Construction and validation of a novel nomogram for predicting recurrent choledocholithiasis after ERCP
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摘要: 目的 探讨经内镜逆行胰胆管造影(ERCP)取石术后胆总管结石(CBDS)复发的危险因素，绘制列线图风险预测模型，并进行验证。方法 选取2017年1月—2020年12月期间于苏州大学附属第一医院消化内科行ERCP治疗的胆总管结石患者共计665例，按照8∶2随机抽取，532例(80%)作为建模组，133例(20%)作为验证组，根据结石是否复发，分为复发组和未复发组，比较2组患者资料差异，运用单因素和多因素分析筛选出ERCP术后胆总管结石复发的独立危险因素，绘制列线图风险预测模型，并进行验证。结果 在建模组532例患者中，131例复发，复发率24.6%。多因素logistic回归分析显示胆囊切除术后、胆总管扩张、胆汁细菌培养阳性、乳头括约肌切开是ERCP术后胆总管结石复发的独立危险因素(P< 0.05)。在建模组和验证组中，列线图模型的C指数和AUC值分别为0.810(95%CI：0.770~0.846)、0.851(95%CI：0.771~0.912)，校正C指数分别为0.822、0.862，校正曲线表明预测结果和实际结果之间具有良好的一致性。决策曲线表示该模型有较高的临床应用价值。结论 胆囊切除术后、胆总管扩张、胆汁细菌培养阳性、十二指肠乳头括约肌切开是ERCP术后胆总管结石复发的独立危险因素。本研究构建了一个新型ERCP术后胆总管结石复发的风险预测模型，经验证具有良好的区分度、一致性和临床实用性。
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关键词:
- 胆总管结石 /
- 复发 /
- 经内镜逆行胰胆管造影术 /
- 列线图 /
- 验证
Abstract: Objective To construct and validate a novel nomogram for predicting recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography(ERCP).Methods A total of 665 patients with choledocholithiasis who received ERCP treatment were admitted to the First Affiliated Hospital of Soochow University from January 2017 to December 2020. The collected data were randomly divided into a training set(n=532, 80%) and a validation set(n=133, 20%). According to whether the stones recurred, they were divided into the recurrence group and the non recurrence group. The data of the two groups were compared, and the independent risk factors for the recurrence of common bile duct stones after ERCP were screened out by univariate and multivariate analysis. A novel nomogram was established by binary logistic regression based on the training set data. The C-index and the area under the receiver operating characteristic curve(AUC) analysis were used to assess the discrimination of the nomogram. The calibration plot was drawn to evaluate the calibration of the nomogram. The bootstrapping method was performed to calculate the bias-corrected C-index.Results Multivariate logistic regression analysis showed that cholecystectomy, positive bile bacterial culture, common bile duct dilation and sphincterotomy were independent risk factors for common bile duct stone recurrence after ERCP. In the training set, the C-index and the AUC value was 0.810(95%CI: 0.770-0.846). The bias-corrected C-index was 0.822. In the validation set, the C-index and the AUC value was 0.851(95%CI: 0.771-0.912). The bias-corrected C-index was 0.862.Conclusion Cholecystectomy, positive bile bacterial culture, common bile duct dilation and sphincterotomy are independent risk factors for recurrent choledocholithiasis after ERCP. We have constructed and validated a novel nomogram for predicting recurrent choledocholithiasis after ERCP. -
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表 1 建模组中未复发与复发患者单因素分析
变量 未复发(n=401) 复发(n=131) P 女性/例(%) 172(42.9) 58(44.3) 0.782 年龄>65岁/例(%) 202(50.4) 67(51.1) 0.878 体重指数/(kg/m2) 23.5±3.2 22.6±3.2 0.013 aCCI 3.0(1.0，4.0) 3.0(1.0，4.0) 0.888 WBC/(×109·L-1) 4.6(3.7，7.9) 5.6(4.4，7.8) 0.653 NE/(×109·L-1) 3.6(2.6，5.7) 3.4(2.6，5.5) 0.872 PCT/(ng·mL-1) 0.1(0.0，0.6) 0.1(0.0，0.6) 0.297 TBIL/(μmol·L-1) 22.4(15.2，58.4) 18.6(12.3，32.1) 0.001 ALT/(U·L-1) 74.4(24.7，190.2) 35.0(17.4，120.1) 0.001 AST/(U·L-1) 40.6(21.6，105.3) 27.4(19.4，65.7) 0.002 GGT/(U·L-1) 251.1(83.8，501.6) 172.5(47.1，335.5) 0.001 ALP/(U·L-1) 136.7(91.9，414.7) 111.7(80.9，201.8) 0.007 术后胰腺炎/例(%) 18(4.5) 5(3.8) 0.735 高淀粉酶血症/例(%) 124(30.9) 30(22.9) 0.074 既往胆道手术史/例(%) 37(9.2) 25(19.1) 0.002 胆囊状态/例(%) < 0.001 a 80(20.0) 18(13.7) b 135(33.7) 10(7.6) c 129(32.2) 96(73.3) d 57(14.2) 7(5.3) 术前胆管炎/例(%) 152(37.9) 52(39.7) 0.715 结石数目多发/例(%) 228(56.9) 84(64.1) 0.143 结石直径/mm 8.0(8.0，11.0) 10.0(8.0，15.0) < 0.001 结石位于中下段/例(%) 279(69.6) 92(69.2) 0.385 胆总管直径/mm 12.0(10.0，18.0) 15.0(12.0，18.0) < 0.001 胆汁培养阳性/例(%) 176(52.4) 22(21.6) < 0.001 壶腹周围憩室/例(%) 104(25.9) 31(31.0) 0.604 乳头括约肌切开/例(%) 339(84.5) 51(46.8) < 0.001 乳头切开长度/mm 5.0(3.0，5.0) 5.0(3.0，5.0) 0.034 治疗方式/例(%) < 0.001 EST 58(14.6) 13(19.4) EPBD 57(14.4) 16(23.9) sEST-EPBD 281(71.0) 38(56.7) 胆道支架置入/例(%) 88(22.1) 25(19.1) 0.463 鼻胆管引流/例(%) 322(80.5) 98(74.2) 0.126 注：EST，内镜下乳头括约肌切开术；EPBD，内镜下乳头括约肌球囊扩张术；sEST-EPBD，内镜下乳头括约肌小切开术联合乳头球囊扩张术。 
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表 2 多因素logistic回归分析
变量 OR 95%CI P 胆囊术后 4.581 2.807~7.477 ＜0.001 胆总管直径 1.088 1.037~1.141 0.001 乳头括约肌切开 2.833 1.429~3.802 0.001 胆汁细菌培养阳性 2.611 1.513~4.525 0.001
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