术前ALT/AST联合多期CT影像学指标对胰十二指肠切除术后临床相关胰瘘的预测价值

Value of preoperative alanine aminotransferase/aspartate aminotransferase combined with multi-phase CT radiological indicators in predicting clinically relevant pancreatic fistula after pancreaticoduodenectomy

目的探讨胰十二指肠切除术后发生临床相关胰瘘(CR-POPF)的危险因素,并建立预测模型,对CR-POPF患者进行早期预测。方法选取北部战区总医院2019年1月—2023年10月244例行胰十二指肠切除术的患者,经过严格的纳入排除标准筛选后最终纳入179例患者,根据是否发生CR-POPF分为非CR-POPF组(n=120)和CR-POPF组(n=59)。采用单因素和多因素Logistic回归分析确定CR-POPF相关的独立危险因素,并构建列线图。采用受试者工作特征曲线评价预测效果,校准曲线评价模型校准度,用临床决策曲线和临床影响曲线分析验证模型的临床应用价值。计数资料组间比较采用χ^(2)检验或Fisher精确概率法;计量资料符合正态分布的2组间比较采用成组t检验,偏态分布的2组间比较采用Mann-Whitney U检验。结果179例患者中59例发生CR-POPF,发生率为33.0%。经过多因素Logistic分析确定术后CR-POPF的独立危险因素:较大的ALT/AST(OR=2.221,P=0.004)、主胰管直径≤3 mm(OR=0.276,P=0.022)、较大的腹膜胰颈前距离(OR=1.034,P=0.027)、较小的细胞外体积分数(OR=0.001,P=0.005)。根据上述4个独立危险因素构建预测胰十二指肠术后CR-POPF的列线图,该模型的受试者工作特征曲线下面积为0.837,敏感度为0.932,特异度为0.725。决策曲线和影响曲线的结果也显示该列线图具有良好的临床实用性。结论术前临床指标联合多期CT共同预测胰十二指肠切除术后CRPOPF的模型效能良好,可以在术前对胰瘘高危患者进行早期识别,进一步指导临床工作。

Objective To investigate the risk factors for clinically relevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD),and to establish a predictive model for early identification of CR-POPF.Methods A total of 244 patients who underwent PD in General Hospital of Northern Theater Command from January 2019 to October 2023 were collected,and based on strict inclusion and exclusion criteria,179 patients were finally enrolled in this study.According to the presence or absence of CR-POPF,these patients were divided into non-CR-POPF group with 120 patients and CR-POPF group with 59 patients.Univariate and multivariate logistic regression analyses were used to determine the independent risk factors for CR-POPF,and a nomogram model was established based on such factors.The receiver operating characteristic(ROC)curve was used to assess the predictive performance of the model,the calibration curve was used to evaluate the calibration degree of the model,and the clinical decision curve and the clinical impact curve were used to analyze and validate the clinical application value of the model.The chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups;the independent-samples t test was used for comparison of normally distributed continuous data between two groups,and the Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups.Results Among the 179 patients,59(33.0%)developed CR-POPF.The multivariate Logistic regression analysis showed that alanine aminotransferase/aspartate aminotransferase(odds ratio[OR]=2.221,P=0.004),main pancreatic duct diameter(OR=0.276,P=0.022),the distance between the peritoneum and the anterior pancreatic neck(OR=1.034,P=0.027),and extracellular volume fraction(OR=0.001,P=0.005)were independent risk factors for CR-POPF.Based on the above four independent risk factors,a nomogram was established to predict CR-POPF after PD,with an area under the ROC curve of 0.837,a sensitivity of 0.932,and a specificity of 0.725.The decision curve and the clinical impact curve also showed that the nomogram had good clinical practicability.Conclusion Preoperative clinical indicators combined with multi-phase CT have a good performance in predicting CR-POPF after PD,which can be used to early identify patients at high risk of pancreatic fistula before surgery and provide further guidance for clinical work.