Ba MQ, Zheng WL, Zhang YL, Zhang LL, Chen JJ, Ma J, Huang JL. Construction of a nomogram prediction model for early postoperative stoma complications of colorectal cancer. World J Gastrointest Surg 2025; 17(1): 100547 [PMID: 39872787 DOI: 10.4240/wjgs.v17.i1.100547]
Corresponding Author of This Article
Jia-Li Huang, PhD, Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), No. 107 Huanhu East Road, Shushan District, Hefei 230031, Anhui Province, China. 2573114749@qq.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Ming-Qin Ba, Wen-Lin Zheng, Yu-Ling Zhang, Lin-Lin Zhang, Jing-Jing Chen, Jie Ma, Jia-Li Huang, Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), Hefei 230031, Anhui Province, China
Author contributions: Ba MQ and Zheng WL contributed equally to this manuscript. Ba MQ designed the article form, collected the data and wrote the manuscript; Zheng WL assisted in collecting the data and writing the manuscript; Zhang YL, Zhang LL, Chen JJ, and Ma J were responsible for the statistical analysis; Huang JL designed the main study and critically revised the manuscript; and all the authors read and approved the final manuscript.
Institutional review board statement: The present study was reviewed and approved by the Ethics Committee of the West Campus of the First Affiliated Hospital of China University of Science and Technology (Anhui Provincial Cancer Hospital) (Approval No. 2024-WCK-03).
Informed consent statement: Patients were not required to provide informed consent for this study, as the analysis used anonymous clinical data that were obtained after each patient agreed to treatment via written consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data are available from the corresponding author upon reasonable request.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jia-Li Huang, PhD, Department of Gastrointestinal Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (Anhui Provincial Cancer Hospital), No. 107 Huanhu East Road, Shushan District, Hefei 230031, Anhui Province, China. 2573114749@qq.com
Received: August 20, 2024 Revised: September 28, 2024 Accepted: October 25, 2024 Published online: January 27, 2025 Processing time: 129 Days and 23.5 Hours
Abstract
BACKGROUND
Postoperative enterostomy is increasing in patients with colorectal cancer, but there is a lack of a model that can predict the probability of early complications.
AIM
To explore the factors influencing early postoperative stoma complications in colorectal cancer patients and to construct a nomogram prediction model for predicting the probability of these complications.
METHODS
A retrospective study of 462 patients who underwent postoperative ostomy for colorectal cancer in the Gastrointestinal Department of the Anhui Provincial Cancer Hospital. The patients’ basic information, surgical details, pathological results, and preoperative inflammatory and nutritional indicators were reviewed. We used univariate and multivariate logistic regression to analyze the risk factors for early postoperative stoma complications in colorectal cancer patients and constructed a nomogram prediction model to predict the probability of these complications.
RESULTS
Binary logistic regression analysis revealed that diabetes [odds ratio (OR) = 3.088, 95% confidence interval (CI): 1.419-6.719], preoperative radiotherapy and chemotherapy (OR = 6.822, 95%CI: 2.171-21.433), stoma type (OR = 2.118, 95%CI: 1.151-3.898), Nutritional risk screening 2002 score (OR = 2.034, 95%CI: 1.082-3.822) and prognostic nutritional index (OR = 0.486, 95%CI: 0.254-0.927) were risk factors for early stoma complications after colorectal cancer surgery (P < 0.05). On the basis of these results, a prediction model was constructed and the area under the receiver operating characteristic curve was 0.740 (95%CI: 0.669-0.811). After internal validation, the area under the receiver operating characteristic curve of the validation group was 0.725 (95%CI: 0.631-0.820). The calibration curves for the modeling group and validation group are displayed. The predicted results have a good degree of overlap with the actual results.
CONCLUSION
A previous history of diabetes, preoperative radiotherapy and chemotherapy, stoma type, Nutritional risk screening 2002 score and prognostic nutritional index are risk factors for early stoma complications after colorectal cancer surgery. The nomogram prediction model constructed on the basis of the results of logistic regression analysis in this study can effectively predict the probability of early stomal complications after colorectal cancer surgery.
