采用例(百分比)[n(%)]进行描述。符合正态分布的计量资料组间比较采用t检验,非正态分布则采用Mann-Whitney U检验进行比较;计数资料比较采用
本研究建模组患者术后DNR发生率为15.4%。根据术后是否发生DNR分为DNR组(n=35)和非DNR组(n=192),两组患者性别、术前血红蛋白(Hb)水平、合并高血压、冠心病和基线rScO2值无明显差异(均P>0.05),但术中rScO2最低值(rScO2min)在DNR组更低(P=0.07)。DNR组患者年龄更大、受教育年限更短、术中失血量更多、BMI值更小且合并糖尿病更多(均P<0.05)(
变量 | DNR组(n=35) | 非DNR组(n=192) | P | |
---|---|---|---|---|
一般资料 | ||||
年龄[岁,M(IQR)] | 69(63~72) | 63(57~68) | -3.077 | 0.002 |
性别[n(%)] | ||||
男 | 27(77.1) | 120(62.5) | 2.781 | 0.095 |
女 | 8(22.9) | 72(37.5) | ||
BMI(kg/ | 22.65±2.30 | 22.68±2.98 | 4.191 | 0.042 |
受教育年限[年,M(IQR)] | 7(6~9) | 9(6~12) | -2.308 | 0.021 |
术前病史资料 | ||||
Hb[g/L,M(IQR)] | 128(115~136) | 128(112~139) | -0.322 | 0.748 |
MMSE评分[M(IQR)] | 28(26~29) | 29(27~30) | -1.230 | 0.219 |
糖尿病[n(%)] | ||||
无 | 26(74.3) | 169(88.0) | 4.612 | 0.032 |
有 | 9(25.7.0) | 23(12.0) | ||
高血压[n(%)] | ||||
无 | 27(77.1) | 135(70.3) | 0.676 | 0.411 |
有 | 8(22.9) | 57(29.7) | ||
冠心病[n(%)] | ||||
无 | 32(91.4) | 182(94.8) | 0.620 | 0.431 |
有 | 3(8.6) | 10(5.2) | ||
手术资料 | ||||
基线rScO2(%,) | 62.89±6.05 | 64.74±5.18 | 1.452 | 0.456 |
rScO2min[%,M(IQR)] | 54.5(52~58.5) | 56.5(53~60) | -1.813 | 0.070 |
术中失血量[mL,M(IQR)] | 100(100~200) | 100(50~150) | -2.641 | 0.008 |
麻醉时间(min,) | 281.31±72.95 | 267.09±75.74 | 0.742 | 0.390 |
手术时间(min,) | 210.77±65.28 | 197.43±69.37 | 0.145 | 0.704 |
腹腔镜转开腹[n(%)] | 2(5.7) | 13(6.8) | 0.054 | 0.817 |
纳入年龄、BMI、受教育年限、术中rScO2min、术中失血量、合并糖尿病、高血压、冠心病构建多因素Logistic回归方程。结果发现:年龄大、合并糖尿病是术后DNR的独立危险因素,而受教育年限长是术后DNR的保护因素,此外,术中rScO2min与术后DNR的发生相关,差异有统计学意义(均P<0.05)(
自变量 | β | SE | Wald | P | OR(95% CI) |
---|---|---|---|---|---|
术中rScO2min | -0.074 | 0.035 | 4.377 | 0.036 | 0.929(0.867~0.995) |
受教育年限 | -0.118 | 0.055 | 4.593 | 0.032 | 0.889(0.789~0.990) |
术中失血量 | 0.001 | 0.001 | 1.773 | 0.183 | 1.001(0.999~1.003) |
年龄 | 0.071 | 0.028 | 6.265 | 0.012 | 1.074(1.016~1.136) |
BMI | 0.042 | 0.074 | 0.329 | 0.556 | 1.043(0.903~1.205) |
糖尿病 | 1.066 | 0.524 | 4.131 | 0.042 | 2.903(1.039~8.111) |
高血压 | -0.738 | 0.500 | 2.177 | 0.140 | 0.478(0.179~1.274) |
冠心病 | 0.282 | 0.774 | 0.133 | 0.716 | 1.326(0.291~6.048) |
常量 | -2.384 | 3.048 | 0.612 | 0.434 | 0.092 |
基于多因素Logistic回归分析结果,建立预测模型:Logit(P)=-2.384-0.074×rScO2min-0.118×受教育年限+0.071×年龄+1.066×合并糖尿病。绘制该模型的ROC曲线(

图1 术后DNR预测模型的ROC曲线
Figure 1 The ROC curve of prediction model for postoperative DNR

