内镜黏膜下剥离术后患者中重度疼痛影响因素分析及预测模型的构建-现代医学

内镜黏膜下剥离术后患者中重度疼痛影响因素分析及预测模型的构建

单位：南京大学医学院附属鼓楼医院消化科, 江苏南京 210008

分类号：R473.5

出版年·卷·期（页码）：2025·53·第十二期（1851-1858）

摘要：

目的：探讨内镜黏膜下剥离术(ESD)后患者中重度疼痛的危险因素，并构建与验证列线图预测模型。方法：回顾性纳入2022年1月至2024年10月期间在我院行ESD的消化道早癌及癌前病变患者297例，根据术后视觉模拟评分(VAS)将患者分为轻度疼痛组(n=175)和中重度疼痛组(n=122)，比较两组患者临床数据。单因素与多因素Logistic回归分析和筛选患者术后中重度疼痛的独立危险因素；R软件中“rms”包构建列线图，十折交叉验证模型的泛化能力和稳定性，并通过区分度、校准度和临床实用性评价模型的预测性能。结果：Logistic回归分析显示，临床诊断(恶性)(OR=1.888，95%CI 1.029~3.466)、术后并发症(OR=4.561，95%CI 2.522~8.248)、手术时间(≥60 min)(OR=2.170，95%CI 1.136~4.145)、创面大小(≥7 cm²)(OR=2.031，95%CI 1.035~3.986)、手术部位(十二指肠：OR=10.616，95%CI 2.684~41.987；食管：OR=5.717，95%CI 1.991~16.417；胃体：OR=4.456，95%CI 1.576~12.602；胃窦：OR=3.250，95%CI 1.040~10.158)是ESD后患者中重度疼痛的独立危险因素(P＜0.05)。十折交叉验证计算的准确率为0.715。Hosmer-Lemeshow拟合优度检验(χ²=2.938，P=0.891)表明该模型拟合良好；曲线下面积(AUC)为0.807(95%CI 0.757~0.856)，提示模型区分度良好。决策曲线分析提示，在高风险阈值4%~77%的范围内，使用本列线图进行临床决策能带来最大的净获益。结论：临床诊断(恶性)、术后并发症、手术时间(≥60 min)、创面大小(≥7 cm²)及手术部位(十二指肠、食管、胃体和胃窦)是ESD术后患者中重度疼痛的独立危险因素；基于上述危险因子构建的列线图预测模型具有良好的区分度与校准能力，可用于消化道早癌及癌前病变行ESD术后高风险患者的早期预警、识别高风险患者并指导围术期个体化镇痛管理，提升患者围术期护理质量。

Objective: To investigate risk factors for moderate to severe postoperative pain in patients undergoing endoscopic submucosal dissection(ESD) and develop a prediction model to validate it. Methods: A retrospective data analysis was conducted in 297 patients who underwent ESD for early gastrointestinal cancer or precancerous lesions from January 2022 to October 2024 at our hospital. Based on postoperative visual analog scale(VAS) scores, patients were stratified into mild pain group(n=175) and moderate to severe pain group(n=122), and then clinical data were compared between two groups. Univariate and multivariate Logistic regression was performed to identify independent risk factors for moderate to severe postoperative pain, followed by a construction of nomogram predictive model using the “rms” package in R software. Thereafter, ten-fold cross-validation was used to verify the generalization capability and stability of the algorithm, and simultaneously its predictive performance was assessed by the discrimination, calibration, and clinical application. Results: Logistic regression analysis showed that clinical malignant diagnosis(OR=1.888,95%CI 1.029-3.466), postoperative complications(OR=4.561,95%CI 2.522-8.248), procedure duration(≥60 min)(OR=2.170,95%CI 1.136-4.145), lesion size(≥7 cm²)(OR=2.031,95%CI 1.035-3.986), and surgical site(duodenal: OR=10.616, 95%CI 2.684-41.987); esophageal: OR=5.717, 95%CI 1.991-16.417; gastric body: OR=4.456, 95%CI 1.576-12.602; gastric antrum: OR=3.250, 95%CI 1.040-10.158) were independent risk factors for moderate to severe postoperative pain in patients with ESD(P<0.05). The accuracy of ten-fold cross-validation was 0.715. The Hosmer-Lemeshow goodness-of-fit test(χ²=2.938, P=0.891) and area under the curve(AUC) of 0.807(95%CI 0.757-0.856) separately suggested a good fit and a good discriminatory power of the model. Finally, the “non-compliance prediction column chart” can derive the greatest net benefit for clinical decision-making within the high-risk threshold range of 4% to 77%. Conclusion: Malignant diagnosis, complications, surgical time(≥60 min), lesion size(≥ 7 cm²), and surgical site(duodenum, esophagus, gastric body, and antrum) are independent risk factors for moderate to severe pain after ESD. Based on these risk factors, the constructed nomogram prediction model has a good discrimination and calibration ability, which can be used to evaluate early warning of high-risk patients with ESD for early gastrointestinal cancer and precancerous lesions, so as to take targeted pain management measures and improve the quality of perioperative care for patients.

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