术前阑尾多层螺旋CT征象对日间腹腔镜阑尾切除术的影响及其在术前风险评估中的价值

Impact of preoperative appendicitis multi-slice spiral CT findings on daycase laparoscopic appendectomy and value of preoperative risk assessment

摘要

目的：探究急性阑尾炎（AA）患者术前多层螺旋CT（MSCT）征象对日间腹腔镜阑尾切除术（DLA）的影响，及其在患者术前风险评估中的应用价值。方法：选取2022年11月—2025年2月于河北大学附属医院就诊的拟进行DLA的AA患者156例，术后根据手术难度将患者分为容易组（n=92）和困难组（n=64）。所有患者均于术前接受MSCT检查。收集患者一般资料、MSCT征象及围手术期指标。使用受试者工作特征曲线（ROC）分析MSCT检查对不同AA分型的诊断效能；使用多因素Logistic回归方程分析影响AA患者手术难度的相关因素；基于多因素Logistic回归分析结果，构建基于MSCT的术前AA评分评估模型，并使用Bootstrap法进行内部验证；通过ROC曲线评估模型的预测效能，计算曲线下面积（AUC）及其95% CI；并于最佳截断值处计算模型的敏感度、特异度、阳性预测值（PPV）及阴性预测值（NPV）；绘制校准曲线评估模型预测值与实际观察值的一致性；采用决策曲线分析（DCA）评估模型的临床净获益。结果：ROC曲线显示，MSCT对单纯性AA、化脓性AA、坏疽性AA分型的诊断效能均较好（AUC=0.900、0.811、0.773）；不同分型AA患者术前阑尾管腔最大外径、阑尾壁厚度、腔内积液最大深度、腔内不连续气体、腔内粪石、阑尾周围渗出等级、最大淋巴结直径、阑尾周围积液、腹水等MSCT影像学特征均存在明显差异性（P<0.05）。容易组阑尾管腔最大外径、阑尾壁厚度、腔内积液最大深度、腔内出现不连续气体占比、存在腔内粪石占比、阑尾周围渗出等级、最大淋巴结直径、阑尾周围出现积液占比、出现腹水占比等均明显低于困难组（P<0.05）；容易组手术时间、住院时间、30 d内再入院占比、30 d内并发症发生率均明显低于困难组（P<0.05）。LASSO-Logistic回归模型分析显示，阑尾管腔最大外径、阑尾壁厚度、腔内积液最大深度、腔内不连续气体、腔内粪石、阑尾周围渗出等级等均为影响AA患者手术难度的危险因素（P<0.05）。在最佳截断值处，训练集模型敏感度为0.875，特异度为0.848，PPV为79.5%，NPV为90.9%；验证集模型敏感度为0.820，特异度为0.826，PPV为77.3%，NPV为88.6%。校准曲线显示，术前风险评估模型具有较为可靠的临床诊断能力（P=0.214）；决策曲线显示，当高风险阈值范围在0.78~0.86时，模型表现为净获益。结论：AA患者MSCT征象与手术难度密切相关，基于MSCT征象的术前风险评估有助于筛选适合DLA的患者，降低术后并发症及再入院风险，对提高DLA的安全性和临床疗效具有重要价值。

Abstract

Objective: To investigate the impact of preoperative multislice spiral computed tomography (MSCT) features on daytime laparoscopic appendectomy (DLA) in patients with acute appendicitis (AA) and its application value in preoperative evaluation. Methods: A total of 156 AA patients scheduled for DLA at Affiliated Hospital of Hebei University from November 2022 to February 2025 were included. Based on surgical difficulty, patients were divided into an easy group (n=92) and a difficult group (n=64). All patients underwent preoperative MSCT. General patient data, MSCT features, and perioperative indicators were collected. Receiver operating characteristic (ROC) curve analysis was used to evaluate the diagnostic efficacy of MSCT for different AA types. Multivariate logistic regression was employed to identify factors influencing surgical difficulty in AA patients. Based on the multivariate logistic regression results, an MSCT-based preoperative scoring model was constructed and internally validated using the Bootstrap method. The predictive performance of the model was assessed using ROC curves, with the area under the curve (AUC) and 95% confidence interval (CI) calculated. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the model were calculated at the optimal cut-off value. Calibration curves were plotted to evaluate the agreement between predicted and observed values, and decision curve analysis (DCA) was used to assess the clinical net benefit of the model. Results: The ROC curve results showed that MSCT had good diagnostic efficacy for different types of AA, including simple AA, purulent AA, and gangrenous AA (AUC=0.900, 0.811, 0.773); there were significant differences in the MSCT imaging features such as the maximum outer diameter of the appendiceal lumen, the thickness of the appendiceal wall, the maximum depth of intraluminal effusion, intraluminal discontinuous gas, intraluminal fecalith, the maximum diameter of lymph nodes around the appendix, the intraluminal effusion around the appendix, and ascites among patients with different types of AA before surgery (P<0.05). The easy group had significantly lower values than the difficult group in the following parameters: maximum appendiceal lumen diameter, appendiceal wall thickness, maximum depth of intraluminal fluid, number of cases with discontinuous intraluminal gas, number of cases with appendicoliths, severity of periappendiceal exudation, maximum lymph node diameter, number of cases with periappendiceal fluid, and number of cases with ascites (P<0.05). The easy group also had significantly shorter operative time, shorter hospital stay, fewer re-admissions within 30 days, and fewer complications within 30 days (P<0.05). The LASSO-Logistic regression model analysis revealed that the maximum outer diameter of the appendix lumen, the thickness of the appendix wall, the maximum depth of intracavitary fluid, the presence or absence of discontinuous gas within the cavity, the existence of intracavitary fecalith, and the grade of exudate around the appendix were all risk factors affecting the surgical difficulty of AA patients (P<0.05). At the optimal cut-off value, the sensitivity of the training set model was 0.875, the specificity was 0.848, the PPV was 79.5%, and the NPV was 90.9%; the sensitivity of the validation set model was 0.820, the specificity was 0.826, the PPV was 77.3%, and the NPV was 88.6%. The calibration curve results showed that the preoperative risk assessment model had a relatively reliable clinical diagnostic ability (H-L test: P=0.214); the decision curve results indicated that when the high-risk threshold range was 0.78 - 0.86, the model showed net benefit. Conclusion: MSCT features in AA patients are closely associated with surgical difficulty. A preoperative risk assessment model based on MSCT can help select suitable candidates for DLA, reduce postoperative complications and readmission rates, and improve the safety and efficacy of DLA.

关键词

急性阑尾炎 / 多层螺旋CT / 日间腹腔镜阑尾切除术 / 术前评估 / 治疗效果

Key words

Acute appendicitis / Multi-slice spiral CT / Daycase laparoscopic appendectomy / Preoperative assessment / Treatment efficacy

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基金资助

保定市科技计划项目(2241ZF105)