腹腔镜胆总管探查术患者术中碎石需求及其早期预测模型的构建

胡淑珍; 冯霞; 张乐逸

doi:10.16766/j.cnki.issn.1674-4152.004291

腹腔镜胆总管探查术患者术中碎石需求及其早期预测模型的构建

doi: 10.16766/j.cnki.issn.1674-4152.004291

1.
淳安县第一人民医院(浙江省人民医院淳安分院)肝胆外科，浙江杭州 311700
2.
浙江省人民医院肝胆胰外科，浙江杭州 310000

基金项目:

浙江省医药卫生科技计划项目 2022ZH008

详细信息

作者简介:
胡淑珍，E-mail：540844921@qq.com

中图分类号: R657.42
计量
- 文章访问数: 7
- HTML全文浏览量: 3
- PDF下载量: 0
- 被引次数: 0
出版历程
- 收稿日期: 2024-11-29
- 网络出版日期: 2026-03-13

Intraoperative lithotripsy demand and its early predictive factors in patients undergoing laparoscopic common bile duct exploration

1.
Department of Hepatobiliary Surgery, Chun' an First People' s Hospital (Chun' an Branch of Zhejiang Provincial People' s Hospital), Hangzhou, Zhejiang 311700, China

摘要

摘要: 目的探讨腹腔镜胆总管探查术(LCBDE)患者的术中碎石需求，并分析相关早期预测因素，以构建LCBDE术中碎石需求预测模型。方法纳入2022年3月—2024年3月浙江省人民医院淳安分院收治的152例LCBDE患者，根据术中腹腔镜下碎石辅助与否分为需求组(33例)和非需求组(119例)。比较2组患者一般资料、临床资料，采用多因素logistic回归分析研究LCBDE患者术中碎石需求的影响因素。结果需求组年龄、胆总管结石直径＜1.1 cm占比均低于非需求组，发热、黄疸、恶心呕吐及胰腺周围渗出占比均高于非需求组(P＜0.05)。多因素logistic回归分析显示，年龄(OR=0.824)、发热(OR=10.112)、黄疸(OR=8.071)、恶心呕吐(OR=5.823)、胆总管结石直径(OR=9.148)均为LCBDE患者术中碎石需求的独立影响因素(P＜0.05)。基于五项指标构建的联合预测模型预测LCBDE患者术中碎石需求的AUC为0.914(95% CI：0.858~0.953)，模型预测LCBDE患者术中碎石需求的发生风险与实际风险一致性良好。结论 LCBDE用于胆总管结石治疗时，仍有部分患者术中需要碎石辅助；年龄、发热、黄疸、恶心呕吐和胆总管结石直径是术中碎石需求的独立影响因素，基于五项指标构建的联合预测模型可作为预测LCBDE患者术中碎石需求的临床工具。
- 腹腔镜 /
- 胆总管 /
- 探查术 /
- 碎石 /
- 影响因素 /
- 校准曲线
Abstract: Objective To explore the lithotripsy demand of patients undergoing laparoscopic common bile duct exploration (LCBDE), and analyze the related early prediction factors, so as to build a prediction model of the lithotripsy demand during LCBDE. Methods One hundred and fifty-two patients with percutaneous LCBDE admitted to Chun' an Branch of Zhejiang Provincial People' s Hospital from March 2022 to March 2024 were divided into demand group (n=33) and non-demand group (n=119) according to the assistance of laparoscopic lithotripsy during operation. The general data and clinical data of patients in the two groups were compared, and the influencing factors of lithotripsy demand in patients with percutaneous LCBDE were analyzed by multivariate logistic regression. Results The ratio of age/common bile duct stone diameter < 1.1 cm in demand group was lower than that in non-demand group, and the ratio of fever, jaundice, nausea and vomiting and peripancreatic exudation was higher than that in non-demand group (P < 0.05). Multivariate logistic regression analysis showed that age (OR=0.824), fever (OR=10.112), jaundice (OR=8.071), nausea and vomiting (OR=5.823) and common bile duct stone diameter (OR=9.148) were the independent risk factors of lithotripsy demand in patients undergoing percutaneous LCBDE (P < 0.05). The ROC curve showed that the AUC of the combined model based on these five indicators was 0.914 (95% CI: 0.858-0.953), and the combined models predicted the risk of lithotripsy demand in patients with percutaneous LCBDE in good agreement with the actual risk. Conclusion There are still some patients who need lithotripsy during the treatment of choledocholithiasis by percutaneous LCBDE. Age, fever, jaundice, nausea and vomiting and the diameter of common bile duct stones are independent risk factors, and the combined prediction model based on these five indicators can be used as a clinical tool to predict the demand for lithotripsy in patients with percutaneous LCBDE.
- Laparoscopy /
- Common bile duct /
- Exploration /
- Gravel /
- Influencing factors /
- Calibration curve

