JAMA Surgery:选择无并发症有症状的胆石症患者进行胆囊切除术的临床决策工具

2023-05-09 Bob Wang MedSci原创 发表于上海

本研究验证的模型可以帮助预测胆囊切除术后疼痛减轻的可能性,从而帮助外科医生决定无并发症的症状性胆石症患者是否可以从胆囊切除术中获益。

在现代社会,胆结石的终生患病率为10%至20%,这在日益肥胖的人群中构成了一个重要且日益严重的健康问题。据不完全统计,只有5%的患者出现胆结石相关并发症,如胆囊炎、胆管炎或胆源性胰腺炎,而其余95%的患者没有胆道并发症。

胆囊切除术是世界范围内常用的胆胰外科手术,适用于复杂的胆结石疾病,而对于非复杂无并发症的胆结石疾病胆囊切除术的适应证尚无共识。典型的症状性胆石症(无并发症的胆结石疾病)表现为胆绞痛,即位于右上腹或上腹部的急性剧烈疼痛发作,持续15至30分钟或更长时间。腹腔镜胆囊切除术的选择通常基于Rome III标准的应用,但试验表明,Rome III标准在选择胆囊切除术患者时具有有限的有效性。

发表在JAMA Surgery杂志上的这篇文章,旨在建立并验证一种预测模型,选择无并发症的症状性胆石症患者进行胆囊切除术,减轻临床相关疼痛或达到无疼痛状态。这篇文章使用了两项临床试验的数据,一项是SECURE试验,另一项是旨在验证SECURE试验的非随机临床试验(Success试验[NL7069])。

这篇文章评估了上述两项多中心前瞻性试验的数据,这些数据来自2014年4月至2019年6月期间荷兰25家医院的门诊诊所,最后1561名症状性无并发症的胆石症患者入组。 

图注1:发展和验证队列入组流程图

在发展队列中,395例患者(80.0%)接受了胆囊切除术。手术后,225名患者(57.0%)报告无疼痛,295名患者(74.7%)报告临床相关的疼痛减轻,356例(95.2%)患者胆绞痛得到缓解。 

表1:治疗、并发症和患者报告的结果

 

多变量预测术后临床相关疼痛减轻的模型显示,老年患者和无腹部手术史、VAS基线评分高、背部疼痛放射、疼痛发作时恶心、口服简单止痛药有效或无烧心症状的患者胆囊切除术后疼痛减轻的机会更高。

表2:胆囊切除术后临床相关疼痛减轻的预测因素

该模型通过内部验证的bootstrapping估计收缩因子为0.91。内部验证后,C统计量为0.80,表明在患者是否有临床相关的疼痛缓解之间有很好的区分,该模型具有很好的整体校准和最小的概率低估。外部验证的C统计量为0.74 ,表明在获得和没有获得临床相关疼痛减轻的患者之间有很好的区分。 

图注2:胆囊切除术后临床相关疼痛减轻的预测因素

文章作者制作了一个在线决策工具来评估无并发症的症状性胆石症患者是否可以从胆囊切除术中获益。该决策工具可在https://gallbladderresearch.shinyapps.io/SUCCESS/上获得。

总之,本研究验证的模型可以帮助预测胆囊切除术后疼痛减轻的可能性,从而帮助外科医生决定无并发症的症状性胆石症患者是否可以从胆囊切除术中获益。

原始出处:

Latenstein CSS, Hannink G, van der Bilt JDW, Donkervoort SC, Eijsbouts QAJ, Heisterkamp J, Nieuwenhuijs VB, Schreinemakers JMJ, Wiering B, Boermeester MA, Drenth JPH, van Laarhoven CJHM, Dijkgraaf MGW, de Reuver PR; SECURE trial collaborators. A Clinical Decision Tool for Selection of Patients With Symptomatic Cholelithiasis for Cholecystectomy Based on Reduction of Pain and a Pain-Free State Following Surgery. JAMA Surg. 2021 Oct 1;156(10):e213706. doi: 10.1001/jamasurg.2021.3706. Epub 2021 Oct 13. PMID: 34379080; PMCID: PMC8358816.

