摘要
目的探讨经内镜逆行胰胆管造影术(ERCP)后胆总管结石复发危险因素及其预测模型的应用价值。方法采用回顾性队列研究方法。收集2015年1月至2017年12月兰州大学第一医院收治的506例胆总管结石病人的临床病理资料;男251例,女255例;年龄为(59±15)岁。病人均行ERCP治疗胆总管结石。观察指标:(1)胆总管结石病人临床病理资料。(2)ERCP后胆总管结石复发危险因素分析。(3)ERCP后胆总管结石复发预测模型建立。正态分布的计量资料以x±s表示,组间比较采用t检验。计数资料以绝对数或百分比表示,组间比较采用χ^(2)检验。采用COX比例风险模型进行单因素和多因素分析。采用回归系数构建预测模型。绘制受试者工作特征曲线(ROC),以曲线下面积(AUC)进行效能评价。结果(1)胆总管结石病人临床病理资料:506例胆总管结石病人中,复发104例,无复发402例。复发与无复发胆总管结石病人年龄、高脂血症、胆总管直径、胆总管远端狭窄、胆总管结石数量、胆囊状态、胆道手术史、内镜下乳头括约肌切开术、术后引流方式比较,差异均有统计学意义(Z=-2.844,χ^(2)=6.243,Z=-2.897,χ^(2)=11.631,4.617,16.589,18.679,2.070,50.274,P<0.05)。(2)ERCP后胆总管结石复发危险因素分析:单因素分析结果显示年龄、首次病程、高脂血症、胆总管直径、胆总管远端狭窄、胆总管结石数量、胆总管结石最大径、既往有胆道手术史、术后引流方式是影响ERCP后胆总管结石复发的相关因素(风险比=1.656,2.179,1.712,1.657,2.497,1.509,1.971,2.635,3.649,95%可信区间为1.113~2.463,1.135~4.184,1.122~2.644,1.030~2.663,1.501~4.154,1.025~2.220,1.122~3.464,1.645~4.221,1.575~8.456,P<0.05);多因素分析结果显示:首次病程<30 d、高脂血症、胆总管远端狭窄、既往有胆道手术史、术后引流方式为胆胰管支架是影响ERCP后胆总管结石复发的独立危险因素(风险比=2.332,1.676,2.088,2.566,3.712,95%可信区间为1.089~4.998,1.060~2.649,1.189~3.668,1.456~4.521,1.296~10.635,P<0.05)。(3)ERCP后胆总管结石复发预测模型建立:根据多因素分析结果,将首次病程<30 d、高脂血症、胆总管远端狭窄、既往有胆道手术史、术后引流方式为胆胰管支架纳入回归系数,建立ERCP后胆总管结石复发预测模型:ln[(λ(t))/(λ0(t))]=0.847×首次病程+0.516×高脂血症+0.736×胆总管远端狭窄+0.942×胆道手术史+1.312×胆胰管支架。绘制ROC评价预测模型的效能,其AUC=0.757(95%可信区间为0.713~0.811,P<0.05),最佳预测截断值为1.41,灵敏度为69.2%,特异度为72.9%。结论首次病程时间<30 d、高脂血症、胆总管远端狭窄、既往有胆道手术史、术后引流方式为胆胰管支架是ERCP后胆总管结石复发的独立危险因素,预测模型评分>1.41的病人为ERCP后胆总管结石复发的高危人群。
Objective To investigate the risk factors for common bile duct calculi recurrence and application value of its prediction model after endoscopic retrograde cholangiopancreato-graphy(ERCP).Methods The retrospective cohort study was conducted.The clinicopatholo-gical data of 506 patients with common bile duct calculi who were admitted to the First Hospital of Lanzhou University from January 2015 to December 2017 for ERCP routine treatment were collected.There were 251 males and 255 females,aged(59±15)years.Patients received ERCP for common bile duct calculi.Observation indicators:(1)clinicopathological data of patients with common bile duct calculi;(2)risk factors for common bile duct calculi recurrence after ERCP;(3)establishment of prediction model for common bile duct calculi recurrence after ERCP.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test.Univariate and multivariate analysis were conducted using the COX proportional hazard model.The prediction model for the recurrence of common bile duct stones after ERCP was established according to the coefficient of regression equation.The receiver operating characteristic curve(ROC)was drawed for efficiency evaluation with area under curve(AUC).Results(1)Clinicopathological data of patients with common bile duct calculi:104 of 506 patients with common bile duct calculi had recurrence and 402 had no recurrence.There were significant differences in the age,hyperlipidemia,common bile duct diameter,distal bile duct stricture,the number of calculi,gallbladder status,history of biliary tract surgery,endoscopic spinecterotomy,postoperative drainage mode between patients with and without recurrence(Z=‒2.844,χ^(2)=6.243,Z=‒2.897,χ^(2)=11.631,4.617,16.589,18.679,2.070,50.274,P<0.05).