HTML全文

图 1 各指标预测经囊LCBDE患者术中碎石需求的ROC曲线

Figure 1. ROC curve of each indicator for predicting intraoperative lithotripsy demand of patients with percutaneous LCBDE

下载: 全尺寸图片幻灯片

图 2 LCBDE患者术中碎石需求预测模型的校准曲线

Figure 2. Calibration curve of prediction model of lithotripsy demand in lcbde patients during operation

下载: 全尺寸图片幻灯片

表 1 2组LCBDE患者临床资料比较

Table 1. Comparison of case data between the two groups of patients with LCBDE

项目	需求组(n=33)	非需求组(n=119)	统计量	P值
性别[例(%)]			0.240^a	0.625
男性	16(48.48)	52(43.70)
女性	17(51.52)	67(56.30)
年龄(x±s, 岁)	47.36±5.02	52.07±6.14	4.531^b	＜0.001
ASA分级[例(%)]			1.195^a	0.274
Ⅰ级	21(63.64)	63(52.94)
Ⅱ~Ⅲ级	12(36.36)	56(47.06)
腹部手术史[例(%)]	9(27.27)	25(21.01)	0.584^a	0.445
ERCP[例(%)]	2(5.06)	4(3.36)	0.496^a	0.481
临床表现[例(%)]
发热	20(60.61)	38(31.93)	10.934^a	＜0.001
黄疸	21(63.64)	33(27.73)	14.541^a	＜0.001
腹痛	20(60.61)	52(43.70)	2.963^a	0.085
恶心呕吐	26(78.79)	55(46.22)	11.010^a	＜0.001
基础疾病[例(%)]
肝脏疾病	1(3.03)	5(4.20)	0.093^a	0.760
糖尿病	4(12.12)	12(10.08)	0.114^a	0.736
高血压	10(30.30)	23(19.33)	1.831^a	0.176
冠心病	2(6.06)	16(13.45)	1.667^a	0.197
胆总管结石直径[例(%)]			10.624^a	0.001
＜1.1 cm	8(24.24)	67(56.30)
≥1.1 cm	25(75.76)	52(43.70)
胆囊周围渗出[例(%)]			3.053^a	0.081
是	5(15.15)	7(5.88)
否	28(84.85)	112(91.12)
胰腺周围渗出[例(%)]			4.532^a	0.033
是	8(24.24)	12(10.08)
否	25(75.76)	107(89.92)
胆总管直径(x±s, cm)	1.40±0.14	1.45±0.16	1.798^b	0.084
淀粉酶[M(P₂₅, P₇₅), U/L]	47(39, 68)	62(45, 89)	1.942^c	0.057
ALP[M(P₂₅, P₇₅), U/L]	178(131, 247)	157(88, 224)	1.779^c	0.078
ALT[M(P₂₅, P₇₅), U/L]	146(89, 307)	102(41, 235)	1.123^c	0.142
注：^a为χ²值，^b为t值，^c为U值。

下载: 导出CSV

表 2 变量赋值情况

Table 2. Variable assignment

变量	赋值方法
术中是否辅助腹腔镜下碎石	是=1，否=0
年龄	以实际值赋值
发热	是=1，否=0
黄疸	是=1，否=0
恶心呕吐	是=1，否=0
胆总管结石直径	以实际值赋值
胰腺周围渗出	是=1，否=0

下载: 导出CSV

表 3 LCBDE患者术中碎石需求的多因素logistic回归分析

Table 3. Multivariate logistic regression analysis of intraoperative lithotripsy demand of LCBDE patients

变量	B	SE	Wald	P值	OR值	95% CI
年龄	-0.194	0.060	10.404	0.001	0.824	0.732~0.927
发热	2.314	0.621	13.880	0.003	10.112	3.000~34.153
黄疸	2.088	0.576	13.151	＜0.001	8.071	2.611~24.950
恶心呕吐	1.762	0.613	8.263	0.004	5.823	1.752~19.357
胆总管结石直径	2.214	0.657	11.337	0.001	9.148	2.522~33.183
胰腺周围渗出	1.003	0.705	2.028	0.154	2.727	0.685~10.851

