Risk prediction nomogram model establishing and clinical DCA analysis based on the risk factors of anastomotic fistula after esophageal cancer surgery

doi:10.3877/cma.j.issn.2095-2015.2025.03.008

Abstract

Abstract:

Objective

To explore the risk factors of postoperative anastomotic fistula of esophageal cancer, establish a risk prediction nomogram model based on the risk factors, and evaluate the prediction efficiency and clinical application value of this model through clinical decision curve analysis(DCA).

Methods

A total of 342 patients undergoing esophageal cancer surgery in Nantong Cancer Hospital from January 2020 to September 2024 were retrospectively selected and divided into occurrence group (n=36) and non-occurrence group (n=306) according to whether postoperative anastomotic fistula was complicated.The differences in baseline data, perioperative relevant indicators and serological factors between the two groups were compared.Lasso and multivariate Logistic regression were used to screen the risk factors of postoperative anastomotic fistula for esophageal cancer, the risk prediction nomogram model was constructed, and the prediction accuracy was verified by receiver operating characteristic (ROC) curve.Bootstrap method and DCA decision curve were used for internal verification to verify the stability and benefits of the nomogram model.

Results

There were statistically significant differences in diabetes mellitus, smoking history, anastomosis mode, low density lipoprotein cholesterol (LDL-C) and albumin between the occurrence group and the non-occurrence group (all P<0.05).Lasso regression showed that diabetes mellitus, anastomotic mode and albumin could be included in the risk prediction model of anastomotic fistula after esophageal cancer surgery.Binary Logistic regression showed that diabetes mellitus, manual anastomosis and low albumin level were independent risk factors for anastomotic fistula after esophageal cancer surgery (all P<0.001).ROC results showed that the area under the curve predicted by diabetes, anastomotic mode, albumin and nomogram models was 0.713, 0.726, 0.787 and 0.904,respectively.The sensitivity was 0.583, 0.583, 0.735 and 0.889, respectively.The specificity was 0.843, 0.869,0.750 and 0.788, respectively.Internal verification was performed by Bootstrap method (B=1000), and C-indexwas 0.807, indicating that the early warning model of anastomotic fistula after esophageal cancer surgery had good stability.Decision analysis showed that the model can bring net benefits, which was obviously better than the ineffective strategy.

Conclusion

Diabetes mellitus, manual anastomosis and low albumin are independent risk factors for anastomotic fistula after esophageal cancer surgery.The established risk prediction model is effective, stable and has net benefit, which is better than the control without strategy.

Key words: Esophageal cancer, Anastomotic fistula, Influencing factors, Receiver operating characteristic curve, Nomogram, Predictive effectiveness

Qiuyan Wang, Aimin Yang, Chun Cheng, Yang Zhou. Risk prediction nomogram model establishing and clinical DCA analysis based on the risk factors of anastomotic fistula after esophageal cancer surgery[J]. Chinese Journal of Digestion and Medical Imageology(Electronic Edition), 2025, 15(03): 229-234.

