【作者】 王楠；

【导师】 赵淑华；

【作者基本信息】 吉林大学 ， 临床医学硕士（妇产科学）（专业学位）， 2021， 硕士

【摘要】 目的:探讨妇科恶性肿瘤患者术后并发VTE的危险因素,评估Caprini风险评估模型、Rogers风险评估模型和G-Caprini风险评估模型在预测妇科恶性肿瘤患者术后发生VTE的能力,同时探索三种风险评估模型的最佳分层策略。方法:本研究为回顾性病例对照研究,纳入2016年1月至2020年12月在吉林大学第二医院妇科住院行手术治疗术后并发VTE的患者71例,其中妇科恶性肿瘤患者有41例,同时按照相同年龄、相同诊断1:2比例随机选取142例作为对照组,采用自行设计的妇科手术患者信息采集表收集213例患者的临床资料。应用三种风险评估模型对每个患者进行风险评分和风险分级,采取单因素和多因素Logistic回归分析确定妇科患者术后并发VTE的危险因素和妇科恶性肿瘤术后并发VTE的危险因素。采取受试者工作特征曲线分析,计算灵敏度、特异度、确定最佳截断值,并绘制ROC曲线,通过比较ROC曲线下面积判断三种风险评估模型对妇科恶性肿瘤术后并发VTE的预测价值。结果:1.单因素分析发现,静脉曲张、严重肺病、卧床>72h、中央静脉通路、术前HCT≤38%、ASA分级为III～V、手术时间≥3h、术后卧床时间≥48h以及开腹手术与妇科手术患者术后VTE的发生具有相关性;多因素分析发现,静脉曲张、术前HCT≤38%、ASA分级为III～V、手术时间≥3h以及术后卧床≥48h是妇科手术患者术后发生VTE的独立危险因素。2.单因素分析发现,术后住院>7天、FIGO分期为III/IV期、静脉曲张、卧床>72h、术后卧床时间≥48h与妇科恶性肿瘤患者术后VTE的发生具有相关性;多因素分析发现,术后住院>7天、静脉曲张和术后卧床时间≥48h是妇科恶性肿瘤患者术后发生VTE的独立危险因素。3.根据Caprini模型,全部妇科恶性肿瘤患者均被评为极高危(≥5分),其余组均无分布。根据Rogers模型,62.6%的妇科恶性肿瘤患者被评为中危,46例被评为高危,低危组没有人员分布,高危组中VTE患者占比高于中危组(43.5%vs.27.3%),VTE发生率在两组间的差异无统计学意义。根据G-Caprini模型,妇科恶性肿瘤手术患者在四个风险分级均有分布,低危2例、中危12例、高危38例和极高危71例,没有出现某一风险分级的缺失,可以看出G-Caprini风险评估模型分级能力较好。趋势卡方检验结果显示,G-Caprini模型VTE发生率在不同风险分级组的差异具有统计学意义,并且随着评分等级升高,VTE发生率呈现逐渐升高趋势。4.妇科恶性肿瘤VTE组的Caprini评分和G-Caprini评分高于对照组,两组间差异有统计学意义(P<0.001),而Rogers评分在两组之间并未显示出统计学差异。以Caprini评分9分、Rogers评分10分以及G-Caprini评分4分作为截断值筛选妇科恶性肿瘤患者术后VTE的能力最强。三种风险评估模型的风险分层预测妇科恶性肿瘤术后并发VTE的AUC分别为:0.610、0.598、0.687。Rogers风险评估模型和G-Caprini风险评估模型与Caprini风险评估模型之间的一致程度均较弱。结论:1.术后住院>7天,静脉曲张和术后卧床≥48h是妇科恶性肿瘤患者术后发生VTE的独立危险因素。2.通过对三种风险评估模型的比较分析后发现,Caprini风险评估模型和Rogers风险评估模型对妇科恶性肿瘤术后VTE预测能力较差,G-Caprini风险评估模型在预测妇科恶性肿瘤患者术后VTE的能力最强。3.推荐使用G-Caprini风险分层对妇科恶性肿瘤手术患者进行静脉血栓风险的划分。更多还原

