急性胆囊炎腹腔镜胆囊切除术后教科书式结局的影响因素分析及列线图模型构建

Analysis of influencing factors of textbook outcome after laparoscopic cholecystectomy for acute cholecystitis and construction of nomogram model

摘要

目的：分析急性胆囊炎患者行腹腔镜下胆囊切除术（LC）后实现教科书式结局（TO）的影响因素，并构建临床预测模型。方法：回顾性分析2023年1月—2025年9月在芜湖市第二人民医院接受LC治疗的213例急性胆囊炎患者的临床资料。依据患者术后是否实现TO分为两组：TO组（n=166）和非TO组（n=47）。收集患者的临床资料，采用单因素及多因素Logistic回归分析，筛选影响急性胆囊炎患者行LC后实现TO的独立影响因素，并据此建立列线图预测模型。通过计算曲线下面积（AUC）、绘制校准曲线及实施决策曲线分析（DCA），对列线图模型的预测区分度、校准能力和临床适用性进行综合评价。结果：多因素Logistic回归分析结果显示，年龄校正查尔森合并症指数（aCCI，OR=3.336，95% CI：1.653~6.734，P=0.001）、POSSUM生理学评分（POSSUM-PS，OR=2.196，95% CI：1.522~3.167，P<0.001）、中重度急性胆囊炎（OR=4.486，95% CI：1.114~18.069，P=0.035）是LC术后实现TO的独立危险因素；预后营养指数（PNI，OR=0.808，95% CI：0.695~0.939，P=0.005）是LC术后实现TO的独立保护因素。基于上述影响因素构建LC术后预测TO的列线图模型，该模型的AUC为0.868（95% CI：0.808~0.929，P<0.001)，敏感度和特异度分别为89.2%和72.3%；校准曲线与理想曲线贴合良好，Hosmer-Lemeshow拟合优度检验良好（χ ²=3.354，P=0.910）；DCA显示该模型具有明显的正向净效益。结论：aCCI、POSSUM-PS、中重度急性胆囊炎是急性胆囊炎患者LC术后实现TO的独立危险因素，而PNI是术后实现TO的独立保护因素；基于以上4项指标构建的列线图模型对TO的预测性能良好。

Abstract

Objective: To analyze the influencing factors of textbook outcome (TO) after laparoscopic cholecystectomy (LC) in patients with acute cholecystitis, and to construct a clinical prediction model. Methods: The clinical data of 213 patients with acute cholecystitis who underwent LC in the Second People's Hospital of Wuhu from January 2023 to September 2025 were retrospectively analyzed. The patients were divided into two groups according to whether they reached TO after operation: TO group (n=166) and non-TO group (n=47). The clinical data of patients were collected. Univariate analysis and multivariate logistic regression analysis were used to screen the independent influencing factors of TO after LC in patients with acute cholecystitis, and a nomogram prediction model was established accordingly. By calculating the area under the receiver operating characteristic curve (AUC), drawing the calibration curve and implementing the decision curve analysis (DCA), the predictive discrimination, calibration ability and clinical applicability of the nomogram model were comprehensively evaluated. Results: Multivariate logistic regression analysis showed that age-adjusted Charlson comorbidity index (aCCI) (OR=3.336, 95% CI: 1.653-6.734, P=0.001), POSSUM physiological score (POSSUM-PS, OR=2.196, 95% CI: 1.522-3.167, P<0.001) and moderate to severe acute cholecystitis (OR=4.486, 95% CI: 1.114-18.069, P=0.035) were independent risk factors for postoperative TO. Prognostic Nutrition Index (PNI, OR=0.808, 95% CI: 0.695-0.939, P=0.005) was an independent protective factor for postoperative TO. Based on the above influencing factors, a nomogram model for predicting TO after LC was constructed. The AUC of the receiver operating characteristic curve of the model was 0.868 (95% CI: 0.808-0.929, P<0.001), and the sensitivity and specificity were 89.2% and 72.3%. The calibration curve was in good agreement with the ideal curve. Hosmer-Lemeshow goodness of fit test was good (χ ²=3.354, P=0.910). The decision curve shows that the model has obvious positive net benefit. Conclusion: aCCI, POSSUM-PS, moderate to severe acute cholecystitis were independent risk factors for TO in patients with acute cholecystitis after LC, while PNI was an independent protective factor for TO after LC. The nomogram model based on the above four indicators has good prediction performance for TO.