(2)Risk factors for common bile duct calculi recurrence after ERCP:Results of univariate analysis showed that age,time of first attack,hyperlipidemia,common bile duct diameter,distal bile duct stricture,the number of calculi,the maximum calculi diameter,gallbladder status,history of biliary tract surgery and postoperative biliary drainage mode were related factors for common bile duct calculi recurrence after ERCP(hazard ratio=1.656,2.179,1.712,1.657,2.497,1.509,1.971,2.635,3.649,95%confidence interval as 1.113‒2.463,1.135‒4.184,1.122‒2.644,1.030‒2.663,1.501‒4.154,1.025‒2.220,1.122‒3.464,1.645‒4.221,1.575‒8.456,P<0.05).Results of multivariate analysis showed that time of first attack<30 days,hyperlipidemia,distal bile duct stricture,history of biliary tract surgery and postoperative biliary drainage mode as cholangiopancreatic stent were independent risk factors for common bile duct calculi recurrence after ERCP(hazard ratio=2.332,1.676,2.088,2.566,3.712,95%confidence interval as 1.089‒4.998,1.060‒2.649,1.189‒3.668,1.456‒4.521,1.296‒10.635,P<0.05).(3)Establishment of prediction model for common bile duct calculi recurrence after ERCP:based on multivariate analysis,indicators including time of first attack<30 days,hyperlipidemia,distal bile duct stricture,history of biliary tract surgery and postoperative biliary drainage mode as cholangiopancreatic stent were included into the coefficient of regression equation,and the prediction model for common bile duct calculi recurrence after ERCP was established:ln[(λ(t))/(λ0(t))]=0.847×time of first attack+0.516×hyperlipidemia+0.736×distal bile duct stricture+0.942×history of biliary tract surgery+1.312×cholangiopancreatic stent.The perfor-mance evaluation showed that the AUC of ROC of prediction model was 0.757(95%confidence interval as 0.713‒0.811,P<0.05),and the optimal cut-off value was 1.41,the sensitivity and specificity were 69.2%and 72.9%respectively.Conclusions The time of first attack<30 days,hyperlipidemia,distal bile duct stricture,history of biliary tract surgery and postoperative biliary drainage mode as cholangiopancreatic stent are independent risk factors for common bile duct calculi recurrence after ERCP.Patients with evaluation score>1.41 in prediction model were at high risk for common bile duct calculi recurrence after ERCP.
作者
徐雯
王正峰
王海平
苗龙
史志龙
周文策
Xu Wen;Wang Zhengfeng;Wang Haiping;Miao Long;Shi Zhilong;Zhou Wence(The First Clinical Medical Collage of Lanzhou University,Lanzhou 730000,China;Department of General Surgery,the First Hospital of Lanzhou University,Lanzhou 730000,China)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2021年第8期890-897,共8页
Chinese Journal of Digestive Surgery
基金
甘肃省卫生厅行业科研计划项目(GSWSKY2018⁃51)
兰州市人才创新创业基金资助项目(2017⁃RC⁃37)。
关键词
胆道疾病
胆石症
胆总管
内镜逆行胰胆管造影术
复发
危险因素
预测模型
Biliary tract diseases
Cholelithiasis
Common bile duct
Endoscopic retro-grade cholangiopancreatography
Recurrence
Risk factors
Prediction model