Core Tip: Despite advances in surgical techniques and products for stoma care, complications are still common, ranging from 25% to 60%. This study aimed to explore the factors influencing early postoperative complications in colorectal cancer patients and construct a nomogram to predict the probability of late postoperative complications in colorectal cancer patients. In this study, a previous history of diabetes, preoperative chemotherapy and radiotherapy, colostomy type, Nutritional risk screening 2002 and prognostic nutritional index were selected as risk factors for early colostomy complications after colorectal cancer surgery through single factor and multiple factor analysis, and a nomogram prediction model was constructed based on the results of multifactor logistics. This model has good prediction efficiency and is helpful for predicting the probability of early colostomy complications after colorectal cancer surgery.
Citation: Ba MQ, Zheng WL, Zhang YL, Zhang LL, Chen JJ, Ma J, Huang JL. Construction of a nomogram prediction model for early postoperative stoma complications of colorectal cancer. World J Gastrointest Surg 2025; 17(1): 100547
In January 2021, the International Agency for Research on Cancer of the World Health Organization released the latest global cancer burden data for 2020[1]. Reports have shown that 1.93 million new colorectal cancer cases were diagnosed worldwide in 2020, ranking third among all cancers. The primary cause of stoma formation is colorectal cancer[2]. Current statistical data show that more than 1 million colorectal cancer patients in China have a stoma, with approximately 100000 new stomas created each year. Research revealed that the number of stoma patients will continue to increase in the future[3]. According to United Kingdom colon cancer audit survey data, approximately 80% of patients with rectal cancer undergo surgery for the creation of a stoma in the abdominal wall during the treatment process, and approximately 120000 people in the United Kingdom currently have stomas[4]. Approximately 130000 patients in the United States undergo colostomy surgery for colorectal cancer each year, with an annual increase of approximately 21000 cases[5]. Denmark has approximately 10000 to 12000 stoma patients, with approximately 4000 patients undergoing stoma surgery each year[6]. The number of stoma patients worldwide is increasing daily, and stoma-related issues are receiving increasing attention from medical staff.
Despite advances in surgical techniques and products for stoma care, complications are still common, ranging from 25% to 60%. These complications affect patients’ quality of life and increase the financial cost to the health system, as shown in prospective research and audits[7-11]. Early complications were defined as those occurring in the first postoperative month. The most common complications include superficial or deep stoma necrosis, retraction, mucocutaneous separation, dermatitis, bleeding and parastomal abscess[12-15]. The aim of this study was to explore the factors influencing early postoperative complications in colorectal cancer patients and construct a nomogram prediction model to predict the probability of late postoperative complications in these patients.
MATERIALS AND METHODS
Study population
A total of 462 patients who were newly diagnosed with colorectal cancer and admitted to the Department of Gastrointestinal Oncology at Anhui Cancer Hospital between January 2021 and December 2023 for surgery were selected. After the collection of blood indices and clinical data, these patients were randomly divided at a 7:3 ratio into a training group and an internal validation group. The patient inclusion criteria were as follows: (1) Patients who underwent ostomy for colorectal cancer; (2) Patients who were confirmed to have colorectal cancer by pathological examination of their postoperative specimens; and (3) Complete medical records and follow-up related information. The exclusion criteria were as follows: (1) Patients with distant metastasis or other malignant tumors; (2) Patients whose clinical data were incomplete; and (3) Patients whose severe blood, liver, kidney or autoimmune diseases were merged.
Method
Data collection: (1) Basic clinical data, including sex, age, Nutritional risk screening 2002, history of diabetes, preoperative radiotherapy and chemotherapy; (2) Laboratory-related indicators, including preoperative albumin (g/L), hemoglobin (g/L), total platelet count (109/L), white blood cell count (109/L), absolute neutrophil count (109/L), and absolute lymphocyte count (109/L); (3) Pathology-related indicators, including tumor-node-metastasis stage and differentiation degree; (4) Diagnostic and treatment-related indicators, including tumor location and stoma type; (5) Prognostic nutritional index (PNI) = albumin (g/L) + 5 × absolute value of lymphocytes (109/L); (6) Neutrophil-lymphocyte ratio = absolute value of neutrophils (109/L)/absolute value of lymphocytes (109/L); and (6) Platelet count and lymphocyte count ratio = platelet review/lymphocyte absolute value (109/L).
