降钙素原对肠瘘患者确定性手术后腹腔感染的预测价值

Predictive value of procalcitonin in postoperative intra-abdominal infections after definitiveoperation of intestinal fistulae

目的探讨降钙素原（PCT）对肠瘘患者行确定性手术后出现腹腔感染的预测价值。方法前瞻性纳入2012年2月至2015年12月期间南京军区南京总医院肠瘘治疗中心连续收治的行肠瘘确定性手术的患者，排除急诊手术、术前有临床感染、术前有慢性肾功能或肝功能不全以及年龄〈18岁的患者，共356例肠瘘患者纳入研究。根据术后有无腹腔感染将患者分为腹腔感染组（26例，其中21例为吻合口瘘，5例为腹腔脓肿）和非腹腔感染组（330例）；再根据是否存在其他感染，将非腹腔感染组分为其他感染组（93例）和无感染组（237例）两个亚组。采用免疫荧光法测定降钙素原水平，血液自动分析仪测定白细胞计数，比浊法测定CRP浓度。比较3组间术前及术后1、3、5、7 d血液中降钙素原水平、C反应蛋白（CRP）浓度和白细胞计数；并绘制以上3种指标预测术后腹腔感染的ROC曲线。 结果腹腔感染组和非腹腔感染组患者一般临床资料的比较，差异无统计学意义（均P 〉 0.05）；但腹腔感染组多发肠瘘比例（53.8%，14/26）和手术切除结直肠的比例（61.5%，16/26）高于非腹腔感染组[20.0%（66/330），χ2= 15.847，P= 0.000；31.2%（103/330），χ2 = 9.961，P= 0.002]。腹腔感染、其他感染和无感染3组术前降钙素原、CRP及白细胞计数间的差异均无统计学意义。这3种指标术后均明显升高，降钙素原和白细胞计数在术后第1天达到峰值，CRP在术后第3天达到峰值。腹腔感染组患者的术后第1、3、5天降钙素原分别为（5.4 ± 4.2）μg/L、（2.9 ± 1.9）μg/L、（1.6 ± 1.8）μg/L，明显高于其他感染组和无感染组[（4.2 ± 8.7）μg/L、（1.9 ± 3.8）μg/L、（0.6 ± 0.8）μg/L以及（2.7 ± 5.8）μg/L、（1.1 ± 1.7）μg/L、（0.5 ± 0.7）μg/L；均P 〈 0.05]；腹腔感染组患者术后第1、3天的CRP均值分别是99.4 mg/L和183.9 mg/L，术后第1、3、5天的白细胞计数均值分别是16.0 × 109/L、10.8 × 109/L及8.7 × 109/L，均明显高于另外两组（均P 〈 0.05）。其他感染组和无感染组的这3种检验指标间的差异均无统计学意义（均P 〉 0.05）。ROC曲线显示，术后第3天和术后第5天降钙素原最佳截值点分别为0.98 μg/L和0.83 μg/L时，曲线下面积（AUC）最大，分别为0.86和0.84，灵敏度和特异度分别为92.0%、74.0%和91.0%、73.0%。CRP和白细胞计数的AUC最大值分别为0.72和0.71，均出现在术后第3天。结论肠瘘患者确定性手术后第3天降钙素原〉 0.98 μg/L和术后第5天〉0.83 μg/L，可以预测腹腔感染的发生。

ObjectiveTo investigate the predictive value of procalcitonin （PCT） in postoperative intra-abdominal infections （IAI） after definitive operation of intestinal fistulae （IF） .MethodsWith the exclusion of emergence operation, preoperative clinical infection, preoperative renal or hepatic dysfunction, and age less than 18 years, a total of 356 consecutive patients who underwent elective digestive tract reconstruction of intestinal fistulae from February 2012 to December 2015 at Intestinal Fistula Center of Jinling Hospital were prospectively enrolled in the study. All the patients were divided into IAI group （26 cases, 21 of anastomosis leakage and 5 of peritoneal abscess） and non-IAI group （330 cases） based on the existence of postoperative IAI. The non-IAI group was then divided into two subgroups of other infection （93 cases） and non-infection （237 cases） according to the presence of other infections. Plasma PCT level, serum CRP concentration and WBC count were assessed preoperatively and on postoperative days （PODs） 1, 3, 5, 7 by immunofluorescence, turbidimetry and automatic blood analyzer, respectively. The predictive value of each marker for IAI was calculated by receiver operating characteristic （ROC） curve.ResultsThere was no significant difference in general clinical data between IAI and non-IAI group （all P 〉 0.05） . The proportions of multi-IF （53.8%, 14/26） and colectomy （61.5%, 16/26） in IAI group were higher than those of non-IAI group[20.0% （66/330） , χ2=15.847, P= 0.000 and 31.2% （103/330） , χ2=9.961, P= 0.002]. Differences of preoperative PCT, CRP and WBC levels among IAI, other infection and non-infection groups were not significant. These three markers all increased obviously and immediately after surgery. PCT and WBC values reached the peak point on POD 1, whereas CRP on POD 3. In IAI group, mean PCT values were （5.4 ± 4.2） μg/L, （2.9 ± 1.9） μg/L and （1.6 ± 1.8） μg/L on POD 1, POD 3 and POD 5, respectively, which were higher than those of other infection group[ （4.2 ± 8.7） μg/L, （1.9 ± 3.8） μg/L and （0.6 ± 0.8） μg/L]and non-infection group[ （2.7± 5.8） μg/L, （1.1± 1.7） μg/L and （0.5 ± 0.7） μg/L, all P 〈 0.05]. Mean CRP values in IAI group were 99.4 mg/L and 183.9 mg/L respectively on POD 1 and POD 3, and mean WBC values of IAI group on POD 1, POD 3 and POD 5 were 16.0 × 109/L, 10.8 × 109/L and 8.7 × 109/L, respectively, which were all significantly higher than those in the other 2 groups （all P 〈 0.05） . No significant differences were obtained between other infection group and non-infection group in all these three markers （all P 〉 0.05） . ROC curve demonstrated that PCT had the biggest area under the curve （AUC） of 0.86 and 0.84 on POD 3 and POD 5, with the cut-off value of 0.98 μg/L and 0.83 μg/L, 92.0% sensitivity and 74.0% specificity, 91.0% sensitivity and 73.0% specificity, respectively. The highest AUC was 0.72 on POD 3 for CRP and 0.71 on POD 3 for WBC, with 80.0% sensitivity and 54.0% specificity, 56.0% sensitivity and 73.0% specificity, respectively.ConclusionThe value of procalcitonin above 0.98 μg/L on POD 3 and 0.83 μg/L on POD 5 can predict the occurrence of IAI after definitive operations of intestinal fistulae.