晚期消化系统癌症手术患者器官/腔隙感染的风险预测模型的建立

doi:10.3877/cma.j.issn.2095-2015.2026.02.005

目的

调查分析晚期消化系统癌症手术患者器官/腔隙手术部位感染（SSI）的发生率和危险因素，建立列线图风险预测模型并验证预测效能。

方法

回顾性分析2018年2月至2023年2月于海安市人民医院确诊晚期消化系统癌症患者共852例，其中男505例，女347例，年龄（58.9±6.6）岁，食管癌90例，胃癌178例，结直肠癌259例，肝癌250例，胰腺癌75例，手术方式包括开腹和腹腔镜手术。根据术后30 d内是否发生器官/腔隙SSI分为两组，比较感染组与未感染组患者的临床资料并筛选危险因素。

结果

术后30 d内发生器官/腔隙SSI共53例（6.2%，53/852），共检出69株病原菌，其中40例为单一感染，13例为混合感染。69株病原菌中革兰阴性菌50株，革兰阳性菌16株，真菌3株。感染组与未感染组比较，患者年龄大，术中失血量多，糖尿病、肠外营养、胃癌和结直肠癌切除术比例高，麻醉时间、ICU停留时间、手术时间和腹腔引流时间长，术前血红蛋白和白蛋白水平低，差异均有统计学意义（P<0.05）。多因素Logistic回归分析显示，手术类型[胃癌（OR=4.526，95% CI 2.264~6.023，P<0.001）和结直肠癌（OR=5.021，95% CI 3.345~6.642，P<0.001）切除术]、麻醉时间≥4 h（OR=2.235，95% CI 1.568~3.235，P<0.001）、ICU停留时间≥24 h（OR=3.754，95% CI 2.569~5.201，P<0.001）和术前白蛋白<30 g/L（OR=1.859，95% CI 1.234~3.125，P<0.001）是器官/腔隙SSI发生的独立危险因素。R软件建立定量列线图模型，总分220分。受试者工作曲线（ROC）计算列线图预测器官/腔隙SSI发生的曲线下面积（AUC）为0.856，提示模型的预测效能较好。校准曲线显示列线图预测器官/腔隙SSI发生概率与实际发生率有较好的一致性。使用Bootstrap内部验证法计算C-index为0.861（95% CI 0.810~0.903），提示列线图有较好的区分度。

结论

晚期消化系统癌症手术患者器官/腔隙SSI有一定的发生率，胃癌和结肠癌切除术、麻醉时间≥4 h、ICU停留时间≥24 h、术前白蛋白<30 g/L是其独立危险因素，建立可视化较好的列线图模型预测器官/腔隙SSI的效能较好。

关键词: 消化系统肿瘤, 手术部位感染, 危险因素, 列线图模型

Objective

To investigate the incidence and analyze the risk factors of organ/space surgical site infection (SSI) in patients with advanced digestive system cancer after surgery treatment, so as to establish a nomogram risk predictive model and verify the predictive efficiency.

Methods

A total of 852 patients with advanced digestive system cancer admitted into Hai'an People's Hospital from February 2018 to February 2023 were retrospectively reviewed. Among them, 505 were males and 347 were females, with an average of (58.9+6.6) years, 90 cases of esophageal cancer, 178 cases of gastric cancer, 259 cases of colorectal cancer, 250 cases of liver cancer, and 75 cases of pancreatic cancer. The surgical methods included open surgery and laparoscopic surgery. The patients were divided into two groups based on whether surgical site SSIs occurred within 30 days after the operation. The clinical data between the infected group and non-infected group were compared, then the risk factors were screened.

