症状性胆囊良性病变合并肝硬化的手术治疗：一项前瞻性随机研究  

A prospective study on cholecystectomy for symptomatic benign gallbladder disease in cirrhotic patients

作　　者：白明东[1] 王建[1] 徐海[1] 章密密[1] 赵严冬[1] 

机构地区：[1]徐州医学院第二附属医院普外科,江苏221006

出　　处：《中华普通外科杂志》2012年第4期306-309,共4页Chinese Journal of General Surgery

摘　　要：目的评价腹腔镜胆囊切除术（1aparoscopic cholecystectomy，LC）与开腹胆囊切除术（opencholecystectomy，OC）的治疗结果及终末期肝病模型（modelfor end—stage liver disease，MELD）评分和CTP（Child．Turcotte．Pugh）分级预测肝硬化患者术中出血和术后并发症的价值。方法将128例症状性胆囊良性病变合并肝硬化CTPA级和B级患者随机分为Lc组（n=64）和OC组（n=64），数据采用t检验、Mann-WhitneyU检验及PearsonX^2检验。结果两组手术时间差异无统计学意义（t=1．761，P=0．081）。Lc组失血量超过200m1人数比例少于OC组（0=4．467，P=0．035）。LC组术后下床活动时间、恢复进食时间、住院时间、VAS-疲乏强度以及VRS-美容满意度评分等均明显优于OC组（t=5．424，t=8．573，t=15．634，Mann-Whitney U=473．0，Mann—Whitney=145．0；均P=0．000）。LC组手术后3日内VAS-疼痛强度评分均明显低于OC组（Mann—Whitney=6．0，Mann—Whitney=22．5，Mann·Whitney=24．0，Mann—Whitney=46．0；均P=0．000）。以CTP分级为基础，Lc组总并发症发生率低于OC组[24％（14／58），38％（24／64）；x。=4．582，P=0．032]。以MELD评分14分为标准，LC组总并发症发生率也低于OC组[21％（12／58），34％（22／64）；X2=4．238，P=0．040]。无论Lc组还是OC组，术前MELD评分〈14分与≥14分者术中失血量和术后并发症发生率两项指标差异均有统计学意义（t=6．604，x^2=5．007；P=0．000，P=0．025和t=6．045，x^2=12．5；P=0．000，P=0．000）；而CTPA级和B级之间术中失血量和并发症发生率差异无统计学意义（t=1．020，x^2=0．110；P=0．312，P=0．741和t=1．897，X^2=0．533；P=0．063，P=0．465）。结论CTPA级和B级患者能够安全实施LC。LC组在术中失血量、疼痛和疲乏强度、恢复进食时间、术后下床时间及住院时间、并发症发病率等方面均优于OC组。Lc是肝硬化患者术式的首选。MELD评�Objective To evaluate laparoscopie cholecystectomy （LC） versus open cholecystectomy （OC） in compensated cirrhotics and model for end-stage liver disease （MELD） score and Child-Turcotte-Pugh （CTP） classification in predicting perioperative morbidity. Methods Between January 1998 and June 2011, 128 cirrhotic patients of symptomatic innocuous gallbladder disease at CPT class A or B liver function were prospectively and randomly divided into LC group （64 patients） and OC group （64 patients ）. Data were analyzed by T test, Mann-Whitney U test and Pearson X2 test. Results There was no statistical differences in operation time between the two groups （ t = 1. 761, P = 0. 081 ）. The intraoperative blood loss 〉 200 ml occurred in 15 （26%） LC patients and 35 （55%） OC patients （X2 = 4. 467,P = 0. 035 ）. LC patients had earlier up and about, earlier oral intake, short hospital stay（t =5.424,t =8. 573, t = 15. 634; P =0. 000, respectively） and lower complication rate [ CTP： 24% （14/58） vs 38% （24/64） ,X2 =4. 582, P =0. 032; MELD scores 21% （12/58） vs 34% （22/64）, X2 = 4. 238, P = 0. 040] compared with OC patients. LC patients＇ VAS- fatigue and VAS-pain scores on first 3 days were lower than OC according to the VAS （visual analogue scale） （Mann-Whitney U = 473. 0, Mann- Whitney = 6.0, Mann-Whitney = 22. 5, Mann-Whitney = 24.0, Mann-Whitney = 46. 0; P = 0. 000,respectively）, and the VRS-cosmetic score was higher in LC group than in the OC group according to the VRS （verbal rating scale） （ Mann-Whitney = 145.0, P =0. 000）. MELD score 〉 14 predicted higher blood loss and complication rate regardless of LC or OC, while CPT classification did not seem to predict intraoperative bleeding volume and morbidity. Conclusions LC can be performed safely in cirrhotic patients with CPT class A and B. LC has less, blood loss lower postoperative complication rate, and quicker postoperative recovery. MELD score system is more valuable than CPT classification syst

关 键 词：肝硬化 胆囊切除术 腹腔镜 肝功能试验 

分 类 号：R657.4[医药卫生—外科学]