Risk Factors And Prediction Model Of Readmission And Reintervention In Patients With Necrotizing Pancreatitis After Discharge

Background:Necrotizing pancreatitis(NP)may involve a complex,variable,and prolonged clinical course.About 70%of the necrotic collections of NP is sterile.If there is no outflow tract obstruction,conservative treatment can be performed.Most necrosis collections can be gradually absorbed and subsided over time.However,some patients require readmission for intervention due to walled-off necrosis with infection,outflow tract obstruction,etc.Nevertheless,few studies have paid attention to the risk factors of readmission and reintervention after discharge of NP patients.Objective:The purpose of this study was to investigate the risk factors for readmission and reintervention in patients with necrotizing pancreatitis after discharge,to explore the correlation between pancreatic necrosis volume(PNV)and readmission as well as reintervention of NP patients after discharge,to establish a new nomogram model for predicting readmission and reintervention.Materials and methods:This study was a single-center retrospective cohort study.The subjects were NP patients with inpatient diagnosis in the Department of Gastroenterology of the First Affiliated Hospital of Nanchang University,who had undergone contrast-enhanced computed tomography(CT)examinations one week before discharge.In this study,all eligible patients were retrieved from the picture archiving and communication system(PACS)to obtain imaging manifestations and clinical data from the case system.The scores and CT severity index(CTSI)were recorded at discharge,PNV was calculated semi-automatically by post-processing workstation software.The patients were divided into readmission group and non-readmission group,reintervention group and non-reintervention group.The correlation between pancreatic necrosis volume and readmission and reintervention was analyzed,and the best cut-off value of pancreatic necrosis volume for predicting readmission and reintervention was obtained by constructing receiver operating characteristic curve(ROC)curve.Univariate and multivariate logistic regression were used to analyze the independent risk factors of readmission and reintervention after discharge,and a predictive model for readmission and reintervention was established according to the risk factors,and a nomogram was constructed.The area under curve(AUC)of the ROC was used to compare the new predictive model with readmission score and CTSI score to verify its diagnostic performance.Result:1.This study included a total of 1028 NP patients who were hospitalized in the Department of Gastroenterology of the First Affiliated Hospital of Nanchang University from January 2015 to October 2019.A total of 167 cases met the inclusion criteria.The total median age was 46 years old(interquartile range(IQR),37.0-53.0),including 106 males(63.5%).After discharge,a total of 94(56.3%)patients were readmitted and 55(32.9%)patients underwent intervention treatment.The median PNV of all patients was 376.6(IQR,129.3-820.5)cm~3.The PNV in the readmission group was significantly higher than that in the non-readmission group(median(IQR),411.7(171.9-907.7)cm~3vs.288.2(81.8-557.2)cm~3,P=0.010).The PNV in the readmission group was significantly higher than that in the non-readmission group(median(IQR),428.5(172.0-1187.9)cm~3vs.299(118.5-614.7)cm~3,P=0.028),and the optimal cut-off value of pancreatic necrosis volume for predicting readmission and reintervention was 620 cm~3.Multivariate logistic regression analysis showed that pancreatic necrosis volume≥620cm~3(adjusted odds ratio(adj OR),3.64;95%CI,1.70-7.79;P=0.001),complete pancreatic duct interruption(adj OR,5.08;95%CI,2.20-11.72;P<0.001)were independent risk factors for readmission.Stents or drainage tubes were placed at discharge(adj OR,2.61;95%CI,1.08-6.32;P=0.034),pancreatic necrosis volume≥620cm~3(adj OR,8.80;95%CI,3.20-24.22;P<0.001),pancreatic duct status(partial interruption of pancreatic duct(adj OR,9.02;95%CI,2.26-35.98;P=0.002)and complete interruption(adj OR,20.40;95%CI,7.12-58.47;P<0.001))were independent risk factors for reintervention.The AUC derived from predictive models based on these factors was the highest among the scoring systems,and the nomogram developed incorporating these factors showed good identification,calibration,and clinical utility.2.This study performed a subgroup analysis of 108 of 167 NP patients who did not undergo any invasive intervention during their first hospitalization.The results showed that among the 108 patients with NP,28(25.9%)underwent invasive intervention after discharge.The median PNV of all patients was 437.0(IQR,223.8-957.8)cm~3.Compared with the non-intervention group,the PNV of the intervention group was significantly higher than that of the non-intervention group(median(IQR),642.0(308.5-1547.3)cm~3vs.398.0(204.1-792.2)cm~3,P=0.017).Multivariate logistic regression analysis showed that pancreatic necrosis volume≥620cm~3(adjusted odds ratio(adj OR),2.49;95%CI,1.05-5.91;P=0.039),complete pancreatic duct interruption(adj OR,5.59;95%CI,1.67-18.63;P=0.005)were independent risk factors for readmission.Pancreatic necrosis volume≥620cm~3at discharge(adj OR,6.80;95%CI,1.94-23.89;P=0.003)and pancreatic duct status(partial interruption(adj OR,9.17;95%CI,1.48-56.61;P=0.017)and complete interruption(adj OR,30.45;95%CI,7.38-125.70;P<0.001))were independent risk factors for post-discharge intervention.The accuracy of post-discharge intervention prediction model was higher than that of CTSI score(AUC,0.855 vs.0.755;P<0.05).Conclusions:1.Pancreatic necrosis volume at discharge is strongly associated with readmission and reintervention in patients with NP after discharge,and the optimal cut-off value of the volume of pancreatic necrosis to predict readmission and reintervention of NP patients after discharge by ROC curve analysis is 620cm~3.2.The volume of pancreatic necrosis≥620cm~3at discharge and pancreatic duct interruption are independent risk factors for readmission of NP patients after discharge.3.Stent or drainage tube placement at discharge,the volume of pancreatic necrosis≥620cm~3and pancreatic duct interruption are independent risk factors for reintervention of NP patients after discharge.4.The risk of readmission and reintervention of NP patients after discharge can be assessed by nomogram,which has good identification,calibration and clinical practicability.It is recommended to formulate an appropriate discharge plan for high-risk patients and closely follow-up,so as to prevent these possible avoided readmission and reintervention.