腹腔镜胆囊切除术治疗急性结石性胆囊炎合并胆汁性腹膜炎的术后感染状况分析

Postoperative infection in laparoscopic cholecystectomy in treatment of acute cholecystitis complicated by choleperitonitis

目的探讨并发胆汁性腹膜炎的急性结石性胆囊炎患者行腹腔镜胆囊切除术(LC)与传统开腹胆囊切除术(OC)后对机体系统性炎症和免疫反应影响的差异。方法对2014年1月-2016年6月于上海市利群医院明确诊断为急性结石性胆囊炎合并胆汁性腹膜炎的45例患者开展前瞻性随机对照试验,根据手术治疗途径的不同将患者随机分为LC组(n=23)和OC组(n=22);观察两组患者的住院天数、术后并发症发生及死亡情况;在术前及术后的第1、3、6天采集患者血液样本,对比两组患者术后中性粒细胞、血清CRP、红细胞沉降率(ESR)、IL-6的水平变化情况以及内毒素血症的发生情况。计量资料组间比较采用t检验;计数资料组间比较采用χ2检验。结果 LC组患者的住院天数显著少于OC组[(5.4±2.7)d vs(10.2±3.5)d,t=-5.46,P<0.001];LC组术后发生腹腔脓肿1例(4.3%),OC组为6例(27.3%),并发症发生率差异有统计学意义(χ2=4.77,P=0.03)。两组患者术后病死率为17.8%(8/45),其中LC组1例(4.3%),OC组7例(31.8%),两组比较,差异有统计学意义(χ2=5.16,P=0.02)。OC组并发腹腔脓肿死亡4例,并发肺栓塞死亡1例;并发心肌梗死死亡两组各1例。两组患者术前各项炎症指标水平差异均无统计学意义。术后第1、3、6天LC组患者中性粒细胞、血清CRP、ESR(除术后第1天)、IL-6水平均低于OC组,差异均有统计学意义(P值均<0.05)。此外,OC组患者术后内毒素浓度显著高于LC组患者(P<0.05),但两组患者术后第2天左右内毒素水平回归正常。结论 LC相较于OC能降低内毒素血症的发生概率和系统炎症反应的水平,有利于短暂免疫防御的建立,可降低术后感染风险。

Objective To investigate the influence of laparoscopic cholecystectomy （LC）versus open cholecystectomy （OC）on postopera-tive systemic infection and immune response in patients with acute cholecystitis complicated by choleperitonitis.Methods A prospective randomized controlled trial was performed for 45 patients who had a definite diagnosis of acute calculous cholecystitis complicated by cho-leperitonitis in Shanghai Liqun Hospital from January 2014 to June 2016.According to surgical procedures,the patients were randomized in-to LC group （23 patients）and OC group （22 patients）.The length of hospital stay,postoperative complications,and deaths were evaluated in both groups.Blood samples were collected from all patients before surgery and at 1,3,and 6 days after surgery to compare the changes in neutrophil count,serum levels of C -reactive protein （CRP）and interleukin -6 （IL -6）,and erythrocyte sedimentation rate （ESR）,as well as the incidence of endotoxemia.The t -test was used for comparison of continuous data between groups,and the chi -square test was used for comparison of categorical data between groups.Results The LC group had a significantly shorter length of hospital stay than the OC group （5.4 ±2.7 d vs 10.2 ±3.5 d,t = -5.46,P 〈0.001）.One patient （4.3%）in the LC group and 6 （27.3%）in the OC group ex-perienced peritoneal abscess after surgery,and there was a significant difference in the incidence rate of complications between the two groups （χ2 =4.77,P =0.03）.In all patients,the mortality rate was 17.8% （8 /45）,with 1 （4.3%）in the LC group and 7 （31.8%）in the OC group,and there was a significant difference between the two groups （χ2 =5.16,P =0.02）.Of all patients in the OC group,4 died of peritoneal abscess,1 died of pulmonary embolism,and 1 died of myocardial infarction;of all patients in the LC group,1 died of my-ocardial infarction.There were no significant differences in inflammatory markers before surgery between the two groups.At 1,3,and 6 days＆nbsp;after surgery,the LC group had significantly lower neutrophil count,serum levels of CRP and IL -6,and ESR （except at 1 day after surger-y）than the OC group （all P 〈0.05）.Furthermore,the OC group had a significantly higher concentration of endotoxin than the LC group （P 〈0.05）,but the level of endotoxin returned to normal at 2 days after surgery in both groups.Conclusion Compared with OC,LC can reduce the probability of endotoxemia,help with the establishment of immunological defense,and reduce the risk of postoperative infection.