关键词

急性胆囊炎 / 腹腔镜胆囊切除术 / 教科书式结局 / 影响因素 / 列线图模型

Key words

Acute cholecystitis / Laparoscopic cholecystectomy / Textbook outcome / Influencing factors / Nomogram model

参考文献

[1] 姜飞， 李霞， 孔祥崇， 等 . 超声引导下PTGBD联合LC治疗中度急性胆囊炎的疗效观察[J]. 腹部外科， 2025， 38（3）： 219-223. DOI: 10.3969/j.issn.1003—5591.2025.03.010.

[2] 季晓克， 蔡斌斌， 郑孺， 等 . 急诊胆囊炎日间手术模式的可行性及安全性评估—基于倾向性评分匹配的回顾性研究[J]. 肝胆胰外科杂志， 2025， 37（6）： 366-371. DOI: 10.11952/j.issn.1007—1954.2025.06.002.

[3] Wakabayashi G , Iwashita Y , Hibi T , et al. Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos)[J]. J Hepatobiliary Pancreat Sci, 2018, 25(1): 73-86. DOI: 10.1002/jhbp.517.

[4] 中华医学会外科学分会胆道外科学组 . 急性胆道系统感染的诊断和治疗指南（2021版）[J]. 中华外科杂志， 2021， 59（6）： 422-429. DOI: 10.3760/cma.j.cn112139—20210421—00180.

[5] Wu H , Ma K , Liao B , et al. Multicenter external validation of a nomogram predicting conversion to open cholecystectomy during laparoscopic surgery for acute calculous cholecystitis: a cross—sectional study[J]. Sci Rep, 2025, 15(1): 18481. DOI: 10.1038/s41598—025—03687—0.

[6] Zeineddin A , Harris J , Olivencia—Delgado M , et al. A 20—year analysis of risk factors for complicated postoperative course following laparoscopic cholecystectomy[J]. Am Surg, 2025, 91(8): 258-1262. DOI: 10.1177/00031348251351000.

[7] 何飞， 周明， 管思强 . 急性胆囊炎腹腔镜胆囊切除术后并发症危险因素与风险预测模型的构建[J]. 中国现代普通外科进展， 2024， 27（9）： 709-713. DOI: 10.3969/j.issn.1009—9905.2024.09.008.

[8] 蒋弟， 陈诚， 刘智鹏， 等 . 肝门部胆管癌根治性切除术后教科书式结局发生的预测因素分析[J]. 肝胆胰外科杂志， 2023， 35（5）： 263-267. DOI: 10.11952/j.issn.1007—1954.2023.05.002.

[9] 唐昌乾， 郭宇麒， 任泳年， 等 . 胰十二指肠切除术后达到教科书式结局的影响因素分析及列线图模型构建[J]. 中华肝胆外科杂志， 2024， 30（6）： 439-444. DOI: 10.3760/cma.j.cn113884—20240129—00035.

[10] Bhatti A . Invited commentary on "Utilizing the concept of textbook outcome for evaluating quality control in the transition from open hepatectomy to laparoscopic hepatectomy for hepatocellular carcinoma"[J]. J Gastrointest Surg, 2025, 29(10): 102174. DOI: 10.1016/j.gassur.2025.102174.

[11] Iseda N , Iguchi T , Itoh S , et al. Textbook outcome in the laparoscopic cholecystectomy of acute cholecystitis[J]. Asian J Endosc Surg, 2023, 16(4): 741-746. DOI: 10.1111/ases.13238.

[12] Fugazzola P , Carbonell—Morote S , Cobianchi L , et al. Textbook outcome in urgent early cholecystectomy for acute calculous cholecystitis: results post hoc of the S.P.Ri.M.A.C.C study[J]. World J Emerg Surg, 2024, 19(1): 12. DOI: 10.1186/s13017—024—00539—6.

