经皮胆囊造瘘术治疗中重度急性胆囊炎的时机和临床经验

The timing and clinical experience of percutaneous cholecystostomy in the treatment of moderate to severe acute cholecystitis

目的探讨经皮胆囊造口术(PC)用于治疗急性胆囊炎的病例选择和临床经验报告。方法对2015年1月至2021年1月期间诊断为急性胆囊炎(AC)患者临床资料进行回顾性分析。根据2013年东京共识指南(TG13),筛选出严重程度为Ⅱ级(中度)和Ⅲ级(重度)AC患者进行临床评估,包括临床特征、治疗、住院时间、结果、发病率和30天死亡情况。结果共134例患者纳入研究,中位年龄63.5岁,其中41例接受PC(PC组),Charlson合并症指数(CCI):0分18例(43.9%)、1分11例(26.8%)、≥2分12例(29.3%)。77例保守治疗(保守组),CCI:0分31例(40.2%)、1分18例(23.4%)、≥2分28例(36.4%)。26例胆囊切除术(胆囊切除组),CCI:0分17(65.4)、1分5(19.2)、≥2分4(15.4)。随访60天,12例失访。三个不同处理组中,与保守组比较,PC组显示更快速的WBC降低、更少的抗生素用药时间、更短住院时间;但与胆囊切除组比较,在住院时间和抗生素用药时间没有优势。PC组:胆汁引流后第一天WBC明显下降,与入院时比较,P<0.001;使用抗生素时间平均(11.4±2.6)天;25例(25/38)执行延迟LC,主要并发症为引流管脱位3例,1例患者PC术后第2天因脓毒性休克、心衰死亡。保守组:主要采取抗生素治疗和营养支持,入院后3天WBC明显下降,与入院时比较差异有统计学意义(P<0.001);使用抗生素时间为(12.9±3.1)天;43例(43/65)患者执行LC;有4例患者死亡,分别为入院后4天、7天、15天和24天,死亡原因包括严重感染、MODS、肺栓塞和脑出血;4例(6.2%,4/65)术后60天内复发。胆囊切除组:腹腔镜手术方式14例,开腹胆囊切除术12例,一例患者术后17天因高血压脑出血死亡。结论对于中重度AC患者,应根据患者实际情况选择治疗方法,PC是不适合手术的中重度AC患者的有效治疗方式,建议早期使用。

Objective To discuss the timing and clinical experience report of percutaneous cholecys⁃tostomy(PC)for the treatment of acute cholecystitis.Methods A retrospective analysis of clinical data was performed in patients diagnosed with acute cholecystitis(AC)from January 2015 to January 2021.According to the Tokyo Guidelines 2013(TG13),patients with AC severity gradeⅡ(moderate)and gradeⅢ(severe)were screened for clinical evaluation,including clinical characteristics,treatment,hospital stay,outcome,morbidity and 30⁃day death.Results A total of 134 patients were included in the study,with a median age of 63.5 years.Among them,41 received PC(PC group),Charlson Compli⁃cation Index(CCI):0 points in 18 cases(43.9%),1 point in 11 cases(26.8%),≥2 points in 12 cases(29.3%);77 received conservative treatment(conservative group),CCI:0 points in 31 cases(40.2%),1 point in 18 cases(23.4%),≥2 points in 28 cases(36.4%);26 had cholecystectomy,CCI:0 points 17(65.4),1 point 5(19.2),≥2 points 4(15.4);The patients were followed up for 60 days in which 12 were lost to follow⁃up.Among the three different management groups,compared with the conservative group,the PC group showed faster WBC reduction,less antibiotic administration time,and shorter hos⁃pital stay;but compared with the cholecystectomy group,there was no advantage in hospital stay and antibiotic administration time.PC group:WBC decreased significantly on the first day after bile drainage(compared with admission,P<0.001);the average time of antibiotic use was 11.4±2.6 days;25 cases(25/38)were performed delayed LC,and the main complication was drainage tube dislocation 3 For example,one patient died of septic shock and heart failure on the second day after PC operation.Conser⁃vative treatment group:antibiotic treatment and nutritional support were mainly taken.WBC decreased significantly 3 days after admission,which was significantly different from that at admission(P<0.001);antibiotics were used for 12.9±3.1 days;43 cases(43/65)underwent LC;4 patients died,4 days,7 days,15 days and 24 days after admission,respectively.The causes of death included severe infection,MODS,pulmonary embolism and cerebral hemorrhage;4 cases(6.2%,4/65)recurrence within 60 days after surgery.Conclusion For patients with moderate to severe AC,the management should be selected according to the actual situation of the patient.PC is an effective treatment for patients with moderate to severe AC who is not suitable for surgery,and early use is recommended.