Definition and evaluation methods of stomal complications: Early ostomy complications were defined as those that occurred within 30 days after miles surgery for rectal cancer. The main complications related to the stoma included stoma prolapse, hernia beside the stoma, stoma stenosis narrowing, ischemic necrosis of the stoma, and infection around the stoma.
Evaluation criteria: (1) Peristomal skin inflammation: Characterized by redness, swelling, pain, and itching of the skin due to direct contact between excrement and skin; (2) Stomal bleeding: Caused by improper surgical techniques or postoperative complications, resulting in bleeding at the stoma site; (3) Stomal stenosis: Due to postoperative scar tissue proliferation or intestinal twisting, leading to narrowing at the stoma site and affecting defecation; (4) Stomal prolapse: Caused by abdominal muscle relaxation or increased intra-abdominal pressure, resulting in part of the intestine protruding from the stoma site; (5) Stomal perforation: Due to improper surgical techniques or postoperative complications, leading to perforation of the intestine at the stoma site; and (6) Obstruction: Due to intestinal torsion, stricture, or adhesions, leading to symptoms such as abdominal distension, pain, vomiting, and constipation.
Statistical analysis
SPSS 26.0 statistical software and R4.2.1 software were used for data analysis. Count data are expressed as frequencies or percentages (%), and the χ2 test or Fisher’s exact test was used. Variables with statistically significant differences in the univariate analysis were included in the multivariate logistic regression analysis. The influencing factors selected from multivariate logistic regression analysis were entered into R software to construct a nomogram prediction model. R software was used to randomly select 30% of the patients from the modeling group as the validation cohort for internal validation. We evaluated the predictive ability of the nomogram prediction model on the basis of the area under the receiver operating characteristic curve and performed consistency testing by generating a correction curve. We used the Hosmer-Lemeshow test to determine the goodness of fit of the model, with P > 0.05 indicating good goodness of fit. All P values are bilateral, and P < 0.05 indicates a statistically significant difference.
RESULTS
This study ultimately included 462 patients (Table 1), including 326 patients in the training set and 136 patients in the validation set. Except for sex and tumor-node-metastasis stage (P < 0.05), there was no statistically significant difference in the other baseline data between the training and validation sets (P > 0.05). The results of univariate analysis revealed that a previous history of diabetes, preoperative radiotherapy and chemotherapy, stoma type, PNI, Nutritional risk screening 2002 score, platelet count and lymphocyte count ratio and neutrophil-lymphocyte ratio were related to early postoperative stoma complications in patients with colorectal cancer (P < 0.05), as shown in Table 2. Further multivariate logistic regression analysis revealed that a previous history of diabetes, preoperative chemoradiotherapy, stoma type, PNI and Nutritional risk screening 2002 score were independent factors (P < 0.05) influencing early complications of ostomy after colorectal cancer surgery, as shown in Table 3.
Table 1 Comparison of baseline data between the training set and the validation set after ostomy for colorectal cancer.
Table 2 Univariate analysis results for early complications after ostomyfor colorectal cancer.
Variable
Train early ostomy complications
Yes (n = 68)
No (n = 258)
χ2
P value
Sex
0.963
0.326
Male
44
150
Female
24
108
Diabetes
10.119
0.001
Yes
16
24
No
52
234
Age
1.198
0.274
< 65
24
110
≥ 65
41
148
BMI
1.911
0.385
< 18.5 kg/m2
7
17
18.5-23.9 kg/m2
33
146
> 23.9 kg/m2
28
95
Neoadjuvant therapy
20.888
< 0.001
Yes
11
6
No
57
252
Differentiation degree
2.576
0.276
Highly differentiated
0
3
Middle differentiation
42
179
Low differentiation
26
76
TNM staging
0.871
0.647
I
18
57
II
20
89
III
30
112
Tumor location
4.395
0.222
Right colon
5
12
Left colon
3
3
Sigmoid colon
5
15
Rectum colon
55
228
Stoma type
13.402
< 0.001
Ileostomy
35
192
Colonostomy
33
66
NRS 2002 score
7.611
0.005
< 3
42
202
≥ 3
26
56
PNI
12.915
< 0.001
≤ 49.5
27
49
> 49.5
41
209
WBC
0.574
0.449
≤ 7.5
52
208
> 7.5
16
50
NLR
13.920
< 0.001
≤ 2.4813
22
149
> 2.4813
46
109
PLR
6.515
0.011
≤ 125.425
16
104
> 125.425
52
154
Table 3 Results of the multivariate regression analysis of early complications after ostomy for colorectal cancer.
