经口内镜食管下括约肌切开术气体相关并发症的危险因素分析及预测模型建立

Risk factors for gas‑related complications of peroral endoscopic myotomy and development of a prediction model

摘要:

目的 分析贲门失弛缓症（achalasia，AC）患者行经口内镜食管下括约肌切开术（peroral endoscopic myotomy，POEM）过程中出现气体相关并发症的危险因素，构建POEM气体相关并发症列线图预测模型。方法 回顾性分析2012年1月至2022年12月于陆军军医大学第一附属医院行POEM的AC患者的临床资料。将纳入病例随机分为建模组（146例）和验证组（37例）。基于建模组单因素与多因素分析筛选出气体相关并发症的危险因素，建立列线图预测模型。结果 在183例接受POEM的AC患者中，有91例（49.73%）出现气体相关并发症。单因素分析中肌切开长度、Eckardt评分、手术时间、高血压、肌层切开方式、既往史、血清肌酐、血小板和血清尿素氮为出现气体相关并发症的影响因素（P<0.05）。多因素分析显示手术时间>2 h（OR=2.03，95%CI：1.06~3.87， P=0.032）、肌切开长度>10 cm（OR=7.55，95%CI：3.09~18.45， P<0.001）、肌层切开方式为全层切开（OR=4.61，95%CI：1.50~14.20， P=0.008）、Eckardt评分为2或3级（OR=6.14，95%CI：2.73~13.80， P<0.001）、高血压（OR=22.69，95%CI：2.71~189.74，P=0.004）、既往行手术治疗（OR=5.27，95%CI：1.57~17.66，P=0.007）和血清尿素氮升高（OR=1.21，95%CI：1.01~1.45，P=0.036）为POEM出现气体相关并发症的独立危险因素。将以上独立危险因素纳入建立预测模型，模型在建模组和验证组的受试者工作特征曲线下面积分别为0.833和0.912。校准曲线、临床决策曲线、Hosmer‑Lemeshow检验结果显示该模型具有良好的预测能力。结论 利用手术时间、肌切开长度、肌层切开方式、高血压、既往史、Eckardt评分和血清尿素氮构建的模型在预测行POEM出现气体相关并发症方面具有良好的预测能力，可指导临床。

Abstract:

Objective To analyze the risk factors for gas‑related complications during peroral endoscopic myotomy (POEM) in patients with achalasia (AC), and to construct a nomogram prediction model. Methods The clinical data of AC patients who underwent POEM from January 2012 to December 2022 at the First Affiliated Hospital of Army Medical University were retrospectively analyzed. The included cases were randomly divided into a modeling group (146 cases) and a validation group (37 cases). Risk factors for gas‑related complications were screened based on univariate and multifactorial analyses in the modeling group, and a nomogram prediction model was developed. Results Gas‑related complications occurred in 91 (49.73%) of 183 AC patients who received POEM. Myotomy length, Eckardt score, operative time, hypertension, myotomy approach, past history, serum creatinine, platelets, and serum urea nitrogen were the influencing factors for the development of gas‑related complications on univariate analysis (P<0.05). Multivariate analysis showed that the operative time >2 h (OR=2.03, 95%CI: 1.06-3.87, P=0.032), myotomy length >10 cm (OR=7.55, 95%CI: 3.09-18.45, P<0.001), the total myotomy (OR=4.61, 95%CI: 1.50-14.20, P=0.008), Eckardt score of 2 or 3 (OR=6.14, 95% CI: 2.73-13.80, P<0.001), hypertension (OR=22.69, 95%CI: 2.71-189.74, P=0.004), previous surgical treatment (OR=5.27, 95%CI: 1.57-17.66, P=0.007) and increased serum urea nitrogen (OR=1.21, 95%CI: 1.01-1.45, P=0.036) were the independent risk factors for gas‑related complications in POEM. Incorporating the above independent risk factors into the prediction model, the area under the receiver operating characteristic curve for this model was 0.833 and 0.912 for the modeling and validation groups, respectively. Calibration curves, clinical decision curves, and Hosmer‑Lemeshow tests were used to validate and evaluate the measurement model, showing that it had excellent predictive power. Conclusion This nomogram prediction model constructed with operative time, myotomy length, myotomy approach, hypertension, previous history, Eckardt score, and serum urea nitrogen has good discrimination and calibration in predicting gas‑related complications of POEM and has clinical reference value.