经皮经肝胆囊穿刺置管引流术后早期和延期腹腔镜胆囊切除术在年龄≥65岁急性重症胆囊炎患者中应用价值的前瞻性研究

Application value of early and delayed laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage in 65 years of age or older patients with severe acute cholecystitis: a prospective analysis

目的探讨经皮经肝胆囊穿刺置管引流术(PTGD)术后早期和延期腹腔镜胆囊切除术(LC)在年龄≥65岁急性重症胆囊炎患者中的应用价值.方法采用前瞻性研究方法.选取2016年5月至2018年1月山西医学科学院山西大医院收治的80例急性重症胆囊炎患者的临床资料.采用随机数字表法将患者随机分为两组,患者行PTGD拔除引流管72h后行LC,设为PTGD+早期LC组;患者行PTGD拔除引流管5~14d后行LC设为PTGD+延期LC组.观察指标:(1)手术情况.(2)两组患者LC手术前后肝功能指标分析.(3)两组患者LC手术前后血清相关炎症因子水平.(4)随访情况.采用门诊和电话方式进行随访,了解患者术后3个月内并发症发生情况.随访时间截至2018年4月.正态分布的计量资料以Mean±SD表示,组间比较采用配对t检验.计数资料以绝对数表示,组间比较采用χ^2检验或Fisher确切概率法.结果筛选出符合条件的患者80例,男41例,女39例;平均年龄为67岁,年龄范围为65~70岁.80例患者中,PTGD+早期LC组40例,PTGD+晚期LC组40例.(1)手术情况:PTGD+早期LC组患者LC手术时间、术中出血量、术后住院时间分别为(52±15)min、(29±11)mL、(18.9±1.6)d,PTGD+晚期LC组上述指标分别为(88±13)min、(69±11)mL、(27.7±4.8)d,两组患者上述指标比较,差异均有统计学意义(t=11.668,16.219,11.000,P<0.05).(2)两组患者LC手术前后肝功能指标分析:PTGD+早期LC组患者LC术前天冬氨酸氨基转移酶、丙氨酸氨基转移酶、碱性磷酸酶、γ-谷氨酰转移酶、总胆红素水平分别为(53±11)U/L、(203±40)U/L、(128±22)U/L、(19±6)U/L、(86±21)μmol/L,LC术后24h上述指标分别为(26±5)U/L、(83±23)U/L、(29±3)U/L、(11±5)U/L、(27±7)μmol/L;上述指标手术前后比较,差异均有统计学意义(t=12.562,16.448,28.199,6.478,16.857,P<0.05).PTGD+晚期LC组患者术前天冬氨酸氨基转移酶、丙氨酸氨基转移酶、碱性磷酸酶、γ-谷氨酰转移酶、总胆红素水平分别为(54±12)U/L、(203±48)U/L、(130±24)U/L、(19±6)U/L、(85±20)μmol/L,LC术后24h上述指标水平分别为(29±5)U/L、(151±36)U/L、(53±7)U/L、(17±3)U/L、(31±8)μmol/L;上述指标手术前后比较,差异均有统计学意义(t=13.622,5.481,2.169,1.988,15.855,P<0.05).PTGD+早期LC组和PTGD+晚期LC组患者LC术前天冬氨酸氨基转移酶、丙氨酸氨基转移酶、碱性磷酸酶、γ-谷氨酰转移酶、总胆红素水平比较,差异均无统计学意义(t=0.389,0.000,0.389,0.000,0.218,P>0.05);两组患者LC术后24h上述指标比较,差异均有统计学意义(t=2.683,10.067,19.931,6.508,2.380,P<0.05).(3)两组患者LC手术前后血清相关炎症因子水平:PTGD+早期LC组患者LC术前白细胞介素-1、白细胞介素-6、超敏C反应蛋白、白细胞介素-10、肿瘤坏死因子-α水平分别为(71±9)ng/L、(82±9)ng/L、(137±16)ng/L、(75±6)ng/L、(67±9)μg/L,LC术后24h上述指标分别为(87±13)ng/L、(97±9)ng/L、(81±19)ng/L、(145±6)ng/L、(85±6)μg/L;上述指标手术前后比较,差异均有统计学意义(t=6.400,7.454,14.259,52.175,10.525,P<0.05).PTGD+晚期LC组患者术前白细胞介素-1、白细胞介素-6、超敏C反应蛋白、白细胞介素-10、肿瘤坏死因子-α水平分别为(71±9)ng/L、(82±10)ng/L、(145±28)ng/L、(75±6)ng/L、(67±10)μg/L,LC术后24h上述指标分别为(145±7)ng/L、(135±16)ng/L、(101±18)ng/L、(146±9)ng/L、(113±10)μg/L,上述指标手术前后比较,差异均有统计学意义(t=41.079,17.766,8.360,41.525,27.578,P<0.05).PTGD+早期LC组和PTGD+晚期LC组患者LC术前血清白细胞介素-1、白细胞介素-6、超敏C反应蛋白、白细胞介素-10、肿瘤坏死因子-α水平比较,差异均无统计学意义(t=0.000,0.000,1.569,0.000,0.000,P>0.05).两组患者术后24h血清白细胞介素-1、白细胞介素-6、超敏C反应蛋白、肿瘤坏死因子-α水平比较,差异均有统计学意义(t=24.844,13.092,4.833,15.185,P<0.05).(4)随访情况:80例患者均获得术后随访3个月,PTGD+早期LC组2例患者发生术后并发症,其中1例胆道损伤、1例切口感染;PTGD+晚期LC组9例患者发生术后并发症,其中3例胆道损伤、3例多器官衰竭、2例切口感染、1例死亡,两组患者术后并发症比较,差异有统计学意义(χ2=5.165,P<0.05).结论对于年龄≥65岁急性重症胆囊炎患者,PTGD拔除引流管后早期行LC能缩短LC手术时间、减少术中出血量、缩短术后住院时间,有效保护肝功能,降低术后24h血清炎症因子表达,减少术后短期并发症.