Variable
β value
SE value
Wald χ2 value
RR (95%CI)
P value
Diabetes
1.128
0.397
8.083
1.419-6.719
0.004
Neoadjuvant therapy
1.920
0.584
10.808
2.171-21.433
0.001
Stoma type
0.750
0.311
5.816
1.151-3.898
0.016
NRS 2002 score
0.710
0.322
4.861
1.082-3.822
0.027
NLR
0.546
0.330
2.739
0.904-3.294
0.098
PLR
0.479
0.357
1.800
0.802-3.250
0.180
PNI
-0.722
0.330
4.788
0.254-0.927
0.029
Constant
-4.013
1.156
12.054
-
0.001
A nomogram model was constructed on the basis of the risk factors selected through multiple logistic regression analysis to predict the probability of early postoperative complications of colorectal cancer. The results are shown in Figure 1. Using R software, 30% of the patients were randomly selected from the modeling group as the validation cohort for internal validation. The areas under the receiver operating characteristic curves for the prediction models applied to the training set and validation set were 0.740 (95% confidence interval: 0.669-0.811) and 0.725 (0.631-0.820), respectively. The results are shown in Figure 2. After 1000 bootstrap samples, the model was validated, and a calibration curve was drawn. The curve graph shows that the predicted points on the nomogram in the training set are approximately evenly distributed on both sides of the calibration line, with relatively small deviations and acceptable consistency (Figure 3A). However, in the validation set, the deviation was relatively large, and the consistency was slightly poor (Figure 3B). Decision curve analysis (DCA) was used to compare the clinical efficacy of the treatments. DCA was used to calculate the clinical validity of each model according to the risk probability threshold (X axis) and net benefit (Y axis). DCA revealed that the prognostic nomogram had good net income in both the training (Figure 4A) and verification groups (Figure 4B).
Figure 1 Line chart model for predicting early postoperative complications in patients with colorectal cancer.
PNI: Prognostic nutritional index; NRS: Nutritional risk screening.
Figure 2 Receiver operating characteristic curves of the training and validation sets for predicting early stomal complications after rectal cancer surgery.
A: Receiver operating characteristic curves of the training set for predicting early stomal complications after rectal cancer surgery; B: Receiver operating characteristic curves of the validation set for predicting early stomal complications after rectal cancer surgery. AUC: Area under the receiver operating characteristic curve.
Figure 3 Correction curves of the training and validation sets for predicting early stomal complications after rectal cancer surgery.
A: Correction curves of the training set for predicting early stomal complications after rectal cancer surgery; B: Correction curves of the validation set for predicting early stomal complications after rectal cancer surgery.
Figure 4 Decision curve analysis images of the training and validation sets of a predictive model for early postoperative stomal complications in rectal cancer patients.
A: Decision curve analysis images of the training set of a predictive model for early postoperative stomal complications in rectal cancer patients; B: Decision curve analysis images of the validation set of a predictive model for early postoperative stomal complications in rectal cancer patients.
DISCUSSION
A bowel stoma is an artificial opening made on the patient’s abdominal wall for the purpose of treatment, and a section of the intestinal tube is pulled out of the abdominal wall opening to form an artificial fecal outflow tract[16]. The basic function of an enterostomy is to replace the original anus for defecation, thereby maintaining the normal physiological function of the human digestive tract. Enterostomy surgery is not only necessary to save the patient’s life but also an important means to improve the patient’s quality of life.