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Figures/Tables 11

组别	例数	性别[例(%)]		年龄(岁, $\overset{ˉ}{x}$ ± s )	体重指数(kg/m², $\overset{ˉ}{x}$ ± s )	合并糖尿病[例(%)]		吸烟史[例(%)]		饮酒史[例(%)]
组别	例数	男	女	年龄(岁, $\overset{ˉ}{x}$ ± s )	体重指数(kg/m², $\overset{ˉ}{x}$ ± s )	有	无	有	无	有	无
发生组	36	22(61.11)	14(38.89)	62.33±8.97	24.10±3.07	21(58.33)	15(41.67)	25(69.44)	11(30.56)	10(27.78)	26(72.22)
非发生组	306	189(61.76)	117(38.24)	61.52±8.76	23.79±2.94	48(15.69)	258(84.31)	148(48.37)	158(51.63)	82(26.80)	224(73.20)
χ ²/t值		0.006		0.528	0.594	36.376		5.725		0.016
P值		0.939		0.598	0.553	＜0.001		0.017		0.900
组别	例数	肿瘤位置[例(%)]			病理分型[例(%)]		手术方式[例(%)]		吻合方式[例(%)]		手术时间(min, $\overset{ˉ}{x}$ ± s )	术中出血量(mL, $\overset{ˉ}{x}$ ± s )
组别	例数	胸上段	胸中段	胸下段	鳞癌	腺癌	开胸	胸腔镜	手工	机器	手术时间(min, $\overset{ˉ}{x}$ ± s )	术中出血量(mL, $\overset{ˉ}{x}$ ± s )
发生组	36	7(19.44)	15(41.67)	14(38.89)	29(80.56)	7(19.44)	13(36.11)	23(63.89)	21(58.33)	15(41.67)	240.78±40.34	322.08±77.37
非发生组	306	58(18.95)	126(41.18)	122(39.87)	252(82.35)	54(17.65)	104(33.99)	202(66.01)	40(13.07)	266(86.93)	241.11±37.96	319.62±75.71
χ ²/t值			0.014		0.071		0.065		45.027		-0.050	0.184
P值			0.993		0.790		0.799		＜0.001		0.960	0.854
组别	例数	收缩压(mmHg, $\overset{ˉ}{x}$ ± s )	舒张压(mmHg, $\overset{ˉ}{x}$ ± s )	总胆固醇(mmol/L, $\overset{ˉ}{x}$ ± s )	LDL-C(mmol/L, $\overset{ˉ}{x}$ ± s )	血红蛋白(g/L, $\overset{ˉ}{x}$ ± s )	白蛋白(g/L, $\overset{ˉ}{x}$ ± s )	白细胞计数(10⁹/L, $\overset{ˉ}{x}$ ± s )
发生组	36	130.39±14.00	78.47±9.46	4.94±1.05	2.87±0.88	126.77±16.37	35.23±4.60	8.55±2.49
非发生组	306	129.63±14.60	79.15±9.09	4.88±1.06	3.31±0.80	127.41±15.16	40.15±3.85	8.64±2.32
t值		0.296	-0.421	0.294	-3.051	-0.239	-7.097	-0.225
P值		0.767	0.674	0.769	0.002	0.811	＜0.001	0.822

组别	例数	性别[例(%)]		年龄(岁, $\overset{ˉ}{x}$ ± s )	体重指数(kg/m², $\overset{ˉ}{x}$ ± s )	合并糖尿病[例(%)]		吸烟史[例(%)]		饮酒史[例(%)]
组别	例数	男	女	年龄(岁, $\overset{ˉ}{x}$ ± s )	体重指数(kg/m², $\overset{ˉ}{x}$ ± s )	有	无	有	无	有	无
发生组	36	22(61.11)	14(38.89)	62.33±8.97	24.10±3.07	21(58.33)	15(41.67)	25(69.44)	11(30.56)	10(27.78)	26(72.22)
非发生组	306	189(61.76)	117(38.24)	61.52±8.76	23.79±2.94	48(15.69)	258(84.31)	148(48.37)	158(51.63)	82(26.80)	224(73.20)
χ ²/t值		0.006		0.528	0.594	36.376		5.725		0.016
P值		0.939		0.598	0.553	＜0.001		0.017		0.900
组别	例数	肿瘤位置[例(%)]			病理分型[例(%)]		手术方式[例(%)]		吻合方式[例(%)]		手术时间(min, $\overset{ˉ}{x}$ ± s )	术中出血量(mL, $\overset{ˉ}{x}$ ± s )
组别	例数	胸上段	胸中段	胸下段	鳞癌	腺癌	开胸	胸腔镜	手工	机器	手术时间(min, $\overset{ˉ}{x}$ ± s )	术中出血量(mL, $\overset{ˉ}{x}$ ± s )
发生组	36	7(19.44)	15(41.67)	14(38.89)	29(80.56)	7(19.44)	13(36.11)	23(63.89)	21(58.33)	15(41.67)	240.78±40.34	322.08±77.37
非发生组	306	58(18.95)	126(41.18)	122(39.87)	252(82.35)	54(17.65)	104(33.99)	202(66.01)	40(13.07)	266(86.93)	241.11±37.96	319.62±75.71
χ ²/t值			0.014		0.071		0.065		45.027		-0.050	0.184
P值			0.993		0.790		0.799		＜0.001		0.960	0.854
组别	例数	收缩压(mmHg, $\overset{ˉ}{x}$ ± s )	舒张压(mmHg, $\overset{ˉ}{x}$ ± s )	总胆固醇(mmol/L, $\overset{ˉ}{x}$ ± s )	LDL-C(mmol/L, $\overset{ˉ}{x}$ ± s )	血红蛋白(g/L, $\overset{ˉ}{x}$ ± s )	白蛋白(g/L, $\overset{ˉ}{x}$ ± s )	白细胞计数(10⁹/L, $\overset{ˉ}{x}$ ± s )
发生组	36	130.39±14.00	78.47±9.46	4.94±1.05	2.87±0.88	126.77±16.37	35.23±4.60	8.55±2.49
非发生组	306	129.63±14.60	79.15±9.09	4.88±1.06	3.31±0.80	127.41±15.16	40.15±3.85	8.64±2.32
t值		0.296	-0.421	0.294	-3.051	-0.239	-7.097	-0.225
P值		0.767	0.674	0.769	0.002	0.811	＜0.001	0.822