Objective To investigate the application value of early and delayed laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage ( PTGD) in 65 years of age or older patients with severe acute cholecystitis. Methods The prospective study was conducted. The clinical data of 80 patients with severe acute cholecystitis who were admitted to Shanxi Dayi Hospital of Shanxi Academy of Medical Sciences from May 2016 to January 2018 were collected. All patients were divided into two groups by random number table, including patients undergoing LC 72 h later after extubation of PTGD in the PTGD + early LC group, and patients undergoing LC 5-14 days later after extubation of PTGD in the PTGD + delayed LC group. Observation indicators:( 1) surgical situations;( 2) analysis of liver function before and after LC in the two groups;(3) analysis of serum-related inflammatory factors before and after LC in the two groups;(4) follow-up situations. Patients were followed up by outpatient examination or telephone interview to detect the postoperative complications in the postoperative three months up to April 2018. Measurement data with normal distribution were represented as Mean ± SD, and comparison between groups was done using the paired t test. Count data were represented as absolute number, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results Eighty patients were screened for eligibility, including 41 males and 39 females, aged from 65 to 70 years, with an average age of 67 years. There were 40 patients in the PTGD + early LC group and 40 in the PTGD + delayed LC group, respectively.( 1) Surgical situations: the operation time, volume of intraoperative blood loss, and duration of postoperative hospital stay were (52±15) minutes,(29±11) mL,(18. 9± 1. 6)days in the PTGD + early LC group, and (88±13)minutes,(69±11)mL,(27. 7±4. 8)days in the PTGD + delayed LC group, respectively, showing significant differences in the above indicators between the two groups (t = 11. 668, 16. 219, 11. 000, P<0. 05).(2) Analysis of liver function before and after LC in the two groups: the levels of aspartate transaminase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (GGT), and total bilirubin (TBil) of PTGD + early LC group were (53±11)U/ L,(203±40)U/ L,(128±22)U/ L,(19± 6)U/ L,(86±21)μmol / L before LC, and ( 26± 5) U/ L,( 83± 23) U/ L,( 29± 3) U/ L,( 11± 5) U/ L,( 27± 7)μmol / L at 24 hours after LC, showing significant differences in the above indicators before and after LC ( t = 12. 562, 16. 448, 28. 199, 6. 478, 16. 857, P< 0. 05). The levels of AST, ALT, GGT, and TBil of PTGD + delayed LC group were (54±12)U/ L,(203±48)U/ L,(130±24)U/ L,(19±6)U/ L,(85±20)μmol / L before LC, and (29±5) U/ L,(151± 36) U/ L,(53± 7) U/ L,(17± 3) U/ L,(31± 8)μmol / L at 24 hours after LC, showing significant differences in the above indicators before and after LC ( t = 13. 