The study revealed that patients who received radiotherapy or chemotherapy had a greater risk of stomal complications than did those who did not receive radiotherapy or chemotherapy. Studies have shown that chemotherapy or radiation therapy can increase excretion in patients with intestinal stomas and even lead to high stoma discharge, where the patient’s stoma excretion exceeds 2 L/24 hours for 3 consecutive days or longer[17,18]. Patients with large stoma excretions have thinner excretions and contain a large amount of digestive fluid, which significantly erodes the skin around the stoma and can easily lead to complications such as stoma edema and skin rupture. On the other hand, radiation therapy or chemotherapy can decrease a patient’s mesenteric blood supply capacity and nutritional status, leading to a decrease in the patient’s ability to resist adverse external factors and a greater likelihood of stoma retraction.
In terms of diabetes, this study revealed that among 286 patients who underwent ostomy in the model group, 40 had diabetes, and 16 had skin injury around the ostomy site; the incidence rate was 40%. This study revealed that patients with diabetes were more likely to have stomal complications. Previous studies have shown that diabetes is an independent risk factor for enterostomy complications[19]. The reason may be that the insulin secretion of diabetes patients is disrupted, which leads to insufficiencies in various systems and defense functions, a weakened ability to respond to external invasions, and a high blood sugar concentration, which fosters the reproduction of pathogenic bacteria. In addition, patients with diabetes cannot efficiently convert sugar in the body into protein or other substances. The high blood sugar levels in the body cause greater plasma osmotic pressure in the tissue fluid than in normal individuals, thus delaying the healing of damaged skin.
In this study, the incidence of stoma complications in patients who underwent colostomy was significantly greater than that in patients who underwent ileostomy (P < 0.001). Pittman et al[20] reported a correlation (P = 0.006) between the type of stoma and the incidence of skin complications around the stoma. The incidence of skin inflammation during ileostomy is greater than that during colostomy. Multiple regression analysis revealed that the type of stoma was an independent risk factor for skin complications around the stoma.
Colorectal cancer, a malignant tumor of the digestive tract, is a chronic wasting disease. Owing to the specific location of the tumor, patients often experience digestive system dysfunction. Colwell et al[21] have noted that patients with malnutrition are more prone to skin damage around the stoma. Poor nutritional status hinders postoperative recovery and increases the risk of related complications. Studies have shown that patients with malnutrition have an increased risk of skin damage around the stoma[22-24]. With the continuous deepening of research, the role of nutritional therapy in preventing stomal complications has gradually been recognized. Nutritional risk screening 2002[25] was developed by the Danish Society of Enteral and Enteral Nutrition in 2003 and has been verified in an analysis of 128 controlled clinical trials. The guidelines of the European Society for Parenteral and Enteral Nutrition have recommended them for nutritional risk screening[26]. The PNI was newly established by Japanese researchers Onodera and others as a new nutritional index to predict the development of diseases and is closely related to the prognosis of a variety of malignant cancers[27,28]. In this study, we used the Nutritional risk screening 2002 score and PNI to investigate the preoperative nutritional status of patients with colorectal cancer, and found that patients with poor nutritional status were more likely to have oral complications.
CONCLUSION
In this study, diabetes, preoperative chemotherapy and radiotherapy, ostomy type, Nutritional risk screening 2002 score and PNI were selected as risk factors for early ostomy complications after colorectal cancer surgery through single-factor and multiple-factor analyses, and a nomogram prediction model was constructed on the basis of the results of multifactor logistics. This model has good prediction efficiency and is helpful for predicting the probability of early ostomy complications after colorectal cancer surgery. The present study has several limitations. First, this was a single-center retrospective study with a relatively small sample of patients, which may affect the stability and generalizability of the model; in addition, there are no data from multiple medical centers for external validation of the model; Therefore, future research that comprehensively considers more influencing factors and establishes more comprehensive predictive models is needed to obtain more clinical data to support our findings.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C
Novelty: Grade C
Creativity or Innovation: Grade C
Scientific Significance: Grade C
P-Reviewer: Yaqub M S-Editor: Wang JJ L-Editor: A P-Editor: Xu ZH
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