图2 腹腔镜结直肠癌患者术后DNR预测模型的校准曲线
Figure 2 The calibration curve of postoperative DNR prediction model for patients undergoing laparoscopic colorectal cancer
根据多因素回归分析结果,使用R语言进一步建立腹腔镜结直肠癌手术术后DNR发生的风险预测列线图(

图3 腹腔镜结直肠癌手术术后DNR的风险预测列线图
Figure 3 Nomogram for risk prediction of DNR after laparoscopic colorectal cancer surgery
建模组与验证组患者的性别、BMI、受教育年限、术中失血量、合并高血压、冠心病、糖尿病以及术后DNR发生率均差异无统计学意义(均P>0.05)。验证组患者年龄、术中rScO2min均高于建模组,而术前Hb水平低于对照组(均P<0.05)(
变量 | 建模组(n=227) | 验证组(n=30) | P | |
---|---|---|---|---|
一般资料 | ||||
年龄[岁,M(IQR)] | 64(58~69) | 68.5(65~71.5) | -3.689 | <0.001 |
性别[n(%)] | ||||
男 | 147(64.8) | 16(46.7) | 1.491 | 0.222 |
女 | 80(35.2) | 14(53.3) | ||
BMI [kg/ | 22.3(20.5~24.6) | 23.1(21.48~25.8) | -1.329 | 0.184 |
受教育年限[年,M(IQR)] | 9(6~12) | 8.5(5~12) | -0.789 | 0.430 |
病史资料 | ||||
Hb [g/L,M(IQR)] | 128(113~138) | 110(99.75~126) | -3.368 | 0.001 |
糖尿病[n(%)] | ||||
无 | 195(85.9) | 26(86.7) | 0.013 | 0.910 |
有 | 32(14.1) | 4(13.3) | ||
高血压[n(%)] | ||||
无 | 162(71.4) | 23(76.7) | 0.369 | 0.543 |
有 | 65(28.6) | 7(23.3) | ||
冠心病[n(%)] | ||||
无 | 214(94.3) | 28(93.3) | 7.848 | 0.837 |
有 | 13(5.7) | 2(6.7) | ||
手术资料 | ||||
基线rSO2(%,) | 63.81±5.62 | 64.58±6.04 | 2.317 | 0.721 |
术中rScO2min [%,M(IQR)] | 56(52.5~60) | 58.5(55.87~61) | -2.253 | 0.024 |
术中失血量[mL,M(IQR)] | 100(50~150) | 100(50~200) | -0.969 | 0.332 |
DNR[n(%)] | ||||
否 | 192(84.6) | 27(90.0) | 0.617 | 0.432 |
是 | 35(15.4) | 3(10.0) |
本研究基于常见的术后DNR影响因素及术中rScO2变化,通过多因素回归分析发现术中rScO2min、年龄、合并糖尿病及受教育年限是术后DNR发生的独立危险因素,进一步将危险因素作为预测因子,开发了腹腔镜结直肠癌手术术后DNR的风险预测模型及列线图,具有较好的预测性能,并且在外部数据中得到有效验证,提示该模型为术后DNR的早期识别及尽早干预提供了一定临床价值的参考依据。
术后DNR被广泛证明与住院时间延长、远期病死率增加等不良预后相
高龄是目前唯一明确的高危因
以上影响因素反映了患者具有不同的临床状态,积极寻找可进行干预的预测因素,可有效降低术后DNR的发生率。近年来多项研
值得注意的是,将本预测模型进行外部验证的患者资料与建模组患者资料进行比较显示,验证组患者的年龄更高、术前Hb浓度更低、术中rScO2min更高,笔者认为有以下三个原因:⑴ 回顾性资料收集可能存在选择偏倚;⑵ 验证组患者数量较少;⑶ 临床上更倾向于对高龄患者行脑氧监测。虽然建模组与验证组临床资料存在差异,不影响模型预测性能的评估,但仍需进一步在多中心开展大样本的前瞻性研究,提供更有力的临床证据。
综上所述,这项研究建立并验证了与rScO2监测相关的术后DNR风险预测模型,该模型可用于对患者进行个体化评估,为术后预防术后DNR提供依据。
作者贡献声明
罗宁负责查阅文献、起草和撰写文章;罗宁、叶春艳、刘星扬、王露收集临床资料并完成数据分析和图表制作,王锷负责本研究课题的构思和设计,李龙艳指导文稿撰写并对文稿的内容进行审阅。
利益冲突
所有作者均声明不存在利益冲突。
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