急性结石性胆囊炎患者腹腔镜胆囊切除术失败的危险因素分析

Analysis of risk factors for failure of laparoscopic cholecystectomy in patients with acute calculous cholecystitis

目的探讨导致急性结石性胆囊炎患者腹腔镜胆囊切除术(LC)失败的影响因素,并建立预测模型。方法选择行LC的急性结石性胆囊炎患者367例,根据术中是否转为开腹手术将其分为成功组和失败组,采用Logistic回归模型分析LC失败的独立危险因素,根据独立危险因素建立列线图模型并对模型进行验证。结果367例患者中有52例(14.17%)手术失败。体温≥38℃、胆囊壁厚度≥5 mm、腹肌紧张、胆囊管结石嵌顿、胆囊肿大、发作至手术时间≥72 h及白蛋白水平降低是患者LC失败的独立危险因素(P<0.05)。基于以上独立危险因素构建列线图模型,其一致性指数(C-index)为0.756(95%CI0.684~0.830),ROC曲线的AUC为0.758(95%CI0.701~0.815),模型具有较好的区分度;校准曲线及临床决策曲线评价结果提示模型准确度及有效性均较好。结论体温≥38℃、胆囊壁厚度≥5 mm、腹肌紧张、胆囊管结石嵌顿、胆囊肿大、发作至手术时间≥72 h及白蛋白水平降低是急性结石性胆囊炎患者LC失败的独立危险因素,临床应重点筛查。本研究所建立的列线图预测模型对手术风险评估具有一定价值。

Objective To investigate the influencing factors leading to the failure of laparoscopic cholecystectomy(LC)in patients with acute calculous cholecystitis,and to establish a prediction model.Methods A total of 367 patients with acute calculous cholecystitis who underwent LC were selected and divided into the successful group and the failed group according to whether the patients were converted to laparotomy.Logistic regression model was used to analyze the independent risk factors of the failure of LC and the nomogram model was established according to the independent risk factors and validated.Results There were 52(14.17%)failed of 367 patients with acute calculous cholecystitis.Body temperature≥38℃,gallbladder wall thickness≥5 mm,abdominal muscle tension,incarceration of cystic duct stones,gallbladder enlargement,time from attack to operation≥72 hours and decreased albumin level were the independent risk factors for the failure of LC(P<0.05).The nomogram model was established based on the above independent risk factors,the consistency index(C-index)was 0.756(95%CI:0.684 to 0.830),and the AUC of the ROC curve was 0.758(95%CI:0.701 to 0.815),with good discrimination;the evaluation results of the calibration curve and clinical decision curve showed that the accuracy and effectiveness of the model were both good.Conclusion Body temperature≥38℃,gallbladder wall thickness≥5 mm,abdominal muscle tension,incarceration of cystic duct stones,gallbladder enlargement,time from attack to operation≥72 hours and decreased albumin level are the independent risk factors for the failure of LC in patients with acute calculous cholecystitis,and clinical screening should be focused.The established nomogram prediction model has certain value for surgical risk evaluation.