开腹和腹腔镜胆囊切除术治疗老年急性坏疽性胆囊炎的临床分析

Efficacy analysis of open cholecystectomy and laparoscopic cholecystectomy in the treatment of elderly patients with acute gangrenous cholecystitis

目的 观察腹腔镜胆囊切除术治疗老年急性坏疽性胆囊炎的临床疗效,总结与开腹胆囊切除术相比的优劣.方法 采取回顾性研究的方式,选取孝感市第一人民医院2010年1月-2015年1月收治的老年急性坏疽性胆囊炎患者68例,依据患者手术方式的不同将其分为微创组(36例)与开腹组(32例),其中微创组患者给予腹腔镜胆囊切除术治疗,开腹组患者给予开腹胆囊切除术治疗.记录两组患者的切口长度、手术时间、术中出血量、中转开腹、术后首次排气时间、引流管拔出时间、术后疼痛程度(视觉模拟评分法)、住院时间、术后并发症等情况并进行统计学分析.采用门诊随访或电话随访的方式,询问患者相关健康状况并进行记录,随访截止日期为2015年7月.正态分布的计量资料用((-x)±s)表示,组间比较采用t检验,计数资料用百分率(％)表示,两组间比较采用x2检验.结果 微创组的切口长度、术中出血量、术后首次排气时间、住院时间、拔管时间分别为(4.67 ±2.13) cm、(65.67 ±23.61) ml、(31.18 ±4.35)h、(7.53±2.33)d、(2.44±.1.31)d,开腹组分别为(8.48±3.49) cm、(103.96±35.65) ml、(40.41 ±5.87)h、(12.34±2.94)d、(3.73±1.52)d,两组相比差异具有统计学意义(均P＜0.05);两组患者手术时间接近(=3.574,P＞0.05);微创组患者术后第1、3、5、7天的疼痛评分分别为(4.96±1.38)分、(3.48±1.04)分、(2.01±0.89)分、(1.11 ±0.85)分,开腹组分别为(6.55±1.84)分、(5.69±1.54)分、(2.97±1.16)分、(1.81±0.94)分,两组相比差异具有统计学意义(均P＜0.05);微创组患者的并发症发病率为17.14％ (6/35),显著低于开腹组的41.94％(13/31)(x2=15.234,P＜0.05),但所有并发症给予抗感染、引流等对症处理后均得到缓解.随访期间无失访病例.在68例入组患者中,微创组1例因粘连过重、术中出血难以控制而中转开腹,开腹组1例术后因感染性休克而死亡,其余患者经手术治疗均获治.结论 胆囊切除术是治疗老年急性坏疽性胆囊炎行之有效的选择,且腹腔镜胆囊切除术具有切口小、出血少、疼痛轻、并发症少、术后恢复快等优势,值得推广应用.

Objective To investigate the clinical curative effect of laparoscopic cholecystectomy in the treatment of elderly patieuts with acute gaugrenous cholecystitis,and summarized the advantages and disadvantages compared with open cholecystectomy.Methods Using retrospective study,68 elderly patients with acute gangrenous cholecystitis patients in Xiaogan First People's Hospital from January 2010 to January 2015 were selected,and divided into minimally invasive group (36 cases) and laparotomy group (32 cases) according to the different surgical treatment methods,the minimally invasive group patients were treated with laparoscopic cholecystectomy,the laparotomy group patients were treated with open cholecystectomy.Recorded and statistical analysised the incision length,operative time,intraoperative blood loss,laparotomy,postoperative first exhaust time,drainage tube pulled out of time,the degree of pain after operation (visual analogue scale),length of hospital stay,postoperative complications of the two groups.All the patients were followed up by outpatient or telephone,inquiried and recorded the patient's health status up to July 2015.The measurement data were expressed by (x ± s),and the t test was used comparison between groups.The enumeration data was expressed by percentage (％),and the x2 test was used comparison between groups.Results The incision length,intraoperative blood loss,postoperative first exhaust time,length of hospital stay,extubation time were respectively (4.67 ±2.13) cm,(65.67 ±23.61) ml,(31.18 ±4.35) hours,(7.53 ±2.33) days,(2.44±1.31) days in the minimallyinvasive group and (8.48 ±3.49) cm,(103.96 ±35.65) ml,(40.41 ±5.87) hours,(12.34 ±2.94) days,(3.73 ± 1.52) days in the laparotomy group,with statistically significant differences between the 2 groups (all P ＜ 0.05).There was no significant difference in the operation time between the two groups (t =3.574,P ＞ 0.05);The pain scores in the minimally invasive group after 1,3,5 and 7 days were respectively (4.96 ± 1.38) scores,(3.48 ± 1.04) scores,(2.01 ± 0.89) scores,(1.11 ± 0.85) scores and (6.55±1.84) scores,(5.69±1.54) scores,(2.97± 16) scores,(1.81 ±0.94) scores in the laparotomy group,with statistically significant differences between the 2 groups (all P ＜ 0.05).The incidence of complications in minimally invasive group was 17.14％ 6/35),which was significantly lower than that of laparotomy group 41.94％ (13/31) (x2 =15.234,P ＜ 0.05),all the complications were relieved after symptomatic treatment such as anti infection,drainage and so on.All patients were followed up.Among 68 patients enrolled in the study group,1 patient in the minimally invasive group was converted to laparotomy because of excessive adhesion and uncontrollable intraoperative bleeding.The laparotomy group died of septic shock in 1 case,and the remaining patients were treated by surgical treatment.Conclusion Cholecystectomy is effective in treatment of elderly patients with acute gangrenous cholecystitis,and laparoscopic cholecystectomy has the advantages of small incision,less bleeding,less pain,fewer complications and faster recovery after operation thus deserving popularization.