622, 5. 481, 2. 169, 1. 988, 15. 855, P<0. 05). There was no significant difference in the levels of AST, ALT, ALP, GGT, TBil before LC between the two groups (t = 0. 389, 0. 000, 0. 389, 0. 000, 0. 218, P>0. 05), meanwhile, there were significant differences in the levels of AST, ALT, ALP, GGT, TBil after LC between the two groups ( t = 2. 683, 10. 067, 19. 931, 6. 508, 2. 380, P<0. 05).(3) Analysis of serum-related inflammatory factors before and after LC in the two groups: the levels of interleukin-1 (IL-1), interleukin-6 (IL-6), high-sensitivity C-reactive protein (CRP), interleukin-10 (IL-10), and tumor necrosis factor-α( TNF-α) of PTGD + early LC group were ( 71±9) ng / L,(82±9)ng / L,(137±16)ng / L,(75±6)ng / L,(67±9)μg / L before LC, and (87±13)ng / L,(97±9)ng / L,(81± 19)ng / L,( 145 ± 6) ng / L,( 85 ± 6)μg / L at 24 hours after LC, showing significant differences in the above indicators before and after LC (t == 6. 400, 7. 454, 14. 259, 52. 175, 10. 525, P<0. 05). The levels of IL-1, IL-6, high-sensitivity CRP, IL-10, and TNF-α of PTGD + delayed LC group were (71±9)ng / L,(82±10)ng / L,(145±28)ng / L,(75±6)ng / L,(67±10)μg / L before LC, and (145±7)ng / L,(135±16)ng / L,(101±18)ng / L,(146±9) ng / L,( 113 ± 10)μg / L at 24 hours after LC, showing significant differences in the above indicators before and after LC ( t = 41. 079, 17. 766, 8. 360, 41. 525, 27. 578, P < 0. 05). There was no significant difference in the levels of IL-1, IL-6, high-sensitivity CRP, IL-10, and TNF-α before LC between the two groups ( t = 0. 000, 0. 000, 1. 569, 0. 000, 0. 000, P>0. 05), meanwhile, there were significant differences in the levels of IL-1, IL-6, high-sensitivity CRP, and TNF-α after LC between the two groups ( t = 24. 844, 13. 092, 4. 833, 15. 185, P< 0. 05).( 4) Follow-up situations: 80 patients were followed up for 3 months. Two patients in the PTGD + early LC group had postoperative complications, including 1 of bile duct injury and 1 of incisional infection;9 patients of PTGD + delayed LC group had postoperative complications, including 3 of bile duct injury, 3 of multiple organ failure, 2 of incisional infection, 1 of death. There was a significant difference in the postoperative complication between the two groups (χ^2 = 5. 165, P<0. 05). Conclusion Early LC after PTGD can effectively shorten operation time, reduce volume of intraoperative blood loss, shorten duration of postoperative hospital stay, protect liver function, reduce the expression of serum inflammatory factors at 24 hours after surgery, and reduce postoperative complications.