影响癌性肠梗阻病人预后的多因素分析

doi:10.16139/j.1007-9610.2022.04.013

摘要/Abstract

摘要：

目的：多因素分析影响癌性肠梗阻(malignant bowel obstruction, MBO)病人预后的危险因素,构建MBO病人生存期预测的列线图模型。方法：回顾性分析我院2013年6月至2019年6月 203例MBO病人的临床资料及随访。结果：随访143例(70.4%)病人。单因素分析结果显示,性别、年龄、血小板、C反应蛋白、总蛋白含量、合并症数量、使用生长抑素治疗、肠内营养和肠外营养治疗、住院时间与MBO病人的生存无相关性。肿瘤TNM分期晚(P<0.001)、肿瘤继发转移(P<0.001)、贫血(P=0.001)、低白蛋白(P<0.001)、高白细胞(P=0.023)、非手术治疗(P=0.013)、生活质量评分低(P<0.001)以及肝功能差[包括高丙氨酸转氨酶(P=0.023)、高天冬氨酸转氨酶(P=0.005)]等因素与预后差有关。多因素分析显示,肿瘤分期(P=0.003)、白蛋白水平(P=0.001)是影响MBO病人预后的独立危险因素。采用TNM晚期、继发肿瘤以及血红蛋白低和白蛋白低4个指标构建的列线图。通过40例病人3~12个月的内部预测生存期,结果良好。结论：构建列线图和预后分析显示,MBO病人不良的主要因素是肿瘤晚期以及全身营养不良。

关键词: 癌性肠梗阻, 预后因素, 手术治疗, 列线图

Abstract:

Objective To analyze the risk factors for prognosis of patients with malignant bowel obstruction (MBO) using multiple factors, and establish the nomogram model for predicting the survival of patients with MBO. Methods The clinical data of 203 patients with MBO from June 2013 to June 2019 who were followed up in our hospital were analyzed retrospectively. Results A total of 143 (70.4%) patients have been followed up. It was shown with univariate analysis that indexes of gender, age, platelet, C-reactive protein, and total protein levels, comorbidities, the treatment with somatostatin, enteral nutrition, and parenteral nutrition, length of hospital were not related to the survival of patients with MBO. There were some factors including late TNM stage of tumor (P<0.001), tumor metastasis (P<0.001), anemia (P=0.001), lower albumin (P<0.001), higher white blood cell(P=0.023), non-surgical treatment(P=0.013), low quality of life score (P<0.001) and poor liver function [including high alanine aminotransferase (P=0.023), high aspartate aminotransferase (P=0.005)] which related with poorer prognosis in patients with MBO. Multivariate analysis showed that tumor stage (P=0.003) and albumin level(P=0.001) were independent risk factors affecting the prognosis of MBO. Nomogram was constructed using 4 indexes including late TNM stage, tumor metastasis, lower hemoglobin and lower albumin. It was indicated that the results of internal prognosis were better for the prediction of survival of 3 to 12 months of 40 cases. Conclusions The study on poor prognosis of patients with MBO combined with nomogram showed that both late stage of tumor and malnutrition were main factors.

Key words: Malignant bowel obstruction, Prognostic factor, Surgical treatment, Nomogram model

中图分类号:

R574.2

程威, 黄雨桦, 王剑, 李幼生. 影响癌性肠梗阻病人预后的多因素分析[J]. 外科理论与实践, 2022, 27(04): 340-345.

CHENG Wei, HUANG Yuhua, WANG Jian, LI Yousheng. Multivariate analysis of prognosis of patients with malignant bowel obstruction[J]. Journal of Surgery Concepts & Practice, 2022, 27(04): 340-345.

