经皮肝穿刺胆囊引流术后二期LC在中度急性胆囊炎中的应用价值  

Evaluation of clinical outcomes of staged LC after PTGBD in moderate acute cholecystitis

作　　者：周程[1] 严白莉[2] 龚昭[1] 杨光耀[1] 夏辉[1] 曾志武[1] 朱鹏[1] Zhou Cheng;Yan Baili;Gong Zhao;Yang Guangyao;Xia Hui;Zeng Zhiwu;Zhu Peng(Department of Hepatobililary Surgery,Wuhan No.1 Hospital,Hubei Wuhan 430022,China;Department of Pain Management,Wuhan No.1 Hospital,Hubei Wuhan 430022,China)

机构地区：[1]武汉市第一医院肝胆外科,湖北武汉430022 [2]武汉市第一医院疼痛科,湖北武汉430022

出　　处：《腹部外科》2019年第1期54-59,共6页Journal of Abdominal Surgery

基　　金：湖北省自然科学基金(2014CFC1039);2012年武汉市人社局回国留学人员择优资助项目

摘　　要：目的评价经皮肝穿刺胆囊引流术(percutaneous trans-hepatic gallbladder drainage, PTGBD)后二期腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)在2013版东京指南(Tokyo Guideline 2013, TG13)中度急性胆囊炎中的临床应用价值。方法回顾性收集武汉市第一医院据TG13分级为中度的急性胆囊炎164例,采用倾向性评分匹配(PSM)法均衡PTGBD+LC组与急诊LC组间的混杂因素后,分析两组间在复杂胆囊判断、手术时间、中转率、并发症、切口感染、留院时间和治疗费用等方面的差异。结果术中"困难胆囊"的发生率PTGBD+LC组(25.5%,12/47)明显低于急诊LC组(55.3%, 26/47)(P=0.003),且多因素分析发现急诊LC是"困难胆囊"发生的独立风险因素;另外,PTGBD+LC组的切口感染率(4.3%, 2/47)也显著低于急诊LC组(21.3%,10/47)(P=0.013);两组在中转开腹率(2.1%比4.3%,P=1.0),手术时间[(100.6±20.0) min比(107.8±17.9) min,P=0.07],Dindo-Clavien 2级以上并发症发生率(6.4%比10.6%,P=0.712)以及住院时间(8.4±2.9 d比9.5±2.9 d,P=0.071)方面差异均无统计学意义;治疗费用PTGBD+LC组为(31 331.9±2 353.1)元,显著高于急诊LC组的(24 864.9±1 749.1)元(P<0.01)。结论 PTGBD术后二期LC处理TG13中度胆囊炎可以有效降低困难腔镜胆囊手术风险,减少术后切口感染,同时具备可接受的手术时间、中转开腹和并发症率,却存在医疗费用较高的不足。Objective To evaluate the clinical outcomes of staged LC after PTGBD in TG13 moderate acute cholecystitis(AC).Methods 164 cases of TG13(Tokyo Guideline 2013)moderate AC cases were collected retrospectively.After the propensity scores match,the cofound factors between PTGBD+LC and emergency LC group were well balanced.Based on PSM data,we analyzed and compared the clinical outcome parameters,including complicated LC procedure,operation time,conversion rate,comorbidity,SSI,length of hospital stay(LOS)and medical cost between two groups.Results The rate of complicated procedure during LC was significantly lower in PTGBD+LC group(25.5%,12/47)than in emergency LC group(55.3%,26/47)(P=0.003).Furthermore,emergency LC was identified as an independent risk factor for complicated LC by multi-variants regression analysis.The SSI rate was significantly lower in PTGBD+LC group than in emergency LC group(4.3%,2/47 vs.21.3%,10/47)(P=0.013).No significant difference was found between two groups in terms of conversion rate(2.1%vs.4.3%,P=1.0),operation time(100.6±20.0 min vs.107.8±17.9 min,P=0.07),complications with severity of grade 2 or greater in Dindo-Clavien classification system(6.4%vs.10.6%,P=0.712)and LOS(8.4±2.9 d vs.9.5±2.9 d,P=0.071).However,medical cost was significantly greater in PTGBD+LC group than in emergency LC group(31 331.9±2 353.1 vs.24 864.9±1 749.1,P<0.01).Conclusion In AC cases with severity of TG13 gradeⅡ,the staged LC after PTGBD could effectively decrease risk of complicated LC procedure,and prevent SSI from emergency LC with acceptable opeation duration,conversion and complications rate,but its costs are high.

关 键 词：腹腔镜胆囊切除术 经皮肝穿刺胆囊引流 倾向性评分匹配 急性胆囊炎 胆石症 急性胆道感染2013版东京指南(TG13) 复杂胆囊切除 

分 类 号：R657.42[医药卫生—外科学]