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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

潘均昊 辛建 王春晖

引用本文:
Citation:

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

DOI: 10.12449/JCH240922
基金项目: 

辽宁省自然科学基金 (2021JH2/10300084)

伦理学声明:本研究方案于2023年11月6日经由北部战区总医院伦理委员会审批,批号:Y(2023)195号。
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:潘均昊负责课题设计,资料分析,撰写论文;辛建参与收集数据,修改论文;王春晖负责拟定写作思路,指导撰写文章并最后定稿。
详细信息
    通信作者:

    王春晖, wangchh_2013@163.com (ORCID: 0000-0001-9082-2611)

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

Research funding: 

Natural Science Foundation of Liaoning Province (2021JH2/10300084)

More Information
  • 摘要:   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χ2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CR-POPF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。

     

  • 图  1  影像学指标测量方法

    Figure  1.  Measurement method for radiography indicators

    图  2  PD术后CR-POPF的列线图

    Figure  2.  The nomogram predicts the CR-POPF in the PD patients

    图  3  PD术后CR-POPF预测模型的校准曲线

    Figure  3.  Calibration curve of the model for predicting the CR-POPF in the PD patients

    图  4  列线图和各危险因素预测PD术后CR-POPF的ROC曲线

    Figure  4.  The ROC curves of the nomogram and the risk factors for predicting the CR-POPF in the PD patients

    图  5  PD术后CR-POPF预测模型的临床决策曲线及临床影响曲线

    注: a,临床决策曲线;b,临床影响曲线。

    Figure  5.  Decision curve and clinical impact curve of the model for predicting the CR-POPF in the PD patients

    表  1  患者临床基线资料

    Table  1.   Clinical baseline data of patients

    变量 数值
    性别[例(%)]
    63(35.2)
    116(64.8)
    年龄(岁) 62.0(56.0~69.0)
    糖尿病[例(%)]
    141(78.8)
    38(21.2)
    高血压[例(%)]
    125(69.8)
    54(30.2)
    BMI(kg/m2 23.38±3.23
    手术方式[例(%)]
    PD 129(72.1)
    LPD 50(27.9)
    术前减黄[例(%)]
    120(67.0)
    59(33.0)
    主胰管直径[例(%)]
    ≤3 mm 120(67.0)
    >3 mm 59(33.0)
    CT判断血管侵犯[例(%)]
    162(90.5)
    17(9.5)
    CR-POPF[例(%)]
    120(67.0)
    59(33.0)
    术前血细胞比容 0.38(0.35~0.41)
    术前血红蛋白(g/L) 129.00(118.00~138.00)
    术前前白蛋白(mg/L) 170.17±55.70
    术前白蛋白(g/L) 37.10(34.20~39.20)
    术前总胆红素(μmol/L) 101.30(18.50~210.10)
    ALT(U/L) 126.19(41.81~237.50)
    AST(U/L) 82.82(30.60~151.45)
    ALT/AST 1.40(1.04~1.85)
    CA19-9(KU/L) 77.12(15.83~335.60)
    胰腺平扫期CT值(Hu) 41.10(35.05~46.13)
    胰腺动脉期CT值(Hu) 84.80(69.50~96.33)
    胰腺静脉期CT值(Hu) 95.95(81.33~109.95)
    胰腺平衡期CT值(Hu) 81.05±14.73
    脾脏平扫期CT值(Hu) 52.65(48.83~55.30)
    肝脏平扫期CT值(Hu) 56.20±6.61
    主动脉平扫期CT值(Hu) 43.30(38.35~47.50)
    主动脉平衡期CT值(Hu) 115.70(105.55~126.35)
    胰/脾CT比值 0.77±0.15
    胰/肝CT比值 0.72±0.15
    肾后脂肪厚度(mm) 8.80(4.30~15.75)
    脐周脂肪厚度(mm) 16.55(12.40~22.71)
    腹膜胰颈前距离(mm) 50.43±1.19
    ECV分数 0.33(0.27~0.39)
    下载: 导出CSV

