困难胆囊切除术对患者术中和术后并发症的影响及其风险预测模型的建立

The influence of difficult cholecystectomy on intraoperative and postoperative complications and the establishment of risk prediction model

目的分析困难胆囊切除术(DC)对患者术中、术后并发症的影响,探讨DC的风险因素,并构建其预测模型。方法回顾性分析我院2018年1月1日—2019年11月10日共201例胆囊切除患者的临床资料。以胆囊切除手术操作时长的第75百分位数(P75)作为分割点划分DC组(≥P75)和常规腹腔镜胆囊切除术(NLC)组(<P75)。采用Logistic回归分析DC的影响因素,并构建其风险模型进行预测。结果201例中DC组为53例,腹腔镜下完成50例,中转开腹3例;NLC组为148例,均经腹腔镜完成。DC组与NLC组相比,术中出血量、术后24 h呕吐频次增加,中转开腹率、术后引流管置放率升高,术后首次排气时间以及住院时间延长(P<0.05)。多因素Logistic回归显示,体质量指数(BMI)>25 kg/m^2、白细胞计数(WBC)>10×109/L、胆囊颈部结石嵌顿、近2个月胆囊炎发作>4次、胆囊壁厚度>0.5 cm以及结石最大直径>2 cm为DC的独立危险因素,回归方程的拟合度良好(χ^2=1.457,P>0.05),预测效能为0.879。结论困难胆囊切除术会增加患者术中、术后并发症的风险,构建困难胆囊切除术的风险预测模型,其拟合度和预测效能均较好,具有一定的临床指导价值。

Objective To analyze the influence of difficult cholecystectomy(DC)on intraoperative and postoperative complications and to explore risk factors of DC,so as to establish a risk prediction model of DC.Methods Data of 201 patients who underwent cholecystectomy from January 1,2018 to November 10,2019 were analyzed retrospectively.The highest quartile(P75)of cholecystectomy operation time was used as a cutting point of DC(≥P75)and NLC(<P75).Logistic regression was used to analyze the influencing factors of DC,and its risk model was constructed for prediction.Results A total of 201 patients were included,53 were in DC group(including 3 cases of conversion to laparotomy)and 148 were in NLC group(all by laparoscope).The intraoperative blood loss,the frequency of vomiting at the first 24-hour after operation,the rates of conversion to abdominal surgery and drainage tube placement were higher in DC group than those of NLC group(P<0.01).The time of the first anal exhaust and length of hospital stay were longer in DC group than those of NLC group(P<0.05).The multivariate Logistic regression analysis showed that body mass index(BMI)>25 kg/m^2,white blood cell(WBC)count>10×109/L,calculus incarcerated in neck of gallbladder,the relapse of acute cholecystitis in the last 2 months>4 times,thickness of gallbladder wall>0.5 cm and maximum diameter of stone>2 cm were independent risk factors for DC.The prediction efficiency of the Logistic regression equation was 0.879(χ^2=1.457,P>0.05).Conclusion The difficult cholecystectomy can increase the risk of intraoperative and postoperative complications.The establishment of a risk prediction model has a certain clinical guiding value for difficult cholecystectomy.