Results

Within 30 days after the operation, 53 cases (6.2%, 53/852) of organ/cavity SSI occurred. A total of 69 pathogenic bacteria were detected. Among them, 40 cases were single infection and 13 cases were mixed infections. Among the 69 pathogens, there were 50 Gram-negative bacteria, 16 Gram-positive bacteria and 3 fungi. Compared with the non-infected group, the infected group had older patients, greater intraoperative blood loss, higher proportions of diabetes, parenteral nutrition, gastric cancer and colorectal cancer resections, longer anesthesia time, ICU stay time, operation time and abdominal drainage time, and lower preoperative hemoglobin and albumin levels, with statistically significant differences (P<0.05). Multivariate Logistic regression analysis showed that operative types [gastric cancer (OR=4.526, 95% CI: 2.264-6.023, P<0.001) and colorectal cancer (OR=5.021, 95% CI: 3.345-6.642, P<0.001) resection], anesthesia time≥4 h (OR=2.235, 95% CI: 1.568-3.235, P<0.001), ICU stay time≥24 h (OR=3.754, 95% CI: 2.569-5.201, P<0.001) and preoperative albumin<30 g/L (OR=1.859, 95% CI: 1.234-3.125, P<0.001) were all the independent risk factors to organ/space SSI. R software was used to establish the quantitative nomogram model and total score was 220. The area under the curve (AUC) of the nomogram for predicting organ/space SSI was 0.856 by receiver operating curve (ROC), suggesting that the predictive efficiency of the model was good. Calibration curve showed that the incidence of organ/space SSI predicted by nomogram was in good agreement with the actual incidence. The C-index calculated by Bootstrap internal verification method was 0.861 (95% CI: 0.810-0.903), suggesting that the nomogram had good discrimination.

Conclusion

There is a certain incidence of organ/space SSI in patients with advanced digestive system cancer after surgery, gastric cancer and colon cancer resection, anesthesia time≥4 h, ICU stay time≥24 h and preoperative albumin<30 g/L are the independent risk factors. The establishment of a visualized nomogram model is effective in predicting organ/space SSI and has good clinical value.

Key words: Digestive system cancer, Surgical site infection, Risk factors, Nomogram model

表1 手术患者器官/腔隙感染病原菌分布

病原菌	株数(n=69)	构成比(%)
革兰阴性菌	50	72.5
大肠埃希菌	24	34.8
铜绿假单胞菌	17	24.6
肺炎克雷伯菌	6	8.7
其他	3	4.4
革兰阳性菌	16	23.2
金黄色葡萄球菌	8	11.6
肺炎链球菌	5	7.2
表皮葡萄球菌	3	4.4
真菌	3	4.3
白假丝酵母	3	4.3

表1 手术患者器官/腔隙感染病原菌分布

病原菌	株数(n=69)	构成比(%)
革兰阴性菌	50	72.5
大肠埃希菌	24	34.8
铜绿假单胞菌	17	24.6
肺炎克雷伯菌	6	8.7
其他	3	4.4
革兰阳性菌	16	23.2
金黄色葡萄球菌	8	11.6
肺炎链球菌	5	7.2
表皮葡萄球菌	3	4.4
真菌	3	4.3
白假丝酵母	3	4.3

表2 器官/腔隙手术部位感染组与未感染组临床资料比较

临床资料	未感染组(n=799)	感染组(n=53)	Z/t/χ²值	P值
男/女(例)	456/343	29/24	0.112	0.737
年龄(岁,±s)	53.9±6.2	64.5±8.4	5.659	0.003
体重指数(kg/m²,±s)	23.2±1.8	23.3±1.9	0.423	0.679
美国麻醉医师协会分级Ⅰ/Ⅱ(例)	429/370	30/23	0.170	0.680
糖尿病[例(%)]	83(10.4)	12(22.6)	7.533	0.006
查尔森共病指数2~4/5~6(例)	498/301	35/18	0.292	0.589
放化疗[例(%)]	721(80.2)	46(86.8)	0.657	0.418
肠外营养[例(%)]	175(21.9)	23(43.4)	12.872	<0.001
开腹手术/腹腔镜手术(例)	504/295	32/21	0.155	0.693
手术类型[例(%)]
食管癌切除术	88(11.0)	2(3.8)	2.642	0.104
胃癌切除术	161(20.2)	17(32.0)	4.277	0.039
结直肠癌切除术	236(29.5)	23(43.4)	4.512	0.034
肝癌切除术	240(30.0)	10(18.9)	2.991	0.084
胰腺癌切除术	74(9.3)	1(1.9)	3.367	0.067
术中出血量[例(%)]			9.420	0.002
<500 mL	714(89.4)	40(75.5)
≥500 mL	85(10.6)	13(24.5)
输血[例(%)]	55(6.9)	6(11.3)	1.457	0.227
麻醉时间[例(%)]
<4 h	697(87.2)	36(67.9)
≥4 h	102(12.8)	17(32.1)	15.422	<0.001
ICU停留时间[例(%)]			9.166	0.002
<24 h	703(88.0)	39(73.6)
≥24 h	96(12.0)	14(26.4)
手术时间[h,M(Q1,Q3)]	4(3,8)	6(5,10)	1.235	0.006
引流时间[d,M(Q1,Q3)]	7(5,12)	10(6,15)	1.102	0.010
术前血红蛋白(g/L,±s)	109.8±12.3	102.5±9.8	4.457	0.013
术前白蛋白[例(%)]			8.230	0.004
<30 g/L	80(10.0)	12(22.6)
≥30 g/L	719(90.0)	41(77.4)