    表  2  PD术后CR-POPF单因素分析

    Table  2.   Univariate analysis of the CR-POPF after PD

    变量 非CR-POPF(n=120) CR-POPF(n=59) 统计值 P
    性别[例(%)] χ2=3.680 0.055
    48(40.0) 15(25.4)
    72(60.0) 44(74.6)
    年龄[例(%)] χ2=0.574 0.449
    ≤60岁 56(46.7) 24(40.7)
    >60岁 64(53.3) 35(59.3)
    糖尿病[例(%)] χ2=1.826 0.177
    98(81.7) 43(72.9)
    22(18.3) 16(27.1)
    高血压[例(%)] χ2=0.005 0.945
    84(70.0) 41(69.5)
    36(30.0) 18(30.5)
    BMI[例(%)] χ2=3.455 0.063
    ≤25 kg/m2 93(77.5) 38(64.4)
    >25 kg/m2 27(22.5) 21(35.6)
    手术方式[例(%)] χ2=1.556 0.272
    开腹 90(75.0) 39(66.1)
    腹腔镜 30(25.0) 20(33.9)
    术前减黄[例(%)] χ2=0.276 0.599
    82(68.3) 38(64.4)
    38(31.7) 21(35.6)
    CT判断血管侵犯[例(%)] χ2=0.046 0.830
    109(90.8) 53(89.8)
    11(9.2) 6(10.2)
    主胰管直径[例(%)] χ2=14.992 <0.001
    ≤3 mm 69(57.5) 51(86.4)
    >3 mm 51(42.5) 8(13.6)
    术前血细胞比容 0.37(0.35~0.41) 0.39(0.34~0.42) Z=-1.166 0.244
    术前血红蛋白(g/L) 126.00(118.00~134.00) 132.00(116.00~142.00) Z=-1.862 0.063
    术前前白蛋白(mg/L) 169.86±52.96 170.80±56.81 t=-0.109 0.913
    术前白蛋白(g/L) 36.90(33.90~39.10) 37.80(34.60~40.30) Z=-1.047 0.295
    术前总胆红素(μmol/L) 99.50(16.82~209.93) 112.50(34.50~221.40) Z=-0.655 0.512
    ALT(U/L) 119.95(40.57~231.06) 143.62(44.98~229.75) Z=-0.331 0.740
    AST(U/L) 85.44(31.86~169.99) 77.73(30.20~121.69) Z=-0.902 0.367
    ALT/AST 1.27(1.00~1.68) 1.53(1.21~2.02) Z=-3.188 0.001
    CA19-9(KU/L) 94.82(10.39~487.13) 53.90(25.47~257.90) Z=-0.124 0.901
    胰腺平扫期CT值(Hu) 41.33(35.65~46.00) 39.05(34.70~46.15) Z=-0.813 0.416
    胰腺动脉期CT值(Hu) 84.17(68.71~95.56) 88.00(76.25~92.00) Z=-1.837 0.066
    胰腺静脉期CT值(Hu) 96.63(82.79~109.51) 95.70(81.10~110.30) Z=-0.175 0.861
    胰腺平衡期CT值(Hu) 85.90(75.13~92.95) 71.50(67.70~79.40) Z=-4.833 <0.001
    脾脏平扫期CT值(Hu) 52.58(48.8~55.21) 52.50(49.45~54.95) Z=-0.075 0.94
    肝脏平扫期CT值(Hu) 56.01±6.76 56.59±6.33 t=-0.546 0.586
    主动脉平扫期CT值(Hu) 42.56±7.06 42.15±6.48 t=0.369 0.713
    主动脉平衡期CT值(Hu) 116.20(105.78~130.78) 116.30(107.40~125.80) Z=-0.074 0.941
    胰/脾CT比值 0.80(0.67~0.89) 0.76(0.66~0.87) Z=-0.942 0.346
    胰/肝CT比值 0.73±0.16 0.71±0.13 t=0.978 0.329
    肾后脂肪厚度(mm) 8.24(3.80~14.51) 11.60(6.30~16.50) Z=-2.068 0.039
    脐周脂肪厚度(mm) 15.95(12.10~21.71) 19.10(14.30~25.30) Z=-2.189 0.029
    腹膜胰颈前距离(mm) 46.99±16.31 57.43±12.56 t=-4.718 <0.001
    ECV分数 0.36(0.32~0.41) 0.29(0.24~0.31) Z=-6.045 <0.001
    下载: 导出CSV

    表  3  多因素Logistic分析

    Table  3.   Multivariate Logistic regression analysis

    变量 β OR(95%CI P
    主胰管直径(≤3 mm vs >3 mm) -1.117 0.276(0.105~0.725) 0.022
    ALT/AST 0.798 2.221(1.281~3.851) 0.004
    胰腺平衡期CT值 -0.008 0.992(0.956~1.030) 0.691
    肾后脂肪厚度 -0.01 0.990(0.937~1.047) 0.732
    脐周脂肪厚度 0.002 1.002(0.956~1.050) 0.937
    腹膜胰颈前距离 0.034 1.034(1.004~1.066) 0.027
    ECV分数 -9.126 0.001(0.000~0.067) 0.005
    下载: 导出CSV

    表  4  相关指标预测效能

    Table  4.   Prediction efficiency of relevant indicators

    变量 AUC(95%CI 敏感度 特异度 PPV NPV Cut-off
    ALT/AST 0.647(0.560~0.734) 0.729 0.542 0.439 0.802 1.322
    主胰管直径 0.645(0.582~0.707) 0.864 0.425 0.425 0.864
    腹膜胰颈前距离 0.686(0.607~0.765) 0.966 0.342 0.419 0.953 38.7
    ECV分数 0.778(0.709~0.847) 0.847 0.717 0.595 0.905 0.325
    Nomogram 0.837(0.766~0.898) 0.932 0.725 0.625 0.956 264
    下载: 导出CSV
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  • 收稿日期:  2023-12-11
  • 录用日期:  2024-02-18
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