术前超声预测腹腔镜胆囊切除术手术难度的分析

Analysis of preoperative ultrasound in predicting difficulty of laparoscopic cholecystectomy

目的:根据术前超声资料建立预测腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)手术难度的评分表,并评价其科学性。方法:连续选择1 078例接受LC的患者,随机分为两组,训练样本960例,验证样本118例。采用自身前后对照试验方案,术前应用超声检测胆囊大小、胆囊壁厚度、胆囊颈结石嵌顿情况、胆囊结石数量与最大长径,以及脐孔、胆囊颈、胆囊底有无粘连;观察手术时间、术中出血量、中转开腹、引流管放置情况、并发症及术后住院时间、切口疼痛、胃肠道反应、肛门排气等指标。根据960例训练样本LC的实际难度分为容易与困难两组,应用t检验、χ2检验筛选有统计学意义的超声检测指标,建立术前超声预测LC手术难度的评分表。进行受试者工作特征曲线(receiver operating characteristic curve,ROC)分析。结果:胆囊大小、胆囊壁厚度、单枚胆囊结石最大径、胆囊颈结石嵌顿、胆囊颈粘连、胆囊底粘连6项检测指标在LC容易与困难两组间差异有统计学意义(P<0.05)。应用6项指标建立术前超声预测LC难度评分表。经ROC分析,曲线下面积为0.948,与完全随机情况下获得的曲线下面积(0.5)相比,差异有统计学意义(P<0.05)。经118例检验样本前瞻性误判概率评估,结果显示术前超声预测LC难度误判率约4.2%。结论:术前超声预测LC手术难度的评分表可正确预测手术难度,对手术适应证的选择具有重要意义。

Objective：To establish and evaluate a scoring system that predicts the difficulty of laparoscopic cholecystectomy（LC） based on preoperative ultrasonic data.Methods：With self-controlled trial,1 078 consecutive patients undergoing LC were divided into two groups：960 in training group,118 in testing group.Preoperative ultrasonic examination parameters including the size of gallbladder,thickness of gallbladder wall,incarcerated stone in neck of gallbladder,the number and the max diameter of stone,and the adhesions in umbilicus,Calot triangle or fundus of gallbladder were collected,postoperative variables including operating time,blood loss,conversion to open cholecystectomy,placement of drainage-tubes,postoperative complications,length of hospital stay,incision pain,gastrointestinal reaction and anal exhaust were also collected.According to the virtual difficulty of 960 training samples,they were divided into easy group and difficult group,Chi-square test and t-test were applied to choose statistically significant ultrasonic preoperative variables which formed a scoring system for ultrasonic predicting difficulty of LC.Receiver operating characteristic curve（ROC） was then applied to analyze the scoring system.Results：The variables of preoperative ultrasonic parameters with statistically significant effect were the size of gallbladder,thickness of gallbladder wall,max diameter of single stone,incarcerated stone in neck of gallbladder and the adhesions in Calot triangle and fundus of gallbladder.A scoring system for predicting the difficulty level of LC in patients was then established.The ROC curve analysis revealed that area under the curve was 0.948,which was statistically higher than that from randomizing scheme（0.5）（P＆lt;0.05）.The appraisal of prospective misjudge possibility was applied to the scoring system for ultrasound predicting difficulty of LC in 118 testing samples,the misjudge rate was about 4.2%.Conclusions：The scoring system for preoperative ultrasound is a good predictor of difficulty in patients undergoing LC,and has an important significance for selection of laparoscopic operation.