下载: 导出CSV

表 4 各指标对LCBDE患者术中碎石需求的预测价值分析

Table 4. Analysis of the predictive value of each indicator for the intraoperative stone fragmentation requirements of LCBDE patients

项目	AUC	95% CI	灵敏度 (%)	特异度 (%)	Youden 指数
年龄	0.723	0.644~0.792	66.67	73.11	0.398
发热	0.674	0.593~0.747	66.67	68.07	0.347
黄疸	0.725	0.647~0.794	72.73	72.27	0.450
恶心呕吐	0.663	0.582~0.737	78.79	53.78	0.326
胆总管结石直径	0.660	0.579~0.735	75.76	56.30	0.321
年龄+黄疸	0.812	0.741~0.871	93.94	53.78	0.477
联合预测模型	0.914	0.858~0.953	87.88	80.67	0.686

下载: 导出CSV

参考文献(21)

[1]	ZDANOWICZ K, DANILUK J, LEBENSZTEJN D M, et al. The etiology of cholelithiasis in children and adolescents: a literature review[J]. Int J Mol Sci, 2022, 23(21): 13376. DOI: 10.3390/ijms232113376.
[2]	李建军, 朱培欣, 陈锦州, 等. 以ALATS球囊行经皮经肝十二指肠乳头肌扩张顺行排石术治疗胆总管结石[J]. 中国介入影像与治疗学, 2023, 20(4): 202-206. LI J J, ZHU P X, CHEN J Z, et al. Treatment of choledocholithiasis with ALATS balloon percutaneous transhepatic papillary muscle dilation[J]. Chinese Journal of Interventional Imaging and Therapy, 2023, 20(4): 202-206.
[3]	樊怡茹, 孙淑珍, 王红建. 经内镜乳头括约肌小切开联合球囊扩张术治疗老年胆总管结石患者的疗效与安全性分析[J]. 中国现代医学杂志, 2021, 31(6): 91-96. FAN Y R, SUN S Z, WANG H J. Efficacy and safety analysis of endoscopic sphincterotomy combined with balloon dilatation in the treatment of elderly patients with common bile duct stones[J]. China Journal of Modern Medicine, 2021, 31(6): 91-96.
[4]	CIANCI P, RESTINI E. Management of cholelithiasis with choledocholithiasis: endoscopic and surgical approaches[J]. World J Gastroenterol, 2021, 27(28): 4536-4554. doi: 10.3748/wjg.v27.i28.4536
[5]	王玉虎, 徐萌, 韩双喜, 等. 腹腔镜联合胆道镜经胆囊管汇入部微切开并一期缝合在胆总管探查取石术中的应用效果[J]. 临床医学研究与实践, 2021, 6(16): 61-63. WANG Y H, XU M, HAN S X, et al. The application effect of laparoscopy combined with choledochoscopy through the inlet of cystic duct and primary suture in common bile duct exploration and lithotomy[J]. Clinical Research and Practice, 2021, 6(16): 61-63.
[6]	SUWATTHANARAK T, AKARAVIPUTH T, PHALANUSITTHEPHA C, et al. Outcomes of laparoscopic common bile duct exploration by chopstick technique in choledocholithiasis[J]. JSLS, 2021, 25(2): e2021.00008. DOI: 10.4293/JSLS.2021.00008.
[7]	马金玉, 吕超, 肖晶晶, 等. 胆总管微创手术取石后两种引流方式发生胆漏的危险因素及其预测模型建立[J]. 贵州医科大学学报, 2023, 48(1): 70-76. MA J Y, LYU C, XIAO J J, et al. Risk factors of bile leakage after minimally invasive choledocholithotomy by two drainage methods and its establishment of prediction model[J]. Journal of Guizhou Medical University, 2023, 48(1): 70-76.
[8]	DAS S, JHA A K, KUMAR M. Laparoscopic common bile duct exploration in cases of common bile duct stones: can LCBDE replace ERCP as first line treatment[J]. Am J Surg, 2023, 226(2): 290. DOI: 10.1016/j.amjsurg.2023.03.006.
[9]	杨小勇, 张斌, 李文美, 等. 微爆破碎石在腹腔镜胆总管探查术治疗胆总管远端结石嵌顿中的应用效果[J]. 临床医学研究与实践, 2021, 6(1): 65-66, 72. YANG X Y, ZHANG B, LI W M, et al. Effect of micro-blasting lithotripsy in laparoscopic common bile duct exploration for incarcerated distal common bile duct stones[J]. Clinical Research and Practice, 2021, 6(1): 65-66, 72.
[10]	NARULA V K, FUNG E C, OVERBY D W, et al. Clinical spotlight review for the management of choledocholithiasis[J]. Surg Endosc, 2020, 34(4): 1482-1491. doi: 10.1007/s00464-020-07462-2
