| Objective: Explore the clinical significance and value of primary duct closure after laparoscopic common bile duct exploration in the treatment of mild to moderate acute calculous cholangitis and the characteristics of biliary drainage after primary duct closure,a risk prediction scoring model for liver function influence after primary duct closure after laparoscopic common bile duct exploration in mild and moderate acute calculous cholangitis was constructed.Methods: This study is mainly divided into two parts.Part Ⅰ : The retrospective analysis assessed the clinical data of patients with mild to moderate acute calculous cholangitis who underwent primary duct closure and T-tube drainage after laparoscopic common bile duct exploration from January 2016 to October 2021 in the Department of Hepatobiliary Surgery,No.940 Hospital of the PLA Joint Logistics Support Force.Propensity score matching analysis(PSM)was used to match the primary duct closure group and T-tube drainage group in a 1:1 ratio.The differences in operation time,intraoperative blood loss,gastrointestinal recovery time,postoperative hospital stay,total hospitalization costs,postoperative complications and changes of liver function before and after surgery were compared between the two groups.Part II: The retrospective analysis assessed the clinical data of patients with mild to moderate acute calculous cholangitis who underwent primary duct closure and T-tube drainage after laparoscopic common bile duct exploration from January 2018 to October 2021 in the Department of Hepatobiliary Surgery,No.940 Hospital of the PLA Joint Logistics Support Force.The case data from January 2018 to December 2020 was set as the modeling group,and the case data from January 2021 to October 2021 was set as the validation group.Taking whether or not the postoperative liver function was affected as the outcome variable,the independent risk factors and protective factors affecting the liver function in patients with mild to moderate acute calculous cholangitis who underwent primary duct closure after laparoscopic common bile duct exploration were screened out by univariate analysis and binary logistic regression analysis,and a risk prediction scoring model was constructed.The receiver operating characteristic curve was used to evaluate the discrimination of the model,the calibration curve was applied to evaluate the predictive accuracy of the model,and the decision curve analysis was determined to evaluate the clinical value of the model.The internal validation of the model is carried out by enhanced Bootstrap method,and the data of validation group is substituted into the risk prediction scoring model for external validation,and then the performance of the model in internal and external validation is evaluated.Web calculators,nomograms,and score sheets were established to visualize the model.Results: Part 1:116 patients in each group were included in the final study through PSM.There was no statistical significance in the preoperative general data,preoperative experimental indicators and imaging data between the two groups.The average operation time in the primary duct closure group was 114.79±34.61 min,the average intraoperative blood loss was 27.16±25.75 ml,and the average postoperative hospital stay was 7.03±3.12 days.The average operation time in the T-tube drainage group was 133.00±53.85 min,and the average intraoperative blood loss was 35.99±35.99± 27.20 ml,and the average postoperative hospital stay was 8.32±5.52 days.The above data were significantly different between the two groups(P<0.05).The recovery time of the gastrointestinal tract in the primary duct closure group was 2.43±0.69 days,and the total hospitalization cost was23818.08±6860.14 yuan.The gastrointestinal tract recovery time in the T-tube drainage group was 2.61±0.77 days,and the total hospitalization cost was 28612.93±14446.66 yuan.There was no statistical difference in the above data between the two groups(P>0.05).2cases(1.7%)of bile leakage and 1 case(0.9%)of residual stones were occurred in the primary duct closure group,and 1 case(0.9%)of bile leakage,1 case(0.9%)of residual stones and 3 cases(2.6%)of incision infection were occurred in the T-tube drainage group.There was no bile duct stricture and abdominal infection in the patients included in the two groups.And there was no statistical difference in the above data between the two groups(P>0.05).The indexes of TBIL,DBIL,AST,ALT,and alkaline phosphatase in the two groups on the 1st,3rd,and 5th days after operation were all decreased compared with those before operation,and the difference within the group was statistically significant(P<0.05).The indexes of TBIL and DBIL in the T-tube drainage group on the 1st and 3rd day after operation were lower than those in the primary duct closure group,and the difference was statistically significant(P<0.05).There was no significant difference in other postoperative liver function indexes between the two groups(P>0.05).Part II: Results of univariate and logistic regression analysis showed that WBC(OR value=1.334)and multiple stones(OR value=4.795)were independent risk factors and albumin(OR value=0.925)was a protective factor.The area under the receiver operating characteristic curve was 0.837(95%CI: 0.774-0.900),and optimal cutoff value was 0.131(specificity = 0.581,sensitivity = 0.929).The calibration curve showed a high degree of agreement between the predicted probability of the model and the actual probability,and the Brier value = 0.131.Decision curve analysis suggested that the model had higher clinical benefit within the threshold probability range of0.1-0.8.The model still has a good degree of discrimination and calibration in internal and external validation.Conclusion: Although the ability of reducing bilirubin by primary duct closure was lower than that of T-tube drainage on the 1st and 3rd postoperative day,there was no statistical difference between the two groups on the 5th postoperative day,suggesting that the effect was transient and did not prolong the recovery.During the process,primary duct closure can achieve the same drainage efficiency as T-tube.In summary,primary duct closure has many advantages over traditional T-tube drainage,and it is more in line with the concept of minimally invasive surgery and enhanced recovery aftersurgery.On the premise of a reasonable grasp of surgical indications,primary duct closure after laparoscopic common bile duct exploration and stone extraction is a safe and effective operation.By screening the independent risk factors and protective factors of liver function influence after primary duct closure after laparoscopic common bile duct exploration,it is suggested that WBC and multiple stones were independent risk factors and albumin was protective factor for liver function after primary duct closure for laparoscopic common bile duct exploration.The established risk prediction scoring model has good performance in discrimination,calibration and clinical value,which can help clinicians quickly identify high-risk patients,and provide a reference in a certain direction for clinical diagnosis and treatment,preoperative individualized evaluation and selection of the surgical approach. |
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