表2 器官/腔隙手术部位感染组与未感染组临床资料比较

临床资料	未感染组(n=799)	感染组(n=53)	Z/t/χ²值	P值
男/女(例)	456/343	29/24	0.112	0.737
年龄(岁,±s)	53.9±6.2	64.5±8.4	5.659	0.003
体重指数(kg/m²,±s)	23.2±1.8	23.3±1.9	0.423	0.679
美国麻醉医师协会分级Ⅰ/Ⅱ(例)	429/370	30/23	0.170	0.680
糖尿病[例(%)]	83(10.4)	12(22.6)	7.533	0.006
查尔森共病指数2~4/5~6(例)	498/301	35/18	0.292	0.589
放化疗[例(%)]	721(80.2)	46(86.8)	0.657	0.418
肠外营养[例(%)]	175(21.9)	23(43.4)	12.872	<0.001
开腹手术/腹腔镜手术(例)	504/295	32/21	0.155	0.693
手术类型[例(%)]
食管癌切除术	88(11.0)	2(3.8)	2.642	0.104
胃癌切除术	161(20.2)	17(32.0)	4.277	0.039
结直肠癌切除术	236(29.5)	23(43.4)	4.512	0.034
肝癌切除术	240(30.0)	10(18.9)	2.991	0.084
胰腺癌切除术	74(9.3)	1(1.9)	3.367	0.067
术中出血量[例(%)]			9.420	0.002
<500 mL	714(89.4)	40(75.5)
≥500 mL	85(10.6)	13(24.5)
输血[例(%)]	55(6.9)	6(11.3)	1.457	0.227
麻醉时间[例(%)]
<4 h	697(87.2)	36(67.9)
≥4 h	102(12.8)	17(32.1)	15.422	<0.001
ICU停留时间[例(%)]			9.166	0.002
<24 h	703(88.0)	39(73.6)
≥24 h	96(12.0)	14(26.4)
手术时间[h,M(Q1,Q3)]	4(3,8)	6(5,10)	1.235	0.006
引流时间[d,M(Q1,Q3)]	7(5,12)	10(6,15)	1.102	0.010
术前血红蛋白(g/L,±s)	109.8±12.3	102.5±9.8	4.457	0.013
术前白蛋白[例(%)]			8.230	0.004
<30 g/L	80(10.0)	12(22.6)
≥30 g/L	719(90.0)	41(77.4)

表3 器官/腔隙手术部位感染危险因素的Logistic回归分析

因素	β	Wald	P	OR	95% CI
胃癌切除术	1.235	3.955	<0.001	3.438	1.018~11.613
结直肠癌切除术	1.502	3.490	<0.001	4.491	0.929~21.711
麻醉时间≥4 h	0.831	2.634	0.037	2.296	0.842~6.262
ICU停留时间≥24 h	0.996	3.440	<0.001	2.707	0.945~7.756
术前白蛋白<30 g/L	0.859	4.203	<0.001	2.361	1.038~5.367
常数项	-0.123	5.659	0.003	-	-

表3 器官/腔隙手术部位感染危险因素的Logistic回归分析

因素	β	Wald	P	OR	95% CI
胃癌切除术	1.235	3.955	<0.001	3.438	1.018~11.613
结直肠癌切除术	1.502	3.490	<0.001	4.491	0.929~21.711
麻醉时间≥4 h	0.831	2.634	0.037	2.296	0.842~6.262
ICU停留时间≥24 h	0.996	3.440	<0.001	2.707	0.945~7.756
术前白蛋白<30 g/L	0.859	4.203	<0.001	2.361	1.038~5.367
常数项	-0.123	5.659	0.003	-	-

图1 晚期消化系统癌症手术患者器官/腔隙手术部位感染的列线图预测模型

图2 列线图预测器官/腔隙手术部位感染的ROC曲线

图3 列线图预测器官/腔隙手术部位感染的校准曲线

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Establishment of a nomogram risk predictive model for organ/space infection for patients with advanced digestive system cancer underwent surgery

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Establishment of a nomogram risk predictive model for organ/space infection for patients with advanced digestive system cancer underwent surgery