急性结石性胆囊炎腹腔镜手术时机及中转开腹影响因素的探讨

Timing of laparoscopic cholecystectomy for acute lithiasic cholecystitis and influencing factors for conversion to open procedure

目的探讨腹腔镜手术治疗急性结石性胆囊炎的最佳时机以及影响中转开腹的因素。方法对468例行腹腔镜胆囊切除术的急性结石性胆囊炎病人的临床资料进行回顾性分析。将468例病人分为A(症状发作48 h内手术)、B(48～72 h内手术)、C(72 h后手术)、D(保守治疗后再择期手术)4组。结果A、B、C、D 4组的术后并发症发生率分别为3．48％(5／146)、3．69％(5／137)、5．88％(6／102)和3．17％(2／63),各组间术后并发症发生率并无显著性差异(P均>0．05);C组的手术时间较其他3组明显延长(P<0．05),且手术中转率也显著高于其他各组(P<0．05);A组的手术时间较其他组短,开腹中转率也较其他组低(P<0．05);单因素分析结果显示体温、右上腹肌紧张、胆囊肿大、白细胞计数、胆囊壁厚度、胆囊颈部结石嵌顿、手术时机7个因素与中转开腹率显著相关(P<0．05)。多因素回归分析显示白细胞计数和手术时机是影响腹腔镜中转开腹率的独立危险因素。结论急性结石性胆囊炎症状发作后48 h内是腹腔镜手术的最佳时机,白细胞计数和手术时机是影响腹腔镜中转开腹率的独立危险因素。

Objective To determine the optimal timing for laparoscopic cholecystectomy in patients with acute lithiasic cholecystitis and evaluate the influencing factors of conversion to open procedure. MethodsThe clinical data of 468 patients with acute lithiasic cholecystitis receiving laparoscopic cholecystectomy in our hospital were retrospectively analyzed. According to the time interval from initial onset of symptoms to receiving the laparoscopic cholecystectomy, the 468 patients were divided in- to 4 groups. The patients in group A （n=146）, B （n=137） and C （n=102） received the procedure within 48 h, during 48-72 h and beyond 72 h after onset, respectively. Those in group D （n=63） received initial conservative treatment followed by delayed laparoscopic cholecystectomy 2-4 weeks later. Results The postoperative complication rate was 3. 48% （5/146）, 3.69% （5/137）, 5.88% （6/ 102） and 3. 17% （2/63） in group A, B, C and D, respectively. There was no significant difference among the 4 groups （P〉0. 05）. Group C had markedly longer operation time and higher rate of conversion to open procedure （P〈0.05） while group A had remarkably shorter operation time and lower rate of conversion to open procedure （P〈0. 05）. Univariate analysis showed that temperature, right upper quadrant tenderness, enlarged gallbladder, leukocyte count, cholecystic wall thickness, stone incarceration in cholecystic neck and timing of operation were significantly correlated with the rate of conversion to open procedure （P〈0. 05）. Multivariate analysis revealed that leukocyte count and timing of operation were independent risk factors for conversion from laparoscopic cholecystectomy to open surgery. Conclusions The optimal timing for laparoscopic cholecystectomy for acute cholecystitis with cholecystolithiasis is within 48 h after onset of symptoms. Leukocyte count and timing of operation are independent risk factors for conversion to open procedure.