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中华腔镜外科杂志(电子版) ›› 2021, Vol. 14 ›› Issue (06) : 326 -331. doi: 10.3877/cma.j.issn.1674-6899.2021.06.002

论著

经皮肾镜治疗重症急性胰腺炎院内死亡风险预测
王雪飞1, 任为正1,(), 刘志伟1, 赵永生1, 徐菁1, 寇佳琪1, 何蕾1   
  1. 1. 100853 北京,解放军总医院肝胆胰外科医学部重症医学科,全军肝胆外科研究所,全军数字肝胆外科重点实验室
  • 收稿日期:2021-10-06 出版日期:2021-12-30
  • 通信作者: 任为正
  • 基金资助:
    北京市自然科学基金(7194317)

Prediction model for in-hospital mortality in patients with severe acute pancreatitis undergoing minimally invasive procedure by percutaneous nephroscope

Xuefei Wang1, Weizheng Ren1,(), Zhiwei Liu1, Yongsheng Zhao1, Jing Xu1, Jiaqi Kou1, Lei He1   

  1. 1. Faculty of Hepato-Pancreato-Biliary Surgery, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepetobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China
  • Received:2021-10-06 Published:2021-12-30
  • Corresponding author: Weizheng Ren
引用本文:

王雪飞, 任为正, 刘志伟, 赵永生, 徐菁, 寇佳琪, 何蕾. 经皮肾镜治疗重症急性胰腺炎院内死亡风险预测[J/OL]. 中华腔镜外科杂志(电子版), 2021, 14(06): 326-331.

Xuefei Wang, Weizheng Ren, Zhiwei Liu, Yongsheng Zhao, Jing Xu, Jiaqi Kou, Lei He. Prediction model for in-hospital mortality in patients with severe acute pancreatitis undergoing minimally invasive procedure by percutaneous nephroscope[J/OL]. Chinese Journal of Laparoscopic Surgery(Electronic Edition), 2021, 14(06): 326-331.

目的

建立和评价包括经皮肾镜等微创手术治疗在内的重症急性胰腺炎(severe acute pancreatitis, SAP)患者住院期间死亡的预测模型。

方法

回顾性分析2015年1月至2019年12月期间,解放军总医院第一医学中心重症急性胰腺炎专病中心收治的314例SAP患者的临床资料。男225例、女89例,中位年龄45.8岁(16,84),中位体质量指数24.26 kg/m2(14.88,52.08)。针对胰腺和胰腺周围坏死感染病灶的局部治疗方法实行升阶梯微创治疗方案,首先行CT引导下经皮穿刺引流,然后根据病情缓解程度,选择经皮肾镜微创或开放手术治疗。收集分析患者住院死亡的潜在危险因素,将单变量逻辑回归中与结局相关的变量(P<0.1)纳入模型筛选。使用基于赤池信息量准则的逐步回归分析法进行模型筛选。

结果

314例SAP患者中,44例患者住院期间死亡,病死率为14.0%(44/314)。逐步回归分析法筛选出变量进入最终模型:年龄>60岁(OR=4.01,P=0.004)、>2个器官功能支持(OR=26.56,P<0.010)、ICU住院时间>2 d(OR=2.38,P=0.162)及住院后微创手术(OR=0.17,P<0.010)。基于此模型制作的列线图可产生<5%(0个不良因素)和>90%(4个不良因素)的住院期间死亡可能性。

结论

该模型可较准确地预测包括经皮肾镜等微创手术治疗在内的SAP患者在院期间的死亡概率。

Objective

To establish a model to predict in-hospital mortality of patients with severe acute pancreatitis undergoing minimally invasive procedure including percutaneous nephrolithotomy.

