失代偿期肝硬化的急性胆囊炎腹腔镜手术风险评估方法的探讨

Discussion on comprehensive assessment atrategy of surgical treatment about acute cholecystitis with liver cirrhosis

目的探讨胆囊炎严重程度分级联合终末期肝病模型(Model for end-stage liver disease,MELD)评分对失代偿期肝硬化的急性胆囊炎患者行腹腔镜手术的风险评估价值。方法回顾性分析2016年1月—2020年3月间新疆维吾尔自治区第三人民医院行腹腔镜手术的失代偿期肝硬化的急性胆囊炎患者58例,分为4组:A组:16例,MELD<15分,胆囊炎严重程度1级;B组:14例,MELD<15分,胆囊炎严重程度≥2级;C组:15例,MELD≥15分,胆囊炎严重程度1级;D组:13例,MELD≥15分,胆囊炎严重程度≥2级。对手术指标、手术损伤及并发症情况进行组间对比分析,并对手术前后肝功能指标和不同评估方法的评估效果进行组内对比分析。结果手术时间的比较:B组和C组长于A组,D组长于C组,差异具有统计学意义(P<0.05);手术出血量、腹腔引流时间、腹腔引流量、进食时间的比较:B组高于A组,D组高于C组,差异具有统计学意义(P<0.05);住院时间的比较:B组长于A组,D组长于A组、B组和C组,差异具有统计学意义(P<0.05);4组中转开腹率的比较差异无统计学意义(P>0.05);A组术后Child评分优于术前,差异具有统计学意义(P<0.05);C组和D组术后血清胆红素水平、血清肌酐水平和MELD评分优于术前,差异具有统计学意义(P<0.05);D组手术并发症总体发生率高于B组和C组,差异具有统计学意义(P<0.01)。结论胆囊炎严重程度分级联合MELD评分能够有效评估失代偿期肝硬化的急性胆囊炎患者行腹腔镜手术的风险,有利于指导外科干预治疗方案的选择。

Objective To assess the value of MELD score combined with cholecystitis severity grade in evaluating the risk of surgical treatment for acute cholecystitis(AC)with decompensated cirrhosis.Methods Retrospective analysis was performed on 58 cases of AC patients with decompensated cirrhosis who underwent laparoscopic surgical intervention in the Third People’s Hospital of Xinjiang from January 2016 to March 2020.The patients were divided into 4 groups:A(16 cases,MELD score<15 and AC severity level 1),B(14 cases,MELD score<15 and AC severity level≥2),C(15 cases,MELD score≥15 and AC severity level 1)and D(13 cases,MELD score≥15 and AC severity level 2 or higher).They were compared based on surgical-related indicators,surgical injury and postoperative complications and the laboratory indexes of liver function and the evaluation effect of different liver function scoring systems were analyzed between the groups.Results The operation time,blood loss,drainage tube removal time,postoperative drainage volume,eating situation and hospital stay were all increased with the amount of AC severity level increased(P<0.05).With increasing of the MELD score,the hospital stay was significantly prolonged(P<0.05),but there was no significant difference between the operation time,the blood loss,the time of abdominal drainage,the drainage volume and the eating time.The change of AC severity level and MELD score were all both unrelated to the conversion rate of laparoscopic surgery.MELD score can evaluate the improvement of liver function before and after the operation(P<0.05).For patients of AC with severe decompensated cirrhosis,both the increase of MELD score or AC severity level can lead to a significant increase in surgical complications(P<0.01).Conclusion Using MELD score combined with AC severity level to evaluate the patients can help to screen high-risk patients and guide reasonable surgical procedures.MELD score has pragmatic value in evaluating perioperative liver function of acute cholecystitis with severe decompensated cirrhosis.