经胆囊注射吲哚菁绿在症状性胆囊结石合并肝硬化手术中的疗效评价

Evaluation of the efficacy of transgallbladder injection of indocyanine green in symptomatic gallbladder stones combined with liver cirrhosis surgery

目的探讨腹腔镜胆囊切除术(LC)中经胆囊注射吲哚菁绿在治疗胆囊结石合并肝硬化患者的可行性及疗效。方法采用回顾性病例对照研究方法,收集2018年1月—2022年5月南京医科大学附属常州第二人民医院肝胆胰外科因胆囊结石伴胆囊炎发作行LC的96例肝硬化患者的临床资料。术前所有患者均经临床病史及辅助检查等确诊并按照组别进行胆囊切除,根据是否使用吲哚菁绿将其分为荧光组(n=49)和白光组(n=47),其中荧光组术中直接经胆囊注射吲哚菁绿后在荧光模式下行LC,白光组为在白光模式下行常规LC。比较两组识别三管时间、手术时间、术中出血量、术中损伤、中转开腹及输血情况、术后引流时间、术后住院时间、术后并发症及手术前后感染及肝功能指标的变化情况。服从正态分布的计量资料采用均数±标准差(x^(-)±s)表示,组间比较采用独立样本t检验。服从偏态分布的计量资料采用M(Q_(1),Q_(3))表示,组间比较采用Mann-WhitneyU检验。计数资料组间比较采用χ^(2)检验或Fisher确切概率法。结果两组均成功实施手术,荧光组识别三管时间、手术时间、术中出血量、术后引流时间、术后住院时间、术后丙氨酸氨基转移酶、术后谷氨酰转肽酶、术后总胆红素分别为(14.96±1.49)min、(52.14±7.36)min、5(5,10)mL、(1.61±0.61)d、(2.37±0.49)d、31.5(22.0,44.8)U/L、38.0(21.0,91.5)U/L、18.0(11.5,22.8)μmol/L,白光组分别为(29.87±3.37)min、(84.36±13.25)min、10(10,20)mL、(2.70±0.69)d、(3.15±0.42)d、45.0(28.0,64.8)U/L、73.0(32.0,132.0)U/L、23.0(16.1,29.3)μmol/L,两组相比差异具有统计学意义(P<0.05)。荧光组无术中损伤及中转开腹例数、有2例术后并发症,白光组有2例术中损伤、1例中转开腹例数、5例术后并发症,两组均无输血例数,两组以上指标相比差异无统计学意义(P>0.05)。荧光组和白光组术前实验室指标比较,差异均无统计学意义(P>0.05)。荧光组和白光组术后第一次白细胞计数、C反应蛋白、天门冬氨酸氨基转移酶、碱性磷酸酶等肝功能指标比较,差异均无统计学意义(P>0.05)。结论症状性胆囊结石合并肝硬化患者行LC时,术中经胆囊注射吲哚菁绿显影胆囊及胆管结构简单易行,在安全高效解剖肝外胆管及胆囊床的同时加快手术进度,减少术后创伤,且能避免吲哚菁绿经肝脏代谢的劣势,该技术具有较好的临床实用价值。

Objective To investigate the feasibility and efficacy of transcystic injection of indocyanine green during laparoscopic cholecystectomy(LC)surgery in the treatment of patients with gallbladder stones combined with liver cirhosis.MethodsThe clinical data of 96 patients with cirhosis who underwent LC for gllbladder stones with cholecysttis ttacks in the Department of Hepatobiliary and Pancreatic Surgery of the Second People's Hospital of Changzhou City from January 2018 to May 2022 were retrospectively analyzed.All patients were diagnosed by clinical history and auxiliary examination before surgery and underwent choleystectomy according to their groups,which were divided into fluorescence group(n=49)and white light group(n=47)according to whether ICG was used or not,where the fluorescence group underwent LC in fluorescence mode after direct intraoperative injection of ICG via gallbladder.The two groups were compared in terms of identification time of the three tubes,operation time,intraoperative bleeding,intraoperative injury,intraoperative open abdomen and blood transfusion,postoperative drainage ime,postoperative hospitalization time,postoperative complications and changes in infection and liver function indexes before and after surgery.The measurement data obeying normal distribution were expressed as meanx^(-)±standard deviation(x^(-)±s),and independent sample t-test was used for comparison between groups.The measurement data obeying the skewed distribution were expressed by M(Q_(1),Q_(3)),and the Mann-Whitney U test was used for comparison between groups.Count data were expressed as rates(%),and the chi-square test or Fisher's exact probability method was used for comparison between groups.ResultsThe procedure was successfully performed in both groups,and the identification of triple-tube time,operative time,intraoperative bleding,postoperative drainage time,postoperative hospital stay,postoperative ALT,postoperative GGT,and postoperative TBIL in the fluorescent group were(14.96±1.49)min,(52.14±7.36)min,5(5,10)mL,(1.61±0.61)d,(2.37±0.49)d,31.5(22.0,44.8)U/L,38.0(21.0,91.5)U/L,18.0(11.5,22.8)μmol/L,and(29.87±3.37)min,(84.36±13.25)min,10(10,20)mL,(2.70±0.69)d,(3.15±0.42)d,45.0(28.0,64.8)U/L,73.0(32.0,132.0)U/L,23.0(16.1,29.3)μmol/L in the white light group and the differences were statistically significant compared with the two groups(P<0.05).In the fluorescence group,there was no intraoperative injury and no cases of intraoperative opening,and there were 2 cases of postoperative complications,while in the white light group,there were 2 cases of intraoperative injury,1 case of intraoperative opening,and 5 cases of postoperative complications,and there were no cases of blood transfusion in both groups.There was no statistically significant diference between the fluorescence group and the white light group when comparing the preoperative laboratory indexes of both groups(P>0.05).When comparing the first postoperative white blod cel count,C-reactive protein,aspartate aminotransferase,and alkaline phosphatase indexes in the fluorescence group and the white light group,there was no statistically significant dfference between the two groups(P>0.05).ConclusionWhen LC is performed in patients with symptomatic gallbladder stones combined with cirhosis,intraoperative injection of indocyanine green via the gllbladder to visualize the gllbladder and bile duct structures is simple and easy to perform,and the safe and efficient dissection of extrahepatic bile ducts and gallbladder bed speeds up the procedure while reducing postoperative trauma.