[13] Lucocq J , Scollay J , Patil P . Evaluation of textbook outcome as a composite quality measure of elective laparoscopic cholecystectomy[J]. JAMA Netw Open, 2022, 5(9): e2232171. DOI: 10.1001/jamanetworkopen.2022.32171.

[14] 鲁为朋， 徐庆春， 孙礼侠， 等 . POSSUM、aCCI评分用于老年胆总管结石患者LCBDE围手术期并发症预测效能比较[J]. 山东医药， 2024， 64（20）： 67-69. DOI: 10.3969/j.issn.1002—266X.2024.20.016.

[15] 武志恒， 万浩浩， 郭玺， 等 . 预后营养指数、系统免疫炎症指数与胃癌预后相关性的研究进展[J]. 中国现代普通外科进展， 2025， 28（8）： 637-641. DOI: 10.3969/j.issn.1009—9905.2025.08.009.

[16] Kolfschoten NE , Kievit J , Gooiker GA , et al. Focusing on desired outcomes of care after colon cancer resections; hospital variations in 'textbook outcome'[J]. Eur J Surg Oncol, 2013, 39(2): 156-163. DOI: 10.1001/jamanetworkopen.2022.32171.

[17] 陈子祥， 陈江明， 郭旗， 等 . 肝胆管结石病肝切除术后教科书式结局的影响因素分析[J]. 中华消化外科杂志， 2023， 22（S1）： 28-33. DOI: 10.3760/cma.j.cn115610—20230906—00061.

[18] 吕蒙， 苏伟， 赵锐， 等 . PTGBD术后早期行LC治疗发病时间>72 h的胆囊结石伴急性胆囊炎的疗效分析[J]. 中国现代普通外科进展， 2024， 27（8）： 639-641. DOI: 10.3969/j.issn.1009—9905.2024.08.010.

[19] 付佳， 肖海敏， 武曦， 等 . 年龄校正查尔森合并症指数对腹腔镜结直肠癌围手术期并发症的预测价值[J]. 中华普通外科学文献（电子版）， 2023， 17（5）： 336-341. DOI: 10.3877/cma.j.issn.1674—0793.2023.05.004.

[20] McKechnie T , Kazi T , Jessani G , et al. The use of preoperative enteral immunonutrition in patients undergoing elective colorectal cancer surgery: A systematic review and meta—analysis[J]. Colorectal Dis, 2025, 27(4): e70061. DOI: 10.1111/codi.70061.

[21] Shiraishi T , Yamaguchi A , Shibasaki Y , et al. Risk factors of poor outcomes after colorectal cancer surgery for patients with severe comorbidities[J]. Anticancer Res, 2024, 44(9): 4073-4083. DOI: 10.21873/anticanres.17236.

[22] Yuan Y , Tang Y , Liu Y , et al. A low prognostic nutritional index level, an independent predictor for postoperative intra—abdominal abscess after laparoscopic appendectomy[J]. Surg Laparosc Endosc Percutan Tech, 2024, 34(6): 603-606. DOI: 10.1097/SLE.0000000000001328.

[23] Guo H , Yang L , Liu J , et al. Prognostic nutritional ndex and the risk of postoperative complications after spine surgery: A meta—analysis[J]. World Neurosurg, 2024, 185: e572-e581. DOI: 10.1016/j.wneu.2024.02.077.

[24] Shekar N , Debata PK , Debata I , et al. Use of POSSUM (physiologic and operative severity score for the study of mortality and morbidity) and Portsmouth—POSSUM for surgical assessment in patients undergoing emergency abdominal surgeries[J]. Cureus, 2023, 15(6): e40850. DOI: 10.7759/cureus.40850.

[25] Hu ZW , Xin RQ , Xia YJ , et al. Application of POSSUM and P—POSSUM in surgical risk assessment of elderly patients undergoing hepatobiliary and pancreatic surgery[J]. Clin Interv Aging, 2020, 15: 1121-1128. DOI: 10.2147/CIA.S258659.