【Abstract】 Objective:The study aims to investigate the risk factors related to postoperative venous thromboembolism in patients with gynecological cancer,evaluate the ability of Caprini risk assessment model,Rogers risk assessment model and G-Caprini risk assessment model to predict the occurrence of postoperative venous thromboembolism in gynecologic oncology patients,and explore the best stratification strategies of three risk assessment models.Methods:We undertook a retrospective case-control study We included 71 patients with gynecological disease who were confirmed VTE and hospitalized for surgery in the Second Hospital of Jilin University from Januanry 2016 to Decemeber 2020,41 patients suffered from gynecological malignant tumor.With the same age and the same diagnosis,142 cases were randomly selected as the control group at a ratio of 1:2.A self-designed gynecological malignant tumor information collection form was used to collect clinical data of 213 patients.Three risk assessment models were used to calculate the risk scores and risk classifications of each patient.Univariate and multivariate Logistic regression analysis were used to determine the risk factors of postoperative VTE in patients undergoing gynecological surgery and the risk factors of postoperative VTE in gynecologic oncology patients.Receiver operating characteristic curve analysis were used to calculate sensitivity,specificity,determine the best cutoff value.The predictive value of the three models was determined by drawing the ROC curve and comparing the area under the curve for postoperative VTE in gynecologic oncology patients.Results:1.Univariate analysis results showed that varicose veins,serious lung disease,including pneumonia(<1 month),patients confined to bed(>72 hours),central venous access,preoperative hematocrit ≤38%,ASA physical status class III～V,operation time(≥3hours),postoperative bed rest time(≥48hours)and open surgery were significantly related to postoperative VTE(P<0.05).Multivariate analysis results showed that varicose veins,ASA physical status class III～V,operation time(≥3hours)and post-operation bed rest time(≥48hours)were independent risk factors of postoperative VTE in patients with gynecological surgeries.2.Univariate analysis results showed that postoperative hospital stay >7days,FIGO stage III/IV,varicose veins,patients confined to bed(>72 hours)and postoperative bed rest time(≥48hours)were significantly related to postoperative VTE in patients with gynecological malignant tumors(P<0.05).Multivariate analysis results showed that postoperative hospital stay >7days,varicose veins,and post-operation bed rest time(≥48hours)were independent risk factors of postoperative VTE in gynecologic oncology patients.3.All gynecologic oncology patients were classified by the Caprini risk assessment as the highest risk(score≥5),and there were no patients in other risk groups.According to the,62.6% of the patients with gynecologic oncology were classified by the Rogers risk assessment model as medium risk(score7～10),46 cases were high risk(score>10),and there were no patients in the low-risk group.The proportion of VTE patients in the high risk group is higher than that in the medium risk group(43.5% vs.27.3%).There was no statistically significant difference in the incidence of VTE between the two groups.The gynecologic oncology patients were distributed in four risk groups.,2patients were classified by the G-Caprini risk assessment model as low risk(score=0),12 patients were moderate risk(score=1),38 patients were higher risk(score=2)and 71 patients were highest risk(score≥3).The results showed that the G-Caprini risk assessment model had good grading ability.Trend chi-square test results showed that the incidence of VTE in the G-Caprini model was statistically significant in different risk groups.And as the score level increasing,the incidence of VTE showed a gradually increasing trend.4.The Caprini scores and G-Caprini scores of the VTE group in gynecologic oncology patients were higher than the control group,and the difference of the scores between the two groups was statistically significant(P<0.001).The Rogers scores did not show statistical differences between the two groups.Taking Caprini score of 9,Rogers score of 10,and G-Caprini score of 4 as cut-off values,the ability to screen postoperative VTE of gynecologic oncology patients was the strongest.The risk stratification of the three risk assessment models predicts the AUC of postoperative VTE for gynecologic oncology patients were respectively 0.610,0.598,0.687.Rogers risk assessment model,G-Caprini risk assessment model and Caprini risk assessment model were in weak agreement.Conclusion:1.Independent risk factors for post-operative VTE in gynecologic oncology patients included post-operative hospital stay >7days,varicose veins,and postoperative bed rest time(≥48hours).2.After comparing and analyzing the results of three risk assessment models,we found that G-Caprini risk assessment model had the strongest ability to predict the risk of postoperative VTE in gynecologic oncology patients,and the ability of Caprini risk assessment model and Rogers risk assessment model were worse.3.It is recommended that gynecologic oncology patients were risk stratified by means of G-Caprini risk assessment model.更多还原