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腹腔镜左肝切除治疗肝胆管结石手术效果评估与预测分析

Surgical outcome evaluation and prediction analysis of laparoscopic left sided hepatectomy for hepatolithiasis

摘要:

目的 探讨腹腔镜左肝切除治疗肝胆管结石远期效果的预后因素并构建预测模型.方法 回顾性收集2011年6月至2016年6月在南昌大学第二附属医院肝胆外科接受腹腔镜左肝切除治疗且随访资料完整的108例肝胆管结石患者的临床资料,其中男性26例,女性82例,年龄(52.4±11.7)岁(范围:20~80)岁,中位随访时间36个月(范围:24~83个月).将患者按3∶1随机分为训练组(79例)和验证组(29例).选取术前和术中25个临床指标作为可能影响远期效果的因素,并以生存质量作为远期效果的间接评价指标.应用单因素分析、多因素Logistic回归分析探讨潜在的预后因素,并以此进行手术效果预测列线图的构建及验证.结果 在108例患者中,结石残留10例(9.3%),结石复发8例(7.4%),反复胆管炎12例(11.1%),死亡3例(2.8%).单因素分析结果显示,既往有肝胆手术史、性别、活化部分凝血活酶时间、碱性磷酸酶、是否使用胆道镜、术后结石残留、血清肌酐、是否术后胆道引流、手术时间是影响远期效果的预后因素(P值均<0.15).多因素分析结果显示,既往肝胆手术史(OR=2.305,95%CI:0.383~4.227,P=0.019)、术后胆道引流(OR=2.043,95% CI:0.182~4.209,P=0.048)、手术时间≥262.5 min(OR=1.971,95%CI:0.154~4.023,P=0.045)是影响远期效果的独立预后因素.以上述因素为基础构建列线图预测模型,内外验证显示该预测模型具有较好的区分度(受试者工作特征曲线的曲线下面积>0.7)及校准度(Hosmer-Lemeshow检验:P>0.05),提示其预测效果良好.结论 既往肝胆手术史、术后胆道引流、手术时间≥262.5min是影响远期疗效的独立预后因素,基于手术效果相关预后因素的预测列线图模型具有良好的临床预测效果,有助于预测腹腔镜左肝切除治疗肝胆管结石的远期效果.

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abstracts:

Objective To explore the risk factors of long-term treatment outcomes and establish predicting model for laparoscopic left hepatectomy in hepatolithiasis.Methods Clinical data of 108 patients with hepatolithiasis who underwent laparoscopic left sided hepatectomy and with complete follow-up data were retrospectively collected from June 2011 to June 2016 at the Second Affiliated Hospital of Nanchang University.Twenty-six males and 82 females were enrolled.The age was (52.4 ± 11.7)years (range:20-80 years),and the median follow-up time was 36 months(range:24-83 months).Patients were randomly divided into training group(79 cases) and validation group(29 cases) with a ratio of about 3 ∶ 1.Twenty-five preoperative and intraoperative clinical factors were selected for potential factors that might affect long-term outcomes,and quality of life was used as an surrogate evaluation index.Univariate analysis and multivariate logistic regression analysis were used to investigate the potential risk factors,and to construct and validate the predictive nomogram for surgical outcomes.Results Among 108 patients,10 patients(9.3%) had residual stones,8 patients(7.4%) had recurrent stones,12 patients(11.1%) had recurrent cholangitis and 3 patients(2.8%) died.Univariate analysis showed that history of hepatobiliary surgery,gender,activation of partial thromboplastin time,alkaline phosphatase,use of choledochoscopy,postoperative stone residual,serum creatinine,postoperative biliary drainage and operation time were risk factors that may affect long-term outcomes(all P<0.15).Multivariate analysis showed that the history of previous hepatobiliary surgery(OR=2.305,95% CI:0.383-4.227,P=0.019),postoperative biliary drainage(OR=2.043,95% CI:0.182-4.209,P=0.048),operation time ≥262.5 minutes(OR=1.971,95% CI:0.154-4.023,P=0.045) were independent risk factor affecting long-term outcomes.Based on the above factors,the predictive nomogram model was constructed.Internal and external validations showed good discrimination(area under the curve of receiver operating curve>0.7) and calibration(Hosmer-Lemeshow test:P>0.05) performance,which indicated that the prediction effect was favorable.Conclusions History of previous hepatobiliary surgery,postoperative biliary drainage and operation time ≥262.5 minutes are independent risk factors for long-term outcome.The predictive nomogram model based on risk factors relates to surgical outcomes presented good clinical predictive effects,which might contribute to the prediction of the long-term outcomes of laparoscopic left sided hepatectomy for hepatolithiasis.

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作者: 徐林龙 [1] 胡志刚 [1] 杨东晓 [1] 邹书兵 [1] 王恺 [1]
第一作者: 徐林龙
期刊: 《中华外科杂志》2019年57卷7期 527-533页 MEDLINEISTICPKUCSCD
栏目名称: 论著
DOI: 10.3760/cma.j.issn.0529-5815.2019.07.010
发布时间: 2019-07-25
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