高龄急性化脓性胆囊炎经皮经肝胆囊穿刺置管引流术后手术时机的选择

Timing of the laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute pyogenic cholecystitis in the advanced age

目的探讨高龄急性化脓性胆囊炎患者经皮经肝胆囊穿刺置管引流术后手术时机的选择。方法回顾性分析2018年1月—2019年2月中国人民解放军联勤保障部队第九〇〇医院肝胆外科56例高龄急性化脓性胆囊炎患者的临床资料,其中男性31例,女性25例,年龄为(75.72±3.57)岁,年龄范围为70~86岁。依据患者经皮经肝胆囊穿刺置管引流术(PTGD)后行腹腔镜胆囊切除术(LC)的时间间隔分为A、B、C3组,A组为PTGD后间隔2个月内行LC患者(n=12),B组为PTGD后间隔2~4个月行LC患者(n=21)、C组为PTGD后间隔4~6个月行LC患者(n=23)。观察指标:(1)手术情况。比较三组患者手术基本情况及术后基本情况。(2)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2019年6月。正态分布的计量资料以均数±标准差(Mean±SD)表示,多组间比较采用单因素方差分析(AVONA检验),两组间比较采用t检验,多组两两比较采用SNK-q检验,等级资料采用Kruskal-WallisH检验;计数资料采用χ2检验或Fisher确切概率法。结果(1)手术情况:A组患者LC术前胆囊壁厚度、中转开腹率、术中出血量、手术时间、术后住院时间分别为(0.57±0.04)cm、50.0%、(95.83±11.45)ml、(107.50±21.90)min、(5.67±3.40)d;B组上述指标分别为(0.43±0.03)cm、9.5%、(69.52±24.59)ml、(71.43±12.16)min、(3.76±2.61)d;C组上述指标分别为(0.43±0.05)cm、39.1%、(68.64±21.89)ml、(77.95±12.88)min、(5.05±2.95)d,上述指标三组间比较,差异均有统计学意义(P<0.05)。A组LC术前胆囊壁厚度、术中出血量、手术时间高于B和C组,差异均有统计学意义(P<0.05);LC术前胆囊壁厚度、术中出血量、手术时间在B和C组之间差异无统计学意义(P>0.05)。B组中转开腹率和术后住院时间分别优于A和C组,差异有统计学意义(P<0.05);中转开腹率和术后住院时间在A和C组之间差异无统计学意义(P>0.05)。成功行LC患者术前胆囊壁厚度、术中出血量、手术时间、术后住院时间分别为(0.43±0.03)cm、(46.67±9.82)ml、(67.69±7.77)min、(2.64±0.58)d,中转开腹患者上述指标分别为(0.52±0.04)cm、(123.53±17.30)ml、(134.12±25.51)min、(8.47±0.80)d,上述指标组间比较,差异均有统计学意义(P<0.05)。(2)随访情况:56例患者均获得随访,无围手术期死亡,随访3个月无并发症发生。结论高龄急性化脓性胆囊炎患者PTGD治疗后2~4个月择期行手术治疗,可减少术中出血量和中转开腹率,缩短手术时间和术后住院时间,利于患者的康复。

Objective To investigate the timing of the laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage for acute pyogenic cholecystitis in the advanced age. Methods The clinical data for 56 advanced age patients with acute pyogenic cholecystitis in the Department of Hepatobiliary Surgery, the 900th Hospital of the Joint Logistics Support Force of People′s Liberation Army from January 2018 to February 2019 were retrospectively analyzed. There were 31 males and 25 females, aged from 70 to 86 years, with average age was (75.52±3.57) years. According to the percutaneous transhepatic gallbladder drainage(PTGD) after laparoscopic cholecystectomy(LC) time interval, all patients were divided into three groups. Patients in the group A(n=12), B(n=21), and C (n=23) performed LC were within 2 months, during 2-4 months, and during 4-6 months, retrospectively. Observation indicators:(1) Surgical situations. The operation and postoperative basic condition of the three groups were compared.(2) Follow-up situations. Patients were followed-up by outpatient examination or telephone interview to detect the postoperative complication in the postoperative three months up to June 2019. Measurement data with normal distribution were represented as (Mean±SD), and comparison multiple groups was done using single factor analysis of variance (AVONA test), and comparison between groups was done using the t test, and comparison of multiple groups in pairs was done using the SNK-q test, and hierarchical data were analyzed using Kruskal-wallis H test. Count data were analyzed using the chi-square test or Fisher exact probability. Results (1) Surgical situations: the thickness of gallbladder wall before LC, the rates of converting to laparotomy, the volume of intraoperative blood loss, the operation duration, and the duration of postoperative hospital stay were (0.57±0.04) cm, 50.0%,(95.83±11.45) ml,(107.50±21.90) min,(5.67±3.40) d in the group A, and (0.43±0.03) cm, 9.5%,(69.52±24.59) ml,(71.43±12.16) min,(3.76±2.61) d in the group B, and (0.43±0.05) cm, 39.1%,(68.64±21.89) ml,(77.95±12.88) min,(5.05±2.95) d in the group C, respectively, showing significant differences in the above indicators between the three groups (P<0.05). The thickness of gallbladder wall before LC, the volume of intraoperative blood loss, the operation duration, those in group A were higher than the group B and C (P<0.05), and with no statistically significant different between the group B and C (P>0.05). The rates of converting to laparotomy, the duration of postoperative hospital stay in group B were better than the group A and C (P<0.05), and with no statistically significant different between the group A and C (P>0.05). The thickness of gallbladder wall before LC, the volume of intraoperative blood loss, the operation duration, and the duration of postoperative hospital stay were (0.43±0.03) cm,(46.67±9.82) ml,(67.69±7.77) min,(2.64±0.58) d in the gallbladder wall thickness of successful LC patients, and (0.52±0.04) cm,(123.53±17.30) ml,(134.12±25.51) min,(8.47±0.80) d in the laparotomy patients, respectively, showing significant differences in the above indicators between the two groups (P<0.05).(2) Follow-up situations: 56 patients were followed up and without perioperative death. No complications occurred after 3 months of follow-up. Conclusion Elective surgery that is performed in 2-4 months after PTGD for patients with acute pyogenic cholecystitis in the advanced age can reduce the volume of intraoperative blood loss and the rates of converting to laparotomy, shorten the operation duration and the duration of postoperative hospital stay, which is beneficial to the recovery of patients.