胸腹腔镜联合食管癌根治术后发生肺部相关并发症风险预测模型的构建及验证

Construction and validation of a prediction model for postoperative pulmonary complications undergoing thoracoscopic and laparoscopic esophagectomy

摘要:

目的 探讨胸腹腔镜联合食管癌根治术后发生肺部并发症（PPCs）的危险因素，并构建风险预测模型，以发现高危患者。方法 纳入2020年1月－2022年12月该院189例行胸腹腔镜联合食管癌根治性手术的患者的临床资料，分析发生PPCs的影响因素，并构建风险预测模型；采用前瞻性分析方式，选择2023年1月－2023年12月于该院行胸腹腔镜联合食管癌根治术的患者68例作为验证，按照预测模型进行分组（高危组和低危组），验证该模型的临床应用价值。结果 189例患者中，发生PPCs的患者53例（28.04%）。单因素分析结果显示，肺部并发症组与无肺部并发症组年龄、吸烟史、慢性阻塞性肺疾病（COPD）、肿瘤部位、一秒率（FEV₁/FVC）、手术时间和术中通气策略比较，差异均有统计学意义（P < 0.05）。多因素Logistic回归分析结果显示，肿瘤部位在胸中上段、年龄 ≥ 65岁、手术时间长于210 min、术前肺功能差（FEV₁/FVC < 70%）、COPD和术中使用传统通气策略，为影响胸腹腔镜联合食管癌根治术后发生PPCs的独立危险因素（P < 0.05）。根据单因素和多因素分析结果，构建预测模型Y = -3.646 + 1.565×肿瘤部位 + 1.451×年龄+1.230×手术时间+1.216×FEV₁/FVC+1.170×COPD+0.953×术中通气策略。采用受试者操作特征曲线（ROC curve）验证上述模型对PPCs的预测价值，曲线下面积为0.869；高危组患者术后7 d PPCs发生率明显高于低危组，差异有统计学意义（P < 0.05）。结论 胸中上段肿瘤、年龄 ≥ 65岁、手术时间长于210 min、术前肺功能差（FEV₁/FVC < 70%）、患有COPD和采用传统通气策略，是导致胸腹腔镜联合食管癌根治术患者发生PPCs的独立危险因素，根据上述因素所构建的风险预测模型，可较为准确地预测发生PPCs的高危患者，其具有较好的临床应用价值，值得进一步深入研究。

Abstract:

Objective To discuss risk factors of postoperative pulmonary complications (PPCs) with esophageal cancer treated by thoracoscopy and laparoscopy, and construct a risk prediction model to identify high-risk patients.Methods A retrospective analysis was performed on 189 patients underwent thoracoscopic and laparoscopic radical resection of esophageal cancer. Multivariate analysis performed on factors that may affect PPCs, and constructed risk prediction model. A prospective study was conducted, and 68 patients who underwent thoracoscopic and laparoscopic radical resection of esophageal cancer from January 2023 to December 2023 were selected and grouped according to the predictive model, and prospective studies were used to verify the clinical application value of prediction model for prediction of PPCs.Results In the 189 patients, 53 patients (28.04%) developed PPCs. The results of univariate analysis showed that the age, smoking history, COPD, tumor location, FEV₁/FVC, operation time, and ventilation strategy during operation were statistically significant between the group with pulmonary complications and the group without pulmonary complications (P < 0.05). The results of multivariate Logistic analysis showed that the tumor location in the mediastinal upper segment, age ≥ 65 years, operation time longer than 210 minutes, poor lung function before surgery (FEV₁/FVC < 70%), COPD, and the use of traditional ventilation strategy during operation were independent risk factors for PPCs in patients (P < 0.05). According to the results of univariate and multivariate analysis, a prediction model was constructed as Y = -3.646 + 1.565 × tumor location + 1.451 × age + 1.230 × operation time + 1.216 × FEV₁/FVC + 1.170 × COPD + 0.953 ×ventilation strategy during operation. The receiver operator characteristic curve (ROC curve) was used to verify the predictive value of the model for PPCs. The area under the ROC curve of the above prediction model for PPCs was 0.869; the PPCs incidence rate in the high-risk group was significantly higher than that in the low-risk group within 7 days after surgery, with a statistically significant difference (P < 0.05).Conclusion A tumor in the upper chest, age of 65 or older, surgery time of more than 210 minutes, poor lung function (FEV₁/FVC < 70%) before surgery, COPD, and traditional ventilation strategy are independent risk factors for the occurrence of PPCs in patients underwent thoracoscopic and laparoscopic radical resection of esophageal cancer. The risk prediction model based on these factors can accurately predict high-risk patients who are likely to develop PPCs, and has good clinical application value, which is worth further in-depth research.