[11]	唐敏, 邵亚平, 杨蕾. 医护一体化模式在老年胆石症腹腔镜术后并发症预防中的应用[J]. 护理实践与研究, 2021, 18(12): 1856-1858. TANG M, SHAO Y P, YANG L. The application of integrated medical care model in the prevention of complications after laparoscopic cholecystectomy in the elderly[J]. Nursing Practice and Research, 2021, 18(12): 1856-1858.
[12]	程尚美, 骆艳玲, 霍蕊. 快速康复外科护理技术在行ERCP的老年患者中的应用效果[J]. 中华全科医学, 2022, 20(3): 531-534. doi: 10.16766/j.cnki.issn.1674-4152.002394 CHENG S M, LUO Y L, HUO R. Application effect of rapid rehabilitation surgical nursing technology in elderly patients undergoing ERCP[J]. Chinese Journal of General Practice, 2022, 20(3): 531-534. doi: 10.16766/j.cnki.issn.1674-4152.002394
[13]	周华波, 李广阔, 何伊嘉, 等. 三入路理论体系指导下的胆系结石病微创治疗研究进展[J]. 中国普通外科杂志, 2021, 30(2): 228-235. ZHOU H B, LI G K, HE Y J, et al. Research progress of minimally invasive treatment of cholelithiasis under the guidance of three-approach theory system[J]. Chinese Journal of General Surgery, 2021, 30(2): 228-235.
[14]	NAVARATNE L, MARTINEZ ISLA A. Transductal versus transcystic laparoscopic common bile duct exploration: an institutional review of over four hundred cases[J]. Surg Endosc, 2021, 35(1): 437-448. doi: 10.1007/s00464-020-07522-7
[15]	NAVARATNE L, MARTíNEZ CECILIA D, MARTíNEZ ISLA A. The ABCdE score for predicting lithotripsy assistance during transcystic bile duct exploration by laparoendoscopy (PRE-LABEL)[J]. Surg Endosc, 2021, 35(11): 5971-5979. doi: 10.1007/s00464-020-08082-6
[16]	MENG M, FENG H, TANG S, et al. Efficacy of ultrasound-guided percutaneous transhepatic biliary drainage for acute obstructive suppurative cholangitis combined with septic shock[J]. Clinics(Sao Paulo), 2023, 78(1): 100258. DOI: 10.1016/j.clinsp.2023.100258.
[17]	王海方, 王旭阳, 兰涛. 腹腔镜联合胆道镜治疗胆囊及胆总管结石中转开腹列线图模型的建立[J]. 国际外科学杂志, 2021, 48(1): 9-15, F4. WANG H F, WANG X Y, LAN T. Establishment of laparotomy nomogram model in the treatment of gallbladder and common bile duct stones by laparoscopy combined with choledochoscope[J]. International Journal of Surgery, 2021, 48(1): 9-15, F4.
[18]	ZHENG Y, LV H, LIN Z, et al. A nomogram to predict conversion of laparoscopic surgery to laparotomy for choledocholithiasis[J]. BMC Surg, 2023, 23(1): 372. DOI: 10.1186/s12893-023-02275-1.
[19]	MA Z, ZHOU J, YAO L, et al. Safety and efficacy of laparoscopic common bile duct exploration for the patients with difficult biliary stones: 8 years of experiences at a single institution and literature review[J]. Surg Endosc, 2022, 36(1): 718-727. doi: 10.1007/s00464-021-08340-1
[20]	黄毅, 宁春玉, 黎结初, 等. 弥漫性大B细胞淋巴瘤预后预测模型的效能与外部验证[J]. 实用临床医药杂志, 2023, 27(17): 29-34, 39. HUANG Y, NING C Y, LI J C, et al. Efficacy and external validation of prognosis prediction model for diffuse large B-cell lymphoma[J]. Journal of Clinical Medicine in Practice, 2023, 27(17): 29-34, 39.
[21]	TUNRUTTANAKUL S, VERASMITH K, PATUMANOND J, et al. Development of a predictive model for common bile duct stones in patients with clinical suspicion of choledocholithiasis: a cohort study[J]. Gastroenterology Res, 2022, 15(5): 240-252. doi: 10.14740/gr1560