变量	赋值
糖尿病	1=有，0=无
吸烟史	1=有，0=无
吻合方式	1=手工，0=机器
低密度脂蛋白胆固醇	计量资料，以实际值纳入
白蛋白	计量资料，以实际值纳入

变量	B	S.E.	Wald	P	OR	95% CI
变量	B	S.E.	Wald	P	OR	下限	上限
糖尿病	2.031	0.501	16.422	＜0.001	7.625	2.854	20.366
吸烟史	0.630	0.506	1.550	0.213	1.878	0.696	5.063
吻合方式	2.251	0.482	21.811	＜0.001	9.500	3.693	24.436
低密度脂蛋白胆固醇	-0.299	0.291	1.058	0.304	0.742	0.420	1.311
白蛋白	-0.324	0.064	25.380	＜0.001	0.723	0.638	0.820

因子	数值	对应Nomogrm 分数
合并糖尿病	0/1	0/26
吻合方式	0/1	0/27
白蛋白	26/28/30/32/34/36/38/40/42/44/46/48/50/50	100/92/85/77/69/62/54/46/38/31/23/15/8/0
列线图模型	72/81/88/93/98/103/108/115/124	0.1/0.2/0.3/0.4/0.5/0.6/0.7/0.8/0.9

检验结果变量	曲线下面积	标准误	P	渐近95% CI		Cut-off 值	约登指数	灵敏度(%)	特异度(%)
检验结果变量	曲线下面积	标准误	P	下限	上限	Cut-off 值	约登指数	灵敏度(%)	特异度(%)
合并糖尿病	0.713	0.051	＜0.001	0.614	0.813	0.5	0.426	0.583	0.843
吻合方式	0.726	0.051	＜0.001	0.627	0.826	0.5	0.452	0.583	0.869
白蛋白	0.787	0.044	＜0.001	0.701	0.872	38.05	0.485	0.735	0.750
列线图模型	0.904	0.029	＜0.001	0.846	0.961	0.076	0.677	0.889	0.788

