经皮经肝胆囊穿刺引流术联合腹腔镜胆囊切除术治疗老年Ⅲ级急性胆囊炎手术时机选择及中转开腹影响因素分析

The timing of laparoscopic cholecystectomy following percutaneous transhepatic gallbladder drainage and influence factors for laparotomic conversion in elderly patients with gradeⅢacute cholecystitis

目的探讨经皮经肝胆囊穿刺引流术(PTGBD)联合腹腔镜胆囊切除术(LC)治疗老年Ⅲ级急性胆囊炎(AC)手术时机及中转开腹的危险因素。方法120例老年Ⅲ级AC患者在PTGBD后2个月内(A组)、2~4个月(B组)、4个月以上(C组)行LC,比较3组围手术期临床指标,并用多因素Logistic回归分析中转开腹的危险因素。结果B、C组术前胆囊壁厚度、术中出血量和手术时间均低于A组(P<0.01),A、C组中转开腹率、住院时间高于B组(P<0.01或0.0125),A、B组引流并发症发生率低于C组(P<0.0125)。术前胆囊壁厚度≥5 mm、胆囊炎发作史和医师临床经验<5 a是中转开腹的独立危险因素,而"PTGBD 2~4个月行LC"是保护因素(P<0.05)。结论老年Ⅲ级AC患者在PTGBD 2~4个月再行LC的效果最佳,中转开腹的危险因素包括胆囊壁厚度、胆囊炎发作史和临床经验。

Objective To investigate the timing of laparoscopic cholecystectomy(LC)following percutaneous transhepatic gallbladder drainage(PTGBD)and influence factors for laparotomic conversion in elderly patients with gradeⅢacute cholecystitis(AC).Methods A total of 120 elderly patients with gradeⅢAC underwent LC within 2 months(group A),2-4 months(group B),and>4 months(group C)after PTGBD.Perioperative clinical indicators were compared among three groups.The risk factors for conversion to open cholecystectomy were analyzed by multivariate logistic regression.Results Gallbladder wall thickness,intraoperative bleeding and operation time were lower in groups B and C than in group A(P<0.01).Conversion rate and hospital stay were higher in groups A and C than in group B(P<0.01 or 0.0125).Incidence of drainage complications was lower in groups A and B than in group C(P<0.0125).Regression analysis showed that gallbladder wall thickness≥5 mm,cholecystitis attack and physician’s clinical experience<5 years were independent risk factors for conversion,while 2-4 month interval between PTGBD and LC was a protective factor(P<0.05).Conclusion The optimal timing of LC is 2-4 months following PTGBD in elderly patients with gradeⅢAC,and risk factors for conversion include gallbladder wall thickness,cholecystitis attack and physician’s clinical experience.