腹壁子宫内膜异位症术前预测补片的可行性分析

摘要

Objective:To explore and compare the clinical and sonographic characteristics of grouped patients with abdominal wall endometriosis (AWE) in terms of whether use mesh or not to repair the fascia defect when wide excision was done,and to find reliable indicators of preoperative prediction.Methods:161 cases of pathologically proved AWE with history of transverse incisional cesarean section during 6-year period (2005-2010)in the department of Obstetrics and Gynecology of Peking Union Medical University Hospital (Beijing,China) were analyzed retrospectively.Patients were divided into two groups according to whether the mesh was needed to repair the fascia defect.Clinical and ultrasound (US)findings were compared between them.Prediction formula and single-index threshold were obtained by Logistic's regression analysis and ROC curve method respectively.The similar surgical cases of 49 patients admitted in 2011 were used to test accuracy and feasibility of two methods prospectively as previously mentioned.Results:Compared with simple excision group,patients who needed artificial mesh to repair abdominal wall had larger size of foci (3.9 cm vs.2.5 cm,P=0.001); more vascular signals by US (41.7％ vs.27.9％,P=0.038) ;higher level of serum CA125 means (48.6 U/mL vs.32.2 U/mL,P=0.041);more chance of entering intraabdominal cavity (79.4％ vs.18.9％,P=0.000) ;larger fascia defect (6.4 cm vs.1.6 cm,P=0.000) ;more perioperative bleeding (73.1 mL vs.29.5 mL,P=0.000); higher frequency of using incisional drainage (76.7％ vs.9.0％,P=0.000); and longer hospital stays (10.2 d vs.6.4 d,P=0.000).In terms of mean age,time since onset of symptoms,character of pain,number and margin of foci,there is no significant difference between two groups.The threshold of maximal diameter by US was 3 cm by ROC curve.Logistic's regression formula was P (mesh)=1/[1+e-(-3.141+0.408max diameter of foci by US+0.019serumCA125)].The predictive outcomes of 49 cases were compared with surgical outcomes.The overall compliance rate were 81.6％ and 91.3％ respectively,which underestimated rate were 7.7％ and 27.3％,overestimate rate were 22.2％ and 2.9％ respectively.Conclusions:The longest diameter of ultrasound lesion has good predictive value of discriminating fascia defect and use of mesh,with 3 cm as warning value.The Logistic regression formula with serum CA125 involved in,does not significantly improve the prediction performance.For positive predicted patients,it is recommended to strengthen counseling and a full range of preparations.%目的:探讨腹壁子宫内膜异位症(AWE)患者行病灶切除术后是否使用筋膜补片的临床和影像学特点差异,寻找有利于术前预测的临床指标.方法:回顾性分析北京协和医院妇产科2005-2010年间收治的161例既往行腹壁横切口剖宫产而后发现AWE患者的临床资料,采用Logistic回归分析得出与“使用补片”结局相关的临床指标及其预测公式,与受试者工作特征(ROC)曲线方法得出的单指标阈值相对比,以2011年收治的49例同类手术病例前瞻性验证其预测的准确性.结果:与单纯切除组相比,需要补片修补的患者局部病灶经超声探测的最大径线更大(3.9 cmvs.2.5 cm,P=0.001)；病灶的血流信号更丰富(41.7％ vs.27.9％,P=0.038)；血清CA125均值更高(48.6 U/mL vs.32.2 U/mL,P=0.041)；术中进入腹腔的概率更高(79.4％vs.18.9％,P=0.000)；腹膜缺损的最长径更长(6.4 cm vs.1.6 cm,P=0.000)；术中出血更多(73.1 mL vs.29.5mL,P=0.000)；伤口引流率更高(76.7％ vs.9.0％,P=0.000)；住院时间更长(10.2 d vs.6.4 d,P=0.000).而2组年龄、潜伏期、症状期以及疼痛性质等方面差异无统计学意义.由术前超声病灶最大径单项指标绘制ROC曲线,得出“使用补片”的界值为3 cm.经二项分类Logistic回归分析,得出回归预测方程为:P(补片)=1/[1+e-(-3.141+0.408超声最大径+0.019CA125)].采用上述两种方法分别预测2011年度收治同类患者使用补片的情况,与手术结局对比,总的符合率分别为81.6％和91.3％,其中低估率分别为7.7％和27.3％,高估率为22.2％和2.9％.结论:超声下病灶的最长径对判别切除术后腹壁缺损程度,进而是否需要补片具有良好的预测价值,警戒阈值为“＞3 cm”.血清CA125水平与超声下病灶最长径共同构成的Logistic回归预测方程,并不比单项阈值预测效能更优越.经术前评估需要使用补片的病例,应做好相应的咨询和材料、人员的准备.