References 26

[1]	胡银燕, 赵林芳, 贺晓映, 等.1 例食管癌术后并发重度免疫检查点抑制剂相关肺炎及吻合口瘘患者的护理[J].中华护理杂志,2024, 59(14): 1752-1756.
[2]	Hagens E, Feenstra M, Lam WC, et al.C-Reactive Protein as a Negative Predictive Marker for Anastomotic Leakage After Minimally Invasive Esophageal Surgery[J].World J Surg, 2023,47(8): 1995-2002.
[3]	魏政道, 周建丰, 杨玉赏, 等.新辅助治疗后食管癌术后肺部并发症和吻合口瘘的预后意义[J].免疫学杂志, 2024, 40(3): 295-302.
[4]	陈海南, 冷雪峰.食管癌术后吻合口瘘预测因子及相关预测模型的研究进展[J].临床外科杂志, 2024, 32(8): 892-895.
[5]	Anas D, Elkharbotly IAMH, Mohammad Y, et al.Novel Mediastinoscope-Assisted Minimally Invasive Esophagectomy for Esophageal Cancer: A Systematic Review and Meta-analysis[J].Ann Surg Oncol, 2023, 30(7): 4030-4039.
[6]	白成云, 李忠诚, 李文军, 等.食管癌切除术后发生吻合口瘘风险的列线图建立和验证[J/OL].肿瘤代谢与营养电子杂志, 2023,10(3): 401-407.
[7]	Ren LF, Xu YH, Long JG.Prognostic Value of Postoperative Complication for Gastric Cancer[J].J Lap Adv Surg Tech, 2024,34(4): 339-353.
[8]	周芝森, 王成, 冯泽伟, 等.外周血炎性指标与食管癌吻合口瘘发生的相关性[J].兰州大学学报(医学版), 2023, 49(10): 40-45, 51.
[9]	Tiainen E, Wirta EV, Tyrväinen T, et al.Calcifications in the descending thoracic aorta predict postoperative anastomotic leakages after esophagectomy for cancer[J].World J Surg, 2024, 48(5):1209-1218.
[10]	靳凤梅, 李转梅.食管癌术后颈部食管胃吻合口瘘的相关影响因素分析[J].实用癌症杂志, 2023, 38(1): 133-135.
[11]	金新天, 王强, 王俊荣, 等.重建贲门、胃底、His 角预防食管癌术后胸内吻合口瘘的应用效果[J].中国老年学杂志, 2022, 42(15):3657-3659.
[12]	Mankarious MM, Portolese AC, Meloria A, et al.Neoadjuvant chemotherapy does not increase risk for anastomotic leak for simultaneous resection of primary colon cancer with synchronous liver metastasis: A NSQIP-colectomy analysis[J].J Surg Oncol,2023, 128(1): 58-65.
[13]	翁艳, 王青, 刘晓川, 等.内镜下钛夹联合氩等离子体凝固治疗食管癌术后吻合口瘘患者的临床效果[J].广西医学, 2023, 45(6):639-641, 665.
[14]	张帅, 葛晓晴, 张进, 等.术后早期血脂代谢水平、C 反应蛋白与白蛋白比值对食管癌术后吻合口瘘的预测效果分析[J].中国综合临床, 2022, 38(3): 199-204.
[15]	Hirano Y, Konishi T, Kaneko H, et al.Author response to: Comment on: Early postoperative non-steroidal anti-inflammatory drugs and anastomotic leakage after oesophagectomy[J].Br J Surg, 2023,110(9): 1243.
[16]	彭胜祖, 王彬, 张凯, 等.经鼻内引流治疗食管癌术后吻合口瘘伴胸腔或纵隔脓肿效果观察[J].肿瘤研究与临床, 2024, 36(11):843-846.
[17]	Zhao J, Zhao Y, Yang S, et al.Thoracoscopic repair for esophageal pulmonary fistula after esophageal atresia repair[J].Pediatr Surg,2022, 57(11): 538-542.
[18]	蒋朋朋, 王兴邦, 霍前伦.全腔镜食管癌根治McKeown 术式发生吻合口瘘的危险因素分析[J].蚌埠医学院学报, 2022, 47(9): 1229-1232.
[19]	王海, 杨更朴, 柴立勋, 等.胸腹腔镜联合食管癌切除术对食管癌患者肺功能、免疫功能的影响及颈部吻合口瘘的影响因素探讨[J].现代生物医学进展, 2022, 22(14): 2668-2672.
[20]	Li S, Qiu R, Yuan G, et al.Body composition in relation to postoperative anastomotic leakage and overall survival in patients with esophageal cancer[J].Nutrition, 2022, 94: 111534.
[21]	阚奇伟, 高元平, 刘泗军, 等.食管癌术后吻合口瘘与无创正压通气之间的关系探讨[J].实用老年医学, 2023, 37(4): 426-428.
[22]	Gao Z, Chen X, Bai D, et al.A Novel Intraoperative Leak Test Procedure (GAM Procedure) to Prevent Postoperative Anastomotic Leakage in Gastric Cancer Patients Who Underwent Gastrectomy[J].Surg Lap Endosc Percut Tech, 2023, 33(3): 224-230.
[23]	高从荣, 范军, 裴韶华, 等.食管癌患者术前营养风险评估及与术后吻合口瘘和住院时间的关系研究[J].现代生物医学进展,2022, 22(16): 3132-3136.
[24]	聂洪鑫, 王兵, 杨思豪, 等.食管癌术后食管胃吻合口瘘危险因素的系统评价与Meta分析[J].中国胸心血管外科临床杂志, 2022,29(2): 166-178.
[25]	Maria NO, Giulio C, Brigida B, et al.Rates of Endoscopic Recurrence In Postoperative Crohn's Disease Based on Anastomotic Techniques: A Systematic Review And Meta-Analysis[J].Inflamm Bowel Dis, 2023, 30(10): 1877-1887.
[26]	林红兰, 任艳军, 杨文超, 等.早期肠内营养对食管癌根治术后患者预后影响的研究[J].中华保健医学杂志, 2023, 25(6): 688-690.

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