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参考文献 24

[1]	Jacquet P, Jelinek JS, Steves MA, et al. Evaluation of computed tomography in patients with peritoneal carcinomatosis[J]. Cancer, 1993, 72(5):1631-1636. pmid: 8348494
[2]	Ripamonti C, Twycross R, Baines M, et al. Clinical-practice recommendations for the management of bowel obstruction in patients with end-stage cancer[J]. Support Care Cancer, 2001, 9(4):223-233. pmid: 11430417
[3]	Selby D, Wright F, Stilos K, et al. Room for improvement? a quality-of-life assessment in patients with malignant bowel obstruction[J]. Palliat Med, 2010, 24(1):38-45. doi: 10.1177/0269216309346544 pmid: 19797338
[4]	Krouse RS. The international conference on malignant bowel obstruction: a meeting of the minds to advance palliative care research[J]. J Pain Symptom Manage, 2007, 34(1 Suppl):S1-S6.
[5]	Kim JS, Hur H, Min BS, et al. Oncologic outcomes of self-expanding metallic stent insertion as a bridge to surgery in the management of left-sided colon cancer obstruction: comparison with nonobstructing elective surgery[J]. World J Surg, 2009, 33(6):1281-1286. doi: 10.1007/s00268-009-0007-5 URL
[6]	Ansaloni L, Andersson RE, Bazzoli F, et al. Guidelenines in the management of obstructing cancer of the left colon: Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Socie-ty[J]. World J Emerg Surg, 2010, 5:29. doi: 10.1186/1749-7922-5-29 pmid: 21189148
[7]	Morris EJ, Taylor EF, Thomas JD, et al. Thirty-day postoperative mortality after colorectal cancer surgery in England[J]. Gut, 2011, 60(6):806-813. doi: 10.1136/gut.2010.232181 pmid: 21486939
[8]	Krouse RS. Malignant bowel obstruction[J]. J Surg Oncol, 2019, 120(1):74-77. doi: 10.1002/jso.25451 URL
[9]	Ho KM, Chan KM, Kwok SY, et al. Colonic self-expan-ding metal stent (SEMS) as a bridge to surgery in left-sided malignant colonic obstruction: an 8-year review[J]. Surg Endosc, 2017, 31(5):2255-2262. doi: 10.1007/s00464-016-5227-9 URL
[10]	Rodrigues-Pinto E, Morais R, Coelho C, et al. Bridge-to-surgery versus emergency surgery in the management of left-sided acute malignant colorectal obstruction - efficacy, safety and long-term outcomes[J]. Dig Liver Dis, 2019, 51(3):364-372. doi: 10.1016/j.dld.2018.11.006 URL
[11]	Anthony T, Baron T, Mercadante S, et al. Report of the clinical protocol committee: development of randomized trials for malignant bowel obstruction[J]. J Pain Symptom Manage, 2007,(1 Suppl):S49-S59.
[12]	顾晋. 肿瘤性肠梗阻的诊断和治疗[J]. 中国实用外科杂志, 2008, 28(9):703-706.
[13]	Tuca A, Guell E, Martinez-Losada E, et al. Malignant bowel obstruction in advanced cancer patients: epidemio-logy, management, and factors influencing spontaneous resolution[J]. Cancer Manag Res, 2012, 4:159-169.
[14]	Arezzo A, Balague C, Targarona E, et al. Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial(ESCO trial)[J]. Surg Endosc, 2017, 31(8):3297-3305. doi: 10.1007/s00464-016-5362-3 URL
[15]	Hoppenot C, Peters P, Cowan M, et al. Malignant bowel obstruction due to uterine or ovarian cancer: are there differences in outcome?[J]. Gynecol Oncol, 2019, 154(1):177-182. doi: S0090-8258(19)31183-7 pmid: 31056111
[16]	Frago R, Ramirez E, Millan M, et al. Current management of acute malignant large bowel obstruction: a systematic review[J]. Am J Surg, 2014, 207(1):127-138. doi: 10.1016/j.amjsurg.2013.07.027 URL
[17]	江志伟, 黎介寿, 李宁, 等. 奥曲肽治疗晚期癌性肠梗阻的作用[J]. 医学研究生学报, 2007, 20(10):1044-1046.
[18]	Currow DC, Quinn S, Agar M, et al. Double-blind, placebo-controlled, randomized trial of octreotide in malignant bowel obstruction[J]. J Pain Symptom Manage, 2015, 49(5):814-821. doi: 10.1016/j.jpainsymman.2014.09.013 URL
[19]	Mercadante S. Octreotide for malignant bowel obstruction: commentary on Currow et al[J]. J Pain Symptom Manage, 2015, 49(5):813. doi: 10.1016/j.jpainsymman.2015.04.001 URL
[20]	Chi DS, Phaeton R, Miner TJ, et al. A prospective outcomes analysis of palliative procedures performed for malignant intestinal obstruction due to recurrent ovarian cancer[J]. Oncologist, 2009, 14(8):835-839. doi: 10.1634/theoncologist.2009-0057 URL
[21]	Cousins SE, Tempest E, Feuer DJ. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer[J]. Cochrane Database Syst Rev, 2016(1):CD002764.
[22]	Bento JH, Bianchi ET, Tustumi F, et al. Surgical ma-nagement of malignant intestinal obstruction: outcome and prognostic factors[J]. Chirurgia (Bucur), 2019, 114(3):343-351.
[23]	Baumgartner JM, Marmor R, Hsu A, et al. Obstruction-free survival following operative intervention for malignant bowel obstruction in appendiceal cancer[J]. Ann Surg Oncol, 2019, 26(11):3611-3617. doi: 10.1245/s10434-019-07507-4 pmid: 31190209
[24]	Stein SL. Expert commentary on malignant bowel obstruction[J]. Dis Colon Rectum, 2019, 62(9):1031-1032. doi: 10.1097/DCR.0000000000001447 URL

指标	病例数	危险比	95%CI	P值
性别	143	0.727	0.469~1.126	0.153
年龄	143	1.003	0.989~1.017	0.679
TNM分期	127	3.768	2.346~6.025	<0.001
原发或继发转移	143	3.506	2.230~5.514	<0.001
白细胞	143	1.050	1.090~1.012	0.023
红细胞	143	0.584	0.436~0.783	<0.001
血小板	143	0.999	0.997~1.001	0.168
血红蛋白	143	0.985	0.976~0.994	0.001
CRP	57	1.003	0.998~1.010	0.235
ALT	143	1.006	1.001~1.010	0.023
AST	143	1.002	1.001~1.003	0.005
总蛋白	143	0.984	0.961~1.007	0.175
白蛋白	143	0.924	0.891~0.958	<0.001
前白蛋白	138	0	0.001~0.002	<0.001
合并慢性病数量	143	1.133	0.860~1.492	0.376
生长抑素	143	0.961	0.594~1.553	0.870
肠内营养	143	0.810	0.439~1.496	0.501
肠外营养	143	0.715	0.440~1.161	0.175
住院时间	143	0.999	0.983~1.014	0.879
是否手术	143	0.522	0.312~0.870	0.013
生活质量评分 QOL	143	0.860	0.883~0.887	<0.001
ZPS	143	8.672	5.440~13.826	<0.001
KPS	143	0.916	0.899~0.934	<0.001

变量	回归系数	标准误	危险比	95%CI	P值
TNM分期	0.838	0.281	2.312	1.331~4.015	0.003
原发或继发转移	0.544	0.350	1.723	0.867~3.423	0.120
血红蛋白	-0.005	0.006	0.995	0.985~1.006	0.395
白蛋白	-0.076	0.023	0.927	0.886~0.970	0.001
ALT	0.002	0.006	1.002	0.989~1.015	0.762
AST	0.001	0.002	1.001	0.996~1.005	0.795
是否手术	-0.090	0.284	0.914	0.524~1.594	0.752