Methods

Patients diagnosed with acute severe pancreatitis during Jan. 2015 till Dec. 2019 at the Pancreatitis Specialized Center were retrospectively analyzed. A total of 314 patients were included, 225 male and 89 female, median age 45.8 years old (16, 84), and median body mass index 24.26 kg/m2 (14.88, 52.08). A surgical step-up approach for pancreatic necrosis or infected necrosis was implemented. The minimally invasive intervention, such as percutaneous puncture and drainage, is preferred. The decision was made whether perform percutaneous nephroscope or open surgery according to the degree of remission. Logistic regression analysis was used to evaluate the association between in-hospital mortality and relevant factors. Significant predictors of in-hospital mortality on univariate analysis (P<0.1) were entered into a stepwise selection using the Akaike information criterion to define the final model.

Results

Of the 314 patients with severe acute pancreatitis, 44 cases (14.0%) died. In stepwise selection, the following factors were identified as predictors of in-hospital mortality: age over 60 (OR=4.01, P=0.004), multiple organ support (OR= 26.56, P<0.010), ICU stay longer than 2 d(OR=2.38, P= 0.162) and minimal invasive surgery after admission (OR= 0.17, P<0.010). The prognostic nomogram based on this model yielded a probability of in-hospital mortality ranging from <5% (0 factors) to >90% (all 4 factors).

Conclusions

This prediction model can accurately predict in-hospital mortality in patients with severe acute pancreatitis including those who undergoing step-up minimally invasive approach including percutaneous nephrolithotomy.

图1 胰腺周围坏死组织包裹局限形成包裹性坏死行CT引导下胰周坏死组织穿刺引流注:A.胰周坏死形成,相对包裹局限良好;B.经腹腔入路穿刺置管;C.胰周包裹性坏死合并感染,CT可见包裹性坏死出现气体影,形成感染性胰腺坏死;D.经左侧腹膜后入路,感染性胰腺坏死穿刺置管
表1 314例转诊重症急性胰腺炎患者死亡的可能预测因素分布情况
项目 例数(%) 院内死亡(例) OR (95% CI) P
性别     1.41(0.67~3.00) 0.367
  225(71.7) 34    
  89(28.3) 10    
年龄(岁)     5.25(2.62~10.54) <0.010
  >60 53(16.9) 25    
  ≤60 261(83.1) 19    
体质量指数(kg/m2)     1.38(0.72~2.66) 0.332
  >25 114(37.3) 20    
  ≤25 200(63.7) 24    
呼吸支持     54.32(12.83~230.03) <0.010
  117(37.3) 42    
  197(62.7) 2    
肾功能支持     23.65(10.28~54.38) <0.010
  79(25.2) 36    
  235(74.8) 8    
循环支持     19.55(7.43~51.46) <0.010
  116(36.9) 39    
  198(63.1) 5    
>2个器官功能支持     34.86(14.15~80.22) <0.010
  62(19.7) 34    
  252(80.3) 10    
ICU住院时间2~7 d     11.27(4.31~29.51) <0.010
  149(47.4) 39    
  165(52.6) 5    
ICU住院时间8~14 d     5.19(2.63~10.23) <0.010
  102(32.5) 29    
  212(67.5) 15    
ICU住院时间>14 d     3.05(1.54~6.05) 0.001
  63(20.1) 17    
  251(79.9) 27    
发病至住院时间>28 d     0.32(0.17~0.63) 0.001
  188(59.9) 16    
  126(40.1) 28    
发病至住院有创干预>28 d     0.34(0.13~0.85) 0.022
  212(67.5) 16    
  102(32.5) 28    
住院后手术治疗     0.21(0.11~0.41) <0.010
  231(73.6) 19    
  83(26.4) 25    
住院后微创手术     0.24(0.12~0.46) <0.010
  207(65.9) 16    
  107(34.1) 28    
住院后开放手术     0.86(0.25~3.03) 0.819
  24(7.6) 3    
  290(92.4) 41    
住院时间>28 d     0.28(0.14~0.59) 0.001
  156(49.7) 11    
  158(50.3) 33    
图2 根据314例重症急性胰腺炎患者一般资料构建的预测模型的预测效能图注:A.基于最终预测模型的受试者工作特征曲线;B.根据逐步回归分析筛选出的最终预测模型制作的列线图
表2 转诊重症急性胰腺炎患者死亡的预测模型
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