Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2020; 26(26): 3800-3813
Published online Jul 14, 2020. doi: 10.3748/wjg.v26.i26.3800
Nomogram for predicting transmural bowel infarction in patients with acute superior mesenteric venous thrombosis
Meng Jiang, Chang-Li Li, Chun-Qiu Pan, Wen-Zhi Lv, Yu-Fei Ren, Xin-Wu Cui, Christoph F Dietrich
Meng Jiang, Xin-Wu Cui, Sino-German Tongji-Caritas Research Center of Ultrasound in Medicine, Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
Chang-Li Li, Department of Geratology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Wuhan 430015, Hubei Province, China
Chun-Qiu Pan, Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong Province, China
Wen-Zhi Lv, Department of Artificial Intelligence, Julei Technology Company, Wuhan 430030, Hubei Province, China
Yu-Fei Ren, Department of Computer Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
Christoph F Dietrich, Department of Internal Medicine, Hirslanden Clinic, Berne 27804, Switzerland
Author contributions: Jiang M, Cui XW and Li CL designed the study; Ren YF and Cui XW supervised the study; Jiang M, Pan CQ and Lv WZ collected and analyzed the data; Ren YF performed the R Script; Jiang M prepared the figures and tables, and drafted the manuscript; Dietrich CF revised the manuscript for important intellectual content; Ren YF and Cui XW contributed equally as co-corresponding authors.
Supported by Wuhan Tongji Hospital, No. 2017A002; and Wuhan Science and Technology Bureau, No. 2017060201010181.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Tongji Medical college, Huazhong University of Science and Technology.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Xin-Wu Cui, MD, PhD, Professor, Deputy Director, Sino-German Tongji-Caritas Research Center of Ultrasound in Medicine, Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan 430030, Hubei Province, China.
Received: February 25, 2020
Peer-review started: February 25, 2020
First decision: May 22, 2020
Revised: May 23, 2020
Accepted: June 5, 2020
Article in press: June 5, 2020
Published online: July 14, 2020
Research background

The prognosis of acute mesenteric ischemia (AMI) caused by superior mesenteric venous thrombosis (SMVT) remains obscure and early detection of transmural bowel infarction (TBI) is crucial. The predisposition to develop TBI is of clinical concern, which can lead to fatal sepsis with hemodynamic instability and multiorgan failure. Early resection of necrotic bowel could improve the prognosis of AMI, however, accurate prediction of TBI remains a challenge for clinicians. When determining eligibility for explorative laparotomy, the underlying risk factors for bowel infarction should be fully evaluated.

Research motivation

Nomograms can provide individualized and highly accurate risk estimation, which are easy to use and can facilitate clinical decision-making. We undertook the present study to develop and externally validate a nomogram to predict TBI in patients with acute SMVT.

Research methods

Consecutive data from 207 acute SMVT patients at the Wuhan Tongji Hospital and 89 patients at the Guangzhou Nanfang Hospital between July 2005 and December 2018 were included in this study. They were grouped as training and external validation cohort. The 207 cases (training cohort) from Tongji hospital were divided into TBI and reversible intestinal ischemia groups based on the final therapeutic outcomes. Then univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for TBI using the training data, and a nomogram was subsequently developed. The performance of the nomogram was evaluated with respect to discrimination, calibration, and clinical usefulness in the training and external validation cohort.

Research results

Univariate and multivariate logistic regression analyses identified the following independent prognostic factors associated with TBI in the training cohort: The decreased bowel wall enhancement (OR = 6.37, P < 0.001), rebound tenderness (OR = 7.14, P < 0.001), serum lactate levels > 2 mmol/L (OR = 3.14, P = 0.009) and previous history of deep venous thrombosis (OR = 6.37, P < 0.001). Incorporating these four factors, the nomogram achieved good calibration in the training set (AUC 0.860; 95%CI: 0.771-0.925) and the external validation set (AUC 0.851; 95%CI: 0.796-0.897). The positive and negative predictive values (95%CIs) of the nomogram were calculated, resulting in positive predictive values of 54.55% (40.07%-68.29%) and 53.85% (43.66%-63.72%) and negative predictive values of 93.33% (82.14%-97.71%) and 92.24% (85.91%-95.86%) for the training and validation cohorts, respectively. Based on the nomogram, patients who had a Nomo-score of more than 90 were considered to have high risk for TBI. Decision curve analysis indicated that the nomogram was clinically useful.

Research conclusions

The nomogram achieved an optimal prediction of TBI in patients with AMI. Using the model, the risk for an individual patient inclined to TBI can be assessed, thus providing a rational therapeutic choice.

Research perspectives

Although we have validated the nomogram in an external cohort, the number of variables evaluated in respect to the number of primary outcome events may have led to an overfitting of the accuracy of the model, thus prospective multicenter validation using a larger group of patients is still necessary to acquire high-level evidence for further clinical application.