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  1. [GetPortalCommentsPageByObjectIdResponse(id=2137816, encodeId=cb34213e8160a, content=谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edcf4883751, createdName=498997979, createdTime=Fri May 19 08:14:17 CST 2023, time=2023-05-19, status=1, ipAttribution=江苏省), GetPortalCommentsPageByObjectIdResponse(id=2131300, encodeId=ccfc2131300bc, content=胆结石的终生患病率为10%至20%, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d3d3015017, createdName=jshbyywk2008, createdTime=Wed May 10 06:11:33 CST 2023, time=2023-05-10, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=2131290, encodeId=cb19213129059, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:34:20 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131288, encodeId=68e5213128825, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:31:08 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131254, encodeId=ab932131254fc, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/23/7f016e48a01c47d183a45783cee50360.jpg, createdBy=cfb11352434, createdName=Thc822, createdTime=Tue May 09 23:09:18 CST 2023, time=2023-05-09, status=1, ipAttribution=上海)]
    2023-05-19 498997979 来自江苏省

    谢谢

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=2137816, encodeId=cb34213e8160a, content=谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edcf4883751, createdName=498997979, createdTime=Fri May 19 08:14:17 CST 2023, time=2023-05-19, status=1, ipAttribution=江苏省), GetPortalCommentsPageByObjectIdResponse(id=2131300, encodeId=ccfc2131300bc, content=胆结石的终生患病率为10%至20%, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d3d3015017, createdName=jshbyywk2008, createdTime=Wed May 10 06:11:33 CST 2023, time=2023-05-10, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=2131290, encodeId=cb19213129059, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:34:20 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131288, encodeId=68e5213128825, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:31:08 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131254, encodeId=ab932131254fc, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/23/7f016e48a01c47d183a45783cee50360.jpg, createdBy=cfb11352434, createdName=Thc822, createdTime=Tue May 09 23:09:18 CST 2023, time=2023-05-09, status=1, ipAttribution=上海)]
    2023-05-10 jshbyywk2008 来自河北省

    胆结石的终生患病率为10%至20%

    0

  3. [GetPortalCommentsPageByObjectIdResponse(id=2137816, encodeId=cb34213e8160a, content=谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edcf4883751, createdName=498997979, createdTime=Fri May 19 08:14:17 CST 2023, time=2023-05-19, status=1, ipAttribution=江苏省), GetPortalCommentsPageByObjectIdResponse(id=2131300, encodeId=ccfc2131300bc, content=胆结石的终生患病率为10%至20%, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d3d3015017, createdName=jshbyywk2008, createdTime=Wed May 10 06:11:33 CST 2023, time=2023-05-10, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=2131290, encodeId=cb19213129059, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:34:20 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131288, encodeId=68e5213128825, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:31:08 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131254, encodeId=ab932131254fc, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/23/7f016e48a01c47d183a45783cee50360.jpg, createdBy=cfb11352434, createdName=Thc822, createdTime=Tue May 09 23:09:18 CST 2023, time=2023-05-09, status=1, ipAttribution=上海)]
    2023-05-10 1581f8c42cm

    学习

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=2137816, encodeId=cb34213e8160a, content=谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edcf4883751, createdName=498997979, createdTime=Fri May 19 08:14:17 CST 2023, time=2023-05-19, status=1, ipAttribution=江苏省), GetPortalCommentsPageByObjectIdResponse(id=2131300, encodeId=ccfc2131300bc, content=胆结石的终生患病率为10%至20%, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d3d3015017, createdName=jshbyywk2008, createdTime=Wed May 10 06:11:33 CST 2023, time=2023-05-10, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=2131290, encodeId=cb19213129059, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:34:20 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131288, encodeId=68e5213128825, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:31:08 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131254, encodeId=ab932131254fc, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/23/7f016e48a01c47d183a45783cee50360.jpg, createdBy=cfb11352434, createdName=Thc822, createdTime=Tue May 09 23:09:18 CST 2023, time=2023-05-09, status=1, ipAttribution=上海)]
    2023-05-10 1581f8c42cm

    学习

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=2137816, encodeId=cb34213e8160a, content=谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=38, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=edcf4883751, createdName=498997979, createdTime=Fri May 19 08:14:17 CST 2023, time=2023-05-19, status=1, ipAttribution=江苏省), GetPortalCommentsPageByObjectIdResponse(id=2131300, encodeId=ccfc2131300bc, content=胆结石的终生患病率为10%至20%, beContent=null, objectType=article, channel=null, level=null, likeNumber=35, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2d3d3015017, createdName=jshbyywk2008, createdTime=Wed May 10 06:11:33 CST 2023, time=2023-05-10, status=1, ipAttribution=河北省), GetPortalCommentsPageByObjectIdResponse(id=2131290, encodeId=cb19213129059, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:34:20 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131288, encodeId=68e5213128825, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200814/81d08245657a4a7f9a1ef713c0ec5878/ec4b201a22194a319b1aeb171bc6bb3d.jpg, createdBy=41e02111625, createdName=1581f8c42cm, createdTime=Wed May 10 05:31:08 CST 2023, time=2023-05-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2131254, encodeId=ab932131254fc, content=谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/23/7f016e48a01c47d183a45783cee50360.jpg, createdBy=cfb11352434, createdName=Thc822, createdTime=Tue May 09 23:09:18 CST 2023, time=2023-05-09, status=1, ipAttribution=上海)]
    2023-05-09 Thc822 来自上海

    谢谢分享

    0

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