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Background <p>Moderate-to-severe acute postoperative pain (APOP) after hepatectomy for hepatocellular carcinoma (HCC) may impede early postoperative recovery. However, predictive tools integrating preoperative and intraoperative risk factors are lacking. This study aimed to develop and internally validate a perioperative nomogram for predicting APOP in this population.</p> Methods <p>Adult patients who underwent elective hepatectomy for primary HCC between January 2021 and January 2025 were retrospectively enrolled and randomly divided into a training cohort (<i>n</i> = 301) and a holdout internal validation cohort (<i>n</i> = 129). Moderate-to-severe APOP was defined as a maximum prerescue NRS score ≥ 4 during repeated pain assessments within 72&#xa0;h after surgery. Candidate predictors included demographic, tumor-related, laboratory, psychological, and intraoperative variables. Multiple imputation was used to address missing data, and LASSO followed by multivariable logistic regression was used to select predictors and construct the perioperative nomogram. Model performance was assessed using the area under the curve (AUC), calibration curves, and decision curve analysis (DCA).</p> Results <p>Moderate–severe APOP occurred in 42.1% of patients. Seven predictors were included: younger age, an actual open surgical approach, a larger maximal tumor diameter, a higher neutrophil-to-lymphocyte ratio, greater intraoperative opioid consumption, and higher preoperative Hospital Anxiety and Depression Scale and Pain Catastrophizing Scale scores. The nomogram showed good discrimination in the training cohort (AUC = 0.818; 95% CI: 0.771–0.865) and the holdout internal validation cohort (AUC = 0.795; 95% CI: 0.720–0.870), with satisfactory calibration and positive net clinical benefit in terms of DCA.</p> Conclusion <p>A perioperative nomogram integrating preoperative and intraoperative variables was developed and internally validated. Because the complete predictor set becomes available only at the end of surgery, the model is intended to support immediate postoperative risk stratification and individualized analgesic and psychological interventions after hepatectomy for patients with HCC.</p>

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Development and internal validation of a perioperative nomogram for predicting moderate-to-severe acute postoperative pain after hepatectomy for hepatocellular carcinoma

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  • 发表日期：

    2026年8月3日

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  • Juan Wang,
  • Chunmei Fan,
  • Wanqiu Zhang,
  • Yan Zhang,
  • Ting Li

摘要

Background

Moderate-to-severe acute postoperative pain (APOP) after hepatectomy for hepatocellular carcinoma (HCC) may impede early postoperative recovery. However, predictive tools integrating preoperative and intraoperative risk factors are lacking. This study aimed to develop and internally validate a perioperative nomogram for predicting APOP in this population.

Methods

Adult patients who underwent elective hepatectomy for primary HCC between January 2021 and January 2025 were retrospectively enrolled and randomly divided into a training cohort (n = 301) and a holdout internal validation cohort (n = 129). Moderate-to-severe APOP was defined as a maximum prerescue NRS score ≥ 4 during repeated pain assessments within 72 h after surgery. Candidate predictors included demographic, tumor-related, laboratory, psychological, and intraoperative variables. Multiple imputation was used to address missing data, and LASSO followed by multivariable logistic regression was used to select predictors and construct the perioperative nomogram. Model performance was assessed using the area under the curve (AUC), calibration curves, and decision curve analysis (DCA).

Results

Moderate–severe APOP occurred in 42.1% of patients. Seven predictors were included: younger age, an actual open surgical approach, a larger maximal tumor diameter, a higher neutrophil-to-lymphocyte ratio, greater intraoperative opioid consumption, and higher preoperative Hospital Anxiety and Depression Scale and Pain Catastrophizing Scale scores. The nomogram showed good discrimination in the training cohort (AUC = 0.818; 95% CI: 0.771–0.865) and the holdout internal validation cohort (AUC = 0.795; 95% CI: 0.720–0.870), with satisfactory calibration and positive net clinical benefit in terms of DCA.

Conclusion

A perioperative nomogram integrating preoperative and intraoperative variables was developed and internally validated. Because the complete predictor set becomes available only at the end of surgery, the model is intended to support immediate postoperative risk stratification and individualized analgesic and psychological interventions after hepatectomy for patients with HCC.